Chapter Summary 44-1

Lilley’s Pharmacology for Canadian Health Care Practice, 4th Canadian

Edition
Chapter 44: Antibiotics Part 2: Aminoglycosides, Fluoroquinolones, and Other Drugs

OVERVIEW

 This chapter covers additional classes of antibiotics used for more serious and harder-to-treat
infections, specifically, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-
resistant Enterococcus (VRE), organisms producing extended-spectrum β-lactamases
(ESBLs), and organisms producing Klebsiella pneumoniae carbapenemase (KPC).
 Over the years, bacteria have developed enzymes and mechanisms to interact with antibiotics
and render the antibiotic ineffective. Multidrug resistance is a significant health issue, and
such resistant organisms include ESBL-producing and carbapenem-resistant
Enterobacteriaceae–producing bacteria, MRSA, and VRE.
 Carbapenem-resistant Enterobacteriaceae (CRE) are bacteria that possess carbapenemase, an
enzyme that renders the organism resistant to all carbapenem antibiotics as well as to β-
lactam antibiotics and monobactams. Such organisms produce a very serious resistant
infection. Currently, the most common type of carbapenemase is KPC.
 Organisms that produce ESBL are resistant to all ß-lactam antibiotics and aztreonam; they
can be treated only with carbapenems or (sometimes) quinolones. As the use of carbapenems
increased, bacteria created a new means of resistance: the ability to produce carbapenemase,
which renders all carbapenems ineffective.
 When patients become infected with CRE, only two known antibiotics can be used:
tigecycline and colistimethate. Colistimethate (Coly-Mycin®) is a polypeptide antibiotic that
penetrates and disrupts the bacterial membrane of susceptible strains of gram-negative
bacteria. It is an old drug that fell out of clinical use when newer, less toxic drugs became
available. Resistance to these antibiotics have been reported; such resistance leaves the
patient untreatable.
 MRSA has been around for many years; new antibiotics have been developed to treat MRSA.
However, the threat of MRSA’s becoming resistant to all currently available antibiotics is all
too real. MRSA is no longer seen just in hospitals; it has spread to the community setting.
Depending on the location, over 50% of staphylococcal infections contracted in communities
involve MRSA.
 These organisms are spread by contact, so all health care providers must wash their hands
before and after all contact with patients.

Aminoglycosides
 The aminoglycosides are a group of natural and semisynthetic antibiotics that are classified
as bactericidal drugs, are very potent, and are capable of potentially serious toxicities (e.g.,
nephrotoxicity, ototoxicity).
 Aminoglycosides include amikacin, gentamicin, and tobramycin.
 Serum levels of aminoglycosides are routinely monitored, and dosages are adjusted to
maintain optimal levels that maximize drug efficacy and minimize the risk of toxicity. This
process is called therapeutic drug monitoring. Aminoglycoside therapy is commonly
monitored in this way due to the nephrotoxicity and ototoxicity associated with these drugs.

Copyright © 2021 by Elsevier Inc. All Rights Reserved.

Chapter Summary 44-2

 Dosing is adjusted to the patient’s level of renal function based on estimates of creatinine
clearance calculated from serum creatinine values.
 The serum level needs to be at least eight times higher than the minimum inhibitory
concentration (MIC), which is a measure of the lowest concentration of drug needed to kill a
certain standard amount of bacteria. This value is determined in vitro for each drug.
 β-Lactams act through time-dependent killing; the amount of time the drug is above the MIC
is critical for maximal bacterial kill. Aminoglycosides work primarily through concentration-
dependent killing; achieving a drug plasma concentration that is a certain level above the
MIC, even for a brief period of time, results in the most effective bacterial kill.
 Once-daily dosing provides a sufficient plasma drug concentration for bacterial kill, along
with equal or lower risk for toxicity compared to multiple daily dosing regimens. Use of a
once-daily regimen also reduces the nursing care time required and often allows for
outpatient or even home-based aminoglycoside drug therapy.
 Trough (lowest) levels are measured to ensure adequate renal clearance and avoid toxicity.
 The therapeutic goal is a trough concentration at or below 1 mcg/mL. Trough levels above 2
mcg/mL are associated with a greater risk of both ototoxicity and nephrotoxicity.
 Aminoglycosides work in a manner similar to that of the tetracyclines in that they bind to
ribosomes, specifically the 30S ribosome, and prevent protein synthesis in bacteria.
 Aminoglycosides are most often used in combination with other antibiotics such as β-lactams
or vancomycin because the combined effect of the two antibiotics is greater than the sum of
the effects of each drug acting separately. This is known as a synergistic effect.
 Aminoglycosides also have a property known as the postantibiotic effect; continued bacterial
growth suppression occurs after short-term antibiotic exposure, as in once-daily dosing.
 Toxicity associated with aminoglycosides limits their use to treatment of serious gram-
negative infections and specific conditions involving gram-positive cocci, in which case
gentamicin is usually given in combination with a penicillin.
 Gram-negative infections treated with aminoglycosides include those caused by
Pseudomonas spp. and several organisms belonging to the Enterobacteriaceae family,
including Escherichia coli, Proteus spp., Klebsiella spp., and Serratia spp.
 Aminoglycosides are also used for prophylaxis in procedures involving the gastrointestinal
(GI) or genitourinary (GU) tract because such procedures carry a high risk for enterococcal
bacteremia.
 Aminoglycosides are to be administered with caution to premature and full-term neonates
because of their renal immaturity.
 Aminoglycosides are very potent antibiotics and are capable of potentially serious toxicities,
especially to the kidneys and ears; in the latter, they can affect hearing and balance functions.
The duration of drug therapy needs to be as short as possible, based on sound clinical
judgement and monitoring of the patient’s progress.

Quinolones
 Quinolones, sometimes referred to as fluoroquinolones, are potent bactericidal broad-
spectrum antibiotics. Currently available quinolone antibiotics include norfloxacin
hydrochloride, ciprofloxacin, levofloxacin, and moxifloxacin hydrochloride. With the
exception of norfloxacin hydrochloride, these antibiotics have excellent oral absorption—in
most cases, comparable to that of intravenous (IV) injection.

Copyright © 2021 by Elsevier Inc. All Rights Reserved.

Chapter Summary 44-3

 Quinolone antibiotics destroy bacteria by altering their deoxyribonucleic acid (DNA).

 Quinolones are active against a wide variety of gram-negative and selected gram-positive
bacteria. Most are excreted by the kidneys as unchanged drug. This, together with the
extensive gram-negative coverage, makes them suitable for treating complicated urinary tract
infections, as well as respiratory, skin, GI, and bone and joint infections.
 The use of quinolones in prepubescent children is not generally recommended because these
drugs have been shown to affect cartilage development in laboratory animals. However,
judicious use in children might be less of a risk than previously thought, and these drugs are
used commonly in children with cystic fibrosis.
 Bacterial overgrowth is a complication of quinolones but is more commonly associated with
long-term use. More worrisome is a cardiac effect that involves prolongation of the QT
interval on the electrocardiogram (ECG).
 Concurrent use of quinolones with antacids, calcium, magnesium, iron, zinc preparations, or
sucralfate causes a reduction in the oral absorption of the quinolone.
 Quinolones can also cause peripheral neuropathy, which may be permanent. New evidence
suggests that they may also cause liver injury in older adults.
 Probenecid can reduce the renal excretion of quinolones. Nitrofurantoin can antagonize the
antibacterial activity of the quinolones, and oral anticoagulants are to be used with caution
because of the antibiotic-induced alteration of intestinal flora, affecting vitamin K synthesis.

Miscellaneous Antibiotics
 Clindamycin (Dalacin C®) is a semisynthetic derivative of lincomycin, an older antibiotic.
Clindamycin can be either bactericidal or bacteriostatic, depending on the concentration of
the drug at the site of infection and on the infecting bacteria. It inhibits protein synthesis in
bacteria and is indicated for the treatment of chronic bone infections, GU tract infections,
intra-abdominal infections, anaerobic pneumonia, septicemia caused by streptococci and
staphylococci, and serious skin and soft-tissue infections caused by susceptible bacteria.
 Clindamycin is contraindicated for patients with a known hypersensitivity to it, those with
ulcerative colitis or enteritis, and infants younger than 1 month of age.
 With clindamycin, GI tract adverse effects are the most common and include nausea,
vomiting, abdominal pain, diarrhea, pseudomembranous colitis, and anorexia.
 Clindamycin is also known to have some neuromuscular blocking properties that may
enhance the actions of neuromuscular drugs used in perioperative and intensive care settings.
 Linezolid (Zyvoxam®) is the first antibacterial drug in a new class of antibiotics known as
oxazolidinones. This drug works by inhibiting bacterial protein synthesis. Linezolid was
originally developed to treat infections associated with vancomycin-resistant Enterococcus
(VRE).
 The most commonly reported adverse effects of linezolid are headache, nausea, diarrhea, and
vomiting. It has also been shown to decrease platelet count. Tyramine-containing foods such
as aged cheese or wine, soy sauce, smoked meats or fish, and sauerkraut can interact with
linezolid to raise blood pressure.
 Metronidazole (Flagyl®) is an antimicrobial drug of the class nitroimidazole, has good
activity against anaerobic organisms, and is widely used for intra-abdominal and gynecologic
infections; it is also used to treat protozoal infections (e.g., amebiasis, trichomoniasis).

Copyright © 2021 by Elsevier Inc. All Rights Reserved.

Chapter Summary 44-4

 Adverse effects of metronidazole include dizziness, headache, GI discomfort, nasal

congestion, and reversible neutropenia and thrombocytopenia. Drug interactions include
acute alcohol intolerance when it is taken with alcoholic beverages.
 Metronidazole may also increase the toxicity of lithium, benzodiazepines, cyclosporine,
calcium channel blockers, various antidepressants (e.g., venlafaxine), warfarin, and other
drugs. In contrast, phenytoin and phenobarbital may reduce the effects of metronidazole.
 Nitrofurantoin (Furantoin®, MacroBID®) is an antibiotic drug of the class nitrofuran and used
primarily for urinary tract infections caused by E. coli, S. aureus, Klebsiella spp., and
Enterobacter spp. Adverse effects include GI discomfort, dizziness, headache, skin reactions
(mild to severe reported), blood dyscrasias, ECG changes, possibly irreversible peripheral
neuropathy, and hepatotoxicity. Although hepatotoxicity is rare, it is often fatal.
 Quinupristin and dalfopristin (Synercid®) are two streptogramin antibacterials approved for
IV treatment of bacteremia and life-threatening infection caused by VRE and for treatment of
complicated skin and skin structure infections caused by S. aureus and S. pyogenes.
 Common adverse effects are arthralgias and myalgias, which may become severe. Adverse
effects at the infusion site (including pain, inflammation, edema, and thrombophlebitis) have
developed in approximately 75% of patients treated through a peripheral IV line.
 Vancomycin is a natural bactericidal antibiotic that destroys bacteria by binding to the cell
wall. It is the antibiotic of choice for treatment of MRSA infection and infections caused by
other gram-positive bacteria. It is not active against gram-negative bacteria, fungi, or yeast.
 Vancomycin is similar to the aminoglycosides in that there are very specific drug levels in
the blood that are safe.
 Nephrotoxicity is more likely to occur with concurrent therapy with other nephrotoxic drugs
such as aminoglycosides, cyclosporine, and contrast media used for computed tomography
scans. Vancomycin can cause additive neuromuscular blocking effects in those taking
neuromuscular blockers.

NURSING PROCESS

Assessment
 Take a history of current symptoms indicative of hypersensitivity or allergic reactions. Note
symptoms from mild reactions with rash, pruritus, or hives to severe reactions with laryngeal
edema, bronchospasm, and hypotension to possible cardiac arrest.
 With any antibiotic, be observant for superinfection or a secondary infection that occurs with
the destruction of normal flora during antibiotic therapy.
 Antibiotic resistance is a concern, especially in pediatrics and in large health care institutions
and long-term care facilities. You must consider this possibility of resistance to certain
antibiotics when assessing patients for symptoms of infection and superinfection.

Implementation
 Aminoglycosides, as well as any antibiotics, are to be given exactly as ordered and with
hydration.
 Instruct the patient to report to the prescriber any changes in hearing, ringing in the ears, full
feeling in the ears, nausea, vomiting with motion, ataxia, nystagmus, or dizziness.
 Quinolones are to be taken exactly as prescribed and for the full course of treatment. Instruct
the patient not to take these medications with antacids, iron, zinc preparations, multivitamins,

Copyright © 2021 by Elsevier Inc. All Rights Reserved.

Chapter Summary 44-5

or sucralfate, because the absorption of the antibiotic will be decreased. If the patient needs
to take calcium or magnesium, instruct the patient to take it 1 hour before or after the
quinolone. Forcing of fluids is recommended unless contraindicated.
 Clindamycin oral dosage forms should be taken with 8 ounces of water or other fluid. With
topical forms, advise patients to avoid the simultaneous use of peeling or abrasive acne
products, soaps, or alcohol-containing cosmetics in order to prevent cumulative effects.
 Linezolid is generally given orally or intravenously. Oral doses are to be evenly spaced
around the clock, as ordered, and given with food or milk to decrease the possibility of GI
upset. Oral suspension forms must be used within 21 days of reconstitution. Protect IV doses
from light, and infuse over 30 to 120 minutes; do not mix with any other medication. Monitor
platelet counts closely (e.g., weekly) during therapy.
 Nitrofurantoin is available in oral forms and should be given with plenty of fluids, food, or
milk to decrease GI upset. Do not crush tablets to help prevent tooth staining and GI upset.
Because of the risk for superinfection, hepatotoxicity, and peripheral neuropathy, constantly
watch for signs and symptoms of these adverse effects and document the findings.
 Too rapid an infusion of vancomycin or administration by IV push may lead to severe
hypotension and red man syndrome. Extravasation may cause local skin irritation and
damage; thus, frequently monitor the infusion, particularly the IV site.
 Because of the significant issue of multidrug-resistant organisms, encourage patients and
family members not to misuse or overuse antibiotics and always to report immediately to the
prescriber any signs and symptoms of an infection that is not resolving or responding to
antibiotic therapy.

Evaluation
 Therapeutic goals include all those previously mentioned plus a return to normal of all blood
counts and vital sign values, negative results on culture and sensitivity testing, and improved
appetite, energy level, and sense of well-being. Signs and symptoms of the infection will
begin to resolve once therapeutic levels are achieved.
 Another aspect of evaluation is monitoring the adverse effects of therapy, such as
superinfections, antibiotic-associated colitis, nephrotoxicity, ototoxicity, neurotoxicity,
hepatotoxicity, and other drug-specific adverse effects.
 Superinfection is a secondary infection that occurs because of the destruction of normal flora
during antibiotic therapy. Superinfections may occur in the mouth, respiratory tract, GI and
GU tracts, and on the skin. Fungal infections are evidenced by fever, lethargy, perineal
itching, and other anatomically related symptoms.

Copyright © 2021 by Elsevier Inc. All Rights Reserved.