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Antimicrobial Drugs

Thye Ngo, RN, MSN, FNP-C, CHFN


Antimicrobial
• Microbiology Overview
• Antibiotics
• Anti-tuberculosis
• Antiviral (Non-HIV)
• Antiretroviral (HIV Drugs)
• Antifungal
• Antimalarial, Antiprotozoal, Anti-Ectoparasites
Microbiology
Gram (+) vs Gram (-)
Gram (+) vs Gram (-)
Gram (+) Gram (-)
• Think Staph, Strep, • Almost everything else
Enterococcus and besides Gram (+)
Clostridium • Examples:
• Highly Resistant Gram (+): – E. coli
– “MRSA” – Haemophilus
– “VRE” – Klebsiella
• Common clostridium – Neisseria
(also anaerobes): – Salmonella
– C. difficile “C-diff” • Highly Resistant Gram (-)
– C. botulinum – Pseudomonas aeruginosa
– C. tetani – “ESBL”
– Acinetobacter
Highly Resistant Gram (+): “MRSA”
• Methicillin-resistant Staphylococcus aureus
• Factors of MRSA Infections:
– Antibiotic use (especially cephalosporins and FQ)
– HIV infection
– Hemodialysis (long term catheter for HD access)
– Long-term care facilities
• Two types:
– Hospital acquired (HA-MRSA)  severe
– Community acquired (CA-MRSA)  skin & soft
tissue infection
Highly Resistant Gram (+): “MRSA”
Treatment:
• HA-MRSA
– Vancomycin
– Daptomycin or Linezolid (if cannot tolerate vanco)
• CA-MRSA
– Clindamycin
– Trimethoprim-sulfamethoxazole (TMP-SMZ)
– Long acting tetracycline (minocycline, doxycycline)

*Mupirocin (Bactroban) – commonly used in the hospitals for MRSA in


nares
Highly Resistant Gram (+): “VRE”
• Vancomycin-Resistant Enterococci
• Colonization occurs in the GI tract and skin
Prevention:
• Hand hygiene!
• Contact precaution
Treatment:
• Daptomycin
• Linezolid
Highly Resistant Gram (-)
• Pseudomonas
• “ESBL” – extended spectrum beta lactamase
• Acinetobacter

• Risk Factors:
– Prolonged or recent hospitalization
– Recent antibiotic use
– Mechanical ventilation
– Long term care facility
– Indwelling lines, tubes, catheter
Highly Resistant Gram (-)
Additional Risk Factors:
• Pseudomonas:
– Immunodeficiency
– Cystic fibrosis
• ESBL:
– Emergency abdominal surgery
• Acinetobacter:
– Warm and humid climate
ESBL
Bacteria
Types of

Acinetobacter
Pseudomonas
3rd + 4th Cephalosporins

+
++
(Ceftazidime & Cefepime)

Extended-Spectrum

+
++
(Piperacillin + Tazobactam)

+
Carbapenems

++
++

-
-
+

Aztreonam
Treatment for

-
+

Aminoglycosides
++
Highly Resistant Gram (-)

Fluoroquinolone
-
-

(Ciprofloxacin and
++

Levofloxacin)
“Anaerobes”
• Bacteria reproduce without the presence of
oxygen
• Found predominantly on GI tract (c-diff
infection), oral and pulmonary cavity (aspiration
PNA)
• Examples:
– Clostridium (difficile, tetanus, and botulism)
– Bacteriodes
– Peptostreptococcus
– Actinomyces
“Anaerobes”
Antibiotics that cause pseudomembranous colitis “c-diff”:
• Clindamycin
• Fluroquinolones
• Beta-lactam drugs
• Other “broad spectrum” antibiotics (tetracycline,
sulfonamide, nitrofurantoin)

Treatment for “C-diff”:


• Metronidazole (IV or PO)
• Vancomycin (PO only)

Treatment for aspiration PNA:


• Clindamycin (broad spectrum)
“Aytpical”
• Unusual in cellular structure, morphology,
biochemistry or life-cycle
• Examples:
– Mycoplasma (lack a cell wall)
• Atypical PNA
– Chlamydia (lack a peptidoglycan in cell wall, obligated
intracellular parasite)
• Atypical PNA
• Sexual transmitted illness
– Rickettsia (obligated intracellular parasite)
• Rocky Mountain Spotted Fever
– Legionella
• Atypical PNA
“Atypical”
Fluoroquinolones
Macrolides Tetracyclines
Types of Bacteria (Levofloxacin,
(Azithromycin) (Doxycycline)
Moxifloxacin)
Mycoplasma ++ ++ ++
Chlamydia ++ ++ ++
Rickettsia - ++ -
Legionella ++ + ++
Common Abbreviations
• MSSA = Methicillin-Sensitive Staph Aureus
• MRSA = Methicillin-Resistant Staph Aureus
• VRE = Vancomycin-Resistant Enterococcus
• ESBL = Extended-Spectrum Beta Lactamase
Bacteriostatic vs Bacteriocidal
• Bacteriostatic – inhibits bacteria from
reproducing but doesn’t kill them
• Bactericidal – actively kills bacteria

• Bactericidal is preferred over bacteriostatic in:


– Endocarditis
– Meningitis
– Osteomyelitis
– Neutropenia
Excretion: Kidneys versus Liver
• Kidneys  think GFR
– usually water soluble  poorly cross cell membrane
and absorbed  preferred in IV form
– nephrotoxic (not for renal insufficiency/failure)
– check BUN/Cr
• Liver  think Cytochrome P450
– Usually fat soluble  easily cross cell membrane &
absorbed  brain, eyes, muscles, pancreas, skin 
preferred in Oral form
– hepatotoxic (not for hepatic dysfunction, ETOH)
– check LFTs
– careful use in pediatrics, geriatrics, pregnancy
Antibiotics
• Inhibit Cell Wall Synthesis  Clindamycin
 Beta-Lactam Family  Linezolid
 PCN
 Cephalosporins • Inhibit Folate Synthesis
 Carbapenems  Sulfonamides
 Aztreonam (monobactam)  Trimethoprim
 Vancomycin
 Fosfomycin
• Alter Bacterial DNA
 Daptomycin
 Fluoroquinolone
 Metronidazole
• Inhibit Protein Synthesis  Nitrofurantoin
 Inhibit 30S
 Aminoglycosides
 Tetracyclines
 Inhbit 50S
 Macrolides
Beta-Lactam Antibiotics &
Beta-Lactamase Inhibitors
Beta Lactams
 Penicillins (PCN)
 Cephalosporins
 Carbapenems
 Aztreonam
Beta Lactamase Inhibitors
 Sulbactam
 Tazobactam
 Clavulanic Acid
Beta Lactam Antibiotics

PBP = Penicillin Binding Protein


PCN
Mechanism of Action:
• Weaken cell wall  cause bacteria to take up
excessive water and rupture

Mainly excreted via kidneys


Types of Penicillins
• Narrow Spectrum (penicillinase sensitive)  Strep, Neisseria
– Penicillin G  IV or IM
– Penicillin V  PO
• Narrow Spectrum (penicillinase resistant)  target Staph aureus
– Nafcillin
– Oxacillin
• Broad-spectrum  H. influenza, E. coli, Enterococci, Neisseria gonorrhea
– Amipicillin
– Amoxicillin
• Extended-spectrum (anti-pseudomonas)  Pseudomonas,
Enterobacter, Klebsiella
– Piperacillin/tazobactam (Zosyn)
– Ticarcillin/clavulanate
PCN
Broad Spectrum Extended-Spectrum
Narrow Spectrum
Types of Bacteria (Ampicillin, (Piperacillin +
(PCN G, PCN V)
Amoxicillin) Tazobactam)

MSSA + ++ +
MRSA - - -

Strep ++ + +
Gram (-) - - ++

Anaerobes - ++ ++
Pseudomonas - - ++
Penicillinases (Beta-Lactamases)
• Enzymes that cause penicillin to be inactive
• Bacteria can produce a large variety of these
enzymes specific for penicillin (and other beta-
lactam antibiotics)
Beta-Lactamase Inhibitors
Mechanism of Action:
• Cleave the beta-lactam rings  Inhibit bacterial beta-
lactamases
Therapeutic Use:
• Combine with PCN to extend antimicrobial spectrum

• Sulbactam
• Tazobactam
• Clavulanic acid

Adverse Effects: usually come from PCN drugs


Combo Drugs
PCN + Beta-Lactamase Inhibitors

• Unasyn = Ampicillin + Sulbactam


• Zosyn = Piperacillin + Tazobactam
• Augmentin = Amoxicillin + Clavulanic acid
PCN
Adverse Effects:
• PCN allergy
– Anaphylaxis (laryngeal edema, bronchoconstriction,
severe HypoTN)  give Epinephrine!
– Delayed allergic reactions  usually rash
– Cross sensitivity with cephalosporins (1-4%)
• If history of mild reaction – consider cephalosporin
• If history of anaphylaxis – avoid administration of penicillin
or cephalosporins  choose macrolides, vancomycin or
clindamycin
• Hyperkalemia  if potassium PCN G rapidly
infused via IV
Exanthematous (morbilliform)
Drug Allergy
PCN
Drug Interactions (negative effects):
• Aminoglycosides
– Inactivate aminoglycosides  never mix PCN and
aminoglycosides in the same IV solution
Drug Interactions (negative/positive effects):
• Probenecid (uricosuric drug)
– Delay renal excretion of PCN  prolong
antibiotic effect or cause nephrotoxicity
Penicillin G (Bicillin) and probenecid (Benemid) are
prescribed for an adolescent who has syphilis. The
adolescent asks the nurse why two medicines are needed.
What should the nurse explain about the rationale for this
combination therapy?
a. "Penicillin treats the syphilis and the probenecid
relieves the inflammation in the urethra."
b. "Probenecid delays excretion of penicillin so the blood
level of penicillin stays stable longer."
c. "Probenecid lowers the risk of an allergic reaction to the
penicillin, which treats the syphilis."
d. "Penicillin attacks the organism during one stage of cell
multiplication and the probenecid attacks it at another
stage."
A client has an anaphylactic reaction after
receiving intravenous penicillin. What does the
nurse conclude is the cause of this reaction?

a. An acquired atopic sensitization occurred.


b. There was passive immunity to the penicillin
allergen.
c. Antibodies to penicillin developed after a
previous exposure.
d. Potent antibodies were produced when the
infusion was instituted.
Cephalosporins
Mechanism of Action:
• Bind to penicillin-binding proteins (PBPs) 
disrupt cell wall synthesis

Resistance:
• 1st generation  destroyed by beta-lactamases
• 2nd generation  less sensitive to destruction
• 3rd and 4th generations  highly resistant

Elimination: Kidneys
Cephalosporins
Antimicrobial Spectrum

1st Generation 4th Generation


• ↑ activity against gram (-) and anaerobes
• ↑ resistance to destruction by beta lactamases
• ↑ ability to reach CSF
• 3rd and 4th generations  against Pseudomonas
Cephalosporins
Types of
1st Gen 2nd Gen 3rd Gen 4th Gen
Bacteria

Gram (+) ++ ++ ++ ++
MRSA - - - -
Gram (-) + ++ ++ ++

Anaerobes +/- ++ + +
Ceftazidime
Pseudomonas - - only
++
Cephalosporins
First Generations Third Generations
• Cefadroxil • Cefixime
• Cefazolin • Ceftriaxone
• Cephalexin • Ceftazidime
Second Generations Fourth Generations
• Cefaclor • Cefepime
• Cefotetan
• Cefoxitin
Cephalosporins
Adverse Effects:
• Allergic Reactions
– Do not give cephalosporins to patients with a history
of severe reactions to PCN
• Bleeding
– Interference with vitamin K  ↓prothrombin
• Thrombophlebitis
– For IV infusion
• Hemolytic Anemia
Cephalosporins
Drug Interactions (negative effects):
• Probenecid  delays renal excretion
• ETOH  disulfiram effect (N/V, flushing,
tachycardia, SOB)
• Aminoglycosides  ↑nephrotoxicity
• Drugs promote bleeding  ↑bleeding
• Calcium + Ceftriaxone  form fatal
precipitates
A client develops an increased temperature
after surgery. Ceftriaxone (Rocephin) is
prescribed. For which potential effect should the
nurse monitor the client?

a. Dehydration
b. Heart failure
c. Constipation
d. Allergic response
A patient taking an oral cephalosporin
complains of nausea. What should the nurse
have the patient do to decrease the nausea?

a. Take the antibiotic with Pepto-Bismol.


b. Take the medication only at bedtime.
c. Take the medication between meals.
d. Take the medication with food.
The nurse recognizes that which generation of
cephalosporins is widely used for prophylaxis
against infection in surgical patients?
Narrower antimicrobial spectrum
a. First generation
b. Second generation
c. Third generation
d. Fourth generation
How likely is a person allergic to a penicillin to
have cross-sensitivity to second-and third-
generation cephalosporins?

a. 0.05% or less
b. 10% to 20%
c. 50% to 60%
d. 90% to 100%
Carbapenems
Mechanism of Action:
• Bind to PBPs  weakening of bacterial cell wall
Antimicrobial Spectrum:
• Very broad  Gram (+), Gram (-), Pseudomonas
(except for ertapenem)
• Very effective against Anaerobes
• Reserve for serious infections

Elimination: kidneys
Carbapenems
• Imipenem
• Meropenem
• Ertapenem
• Doripenem

Adverse Effects:
• GI effects (N/V/D)
• Superinfections
• Hypersensitivity
Carbapenems
Drugs Interactions (negative effect):
• Valproate  reduce blood levels of valproate
 cause seizure
Aztreonam
Mechanism of Action:
• Binds to PBP  inhibits cell wall synthesis 
promote cell lysis and death
Antimicrobial Spectrum:
• Only active against Gram (-) aerobic
• Highly resistant to beta-lactamases
Elimination: kidneys
Adverse Effects:
• Thrombophlebitis
Vancomycin
Mechanism of Action:
• Binds to precursors of cell wall  Inhibit cell wall
synthesis  bacteria lysis and death
• Does not interact with PBPs
Antimicrobial Spectrum:
• Against Gram (+) bacteria, esp staph and
anaerobes (c-diff)
Absorption: poorly in GI (IV is a preferred route; PO
is reserved for c-diff)
Elimination: kidneys
Vancomycin
Therapeutic Uses:
• MRSA (drug of choice)
• Severe CDI (clostridium difficile infection)  PO only
– Use metronidazole for mild to moderate CDI
• Severe staph and strep infections for patients allergic
to PCN and cephalosporins

Vancomycin target trough level:


• 10-15 mcg/mL (most patients)
• 15-20 mcg/mL  bacteremia, HAP, endocarditis,
osteomyelitis, meningitis, prosthetic joint infections
• Should be checked 30 mins before 4th to 5th dose
Vancomycin
Adverse Effects:
• Nephrotoxicity
– Need to check trough serum to adjust dosage
• Ototoxicity
• “Red Man Syndrome”
– Flushing, rash, pruritus, urticaria, tachycardia, hypoTN
– Due to rapid infusion of vanco
– Infuse vanco over 60 minutes
• Thrombophlebitis
• Thrombocytopenia
Vancomycin
Drug Interactions (negative effects):
• Nephrotoxic Drugs (aminoglycosides, NSAIDs,
cyclosporine)  ↑risk of nephrotoxicity
• Ototoxicity Drugs (aminoglycosides,
ethacrynic acid)  ↑risk of ototoxicity
After surgery a client develops a deep vein thrombosis and a
pulmonary embolus. Heparin via a continuous drip at 1200
units/hr is prescribed. Several hours later, vancomycin
(Vancocin) 500 mg intravenously every 12 hours is prescribed.
The client has one intravenous (IV) site: a peripheral line in
the left forearm. What action should the nurse take?
a. Stop the heparin, flush the line, and administer the
vancomycin.
b. Use a piggyback setup to administer the vancomycin into
the heparin.
c. Start another IV line for the vancomycin and continue the
heparin as prescribed.
d. Hold the vancomycin and tell the health care provider that
the drug is incompatible with heparin.
A health care provider prescribes peak and trough
levels of an antibiotic for a client who is receiving
vancomycin intravenous piggyback (IVPB). When
should the nurse have the laboratory obtain a blood
sample to determine a peak level of the antibiotic?
a. Between 30 and 60 minutes after a dose
b. Halfway between two doses of the drug
c. Immediately before the medication is
administered
d. Anytime it is convenient for the client and
laboratory
Twenty minutes after the start of an intravenous (IV)
vancomycin (Vancocin) infusion, the client appears
flushed and complains of palpitations. What action
should the nurse take?
a. Stop the infusion; the client is having an allergic
reaction
b. Contact the primary health care provider to obtain a
prescription to decrease the infusion rate
c. Contact the primary health care provider to obtain a
prescription for an antianxiety medication
d. Continue to monitor the client; this is an expected
reaction
Allergic Reaction vs
“Red Man Syndrome”
Allergic Reaction “Red Man Syndrome”
• Rash • Flushing
• Urticaria (hives) • tachycardia, palpitation
• Pruritus (itching) • hypotension
• Fever
• Swelling
• Wheezing, SOB
• Runny nose, watery
eyes
Fosfomycin
Mechanism of Action:
• Disrupt synthesis of peptidoglycan polymer
strands that compose the cell wall
Therapeutic Use:
• Single dose therapy in women with
uncomplicated UTI
Daptomycin
Mechanism of Action:
• Inserts itself into the bacterial cell membrane
 form channels that permit efflux of K 
depolarizes the cell membrane + inhibit
synthesis of DNA, RNA, and protein
Antimicrobial Spectrum:
• Only against Gram (+) bacteria including MRSA
and VRE
Daptomycin
Therapeutic Use:
• Bloodstream infection with staph aureus
• Complicated skin infections caused by gram
(+) bacteria

Adverse Effects:
• GI – C/N/D
• Myopathy
The patient is taking daptomycin for an MRSA
infection. What side effects should the nurse
monitor for in this patient?

a. Severe tachycardia
b. Increased blood pressure
c. Increased blood glucose levels
d. Muscle injury
Drug-Induced Myopathy
• ETOH
• Glucocorticoids Check
• Statins creatine
kinase (CK)
• Colchicine
• Cocaine
• First Generation Antipsychotics (FGAs)
– Neuroleptic malignant syndrome
• Antiretroviral (NRTI)
Inhibit Protein Synthesis
Aminoglycosides Tetracyclines
• Gentamicin • Doxycycline
• Streptomycin • Demeclocycline
• Neomycin • Minocycline
• Amikacin Macrolides
• Azithromycin
• Clarithromycin
• Erythromycin
Aminoglycosides
Mechanism of Action:
• Bind to 30S ribosomal subunit  disrupt
bacterial protein synthesis
Antimicrobial Spectrum:
• Only active against Gram (-) bacilli aerobic
(narrow spectrum)

Absorption: not absorbed from GI tract


Elimination: kidneys (except for Amikacin 
eliminated via liver)
Aminoglycosides
Therapeutic Use:
• Serious infections due to aerobic gram (-)
bacilli (Pseudomonas, E. coli, Klebsiella)
• Gentamicin  eyes (conjunctivitis)
• Neomycin  skin, eyes, ears infection;
suppress bowel flora before GI surgery;
remove ammonia in hepatic encephalopathy
Aminoglycosides
Peak & Trough Monitoring:
• Peak  30 - 60 minutes after the end of the
medication
• Target peak = 6 – 8 mcg/mL (8 – 10 mcg/mL for severe
infection)
• Trough  30 – 60 minutes before the next dose
(for once a day dosing) and right before the next
dose (divided dose)
• Target trough < 1 – 2 mcg/mL
• Ototoxicity and nephrotoxicity  measure trough
level (trough should be < 1 mcg/mL)
Aminoglycosides
Adverse Effects:
• Ototoxicity + Vertigo
– Trough levels are persistently elevated
– Damage to cochlear  ototoxicity  irreversible
– Damage to vestibular  vertigo
– Renal impairment worsen ototoxicity
• Nephrotoxicity
– High trough levels and total accumulative dose
• Neuromuscular Blockade
– Cause flaccid paralysis and potential resp depression
• Teratrogenic
Aminoglycosides
Drug Interactions (positive effects):
• PCN  enhance bacterial kill
– Cannot be used together in the same IV solution
 PCN inactivate aminoglycosides
• Cephalosporins  enhance bacterial kill
• Vancomycin  enhance bacterial kill
Aminoglycosides
Drug Interactions (negative effects):
• Ototoxic Drugs
– Ethacrynic acid (most negative effects),
furosemide, bumetanide
• Nephrotoxic Drugs
– Amphotericin B, cephalosporins, vancomycin,
cyclosporine, NSAIDs
• Skeletal Muscle Relaxants
– Pancuronium  intensify neuromuscular blockade
After receiving streptomycin sulfate for 2 weeks as part
of the medical regimen for tuberculosis, the client
states, "I feel like I am walking like a drunken seaman."
The nurse withholds the drug and promptly reports the
problem to the health care provider. Which part of the
body does the nurse determine is being affected as
indicated by the symptom reported by the client?
Ototoxic
a. Pyramidal tracts
b. Cerebellar tissue
c. Peripheral motor end-plates
d. Eighth cranial nerve's vestibular branch
A nurse is teaching a client about gentamycin
(Garamycin) that has been prescribed for a severe
infection. Which statement indicates to the nurse
that the client needs further teaching?
a. "I should report any problems with my
hearing."
b. "I may be required to get additional blood
tests."
c. "It is okay for me to stop taking this medication
after a few days."
d. "If I develop a fever, I will notify my primary
health care provider."
What therapeutic effect should the nurse
identify as the reason for administration of
neomycin sulfate to a client before colon
surgery?

a. Destroy intestinal bacteria


b. Increase production of vitamin K
c. Decrease the incidence of any secondary
infection
d. Prevent the possibility of postoperative
urinary tract infection
A client with hepatic cirrhosis develops hepatic
encephalopathy. Neomycin sulfate (Mycifradin)
is prescribed. The nurse concludes that the
purpose of neomycin is to:

a. Decrease intestinal edema


b. Reduce abdominal distention
c. Diminish the blood ammonia level
d. Limit development of systemic infections
Drugs to Reduce Ammonia Level
• Lactulose  trapping of ammonia and
eliminate via feces
• Antibiotics  decrease bacterial flora 
decrease ammonia level
– Rifaximin
– Neomycin
Tetracyclines
Mechanism of Action:
• Bind to 30S ribosomal unit  inhibit protein
synthesis
Antimicrobial Spectrum:
• Broad spectrum  Gram (+) and Gram (-) and
atypical

• Doxycycline
• Demeclocycline
• Minocycline
Tetracyclines
Therapeutic Use:
• Infectious Diseases:
– Rickettsial diseases (Rocky Mountain spotted fever,
typhus fever, Q fever)
– Infections caused by Chalmydia trachomatis
– Cholera
– Mycoplasma pneumonia
– Lyme disease
– Anthrax
– Gastric infection with H. pylori
Tetracyclines
Therapeutic Use:
• Acne
• Peptic Ulcer Disease
– H. pylori
• Periodontal Disease
– Doxycycline and minocycline
Tetracyclines
Absorption:
• Orally effective
• Decreased in absorption with:
– Calcium supplements
– Milk products (contain calcium)
– Iron supplements
– Magnesium-containing laxatives
– Most antacids (containing magnesium and/or
aluminum)
* Tetracyclines form chelates with metal ions
Tetracyclines
Elimination:
• Kidneys (tetracycline and demeclocycline –
both are short and intermediate acting)
• Liver (doxycycline and minocycline – both are
long acting)
Tetracyclines
Adverse Effects:
• GI Irritation & Suprainfection  C-diff and
Candida
• Yellowish Teeth  hypoplasia of the enemal
• Suppress long-bone growth in infants
• Photosensitivity
• Hepatotoxicity (for doxycycline and minocycline)
• Nephrotoxicity (for tetracycline and demeclocycline)
Mnemonic = Tummy, Teeth, Taller, Terrible Vision
Tetracyclines
Drug and Food Interactions:
• Milk products, calcium supplements, iron
supplements, magnesium laxatives, and most
antacids  ↓absorption of tetracyclines
• Administer at least 1 hour before or 2 hours
after ingestion of chelating agents
A client with an intractable infection is receiving
tetracycline. Which laboratory blood test result
should the nurse report?

a. Hematocrit: 45%
b. Calcium: 9.0 mg/dL
c. White blood cells (WBC): 10,000 mm3
d. Blood urea nitrogen (BUN): 30 mg/dL
A pregnant client with an infection tells the nurse
that she has taken tetracycline (Tetracyn) for
infections on other occasions and prefers to take it
now. The nurse tells the client that tetracycline is
avoided in the treatment of infections in pregnant
women because it:

a. Affects breastfeeding adversely


b. Influences the fetus's teeth buds
c. Causes fetal allergies to the medication
d. Increases the fetus's tolerance to the medication
A client who has been diagnosed with Lyme disease
is started on doxycycline (Vibramycin) as part of the
therapy. What should the nurse do when
administering this drug?
a. Administer the medication with meals or a
snack.
b. Provide orange or other citrus fruit juice with
the medication.
c. Give the medication an hour before milk
products are ingested.
d. Offer antacids 30 minutes after administration if
gastrointestinal side effects occur.
A practitioner orders doxycycline (Vibramycin) for a
sexually active woman with a history of a
mucopurulent discharge and bleeding associated
with cervical dysplasia, dysuria, and dyspareunia.
With which sexually transmitted infection are these
clinical findings and medication therapy commonly
associated?
a. Herpes simplex 2
b. Chlamydial infection
c. Treponema pallidum
d. Neisseria gonorrhoeae
Drugs for STIs
• Gonorrhea (Neisseria gonorrhoeae)
– Ceftriaxone IM or cefixime PO
• Syphilis (Treponema pallidum)
– PCN G or doxycycline
• Chlamydia (Chlamydia trachomatis)
– Doxycycline or azithromycin
• Genital herpes (Herpes simplex virus)
– Antiviral (acyclovir, valacyclovir, famciclovir)
• Genital warts (Human papillomavirus)
– Podofilox topical, imiquimod
– HPV vaccine
Macrolides
Mechanism of Action:
• Binds to 50S ribosomal subunit  Inhibit
protein synthesis
Antimicrobial Spectrum:
• Broad  active against Gram (+) and Gram (-)
and atypical

Elimination: liver via cytochrome P450


Macrolides
Azithromycin
Clarithromycin
Erythromycin

Drugs of choice for patients who have PCN


allergy.
Macrolides
Therapeutic Uses:
• Respiratory tract infection (non-complicated PNA)
• Otitis media
• Uncomplicated skin and skin infection
• Mycobacterium Avium Complex (Azithromycin
and Clarithromycin)
• Chlamydia trachomatis (Azithromycin)
• H. pylori (Clarithromycin)
• Bordetella pertussis (Erythromycin)
• Acute diphtheria (Erythromcyin)
Macrolides
Adverse Effects:
• GI (N/V/D) and superinfection
• QT prolongation and Sudden Cardiac Death
• Acute hepatitis
• C-diff infection
Drug Interactions (negative effects):
• Inhibit Hepatic P450 drug enzymes and increase
toxicity of:
– Theophylline
– Carbamazepine
– warfarin
A new mother asks the nurse administering
erythromycin ophthalmic ointment to her newborn
why her baby must be subjected to this procedure.
What is the best response by the nurse?
a. "It will keep your baby from going blind."
b. "This ointment will protect your baby from
bright lights."
c. "There is a law that newborns must be given this
medicine."
d. "This antibiotic helps keep babies from
contracting eye infections."
Shortly after birth the nurse instills erythromycin
ophthalmic ointment in the newborn's eyes. The
father asks why an antibiotic is needed because
the mother does not have an infection. The
nurse explains that it protects the newborn
from:

a. Chlamydia and gonorrhea


b. Syphilis and toxoplasmosis
c. Rubella and retrolental fibroplasia
d. Cytomegalovirus and varicella zoster
A nurse determines that the teaching about the
side effects of azithromycin (Zithromax) has
been understood when the adolescent client
tells the nurse that the most common side
effects of this medication is:

a. Tinnitus
b. Diarrhea
c. Dizziness
d. Headache
Clindamycin
Mechanism of Action:
• Binds to 50S ribosomal subunit  inhibit protein
synthesis
Antimicrobial Spectrum:
• Broad  against Gram (+) and Gram (-)
Therapeutic Uses:
• Alternative to PCN
• Group A strep infection
• Gas gangrene
Elimination: mostly liver
Clindamycin
Adverse Effects:
• Clostridium difficile-associated Diarrhea
(CDAD)
– Can be treated with vanco and metronidazole
• Hepatotoxicity
• Blood dyscrasias
Linezolid (Zyvox)
Mechanism of Action:
• Binds to 50S ribosomal subunit  inhibit
protein synthesis
Antimicrobial Spectrum:
• Only active against gram (+)

Elimination: both kidneys and liver


Linezolid (Zyvox)
Therapeutic Uses:
• Infections cause by VRE (Vanco-resistant
enterococci)
• Infections caused by MRSA

* Should only be reserved for these two types of


infections due to delay resistance
Linezolid (Zyvox)
Adverse Effects (MANY!):
• Diarrhea, nausea
• Headache
• Reversible myelosuppresion
– Anemia, leukopenia, thrombocytopenia
– Check CBC weekly
• Optic and Peripheral Neuropathy
Linezolid (Zyvox)
Drug or Food Interactions (negative effects):
• Indirect acting sympathomimetics  HTN crisis
– Ephedrine, pseudoephedrine, cocaine
• Foods containe tyramine  HTN crisis
– Aged or fermented food (cheese, wine, pickled meat,
fermented soy and vegetables)
– Sourdough and yeast extract
– Soy sauce or fish sauce

• Linezolid is a weak monoamine oxidase inhibitor (MAOI)


• MAO  important for neurotransmitter  excess MAO can cause psych issues
Linezolid (Zyvox)
Drug or Food Interactions (negative effects):
• Selective Serotonin Reuptake Inhibitor (SSRI)
– Paroxetine, duloxetine
– Increase the risk of serotonin syndrome
 tachycardia and HTN
 hyperthermia
 agitation, tremor, deep tendon hyperreflexia, muscle
rigidity
 flushed skin and diaphoresis
Inhibit Folate Synthesis
Mechanism of Action:
• Sulfonamides  Disrupt the synthesis of folic
acid (compound needed for cells to make DNA,
RNA, and proteins)
• Trimethoprim  Inhibits dihydrofolate reductase
to convert hydrofolic acid to its active form 
suppress synthesis of DNA, RNA, and proteins.

Elimination: kidneys
Inhibit Folate Synthesis
Antimicrobial Spectrum:
• Sulfonamides and Trimethoprim  Broad
spectrum  Gram (+), Gram (-), protozoa,
fungi (pneumocystis jiroveci in HIV patients)

Therapeutic Uses:
• UTI (uncomplicated)
• TMP/SMZ  Pneumocystis PNA
Inhibit Folate Synthesis
• Sulfonamides
– Sulfamethoxazole
– Sulfisoxazole
– Sulfadiazine
– sulfacetamide
• Trimethoprim
• Trimethoprim/Sulfamethoxazole (TMP/SMZ) -
combo
Inhibit Folate Synthesis
Adverse Effects (Sulfonamides):
• Hypersensitivity Reactions
– Photosensitivity, rash, fever
– Most severe  Stevens-Johnson syndrome (widespread
lesions of skin and mucous membrane)
• Nephrotoxicity
• Crystalluria
– Crystalline aggregates in urinary tract  renal damage
• Hemolytic Anemia
• Kernicterus
– Deposition of bilirubin in the brain  neurotoxic
– Cannot be given to infants < 2y/o or near term pregnancy
Inhibit Folate Synthesis
Adverse Effects (Trimethoprim):
• Pancytopenia – anemia, thrombocytopenia,
neutropenia
• HyperK  suppress renal secretion of K
• Fetal malformations
Inhibit Folate Synthesis
Drugs Interactions (Sulfonamides):
• Warfarin  intensify bleeding
• Phenytoin  increase phenytoin levels
• Sulfonylurea oral hypoglycemic  cause
hypoglycemia
• Drugs containing sulfa
– Thiazide and loop diuretics
– sulfonylurea oral hypoglycemics
A 7-year-old child contracts a urinary tract
infection. A sulfonamide preparation is
prescribed. What is the priority nursing
responsibility when the nurse is administering
this drug?

a. Weighing the child daily


b. Giving the medication with milk
c. Taking the child's temperature frequently
d. Administering the drug at the prescribed
times
Trimethoprim/sulfamethoxazole (Bactrim) is
prescribed for a child with a urinary tract infection.
Which statement by the parent about the drug
indicates that the nurse's instructions about
administration have been understood?
a. "Mealtime is a good time to give the
medication."
b. "I'll make sure to give each pill with 6 to 8 oz of
fluid."
c. "It must be taken with orange juice to ensure
acidity of urine."
d. "The drug has to be taken every 4 hours to
maintain a blood level."
A child who is known to be infected with HIV is
admitted to the hospital with the diagnosis of
Pneumocystis jiroveci pneumonia. The nurse
administers the prescribed
trimethoprim/sulfamethoxazole (Bactrim). Which
common side effects should the nurse anticipate?
Select all that apply.
a. Jaundice
b. Vomiting
c. Headache
d. Toxic nephrosis
e. Hypersensitivity reactions
A nurse administers trimethoprim-
sulfamethoxazole (Bactrim) to a client diagnosed
with a urinary tract infection. What should the
nurse monitor to determine the therapeutic
effectiveness of the drug?

a. Breath sounds
b. Hemoglobin level
c. Consistency of stool
d. White blood cell (WBC) count
Alter Bacterial DNA
Fluoroquinolones (FQ)
• Ciprofloxacin*
• Moxifloxacin
• Levofloxacin*
• Gemifloxacin
• Ofloxacin
• Norfloxacin

Metronidazole
Nitrofurantoin*

*UTI drugs (including TMP/SMZ and fosfomycin)


Fluoroquinolones
Mechanism of Action:
• Inhibits bacterial enzymes  disrupt DNA
replication and cell division
Antimicrobial Spectrum:
• Broad  Gram (+), Gram (-) and atypical
• C-diff is resistant

Elimination: Liver and Kidneys


Fluoroquinolones
Types of Bacteria Ciprofloxacin Levofloxacin Moxifloxacin

Gram (+) MSSA only ++ ++


MRSA - - -
Gram (-) ++ ++ ++
Anaerobes - +/- +

Pseudomonas ++ + -

Atypical + ++ ++
Fluoroquinolones
Therapeutic Uses:
• Respiratory Infections (sinusitis, bronchitis,
PNA) except for Cipro*
• UTI and prostatitis
• Complicated skin infections
• Anthrax

*cipro = usually a “below the diaphragm” drug


Fluoroquinolones
Adverse Effects:
• GI (N/V/D)
• CNS (dizziness, HA, restlessness, confusion,
seizure)
• Candida (pharynx and vagina)
• Tendon rupture  disrupt the matrix of cartillage
• Muscle weakness in myasthenia gravis
• Photosensitivity
• C-diff infection
Fluoroquinolones
Drug and Food Interactions:
• Cationic Compounds  reduce FQ absorption
– Aluminum or magnesium antacids
– Iron salts
– Zinc salts
– Sucralfate
– Calcium supplements
– Milk and dairy products (containing Ca)
• Give at least 6 hours before FQ or 2 hours
after FQ
Fluoroquinolones
Drug and Food Interactions:
• Theophyline  increase theophylline levels
• Warfarin  increase warfarin levels
• Tinidazole  increase tinidazole levels
A teenager has a prescription for levofloxacin
(Levaquin) to treat a sinus infection, and the
nurse explains when the medication should be
taken. The nurse concludes that the teaching
has been effective when the teenager says:
a. "I should take the medication at mealtime."
b. "I should take the medication just before a
meal."
c. "I should take the medication 1 hour before a
meal."
d. "I should take the medication 30 minutes
after a meal."
Levofloxacin (Levaquin) is prescribed for a
woman who has been experiencing urinary
frequency and burning for the past 24 hours.
The nurse concludes that the teaching about
this medication has been understood when the
client says that she should:
a. Limit her fluid intake.
b. Strain her urine for calculi.
c. Expect that her urine will turn orange in 1
hour.
d. Delay taking her mineral supplements within
2 hours of each dose.
Metronidazole (Flagyl)
Mechanism of Action:
• Interacts with DNA  inhibits nucleic acid
synthesis and cell death
Antimicrobial Spectrum & Clinical Uses:
• Against obligate anaerobes only
– C. difficile
– Gardnerella vaginalis (Bacterial Vaginosis)
– Bacteroides fragilis (prophylaxis for surgical
procedures)
– Fusobacterium (co-infection with H. pylori)
– Trichomoniasis (STD)  protozoa
Metronidazole (Flagyl)
Elimination: mostly liver, and kidneys

Therapeutic Uses: think “below the diaphragm”


• C-diff, BV, H. pylori, STD

Adverse Effects:
• GI – A/N/V/D/C and metallic taste “dysguesia”
• CNS – confusion, dizziness, peripheral neuropathy
• Allergic reactions – urticaria, flushing,
bronchospasm
Metronidazole (Flagyl)
Drug and Food Interactions:
• ETOH and ETOH-containing drugs (cough/cold
syrups)
– disulfiram-like reaction (tachycardia, palpitation, N/V)
• Lithium
– Renal retention of lithium  ↑lithium toxicity
• Phenytoin  increase phenytoin level
• Warfarin  increase warfarin level
• Carbamazepine  increase carbamazepine level
A client with gastric ulcer disease asks the nurse
why the health care provider has prescribed
metronidazole (Flagyl). The nurse explains,
"Antibiotics are prescribed to:

a. Augment the immune response."


b. Potentiate the effect of antacids."
c. Treat Helicobacter pylori infection."
d. Reduce hydrochloric acid secretion."
Nitrofurantoin
Mechanism of Action:
• Injures bacteria by damaging DNA

Antimicrobial Spectrum:
• Broad  Gram (+) and Gram (-)

Therapeutic Use:
• For lower urinary tract infection (uncomplicated)
• NOT for upper UTI (such as pyelonephritis)

Elimination: liver and kidneys


Nitrofurantoin
Adverse Effects:
• GI (A/N/V/D)
• Pulmonary (dyspnea, chills, fever, cough)
– Possible due to hypersensitivity
• Pancytopenia
• Peripheral neuropathy
• Hepatotoxicity
• CNS effects (HA, vertigo, drowsiness)
• Urine  dark yellow or brown
A client will be taking nitrofurantoin (Macrobid)
50 mg orally every evening at home to manage
recurrent urinary tract infections. What
instructions should the nurse give to the client?

a. Increase the intake of fluids.


b. Strain the urine for crystals and stones.
c. Stop the drug if urinary output increases.
d. Maintain the exact time schedule for taking
the drug.
Quick Review on Adverse Effects
• Allergic Reactions (ALL antibiotics!):
– IgE-mediated
• Anaphylaxis
• Angioedema
• Bronchospasm
• Urticaria
– Hemolytic anemia, thrombocytopenia
– Delayed hypersentivitiy
• Stevens Johnson syndrome
• Toxic epidermal necrolysis
Quick Review on Adverse Effects
• C-diff (pseudomembranous colitis)
– Clindamycin
– Beta-lactam drugs
– Quinolones
– Macrolides
– Sulfonamides
• QT prolongation
– Macrolide (such as Azithromycin)
– Fluoroquinolones
Quick Review on Adverse Effects
• Interactions with Warfarin  ↑ bleeding
– TMP-SMX
– Cephalosporins
– PCN
– Macrolides
– Quinolones
– “Azole” drugs (anti-fungal drugs)
Quick Review on Adverse Effects
• Ceftriaxone  “biliary sludge”  pancreatitis
• Vancomycin  “red man syndrome” and
“ototoxicity”
• Daptomycin  myopathy
• Linezolid  Lactic acidosis, peripheral
neuropathy, optic neuritis, serotonin
syndrome, reversible myelosuppresion
• Florouinolones  hypo/hyperglycemia,
tendonopthy
Quick Review on Adverse Effects
• TMP/SMX  HyperK
• Nitrofurantoin  Pulmonary fibrosis, hepatitis
• Carbapenems  lower seizure threshold
• Metronidazole  disulfiram effect with ETOH
• Doxycycline  Photosensitivity
• Aminoglycosides  exacerbate myasthenia
gravis, ototoxicity, nephrotoxicity
Anti-tuberculosis
• Rifampin
• Isoniazid
• Pyrazinamide
• Ethambutol
• Second-Line Anti-tuberculosis Drugs
 Streptomycin
 Fluoroquinolones
 Amikacin (aminoglycoside)
* Second-line drugs are less effective, more toxic, and more expensive
Drug Resistance in TB
• The principal cause underlying the emergence of
resistance is inadequate drug therapy.
– Treatment too short
– Dosage too low
– Non-adherence by the patients
– Regimen containing too few drugs
• Multidrug-resistant TB  resistant to both isoniazid
and rifampin
• Extensively drug resistant  resistant to isoniazid,
rifampin, FQ and at least one injectable second line TB
drugs (amikacin, kanamycin)
TB Drug Regimens
• Therapy is usually initiated with four-drug
therapy
• Isoniazid and rifampin is almost always included
• Two phases:
– Induction  eliminate actively dividing extracellular
tubercle bacilli
– Continuation  eliminate intracellular “persisters”
• Duration: minimum 6 months
– For multidrug resistant and HIV/AIDS  may last as
long as 24 months
Isoniazid
Mechanism of Action:
• Not fully understood. Possibly due to inhibition of
synthesis of mycolic acid for cell wall.

Therapeutic Use:
• Active and latent TB

*Strong inhibitor of P450  increase levels of other


drugs
Isoniazid
Adverse Effects:
• Hepatotoxicity
– Advancing age is the greatest risk factor
• Peripheral Neuropathy
– Isoniazid-induced deficiency in pyridoxine (vitamin
B6)
• CNS (optic neuritis, seizures, dizziness)
Isoniazid
Drug Interactions:
• Phenytoin, Carbamazepine  ↑drug levels
– Isoniazid  strong inhibitor P450  raise levels of
other drugs
• ETOH, Rifampin, Rifapentine, Rifabutin,
Pyrazinamide
– Increase risk of hepatotoxicity
Rifampin
Mechanism of Action:
• Suppress RNA synthesis and protein synthesis

Therapeutic Uses:
• TB
• Leprosy

Elimination: liver (mostly)

* Powerful inducer of P450  decrease levels of other


drugs
Rifampin
Adverse Effects:
• Hepatotoxicity
• Red-orange secretions
– Urine, sweat, saliva, tears
• GI (A/N/V)
Drug Interactions:
• Oral contraceptives, warfarin, protease inhibitors
and NNRTIs (for HIV)  ↓drug levels
• Isoniazid & Pyrazinamide  hepatotoxicity
Pyrazinamide
Mechanism of Action: unknown

Therapeutic Uses:
• Active TB  combine with rifampin, isoniazid,
and ethambutol
• Latent TB  combine with rifampin
Pyrazinamide
Adverse Effects:
• Hepatotoxicity
• Non-gouty polyarthralgias
• Hyperuricemia
– Inhibit excretion of uric acid
Ethambutol
Mechanism of Action:
• Poorly understood – possible suppression of
mycolic acid in the cell wall
Therapeutic Uses:
• TB
Adverse Effects:
• Optic Neuritis
– Red/green color vision, blurred vision
A client with tuberculosis is to begin Rifater
(combination of isoniazid [INH], rifampin [RIF], and
pyrazinamide [PZA]), and streptomycin sulfate
(streptomycin) therapy. The client says, "I've never had
to take so much medication for an infection before."
The nurse should explain:

a. "This type of organism is difficult to destroy."


b. "Streptomycin prevents side effects of Rifater."
c. "You'll only need to take the medications for a
couple of weeks."
d. "Aggressive therapy is needed because the infection
is well advanced."
The chemotherapy protocol prescribed for a
client with tuberculosis includes vitamin B6 and
isoniazid (INH). The nurse determines that
vitamin B6 is used to:
a. Improve the nutritional status of the client
b. Enhance the tuberculostatic effect of
isoniazid
c. Accelerate the destruction of dormant
tubercular bacilli
d. Counteract the peripheral neuritis that
isoniazid may cause
A client with a diagnosis of tuberculosis is
receiving isoniazid (INH) as part of a
chemotherapy protocol. The nurse assesses the
client for adverse responses to the medication.
The nurse determines that prompt intervention
is needed for which client response?
a. Orange feces
b. Yellow sclera
c. Temperature of 96.8° F
d. Weight gain of 5 pounds
A health care provider has prescribed isoniazid
(Laniazid) for a client. Which instruction should
the nurse give the client about this medication?
a. Prolonged use can cause dark concentrated
urine.
b. The medication is best absorbed when taken
on an empty stomach.
c. Take the medication with aluminum
hydroxide to minimize GI upset.
d. Drinking alcohol daily can cause drug-
induced hepatitis.
A client diagnosed with tuberculosis is taking
isoniazid (INH). To prevent a food and drug
interaction, the nurse should advise the client to
avoid:

a. Hot dogs
b. Red wine
c. Sour cream
d. Apple juice
A nurse is reviewing the history and physicals of
several clients from the clinic who are taking
rifampin (Rifadin) for the treatment of
tuberculosis. Which client presents a specific
concern for the nurse?

a. 45-year-old taking a loop diuretic


b. 26-year-old taking oral contraceptives
c. 32-year-old taking a proton pump inhibitor
d. 72-year-old taking intermediate-acting
insulin
A client who is taking rifampin (Rifadin) tells the
nurse, "My urine looks orange." What action
should the nurse take?

a. Explain this is expected.


b. Check the liver enzymes.
c. Strain the urine for stones.
d. Ask what foods were eaten.
A nurse is caring for a female client who is receiving
rifampin (Rifadin) for tuberculosis. Which statements
indicate that the client understands the teaching about
rifampin? Select all that apply.
a. "This drug may be hard on my liver so I must avoid
alcoholic drinks while taking it."
b. "This drug may reduce the effectiveness of the oral
contraceptive I am taking."
c. "I cannot take an antacid within two hours before
taking my medicine."
d. "My health care provider must be called immediately
if my eyes and skin become yellow."
e. "If I can't swallow the pill, I can't open the capsule
and mix the powder with applesauce."
The nurse provides teaching to a client
diagnosed with pulmonary tuberculosis that will
begin taking pyrazinamide (PZA). The nurse
concludes that the teaching is effective when
the client says, "I will:
a. Drink at least 2 quarts of fluid a day."
b. Report changes in vision to my health care
provider."
c. Take the medication two hours after each
meal."
d. Expect a discoloration of urine, sweat, and
tears."
Antiviral (Non-HIV)
• Drugs for HSV & VZV  Hepatitis B
 Acyclovir  Interferon Alfa
 Lamivudine
 Valacyclovir
 Famciclovir • Drugs for Influenza
 oseltamivir
• Drugs for CMV
 zanamivir
 Ganciclovir
 amantadine
• Drugs for Hepatitis
 Hepatitis C
 Interferon Alfa
 Ribavirin (oral)
Antiviral Drugs
• Viruses  use host-cell enzymes and
substrates to reproduce  difficult to
suppress viral reproduction without harming
host’s cells
Drugs for HSV & VZV
HSV = Herpes Simplex Virus
– Oropharynx and face  HSV-1
– Genitalia  HSV-2
VSV = Varicella-Zoster Virus
– Varicella (chickenpox)
– Zoster (shingles)  dermatome

• Acyclovir  most widely use for HSV and VZV


• Valacyclovir
• Famciclovir
Drugs for HSV & VZV
Mechanism of Action:
• Inhibits viral replication by suppressing synthesis
of viral DNA
• Thymidine kinase is responsible to convert
antimicrobial to its active form
Resistance:
• Due to decrease production of thymidine kinase
Elimination: kidneys
Drugs for HSV & VZV
Therapeutic Uses:
• Antivirals do not “cure” herpes infection.
• Antivirals only reduce symptoms and duration.
• Antivirals do NOT prevent transmission (including
sexual partners)
Adverse Effects:
• Phlebitis at infusion site
• Nephrotoxicity
• Neurologic toxicity (in renal patients)
– Agitation, tremors, delirium, hallucination
Drugs for CMV
CMV = Cytomegalovirus
• A member of herpesvirus
• Transmission via body fluids
• High risk of morbidity and mortality in
immunocompromised patients

Ganciclovir
Valganciclovir
Ganciclovir
Mechanism of Action:
• Converted to its active form inside infected cells
 suppresses replication of viral DNA

Therapeutic Uses:
• Treat and prevent CMV in immunocompromised
patients (HIV/AIDS pts, chemo-use)

Elimination: Kidneys
Ganciclovir
Adverse Effects:
• Nephrotoxicity
• Granulocytopenia and thrombocytopenia
• Teratogenic
Drugs for Hepatitis
• Hepatitis C
– Interferon Alfa
– Ribavirin (oral)
– Protease Inhibitors

• Hepatitis B
– Interferon Alfa
– Nucleoside Analogs
• Lamivudine
Drugs for Hepatitis C
Traditional Therapy:
• Pegylated* Interferon Alfa (peginterferon alfa) +
Ribavirin
New Standard of Care:
• Adding Protease Inhibitor (boceprevir or telaprevir) to
the traditional therapy

No vaccine for HCV

*pegylated = conjugate interferon alfa with polyethylene


glycol (PEG)  delay elimination  long acting
Drugs for Hepatitis C: Interferon Alfa
Mechanism of Action:
• Bind to receptors on host cell membranes 
block viral entry into cells, synthesis of viral
messenger RNA and viral proteins, and viral
assembly and release

Two types:
• Conventional – short ½ life  at least 3x/week
• Long Acting – long ½ life  once a week 
increase compliance
Drugs for Hepatitis C: Interferon Alfa
Adverse Effects:
• Flu-like symptoms
– Fever, fatigue, myalgia, HA, chills
• Neuropsychiatric Effects
– Depression, suicidal ideation
Drugs for Hepatitis C: Ribavirin
Mechanism of Action: unclear

Therapeutic Uses:
• HCV – cannot use alone, must combine with
interferon
• Respiratory syncytial virus in children
Adverse Effects:
• Hemolytic anemia
• Fetal injury (pregnancy category X)
Drugs for Hepatitis C:
Protease Inhibitors
Protease Inhibitors:
• Boceprevir
• Telaprevir

• Usually combine with peginteferon alfa + ribavirin


 triple therapy
• Highly effective as triple therapy but expensive,
difficult to use, extensive drug interactions
Drugs for Hepatitis C:
Protease Inhibitors
Mechanism of Action:
• Inhibits protease (enzyme require for HCV
replication)  arrest HCV replication

Adverse Effects:
• Pancytopenia
Drugs Interactions:
• Drugs that Induce and Inhibit P450  many
drugs interactions!
Drugs for Hepatitis B
Interferon Alfa
Nucleoside Analog
• Lamivudine

* Vaccine is available for HBV


Drugs for Hepatitis B: Lamivudine
Mechanism of Action:
• Inhibit viral DNA synthesis  suppress HBV
replication.

Therapeutic Uses:
• HBV
• HIV
Drugs for Hepatitis B: Lamivudine
Adverse Effects:
• Lactic acidosis
• Pancreatitis
• Severe hepatomegaly
Drugs for Influenza
Neuraminidase Inhibitors
• oseltamivir
• zanamivir

• Active against Influenza A and B

Therapeutic Uses:
• Treatment and Prevention of Influenza
Drugs for Influenza
Treatment of Influenza:
• Dosing must begin early (no later than 2 days after
symptom onset)
• If treatment is started within 12 hours  symptom
duration reduced by 3 days; 24 hours  less than 2
days; 36 hours  less than 30 hours

Prevention of Influenza:
• Nursing home patients
• Family members of someone with the flu
Drugs for Influenza
Mechanism of Action:
• Inhibit neuraminidase (viral enzyme required
for replication)

Adverse Effects:
• N/V
• Severe hypersensitivity
• Neuropsychiatric effects (younger patients)
– Delirium, abnormal behavior, death
Antiretroviral
• NRTI
• NNRTI
• Protease Inhibitors
• Integrase Inhibitor
• Fusion Inhibitor
Antiretroviral Therapy (ART)
Primary goals of ART:
• increase disease-free survival through suppression of HIV
replication
• improvement in immunologic function

When to initiate ART?


• CD4 count < 350 or history of an AIDS-defining illness
• CD4 between 350 – 500
– ART is recommended
– Potential risks and benefits should be discussed
• CD5 > 500
– If patient is motivated, ART is suggested
Nucleoside Reverse
Transcriptase Inhibitors (NRTI)
Mechanism of Action:
• Inhibit HIV replication by suppressing
synthesis of viral DNA

Therapeutic Use:
• Treat HIV infection
– Decrease viral load
– Increase CD4 T-cell counts
– Delay onset of disease symptoms
NRTI
Abacavir
Tenofovir
Zidovudine
Stavudine
Lamivudine
Zalcitabine
Emtricitabine
NRTI
Adverse Effects:
• Lactic Acidosis and Hepatic Steatosis (All NRTIs)
– A/N/V, fatigue, hyperventilation
– Check lactic acid level
• Peripheral Neuropathy (Didanosine and
Stavudine)
• Bone marrow suppression (Zidovudine)
– Severe anemia and neutropenia
• Pancreatitis (Didanosine)
Non-Nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
Mechanism of Action:
• Binds directly to HIV reverse transcriptase 
inhibit the enzyme

Adverse Effects:
• CNS symptoms
– Dizziness, insomnia, drowsiness, vivid dreams,
nightmares, hallucinations, delusions
• Rash
• Hepatotoxicity
• Teratogenic
NNRTIs
Efavirenz  recommended first line
Nevirapine
Delavirdine
Etravirine
Protease Inhibitors
Mechanism of Action:
• Bind to HIV protease  prevent the enzyme
from cleaving HIV polyproteins  HIV remain
non-functional, immature, and non-infectious
Protease Inhibitors
Adverse Effects:
• Hyperglycemia, new onset diabetes
• Lipodystrophy
• Hyperlipidemia
• Increase bleeding in Hemophilia
• Reduced Bone Mineral Density
• Liver damage
Protease Inhibitors
Lopinavir
Ritonavir
Indinavir
Saquinavir
Nelfinavir
Fosamprenavir
Integrase Inhibitor: Raltegravir
Mechanism of Action:
• Prevents insertion of HIV-derived DNA into
DNA of CD4 cells  blocks HIV replication

Adverse Effects:
• Myopathy and rhabdomyolysis
A client with acquired immunodeficiency
syndrome (AIDS) is receiving a treatment
protocol that includes a protease inhibitor.
When assessing the client's response to this
drug, which common side effect should the
nurse expect?

a. Diarrhea
b. Hypoglycemia
c. Paresthesias of the extremities
d. Seeing yellow halos around lights
Antifungal
• Drugs for Systemic Mycoses
 Amphotericin B
 Azoles
• Drugs for Superficial Mycoses
 Azoles
 Griseofulvin
 Nystatin
 Allylamines
 Terbinafine
Drugs for Systemic Mycoses
Common systemic opportunistic mycoses:
• Candidiasis
• Aspergillosis
• Cryptococcosis

Amphotericin B
Azoles
Antifungal: Amphotericin B
Mechanism of Action:
• Binds to components of the fungal cell
membrane (ergosterol)

Therapeutic Use:
• Most systemic mycoses

Elimination: unknown. Complete elimination might


take up to one year!
Antifungal: Amphotericin B
Adverse Effects:
• Infusion reactions
– Fever, chills, rigors, nausea, HA
– Phlebitis
• Nephrotoxicity
– Avoid other nephrotoxic drugs (aminoglycosides,
NSAIDs)
• HypoK d/t damage to kidneys
• Bone marrow suppression  anemia
Antifungal: “Azole” Drugs
Mechanism of Action:
• Inhibits the synthesis of ergosterol

Therapeutic Use:
• Target broad spectrum of fungal pathogens

Elimination: mostly liver


Antifungal: “Azole” Drugs
Adverse Effects:
• Cardiac suppression
– Negative inotropic
– Should not be used in HF and ventricular
dysfunction
• Hepatotoxicity
Antifungal: “Azole” Drugs
Drug Interactions:
• “Azole” drugs are P450 inhibitors  increase
levels of many other drugs
– Warfarin
– Sulfonylureas
– Dilantin
– Statin
– CCB
– Quinidine
“Azole” vs –azole drugs
Do not get confused with other “-azole” drugs
• Proton Pump Inhibitors (PPIs) – anti-ulcers
– Pantoprazole, lansoprazole, esomeprazole
• Antibiotics:
– Metronidazole
– Sulfamethoxazole
• Antipsychotic:
– Aripiprazole
“Azole” drugs vs “-azole” drugs
Do not get confused with other “-azole” drugs
• Anti-parasitic
– Mebendazole, metronidazole
• Drugs for hyperthyroidism
– methimazole
Drugs for Superficial Mycoses
• “Azole” drugs
• Griseofulvin
• Nystatin
• Terbinafine (an allylamine drug)
Antifungal: Griseofulvin
Mechanism of Action:
• Inhibit fungal mitosis

Therapeutic Uses
• Dermatophyte infections (ringworms)
• Not active against Candida

Adverse Effects: hepatotoxicity, phototoxicity


Antifungal: Nystatin & Terbinafine
Nystatin
• Drug of choice for intestinal candidiasis and
candida infections of the skin, mouth,
esophagus, and vagina

Terbinafine (Lamisil):
• Highly against dermatophytes (ringworm and
onychomycosis), less active against candida
A client is receiving antibiotics and antifungal
medications for the treatment of a recurring
vaginal infection. What should the nurse
encourage the client to do to compensate for
the effect of these medications?

a. Eat yogurt daily.


b. Avoid spicy foods.
c. Drink more fruit juices.
d. Take a multivitamin every day.
Anti-malaria
• Chloroquine
• Primaquine
• Quinine
• Quinidine Gluconate
Anti-Malaria
• Chloroquine  treatment and prophylaxis of
malaria
• Intravenous quinidine (combine with
doxycycline, tetracycline or doxycycline) 
treatment for severe malaria

Common Adverse Effects:


• Hemolytic anemia
After several days of intravenous (IV) therapy for
chloroquine-resistant malaria, the health care
provider replaces the IV medication with oral
quinine, 2 g per day in divided doses. The nurse
advises the client to take this medication after
meals to:

a. Delay its absorption.


b. Minimize gastric irritation.
c. Decrease stimulation of appetite.
d. Reduce its antidysrhythmic action.
Anti-Protozoa
Disease Causative Protozoan Drugs of Choice
Amebiasis
Entamoeba histolytica Tinidazole, Metronidazole

Giardiasis
Giardia lamblia Metronidazole, tinidazole

Toxoplasmosis
Pyrimethamine plus
Toxoplasma gondii
clindamycin

Trichomoniasis
Trichomonas vaginalis Metronidazole, tinidazole
Anti-Ectoparasites
• Pediculosis (head, body, or pubic lice)
– Premethrin 1%
• Adverse Effects: burning, stinging, erythema
• Apply for 10 minutes then wash
• Scabies (mites)
– Premethrin 5%
• Apply for 8 to 14 hours before washing
Clinical Practice: CBC
Clinical Practice: Urinalysis
Clinical Practice: Wound Culture
Clinical Practice: Blood Culture
Clinical Practice: BMP, CMP, LFT,
PT/PTT

BMP PT/
LFT
PTT

CMP = BMP + LFT + Protein/Albumin