Antimicrobial

Front 1

Infection

Back 1

is an invasion and multiplication of pathogenic microorganisms in body tissues; these microorganisms cause disease by local cellular injury, secretion of toxin or an antigen-antibody reaction in a host (local or systemic)

Front 2

Inflammation

Back 2

a protective mechanism of the body tissues in response to invasion or toxins produced by colonizing microorganisms

Front 3

Bacteremia

Back 3

(usually self-limiting)- the presence of viable bacteria in the circulatory system

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Septicemia

Back 4

refers to a systemic infection caused by multiplication of microorganisms in the circulation

Front 5

Sepsis

Back 5

a syndrome in which multiple organs are involved as a result of the circulation of microorganisms or their toxins in the blood

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Antimicrobials

Back 6

they reduce the number of viable pathogens; they are an essential part of treatment of septicemia and sepsis

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Transmission of an infection requires 3 items

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1. Reservoir (or source) of the infectious agent
2. Susceptible host with a portal of entry
3. Mode of transmission

Front 8

Reservoir (or source) of the infectious agent

Back 8

people, animals, insects, soil, water, medical equipment. A person’s body can be a reservoir- the saliva, sputum, or feces can hold the agent. For example Enterococcus which normal resides in the GI tract is ok unless it comes in contact with the bloodstream; at that point it can cause a disease. Once the pathogen begins to multiply a toxin may or may or be produced

Front 9

Susceptible host with a portal of entry

Back 9

Factors that affect the development of an infection include
-Normal flora
Natural immunity
Age
Hormonal factors
Phagocytosis
Skin/mucus membranes
Nutrition
Environmental factors

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Mode of transmission

Back 10

Contact
-Direct-physical contact between the source and host
-Indirect-from a source to a host by passive transfer from a contaminated object
Droplet-indirect transmission with infected secretions
Airborne-small airborne particles containing pathogens leave the infected source and enter a susceptible host

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Portal of exit

Back 11

completes the chain of infection; most often a microbe will exit the same way it entered; respiratory tract

Front 12

How do we defend against infection?

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Specific defenses
*Antibody mediated (AMI)- antibodies that are formed by sensitized B-lymphocytes will neutralize and destroy invading antigens
*Cell mediated- (CMI)- is the command center for the immune system- regulate the AMI and inflammation process byt the release of cytokines
* Infection control methods
*Hand washing
*Proper hygiene
*Sanitation
*Disinfection/ sterilization
*Barriers

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Assessment of history for antimicrobials

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the patients age, tobacco use or alcohol use, current illness or disease, past and current drug use, poor nutritional status, vaccinations/ immunizations, whether they have been exposed to an infectious agent, if they have recently traveled, contact with animals, sexual history, identify type and location of S/S

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Physical assessment/ clinical manifestations for use of antimicrobials

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inspect areas of concern to the pt (where they are c/o of the s/s), common sites of interest are skin and wounds, VS assessment, inspect lymph nodes, GI issues, N/V, examine throat. Examine the pt for any psychosocial issues- anxiety, fatigue, LOC, activity level, determine the level of understanding of the pts issue, do they feel labeled (IV drug use= druggies)

Front 15

Culture (lab test)

Back 15

Culture is the best procedure for identifying an organism. This isolates the organism to a specific genus and species.

Front 16

Sensitivity (lab test)

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Sensitivity testing occurs after the organism is identified and helps to identify which drug will have maximum impact on the organism

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White Blood Cell Count- (WBC)

Back 17

in most infections the WBC count wil increase

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Neutrophils

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if there is an increase in immature neutrophils (band cells) it is considered a “shift to the left” (the body cannot keep up with the infection and is kicking out immature cells to fight the infection- therefore the body is LOSING the battle)
- Participate in only 1 phagocytic event

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Monocytes

Back 19

(immature macrophages) monocytes become macropahges once they enter a specific tissue and are given a specific “job” They play a large role in protection and are an impt part of the inflammatory response and stimulate the AMI and CMI
- Take part in many phagocytic events

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Eosinophils

Back 20

contain vasoactive chemicals; they act specifically against infestations of parasites

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Basophils

Back 21

cause inflammation; they contain enzymes that act on blood vessels

Front 22

Erythrocyte Sedimentation Rate (ESR)

Back 22

measures the rate at which blood cells fall through plasma. Elevated ESR (>20mm/hr) indicates inflammation or infection somewhere in the body

Front 23

what does ALT- alanine aminotransferase measure?

Back 23

specically measures the function of the liver. The liver will kick this out and elevate the lab reading when there is a dysfunction present

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What does AST- aspartate aminotransferase mean?

Back 24

this enzyme is found in high amounts within highly metabolic tissues. When an injury occurs or disease is affecting the body this enzyme will be kicked out into the bloodstream and levels will be elevated in testing. AST used with ALT can explain what might be occurring within the liver.

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What test do you look at?

Back 25

*Liver (AST, ALT)
*Kidneys (BUN, Cr)

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what are other studies that are used?

Back 26

X-ray
CT scan/ MRI
Echocardiogram
Gallium Scan
Biopsy

Front 27

What are Antimicrobials?

Back 27

are also called anti-infective agents are the cornerstone of drug therapy. The goal of therapy is to destroy or suppress the growth of infecting microorganisms so that normal host defenses and other supporting mechanisms can control the infection, resulting in its cure.

Front 28

an antimicrobial agent can be?

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–static- inhibit growth or
–cidial- kill the cells

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Prophylactic therapy

Back 29

is used when there is a high risk of dangerous microbial contamination during surgery

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Emperic therapy is?

Back 30

therapy started without knowing what the bacterium is. It is usually started after the specimen is got and goes off of other clinical signs and past treatments that are similar.

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Nursing considerations for antimicrobial use

Back 31

o Monitor the pts response to the drug therapy
*CBC, Vanco level, S/S,C/S
o Monitor the pts VS for return to baseline
o Review the patients current medications to check for D to D interactions
o Evaluate the pts and family’s knowledge of infection, transmission- based precautions, and drug therapy
o Monitor the staff’s compliance with hand hygiene and personal protective equipment
o Evaluate the pts and family coping mechanism
o Think about ways to make the pt more comfortable
o Decide whether more teaching needs to take place

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Nursing diagnosis for antimicrobial use

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o Hyperthermia r/t an increased metabolic rate
o Risk for social isolation r/t altered state of wellness
o Acute pain r/t physical injury
o Fatigue r/t disease state
o Risk for deficient fluid volume r/t hypermetabolic state

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Describe patient teaching associated with antimicrobial therapy.

Back 33

-When antibiotics are not appropriate
-Drug specific information
-Side effects (SE)/ Adverse events or reactions (AE)
-Importance of compliance
-DO NOT SHARE ANTIBIOTICS
-Transmission prevention
-Care of venous access devices

Front 34

Allergy or hypersensitivity

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-State of altered reactivity
-May occur with any agent
-Can be mild or severe
• Anaphylaxis- epinephrine
-Treatment

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Superinfections

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-AKA- secondary infections
• Usually will see tests done on fecal and the upper respiratory tract done
• Susceptible pts are kids, elderly and immuno-compromised
• D. Diff, somatitis, diarrhea and recurrent fever
-Occur when normal flora are reduced or completely eliminated

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Resistance

Back 36

Resistance means that the microorganism cannot be killed with levels of the antimicrobial that would be tolerated by the patient

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Antibiotics/ antibacterials mechanism of action

Back 37

-Disrupts cell wall synthesis
-Inhibits bacterial protein synthesis
-Interferes with bacterial DNA
-Inhibits bacterial metabolic enzymes
-Alters cell membrane permeability

Front 38

Classifications of Antibiotics

Back 38

*Beta-lactam antibiotics
• Penicillin
• Cephalsporins
• Monobactams
• Carbapenems
* Macrolids
* Aninoglycosides
* Tetracyclines
* Quinolones (fluroquinones)
* Sulfonamides
* Miscellaneous antimicrobials

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Beta-lactam antibacterials

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Named because of the beta-lactam ring that is part of their structural make-up
-Include- Penicillin, Cephalosporins, Carbapenems and Monobactams

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Penicillin

Back 40

• Inhibit synthesis of the bacterial wall (bactericidal)

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Penicillin
• Four classes

Back 41

o Natural penicllins (penicillin G, penicillin V)
o Penicillinase-Resistant pencillins (nafcillin)
o Aminopecillins or BROAD-SPECTRUM penicillins (ampicillin, amoxicillin)
o Extended- spectrum penicillins (carbenicillin, ticarcillin, piperacillin)

Front 42

Administration of penicillin

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DO NOT GIVE WITH FOOD

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Adverse effects of penicillin

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Most common hypersensitivy or allergic reactions- uticaria (hives), pruritis, GI upset, ↑ AST, ↑ ALT, ↑ K+ levels and seizures, headache, oral and vaginal candidiasis

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Drug interaction of penicillin

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o ↓ effectiveness of oral contraceptives
o In combination with aminoglycosides there is a synergistic effect at killing bacteria
o Probenicid (benemid) prolongs the effects of penicillins

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Nursing considerations for penicillin

Back 45

o DO NOT GIVE WITH FOOD (Mckenry 1022)
o Penicilins given IV- closely monitor serum electrolytes and cardiac status (hyperkalemia= cardiac dysrhythmias) & hypernatremia (edema) this is d/t the fact that most IV penicillin is in sodium or potassium salts (Mckenry 1022)
o Monitor lab values of AST, ALT, renal function, potassium
o Monitor allergies to the class of penicillin’s d/t cross-sensitivity of the class
o Pts who have a history of bleeding disorders require monitoring during the administration of certain penicillin’s
o Pts who have a history of GI diseases are at a greater risk for pseudomembranous colitis (Mckenry 1019)
o Certain penicillin medications have a high sodium content and should be monitored in pts who are on a restrictive diet
o Pts who are on the pill may have a reduction in its effectiveness

Front 46

Cephalosporins

Back 46

• Inhibits bacterial cell wall synthesis (bactericidal)

Front 47

Therapeutic use of cephalosporins

Back 47

o 1st generation- most Gram + cocci and some Gram – bacilli (rods).
*Respiratory, skin, GU, bone, and otits media
o 2nd generation- broader Gram - coverage
*Respiratory, skin, GU, bone, and otitis media
o 3rd generation- broader Gram – and anaerobic coverage
*Pre-op prophylaxis, pseudomembraneous colitis
o 4th generation- broader Gram + coverage and more resistant to beta-lactamases.
*Respiratory, skin, and intra-abdominal infections

Front 48

Drug interactions with cephalosporins

Back 48

o ANTICOAGULANTS, THROMOBOLYTICS (aspirin, Coumadin) both ↑ risk of BLEEDING
*NSAID’s- esp aspirin
o Alcohol use can cause headache, flushing, dizziness, N/V

Front 49

Adverse effects of cephalosporins

Back 49

o Most common- HYPERSENSITIVTY
o Other- bleeding, D/N/V, abdominal cramping, Pseudomembraneous colitis, seizures, Nephrotoxicity

Front 50

Pseudomembranous colitis

Back 50

is an inflammation of the colon that occurs in some people who have received antibiotics. Pseudomembranous colitis is sometimes called antibiotic-associated colitis or C. difficile colitis. The inflammation in Pseudomembraneous colitis is almost always associated with an overgrowth of the bacterium Clostridium difficile (C. difficile), although in rare cases, other organisms can be involved. It can cause you to experience painful, alarming symptoms and can even become life threatening. Treatment for most cases of pseudomembranous colitis is successful.

Front 51

Nursing considerations with cephalosporins

Back 51

o Monitor PT/INR in long term use because hypoprothrombinemia may occur with cephalosporins (Mckenry 1024)
o Monitor the use of ANTICOAGULANTS, THROMOBOLYTICS (aspirin, Coumadin) both ↑ risk of BLEEDING
o Monitor WBC and Culture results -this is because of the increased risk of superinfection or over growth of bacteria and fungal infections. (Mckenry 1024)
o There is the possibility of dosage adjustments in really impaired pts

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Monobactams

Back 52

• Aztreonam (Azactam)
• Disrupts bacterial cell wall synthesis (bactericidal)
• Excreted in urine
• Adverse effects
o Hypersensitivity, GI distress, thrombophlebitis

Front 53

Carbapenems

Back 53

• Inhibits cell wall synthesis (bactericidal)
• Drugs
o Imepenem/ cilastatin (Primaxin)
o Meropenem (Merrem)

Front 54

Carbapenems
• Uses

Back 54

o Bone, joint, skin, soft tissue and pelvic infections
o Endocarditis
o UTI
o Septicemia

Front 55

Carbapenems
• Adverse effects

Back 55

o GI distress, allergic reactions, seizures, pseudomembraneous colitis

Front 56

Macrolides

Back 56

*Inhibits bacterial protein synthesis (bacteriostatic or bactericidal)
*Erythromycin (E-mycin), clarithromycin (Biaxin), azithromycin (Zithromax, Z-pack)

Front 57

Macrolides
*Adverse effects

Back 57

- Hypersensitivity reactions, Hepatotoxicity, Ototoxicity, N/V/D, abdominal pain, phlebitis or burning at the site of infusion

Front 58

Macrolides
*Drug interations

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antacids, theophylline, corticosteroids, phenytoin, carbamazepine, digoxin, non-sedating antihistamines

Front 59

Macrolides
*Nursing considerations

Back 59

• Monitor VS (temperature esp), WBC, cultures, and focal examination o fhte infection
• With long term therapy monitor hepatic function (AST, ALT) since it has bilary excretion and ECG to look for a prolonged QT interval which can lead to sudden cardiac death

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Aminoglycosides

Back 60

*Inhibits bacterial protein synthesis (bactericidal)
*Gentamycin, Tobramycin, Amikacin

Front 61

Aminoglycosides
*Adverse effects

Back 61

• Hypersensitivity, Ototoxicity, Nephrotoxicity
• Monitor peak and trough levels and renal function

Front 62

Aminoglycosides
*Drug interactions

Back 62

• Penicillins and Cephalosporins may be used with aminoglycosides for their synergistic effect

Front 63

Aminoglycosides
*Nursing considerations

Back 63

• Older adults are at a greater risk for Nephrotoxicity and ototxoicity because of renal function
• Uringalysis should be monitored for albumin, casts, and cells, and for decreased specific gravity
• Monitor trough levels

Front 64

Peak levels

Back 64

Drawn 30-60 min after the IV dose is finished

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Trough levels

Back 65

Drawn 15 min or immediately prior to starting the dose

Front 66

Tetracyclines

Back 66

*Inhibits the bacterial protein synthesis (bacteriostatic or bactericidal)
*Tetracycline, doxycycline, minocycline

Front 67

Tetracyclines
*Adverse effects

Back 67

• Photosensitivity, GI upset, N/V/D, decreased effectiveness of BCP
• Binds to calcium in teeth and bones
• do not take if pregnant

Front 68

Tetracyclines
• Nursing considerations

Back 68

• If given for acne monitor the lesions
• Monitor cultures, VS (temperature esp), WBC
• Monitor for the presence of a secondary infection, esp Candida
• Provide meticulous oral and perineal hygiene care to prevent Candida superinfection

Front 69

What do Fluoroquinolones do?
and what are some examples?

Back 69

*Interferes with bacterial DNA (bactericidal)
*Broad-spectrum of activity (varies by individual drug)
*Ciprofloxacin (Cipro), levofloxacin (Levaquin), gatifloxacin (Tequin)

Front 70

Fluoroquinolones
*Adverse effects

Back 70

• Hypersensitivity, dizziness, drowsiness, N/V/D, GI distress, vaginitis, cardiac dsyrhythmias
• Rarely causes confusion and hallucinations

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Fluoroquinolones
drug interactions

Back 71

• Antaids, caffeine, phenytoin, theophyline, Coumadin

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Fluoroquinolones
Nursing consideration
s

Back 72

• Monitor VS (esp temperature, breath sounds, pulse ox), WBC, cultures, S/S of infection, AE’s, chest radiographs, and S/S of superinfection
• Pay close attention to medicines that will interact with these meds (Coumadin)-> this medication may result in an increase in the anticoagulatnt effect and the potiental for bleeding. MONITOR PT/INR closely
• Monitor for caffeine –related CNS stimulation -> the pt should avoid caffenine
• Monitor pts who are only phenytoin (Dilantin for seizures)-> these medications reduce their serum levels by 34-80% and the pt may experience seizures

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what do Sulfonamides do?
some examples?

Back 73

Inhibits bacterial growth
• Sulfadiazole, Sulfamethoxazole, Sulfosoxazole

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what are the effective in treating?

Back 74

Highly concentrated in the kidneys
• Effective in treating UTI’s and sometimes respiratory infections or otits media

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Sulfonamides
Drug interactions

Back 75

• Prolongs PT in pts on Coumadin
• Can potientate effects of oral hypoglycemics esp sulfonylureas

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Sulfonamides
Adverse effects

Back 76

• Hypersensitivity reactions- typically delayed skin reactions
• Stevens Johnson syndrome in immuno -suppressed pts
o Stevens-Johnson syndrome is a rare, serious disorder in which your skin and mucous membranes react severely to a medication or infection. Often, Stevens-Johnson syndrome begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters, eventually causing the top layer of your skin to die and shed. It is an emergency medical condition that usually requires hospitalization. Treatment focuses on eliminating the underlying cause, controlling symptoms and minimizing complications.

Front 77

while on sulfonamides how much fluid should the person drink?

Back 77

Clients should drink 3L of fluid/day if tolerated

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Sulfonamides
Nursing considerations

Back 78

• Monitor pts with long term use for renal toxicity- closely monitor I/O; examine the urine for crystals
• Monitor the pt for toxic effects such as rash, sore throat, or purura (purple colored spots that occur on the skin, organs, and mucus membranes)
• Monitor for Steven Johnson syndrome
• Monitor blood studies for anemia, granulocytopenia AKA agranulocytosis (failure of the bone marrow to produce WBC’s (neutrophils)), and thrombocytopenia (low platelets

Front 79

what does Clindamycin (cleocin) do?

Back 79

• Inhibits bacterial protein synthesis

Front 80

where is clindamycin metabolized?

Back 80

• Metabolized in the liver and excreted in bile and urine

Front 81

Clindamycin
• Adverse effects

Back 81

o Local thrombophlebitis, hypersensitivity, Diarrhea, Pseudomembranous colitis

Front 82

Clindamycin
• Nursing considerations

Back 82

o Monitor VS (temperature esp), WBC, cultures, cytotoxin assays of stool samples (C diff esp) and focal examination of infection

Front 83

what does Vancomycin do?

Back 83

• Inhibits bacterial cell wall synthesis and RNA synthesis (bactericidal)
o Drug of choice for MRSA
o May be used PO to treat C DIFF

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When using Vancomycin what levels should be monitored?

Back 84

• Peak and trough levels should be monitored

Front 85

Vancomycin
• Adverse effects

Back 85

o Hypersensitivity, Ototoxicity, Nephrotoxicity, thrombophlebitis, neutropenia, thrombocytopenia, profound hypotension
o Red man syndrome or Red-neck syndrome

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Vancomycin
• Nursing considerations

Back 86

o Monitor renal function and Vanco serum trough levels (between 5-15 mcg/ml)
o Review other medications RX’ed to avoid possible interactions
o Review urinalysis (presence of protein in the urine), WBC, RBC

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what does Metronidazole (Flagyl) do?

Back 87

• Interferes with bacterial DNA (bactericidal)

Front 88

Where is Metronidazole (Flagyl) metabolized?

Back 88

• Extensively metabolized by the liver with little excreted in the urine

Front 89

Metronidazole (Flagyl)
• Adverse effects

Back 89

o Hypersensitivity, N/D, anorexia, cramping, dry mouth, metallic taste, dizziness, vertigo, numbness/tingling in the extremities, dark urine, neutropenia, thrombophlebitis

Front 90

Metronidazole (Flagyl)
Drug interactions

Back 90

alcohol, Coumadin

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Metronidazole (Flagyl)
• Nursing considerations

Back 91

o Long-term use- monitor the pt for CNS issues such as peripheral neuropathy (numbness/tingling), mood changes and irritability it may indicate toxicity. Also, monitor CBC for blood dyscrasias (diseases or disorders of the blood) (Mckenry 1034)
o Stool samples may be taken

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Antifungals facts

Back 92

o Fungal infections range from mild and superficial to severe and life threatening
o Infecting organisms can be inhaled, ingested, or implanted under the skin after injury
o Commonly seen in immuno-suppressed pts
o Candida albicans is part of the body’s normal flora
o Antifungal agents may be administered PO, IV, or topical

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most common drug Amphotercin B

Back 93

• Fungicidal and fungistatic
• Broad antifungal spectrum

Front 94

Amphotercin B
• Adverse effects

Back 94

o Infusion reactions, fever, chills, hypotension, thrombophlebitis, hypokalemia, hypomagnesium impaired renal function (Nephrotoxicity

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Amphotercin B
• Nursing considerations

Back 95

o If test dose is given (1mg over 20 -30 min) monitor VS Q30min for at least 4 hours-> look for febrile reactions (fever, chills, headache, nausea, and vomiting)
o Monitor BUN and serum creatinine values- usually ordered every other day to determine the optimal level of the medication
o Monitor blood counts for bone marrow suppression (S/S are fever, sore throat, and unusual bleeding and bruising)
o Monitor IV site for extravasation, GI disturbances (anorexia, indigestion, nausea, vomiting, and diarrhea)
o Record daily weights; monitor I/O; and appearance of the urine (look for pink or red color)
o Observe for S/S of hypokalemia and hypomagnesium (muscle cramps, irregular pulse, weakness or lethargy)

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what does Fluconazole (Diflucan) do?

Back 96

• Classified as an Azole antifungal
• Impairs fungal cell membrane

Front 97

Fluconazole (Diflucan)
• Adverse effects

Back 97

o Mild nausea, vomiting, abdominal cramps, headaches, hypersensitivity, hepatoxicity

Front 98

Fluconazole (Diflucan
• Drug interactions

Back 98

o Cyclosporine, Coumadin, oral hypoglycemic agents, phenytoin

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Fluconazole (Diflucan)
• Nursing considerations

Back 99

o Monitor the infection for improvement- clinical symptoms and lab specific tests
o Assess the pt for GI disturbances- anorexia, indigestion, nausea, vomiting and diarrhea
o Record daily weights, I/O to determine fluid loss and renal status
o Monitor serum potassium- hypokalemia can lead to ventricular fibrillation
o Monitor liver function AST,ALT- S/S anorexia, dark urine, jaundice, RUQ pain

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What does Nystatin (Mycostatin) do?

Back 100

• Alters cell membrane permeability
• Used to treat oral, vaginal, and GI infections caused by Candida species

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Nystatin (Mycostatin)
Adverse effects

Back 101

N/V/D

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Antivirals facts:

Back 102

o Viruses are very small organisms that are wide spread and difficult to treat
*Replicate within the host cell
*Late onset of symptoms

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Antivirals
Side effects and adverse effects

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*Because viruses replicate in human cells, it is difficult to destroy viruses without destroying healthy human cells
*Adverse effects
• Vary greatly between specific drugs
• Less with topicals
• Most common –
o Bone marrow suppression
o Nephrotoxicity doses; should be decreased if renal impairment
o GI upset