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Saturday, October 20, 2007

Pharmacology - Antibiotics Drugs :: Nursing Pharmacology :: Review For Nursing Licensure Examination

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Antibiotics :: Pharmacology :: Review For Nursing Licensure Examination Slide Transcript
Slide 1: Pharmacology of the Antibiotics Nurse Licensure Examination Review

Slide 2: The anti-infectives  ANTI-INFECTIVES  Anti-infective agents are drugs that are designed to act selectively on foreign organisms that have invaded and infected the body  Anti-infectives- range from antibiotics, antifungals, antiprotozoals, antihelmintics, antivirals and antimycobacterial.

Slide 3: General Mechanisms of Action of anti-infective  Some interfere with the biosynthesis of bacterial cell WALL  Some inhibit protein synthesis  Some change the cell membrane permeability  Some inhibit DNA synthesis

Slide 4: Spectrum of Activity of Anti- infectives  Narrow spectrum anti-infectives affect only a few bacterial types. The early penicillin drugs are examples.  Broad-spectrum anti-infectives affect many bacteria. Meropenem is an example. Because narrow spectrum antibiotics are selective, they are more active against those single organisms than the broad spectrum antibiotics.

Slide 5: Spectrum of Activity of Anti- infectives  Anti-infectives that interfere with the ability of the cell to reproduce/replicate without killing them are called BACTERIOSTATIC drugs. Tetracycline is an example.  Antibiotics that can aggressively cause bacterial death are called BACTERICIDAL. These properties (-cidal and –static) can also depend on the antibiotic concentration in the blood.

Slide 6: Common Adverse Reactions to Anti-infective Therapy The most common adverse effects are due to the direct action of the drugs in the following organ system- Neuro, nephro and GI system 1. Nephrotoxicity – Antibiotics that are metabolized and excreted in the kidney most frequently cause kidney damage..

Slide 7: Common Adverse Reactions to Anti-infective Therapy 2. Gastro-intestinal toxicity  Direct toxic effect to the cells of the GI tract can cause nausea, vomiting, stomach pain and diarrhea. Some drugs are toxic to liver cells and can cause hepatitis or liver failure.

Slide 8: Common Adverse Reactions to Anti-infective Therapy 3. CNS toxicity  When drugs can pass through the brain barrier and accumulate in the nervous tissues, they can interfere with neuronal function.

Slide 9: Common Adverse Reactions to Anti-infective Therapy 4. Hypersensitivity  Most protein antibiotics can induce the body’s immune system to produce allergic responses. Drugs are considered foreign substances and when taken by the individual, it encounters the body’s immune cells.

Slide 10: Common Adverse Reactions to Anti-infective Therapy 5. Superinfections  Opportunistic infections that develop during the course of antibiotic therapy are called SUPERINFECTIONS.

Slide 11: The PENICILLINS Narrow spectrum penicillins – Penicillin G – Penicillin V Broad Spectrum Penicillins (aminopenicillin) – Amoxicillin – Ampicillin – Bacampicillin Penicillinase-resistant Penicillin (anti-staphyloccocal penicillins) – Cloxacillin – Nafcillin – Methicillin – Dicloxacillin – Oxacillin  Extended-Spectrum penicillins (Anti-pseudomonal penicillins) – Carbenicillin – Mezlocillin – Piperacillin – Ticacillin  Beta-lactamase inhibitors – Clavulanic acid – Sulbactam – Tazobactam

Slide 12: Penicillin The structure of Penicillin Penicillin is a beta-lactam drug, with a beta-lactam ring. The group of penicillins is called beta lactam antibiotics.

Slide 13: Penicillin Pharmacodynamcs: The action of Penicillins  The penicillin and penicillinase-resistant penicillins produce BACTERICIDAL effects by interfering with the ability of susceptible bacteria from biosynthesizing the framework of the cell wall.  The bacterium will have weakened cell wall, will swell and then burst from the osmotic pressure within the cell.

Slide 14: Amoxicillin is well absorbed in the GIT

Slide 15: Therapeutic Indications of penicillin The penicillins are indicated for the treatment of streptococcal infections.

Slide 16: Adverse Effects of Penicillins  GI system effects- the major adverse effects of penicillin therapy involve the GIT. Nausea, vomiting, diarrhea, abdominal pain, glossitis, stomatitis, gastritis, sore mouth and furry tongue.  The reason for some of these effects (superinfection) is associated with the loss of bacterial flora.  Hypersensitivity reactions- rashes, pruritus, fever. These indicate mild allergic reaction. Wheezing and diarrhea may also occur. Anaphylaxis can also happen leading to shock or death. It occurs in 5-10% of those receiving penicillins.  Pain and inflammation on injection sites

Slide 17: IMPLEMENTATION  Obtain culture and sensitivity testing results to check if penicillin is the drug of choice  Monitor the renal status and function regularly  Administer the correct dosage and stress the importance of completing the full course and duration of therapy even though the patient experiences relief earlier in the treatment

Slide 18:  Monitor the site of injection and the signs and symptoms related to the drug administration  Provide small frequent meals, frequent mouth care, ice chips or sugarless candy to suck if stomatitis and sore mouth occurs.  Provide patient teaching. Tell the patient to drink a lot of fluids and eat nutritious foods. Advise to report difficulty of breathing, severe diarrhea, dizziness, weakness and vaginal itching.

Slide 19: EVALUATION Monitor patient response to therapy Monitor for adverse effects and evaluate the effectiveness of health teaching Monitor the effectiveness of comfort and safety measures

Slide 20:  THE CEPHALOSPORINS  First Generation cephalosporins- are largely effective against the same gram-positive organisms affected by penicillin.  Second generation cephalosporins- are effective against those strains as well as Haemophilus influenza, Entreobacter aerogenes and Nesseria sp. These drugs are less effective against gram positive bacteria  Third Generation cephlosporins- are relatively weak against gram-positive bacteria but more potent against gram-negative bacteria, to include Serratia marcescens.  Fourth generation cephalosporins- are developed to fight against the resistant gram-negative bacteria. The first drug is cefepime. – First generation cephalosporins • cefadroxil • Cefazolin • Cephalexin • Cephalotin • Cephapirin • Cephadrine – Second Generation cephalosporins • Cefaclor • Cefamandole • Cefonizind • Cefotetan • Cefoxitin • Cefmetazole • Cefprozil • Cefuroxime – Third Generation Cephaosporins • Cefnidir • Cefixime • Cefoperazone • Cefotaxime • Cefpodoxime • Ceftazidime • Ceftibuten • Moxalactam – Fourth Generation Cephalosporin • Cefepime

Slide 21:  Pharmacodynamics; The mechanism of action of cephalosporins – The cephalosporins are primarily BACTERICIDAL. They interfere with the cell-wall building ability of bacteria when they divide. They prevent the bacteria from biosynthesizing the framework of their cell wall. The weakened cell wall will swell and burst causing cell death.  Pharmacokinetics – Only a few cephalosporins are administered orally, most are administered parenterally. Their half- lives are short and they are excreted mainly in the urine.  Contraindications and Precautions – The drugs are contraindicated in patients with known allergies to cephalosporins and penicillins. – Adverse Effects  GI system- Nausea, vomiting, diarrhea, anorexia, abdominal pain and flatulence are common effects.  CNS – headache, dizziness, lethargy and paresthesias have been reported.  Renal system- nephrotoxicity in individuals with pre-existing renal disease  Drug-Drug interactions  Aminoglycosides- if given with cephalosporins may increase the risk of kidney toxicity  Anti-coagulants- may experience increased bleeding tendencies  ALCOHOL- many patients experience a disulfiram-like reactions when taken with some specific cephlosporins ( cefamandole, cefoperazone or moxalactam). The patient may experience flushing, headache, nausea, vomiting and muscular cramps. This may occur even up to 72 hours of cephalosporin discontinuance.  The Nursing Process and Cephalosporins  ASSESSMENT  Patient History- The nsure must assess for cephalosporin and penicillin allergies. Pregnancy, lactation and kidney status must also be ascertained  Physical Examination- baseline data for evaluation. Renal function should be checked by obtaining BUN and Creatinine levels, urine output monitoring and temperature monitoring.  DIAGNOSIS  Pain related to GIT and CNS effects  High risk for infection  Fluid volume deficit  Knowledge deficit  Non-compliance with medication  IMPLEMENTATION  Check the culture and sensitivity results to determine if cephalosporin is the drug of choice  Monitor renal function test prior to and periodically during therapy  Ensure that the patient receives the full course of cephalosporins as prescribed for the duration specified. Advise the patient to consume all the drugs even though signs/symptoms may resolve earlier in the course.  Provide small frequent meals as tolerated, mouth care, ice chips if stomatitis occurs.  Provide safety measures including safety side-rails, adequate lighting and assistance with ambulation.  Provide heath teaching and advise the patient to take safety precaution in changing positions carefully, avoid driving and hazardous tasks, drink fluids liberally, report severe reactions to the drug and AVOID alcoholic beverages for 72 hours after completing the drug.  Take medication with food if gastric irritation occurs.  EVALUATION  Monitor patient response to the drug regimen

Slide 22:  The Aminoglycosides  The following are the aminoglycosides  1.Gentamycin  2.Tobramycin  3.Amikacin  4.Netilmicin  5.Kanamycin  Pharmacodyanmics:  These are BACTERICIDAL. They inhibit protein synthesis in susceptible strains of gram-negative bacteria, leading to loss of functional integrity of the bacterial cell membrane, which causes cell death.  Therapeutic Use of the Aminoglycosides  These drugs are used to treat serious infections caused by gram-NEGATIVE bacteria.  Contraindications and Precautions with the use of Aminoglycosides  These drugs are contraindicated in known allergies to aminoglycosides, in patients with renal failure, hepatic disease, pre-existing hearing loss, myasthenia gravis, Parkinson’s, pregnancy and lactation.  Adverse Effects of Aminoglycosides  CNS- irreversible deafness, vestibular paralysis, confusion, depression, disorietnation, numbness, tingling and weakness related to drug effects.  Kidney- renal toxicity, which may progress to renal failure caused by the direct toxicity of the aminoglycosides.  Hema- bone marrow depression resulting from direct drug effect may lead to immune suppression and superinfection.  GI system- nausea, vomiting, diarrhea, weight loss, stomatiits and hepatic toxicity. The effects are due to the direct GI irritation, loss of bacterial flora and toxicity to mucucs membrane and liver as the drugs are metabolized.  Skin effects- photosensitivity, purpura, rash, urticaria and exfoliative dermatitis  Cardiac- palpitaions, hypotension or hypertension  Drug to drug interactions  Diuretics- increased incidence of ototoxicity, nephrotoxicity and neurotoxicity.  Anesthetics and Neuromusular blockers- increased neuromuscular blockage and paralysis may be possible  Penicillin- synergistic action  The Nursing Process and Aminoglycosides  ASSESSMENT  Patient History- the nurse assesses the allergy to aminoglycosides, history of renal and hepatic disease, parkinsonism, myasthenia gravis, existing hearing loss, active herpes infecion, current pregnancy and lactation.  Physical examination- baseline data should be obtained. Auditory and CNS assessement must be done prior to thrapy. Culturea nd sensitivity specimen must be sent to laboratory. Renal and hepatic function tests should be checked.  DIAGNOSIS  Pain related to GU, CNS effects  Sensory-Perceptual alteration  Potential for infection  Fluid volume excess related to nephrotoxicity  Knowledge deficit  IMPLEMENTATION  Check the culture and sensitivity results to determine if aminoglycosides are the drug of choice.  Monitor the course of therapy. Ensure that the patient receives the correct dose and duration of treatment.

Slide 23:  The Macrolides  The macrolides are  Azithromycin  Clarithromycin  Dirithromycin  Erythromycin  Pharmacodynamics: Mechanism of Action of the Macrolides – The macrolides are primarily BACTERICIDAL and sometimes bacteriostatic. They exert their effect by binding to the bacterial cell ribosomes and changing or altering protein production/function. This will lead to impaired cell metabolism and division.  Pharmacokinetics – Erythromycin is destroyed by the gastric juice, which is why slats are added to stabilize the drug. Food does not interfere with the absorption of the macrolides.  Therapeutic Use of Macrolides – These are indicated for the treatment of the following conditions: Steptococcal infection, Mycoplasma infection, Listeria infection and group A beta hemolytic strep infection.  Contraindications and Precautions in the Use of Macrolides – These agents are contraindicated in the presence of known allergy to any macrolide, because cross-sensitivity occurs. Caution should be used in patients with hepatic dysfunction that could alter the metabolism of the drug; in lactating women because of drug excretion in breast milk and in pregnant women because potential adverse effects on the developing fetus.  Adverse Effects of Macrolides  GI system- abdominal cramping, anorexia, diarrhea, vomiting and pseudomembranous colitis. HEPATOTOXICITY can occur if the drug is taken in high doses with other hepatotoxic drugs.  CNS- confusion, abnormal thinking and uncontrollable emotions.  Hypersensitivity reactions  Drug-Drug Interactions  Digoxin- increased level of dioxin can occur  Anticoagulants, theophyllines and corticosteroids- increased effects of these drugs due to impaired hepatic metabolism  Astemizole- when used with macrolides, will cause fatal cardiac arrhythmias  Clindamycin or lincomycin – should not be given with erythromycin because they compete for receptor sites.  The Nursing Process and Macrolides  ASSESSMENT  Patient History- the nurse should obtain history of allergy, current pregnancy or lactation before administering the drug  Physical Examination- Assess baseline data and perform C/S before instituting therapy. The nurse then obtains information about the status of the liver and kidney, skin and GI system.  DIAGNOSIS  Pain related to GI, CNS effects  Potential for infection related to super infections  Knowledge deficit regarding drug therapy  IMPLEMENTATION

Slide 24:  The Lincosamides  These agents are similar to the Macrolides but are more toxic. They are bactericidal and bacteriostatic depending on the dose.  The following are the Lincosamides:  Clindamycin  lincomycin  Pharmacodynamics: The Mechanism of Action of Lincosamides – These agents penetrate the cell membrane and bind to the ribosome in the bacterial cytoplasm to prevent the protein production  Side effects and Adverse Reactions  GIT- GI irritation, nausea, vomiting and stomatitis  Allergic reactions  Drug Interactions  Lincomycin and clindamycin are incompatible with aminophyline, phenytoin, barbiturates and ampicillin.

Slide 25:  The Tetracyclines  These agents were first isolated from Streptomyces aureofaciens  The following are the tetracyclines  Short-acting tetracyclines – tetracycline – oxytetracycline  Intermediate acting tetracyclines – demeclocycline – methacycline  Long acting tetracyclines – doxycycline – minocycline  Pharmacodynamics: The Mechanism of Action of Tetracyclines – The tetracyclines inhibit protein synthesis in susceptible bacteria leading to the inability of the bacteria to multiply.  Therapeutic indications of the Tetracycline – Tetracyclines are effective against a wide range of bacteria. They are primarily BACTERIOSTATIC.  Contraindications and Precautions in the use of Tetracyclines – These agents are contraindicated in the presence of known allergy to tetrayclines and the tartrazine dye. It is not recommended for use in pregnancy and lactation because the drug can affect the bones and teeth, causing permanent discoloration and sometimes arrest of growth. Tetracyclines are also avoided in children less than 8 (eight) years of age because of the potential damage to the bones and permanent discoloration of the teeth.  Adverse Effects of the Tetracycline  GI system- nausea, vomiting, diarrhea, abdominal pain, glossitis and dysphagia. Fatal hepatotoxicity related to tetracycline’s irritating effect on the liver cells has been reported.  Musculoskletal- Tetracyclines have an affinity for teeth and bones; they accumulate there, leading to weakening of the bone/teeth and permanent staining and pitting.  Skin- photosensitivity and rash are expected.  Less frequent- bone marrow depression, hypersensitivity, super infections, pain and hypertension  Drug-Drug Interactions  Penicillin- if taken with tetracyclines, will decrease the effectiveness of penicillin.  Oral contraceptives- if taken with tetracycline, will have decreased effectiveness. Nurse must advise alternative methods of contraception  Digoxin- digoxin toxicity rises when tetracyclines are used together  Drug-Food Interaction  Dairy products- can complex with tetracycline and render unabsorbable. Tetracyclines should then be given on an EMPTY stomach 1 hour before meals or 2-3 hours after any meal or other medications.  The Nursing Process and Tetracyclines  ASSESSMENT  Patient History- The nurse screens the patient for allergy to tetracyclines and tartrazine. She should elicit history of renal and liver diseases,

Slide 26:  The Fluoroquinolones  The fluoroquinolones are broad-spectrum antibiotics. They are usually manufactured synthetically and are associated with mild adverse reactions.  The examples are:  1. Nalidixic acid  2. ciprofloxacin  3. oxacillin  4. norfloxacin  5.Levfofloxacin  6.Sparfloxacin  Pharmacodynamics: Mechanism of action of the Fluoroquinolones – These agents enter the bacterial cell by diffusion through cell channel. Once inside they interfere with the action of DNA enzymes (DNA gyrase) necessary for the growth and reproduction of the bacteria. This will lead to cell death.  Therapeutic Use of the Fluoroquinolones – ]These agents are indicated for the treatment of infections caused by susceptible strains of gram-negative bacteria including E. coli., Proteus, pseudomonas, Strep and Staph spp.  Contraindications and Precautions – Known drug allergy to these agents contraindicate their use. Pregnancy and lactation are also contraindications. These agents are found to cause significant damage to the cartilages such that they are given cautiously to growing children and adolescents less than 18 years of age.  Adverse Effects of the Fluoroquinolones  CNS- dizziness, insomnia, headache, and depression related to possible effects on the CNS membrane.  GI system- nausea, vomiting, diarrhea and dry mouth related to the direct effect on the GIT  Hema- bone marrow depression related to the direct effect of the drug on the cells of the bone marrow that rapidly turn over.  Other effects- skin reactions, rash, fever and photosensitivity  Drug-Drug Interaction  Iron salts, Sucralfate, mineral supplements and antacids- all of these will decrease the effectiveness of the fluoroquinolones  Quinidine, Procainamide, terfenadine, henothiazines- can prolong the QT interval and when used with the fluoroquinolones 

Slide 27:  The Sulfonamides  These are called sulfa drugs that inhibit folic acid synthesis. Folic acid is necessary for the synthesis of purine and pyrimidine precursprs of DNA and RNA. Humans cannot produce folic acid and must obtin it form the diet. While bacteria need to manufacture their own folic acid inside their cell structure.  The following are the sulfonamides:  1.Sulfazalazine  2.Sulfamethoxazole  3. Sulfadiazine  4.Sulfixoxazole  Pharmacodynamics: The Mechanism of Action of Sulfonamides – The sulfa drugs competitively block the para-amino benzoic acid to prevent the synthesis of folic acid in susceptible bacteria that synthesize their own folates for the production of RNA and DNA.  Therapeutic indications – The spectrum of activity includes the following bacteria- Chlamydia, Nocardia, Haemophilus, E, coli and Proteus. Sulfa drugs are used to treat trachoma and brain abscess.  Contraindications and precautions – These agents are contraindicated to patients with known allergy to sulfa drugs, sulfonylureas and thiazide diuretics because they share similar structures. It is not recommended for use in pregnancy because it can cross the placenta and cause birth defects and kernicterus. Lactating women who take these drugs will excrete them in the breast milk potentially causing kernicterus, diarrhea and rash in the newborn.  Adverse Effects of the Sulfonamides  GI system- nausea, vomiting, diarrhea, abdominal pain, anorexia, stomatitis and hepatic injury, which are all related to the direct irritation of the GIT and death of normal flora.  Renal system- crystalluria, hematuria and proteinuria which can progress to a nephrotic syndrome.  CNS- headache, dizziness, vertigo, ataxia, convulsions and depression related to drug effects on the nerves  Hema- bone marrow depression related to drug effects on the cells of the bone marrow that turn over rapidly.  Dermatologic effects- photosensitivity and rash and hypersensitivity  Drug-Drug Interaction  Tobultamide, tolazamide, glyburide, glipizide, acetohexamide or chlorpropamide (all are oral Anti-diabetic agents) can increase the risk of hypoglycemia if taken with the sulfa drugs  The Nursing Process and the Sulfonamides  ASSESSMENT  Patient History- The nurse screens for known allergy to sulfonamides, sulfonylureas and thiazide diuretics because of cross sensitivity. Elicit history of renal disease and current pregnancy/lactation  Physical Examination- PE should be performed to establish baseline data for assessing the drug effectiveness. Culture and sensitivity should be performed before instituting therapy. The nurse should also monitor the renal status. CBC should be performed to establish a baseline data to monitor for adverse effects.  DIAGNOSIS  Pain related to GI, CNS and skin effects of the drug  Sensory-Perceptual alteration related to CNS effects  Alteration in nutrition related to multiple GI effects  Knowledge deficit regarding drug therapy

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