ANTIINFECTIVES/ANTIMICROBIALS ANTIBACTERIAL/ANTIBIOTICS

Þ substances that inhibit bacterial growth or kill bacteria and

FACTS TO REMEMBER: other microorganisms.
• Check for C&S culture & sensitivity (Gram’s stain) to
specify the specific microorganism prior to administration of CLASSIFICATION OF ANTIBIOTICS
drug. Repeat as required.
• Assessment to determine effectiveness of antimicrobial I. ACCORDING TO THEIR MECHANISM OF ACTION (MOA)
agents
• Resolution of infection, & absence of infection Action Drugs
Agents that inhibit Penicillin
• Return to normal lab values
bacterial cell wall Bacitracin
• Patient’s feeling of comfort
synthesis Cephalosporins
• Absence of GI discomfort
Vancomycin
• Treatment of viral infections requires round-the-clock (Pe-Ba-Ce-Va)
administration
Agents that alter Polymyxin B
• Photosensitivity bacterial cell
- All anti-infectives are photosensitive membrane synthesis
- Avoid use of sunscreens in patients receiving antibiotics
(source of infection in case photosensitivity occurs)
Agents that inhibit Tetracyline
- Use of almost all antimicrobial agents causes problems protein synthesis Chloramphenicol
Erythromycin
GENERAL SIDE EFFECTS OF ANTIBIOTICS Clindamycin
• Local irritation – (Erythromycin, tetracycline, Aminoglycosides
cephalosporins, chloramphenicol – irritants) (TCECA)
• Hypersensitivity reaction – (penicillin, cephalosporins) Agents that inhibit Rifampicin
• Acquired drug resistance – (sulfonamides - nucleic acid synthesis Quinolone
Staphylococci, coliforms, tubercule bacilli)
• Superinfection – is the appearance of a new infection as a Agents that inhibit the Sulfonamides
result of broad-spectrum antimicrobial therapy over an synthesis of essential 1. Folic Acid (FA)
extended period of time metabolites necessary - important for maturation &
- destroy the normal flora for the synthesis of replication of cells
- infection folic acid 2. PABA (ParaAminoBenzoic
- seen in immunocompromised patients Acid) - precursor of FA
GENERAL NURSING IMPLICATIONS II. ACCORDING TO BACTERIAL SPECTRUM OF ACTIVITIES
WHILE USING ANTIMICROBIALS
• Assess the culture & sensitivity reports, and identify the Narrow Spectrum Penicillin, Erythromycin,
infecting organism before starting the antimicrobial agent - agents that inhibit or kill Vancomycin (PEV)
therapy narrow varieties of
• Know the difference b/w bacteriostatic and bactericidal bacteria
Bacteriostatic - inhibit the growth of microorganism 1. Broad Spectrum Ampicillin, Amoxicillin,
Bactericidal - kills bacteria - agents that inhibit or kill Aminoglycosides,
• Educate the client to complete the course of antimicrobial wide varieties of bacteria Cephalosporins, Tetracycline
agents, even after symptoms subside, to prevent the (AAACT)
recurrence of infection, and to minimize the risk of infecting
organisms developing resistance to the antimicrobial III. ACCORDING TO ANTIMICROBIAL ACTIVITY
agents
• Many antibiotics decrease the effectiveness of birth control Bactericidal Penicillin, Cephalosporin,
pills. Hence, advise the clients to use other types of - kills bacteria Bacitracin, Vancomycin,
contraception if the patient is taking birth control pills Aminoglycosides
• Any signs of allergic reactions should be reported 2. Bacteriostatic Erythromycin, Tetracycline,
immediately - inhibit multiplication of Chloramphenicol, Sulfonamide
• Drug therapy monitoring should be carried out to know the the bacteria - Viricidal / viriostatic
Peak time (Time of maximum effect) and Trough level - Fungicidal/ fungistatic
(Level just before the next dose) by drawing blood samples
immediately after administration of drug and again 10 to 30 IV. ACCORDING TO ABSORBABILITY FROM THE SITE OF
minutes before the administration of the next dose ADMINISTRATION
• Monitor the blood counts to evaluate the effectiveness of
the antimicrobial agents (leukocyte counts should return to Local Acting absorbed only at the site of
normal range) application with little systemic
• In case the patient complains of diarrhea, instruct the absorption (topical agent)
patient to take buttermilk to restore normal intestinal flora 3. Systemic Acting reaches the general blood
• After doing ANST and still in doubt, compare positive and circulation
negative results. Make a control test. Maybe the pt is only
sensitive to the diluent.
 FACTORS WHICH CONFER BACTERIAL - Hemorrhage/Blood dyscrasia: hemolytic anemia,
RESISTANCE TO ANTIBIOTICS neutropenia, leukopenia
- GI disturbances: nausea & diarrhea caused by oral
1. Bacteria developed enzymes that destroy the active drug medications via direct irritation or overgrowth of G+ organism
Ex. Penicillinase or beta lactamase - Electrolyte disturbance: a possible toxic effect of Na or K
2. Bacteria change their permeability to the drugs when doses of penicillin are used in patients with cardiovascular
3. Bacteria developed altered metabolic pathways that bypass or renal diseases
the reaction inhibited by the drugs Spectrum of Activity:
4. Bacteria developed an altered structural target for the - G+ cocci, G– cocci, G – rods(bacilli)
disease
5. Bacteria developed an altered enzyme that can still perform CLINICAL USES:
its metabolic function but is much less affected by the - bronchitis, pneumonia, otitis, sinusitis, skin infections, UTIs,
disease than the enzyme in the susceptible bacteria gynecologic infections, intraabdominal infections
- anti-pseudomonas penicillin – for burn patients, appears
CLASSIFICATION OF PENICILLINS green because of pyocyanin; sweet smelling; invades burn
cases
Penicillin G (Pen G) - Benzyl Penicillin
Penicillin V (Pen V) – Phenoxymethylpenicillin NURSING IMPLICATIONS:
MRSA – Methicillin Resistant Staphylococcus aureus • Ask previous history of allergy, if (+) Discontinue, notify AP,
treat allergic reaction
Co-Amoxiclav = Amoxicillin + Clavulanic Acid - If mild: Diphenhydramine Hcl
- Brand Name: Augmentin (po) - If severe: (resp. distress) Epinephrine IV, subQ
- IV- not stable in acid pH • Report if with thrush, vaginitis, or other infections
• Pen G - give with food
Unasyn = ampicillin + sulbactam • Injectable Penicillin for STD - give deep IM Z-tract method
Timentin = ticarcillin + clavulanic acid (G16 or 18 needle)
Zosyn = piperacillin + tazobactam • Shake suspension (14 days if refrigerated)
• Collect for C&S for proper identification of microorganisms
• Amoxicillin • Monitor lab results, evidence of clinical improvement
• Ampicillin • Take missed doses as soon as possible, do not take a double
• Azlocillin dose at the next administration time
• Bacampicillin *Adjust a dose if medication has been delayed, follow the
• Cloxacillin correct time intervals (if BID, TID, QID) then follow the original
• Carbenicillin time the next day.
• Hetacillin • Provide good nutrition and hydration
• Increase fluid intake (6-8 glasses per day)
• Methicillin
• Report immediately any untoward reactions
• Mezlocillin
*For nausea – crackers, ice chips
• Nafcillin • Evaluate for effectiveness
• Oxacillin
• Piperacillin - common in hospitals AMINOGLYCOSIDES
• Ticarcillin - common in hospitals
- Contains amino sugars linked in glycosidic linkages
- Discovered by Alexander Fleming - Naturally occurring, coming from Streptomyces
- Very narrow spectrum - Not stable in acid and produces malabsorption syndrome
- Crosses BBB if meningeal inflammation is present (S/S: diarrhea, therefore, no oral preparation - ionize in solution;
- Derived from fungus or mold evidenced on fruit or bread active at alkaline pH)
- Least toxic, antibiotic of choice due to low toxicity potential in - Usually in parenteral preparation
allergic client - Bacteriostatic at low concentration
- Tx of infections caused by meningococci, pneumococci, - Bactericidal at higher concentration
streptococci, and wound infections; UTI
- Drug of choice (DOC) for syphilis MOA: inhibit protein synthesis by binding to 30’s ribosomal unit
- Used as prophylaxis against endocarditis, for oral, GI
pulmonary procedures when bacteremia may enter circulation • Tobramycin
(Amoxicillin, Ampicillin) • Amikacin – newest, semi-synthetic coming from Kanamycin
- Used in beta-hemolytic streptococci Group A infections that • Kanamycin
can be associated with rheumatic fever (RF) or Acute
• Spectinomycin
Glomerulonephritis (AGN), pharyngitis
• Gentamycin
- Gonorrhea are mostly resistant to penicillin
- Taken on empty stomach (Amoxicillin not affected by food) • Neomycin – prevent blindness; given only topically, highly
nephrotoxic; usually in combination with polymyxin B,
S/E: A/E: Bacitracin, Colistin
- Hypersensitivity/allergic reaction (most common) 10% of • Streptomycin – can cause blindness
people who are allergic to penicillin are also allergic to
cephalosporins (Cross Sensitivity) INDICATION/USES
- Superinfection (due to destruction of normal flora) - Gram (+) bacilli, Enterococci (Endocarditis) & tubercle bacilli
- Diarrhea/LBM: Do not give ampicillin, instead use Amoxicillin - Bacterial infection in the respiratory system, skin, eyes, ears
w/c can be taken with or w/o food - Pulmonary tuberculosis (Streptomycin)
- Gonorrhea (Spectinomycin)
S/E S/E AND MANAGEMENT
- Ototoxicity (transient deafness/ temporary) - Rash, urticaria, maculopapular (Assess for
- Nephrotoxicity allergy/hypersensitivity)
- Neuromuscular paralysis (due to ↓ Acetylchoilne/Ach - N&V, diarrhea, abdominal pain, jaundice, stomatitis
release→ neurotoxicity - Headache, insomnia, drowsiness, depression, psychosis
- Tinnitus – side effect of anti-TB drugs - Photosensitivity
- Crystalluria (↑fluid intake 3000-4000 ml /day)
S/S of Neurotoxicity: headache 1st, N&V, dizziness, - Drug resistance (complete course of tx)
nystagmus, vertigo & ataxia)
Treatment: Ca gluconate - Neostigmine Macule – flat
- Scotoma → blindness (use streptomycin) Papular – raised
- Malabsorption syndrome Vesicle – with fluid
- Allergic reaction
A/E: TOXICITY
DRUG INTERACTION - Peripheral neuritis/neuropathy
- Get inactivated when mixed with extended-spectrum penicillin - Tinnitus, hearing loss, vertigo
- Give separately 2 hrs. apart (e.g., penicillin at 8 pm then eye - Exfoliative dermatitis
treatment at 10 pm) - Steven-Johnson’s syndrome (an adverse reaction of skin
- Interacts with anesthetic and muscle relaxants that resembles the appearance of 2nd-degree burns)

NURSING MANAGEMENT URINARY TRACT ANTISEPTICS

- No driving / no machine operation if muscle weakness occurs
- Assess renal function by monitoring serum creatinine Action/Use: drugs that act against bacteria in the urine but
- Monitor drug levels in the blood (Peak & trough levels) have little or no systemic antibacterial effects (UTI) only
- Monitor for hearing loss- ototoxicity
- Increase fluid intake • Cotrimoxazole
• Nitrofurantoin
SULFONAMIDES
• Methenamine
- Derivative of sulfanilamide of para-amino benzene • Phenazopyridine
sulfonamide • Oxolinic Acid
- First effective group of antibiotics (1935) • Pipemidic Acid
• Nalidixic Acid
CLASSIFICATION • Quinolones:
- Ciprofloxacin
Agent that is absorbed rapidly & excreted rapidly: - Enoxacin
• Sulfisoxazole (Gantrisin) - Fluroxacin
• Sulfadiazine – burns (Silvadene, Flammazine, Micorsulfon) - Gatifloxacin
- Levofloxacin
Agent that is absorbed rapidly but excreted slowly: - Norfloxacin
• Sulfamethoxypyridazine - Ofloxacin
• Sulfadimethoxine - Perfloxacin
- Resoxacin
Agent that is absorbed very poorly: - Sparfloxacin
• Succinyl sulfathiozole - Tosufloxacin

Agent that is used topically: MACROLIDES

• Sulfadiazine (burns)
• Mefenide - Have macrocyclic lactone ring with attached sugar
- Bacteriostatic
Sulfamethoxazole + Trimethoprim = COTRIMOXAZOLE - Highly bound protein
- Action is similar to other antibiotics
MOA: inhibit folic acid synthesis
(PABA) – paraaminobenzoic acid; no multivitamins with FA Erythromycin (Erythrocin)

INDICATION/USES MOA: inhibit protein synthesis by binding with 50’s

- Burns (Sulfadiazine) ribosomal unit
- Ocular infection (conjunctivitis & trachoma ) → blindness
(Rickettsia trachomatis) • Azithromycin (Zithromax )
- UTI /RTI (Cotrimoxazole = Sulfamethoxazole + Trimethoprim) • Clarithromycin (Klaricid)
- G (+) infections • Dirythromycin (Dynabac)
- Otitis media • Troleandomycin (Tao)
- Pneumonia • Clindamycin (Cleocin)
- Dysentery - No Iv push but by IV infusion
- Vaginal infections - Empty stomach or w/ at least 80oz of fluid
 DOC: Bacteroides Infection
S/E: Pseudomembranous colitis – if given orally THIRD GENERATION
• Vancomycin
HENPECK + SSS ( ... Shigella, Serratia, Salmonella)
DOC: Pseudomembranous colitis • Cefoperazone (Cefobid)
S/E: Ototoxicity & Nephrotoxicity • Cefotaxime (Claforan)
• Lincomycin (Lincocin) – empty stomach • Ceftizoxime
• Cefixime (Tergicef/Suprax)
INDICATIONS • Ceftazidime (Fortum) – for Pseudomonas
- Upper & lower tract infections, skin, soft tissue infections • Ceftriaxone (Rocephin) – for meningitis, Gonorrhea ;
- Syphilis, gonorrhea, chlamydia with longest half life
- DOC: Legionnaire’s disease (Pneumonia) • Moxalactam
- Tonsillopharyngitis – (Give Erythromycin as initial drug)
- Useful for patients with allergic reaction to most of FOURTH GENERATION
antibiotics and safe for bronchial asthma • Cefepime (Maxipime) - for nosocomial infection; G(+)
microorganism, skin & soft tissue infection, people with
S/E leukopenia, pneumonia, UTI, abdominal, meningitis,
- Epigastric distress (most common)- give p.c. sepsis
- Transient deafness (in large doses)
- Superinfection (thrush, vaginitis) FIFTH GENERATION
- Hepatotoxicity • Ceftaroline (Teflaro) – treatment for MRSA &
streptococcus species
DRUG INTERACTIONS
- Can elevate theophylline levels SIDE EFFECTS
- Cross resistance with clindamycin & chloramphenicol - Allergic reactions
since ribosomal binding sites for all these are proximal - Superinfection
- Bleeding/hypoprothrombinemia ( common to Moxalactam)
NURSING IMPLICATION - Nephrotoxic ( Cephradine)
- Erythromycin - Give with juice or apple sauce if with
bitter taste Other Beta Lactam Antibiotics
- Macrolides are acid labile; Do not give fruit juices or - Acts similar to cephalosporins
empty stomach, except for some
• Aztreonam (Azactam)
- Monitor for hepatotoxicity, (elevated ALT, AST) since the
• Imepenem (Cilastatin/ Primoxin)
liver mostly excretes macrolides
- Monitor for superinfection • Loracarcef (Lorabid)
- In pregnant woman → cause cholestatic jaundice which
clears on discontinuation NURSING CONSIDERATIONS/MGT
• Monitor renal function
• Diarrhea: use buttermilk to reduce diarrhea
CEPHALOSPORINS • If diabetic: Monitor blood glucose level
• No Alcohol
- More stable at acid pH (so with oral preparation) • If with history of vaginitis- use antifungals simultaneously
- 1st @ 2nd generation are mostly oral preparation with antibiotics
- Enhanced action through potentiation
- DOC: Klebsiella Pneumonia

FIRST GENERATION (mild)

PEcK (Proteus, E. Coli, Klebsiella)

• Cephalothin (Keflin)
• Cephapirin (Cefadyl)
• Cephradine (Anspor)
• Cephalexin (Keflex)
• Cefazolin
• Cefadroxil (Duricef)

SECOND GENERATION

HENPEcK (H Influenza, Enterobacter, Neisseria Gonorrhea, +

PEcK)
• Cefamandole (Mandol)
• Cefoxitin (Mefoxin)- DOC for Bacteroides Infection –
pus in stomach)
• Cefaclor (Ceclor) - DOC for Pneumonia
• Cefonicid-
• Cefuroxime (Zinacef)
• Ceforanide