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266 Cards in this Set

  • Front
  • Back
1st line treating high cholesterol
therapeutic lifestyle changes
2nd line treating high cholesterol
Statins: HMG-CoA reductase inhibitors
Niotinic Acid: Niacin
Bile-acid sequestrants: Colesevalam, Ezetimibe
Fibrates: GEmfibrozol
Drugs for Angina
3 families
1. organic nitrates
2. Beta Blockers
3. Ca Channel Blockers
Examples of Orangic Nitrates
Nitroglycerin, isosorbide mononitrate, isosorbide dinitrate, amyl nitrite, ranolazine
Examples of Beta Blockers
Propranolol (1st gen. B1&2), Metoprolol (2nd gen. B1)
Examples of Ca Channel Blockers
Nifedipine (arterioles only), Verapamil and Diltiazem (arterioles and heart)
Drugs for coronary heart disease
3 groups
1. anticoagulants
2. Anti-platelets
3. Thrombolytic
Examples o fAnticoagulants
Heparin (unfractionated & low-molecular weight), Warfarin
• thrombin direct inhibitors: Dabigatran Etexilate, Hiruden Analog: Bivalirudin (Angiomax) ~ prototype,
Fondaparinux, Rivaroxaban, Antithrombin (AT)
Examples of Anti-Platelets
Aspirin, Ticlopidine (Ticlid), Clopidogrel (Plavix), Other anti-platelet drugs Glycoprotein (GP) IIb/IIIa
receptor antagonists
Examples of Thrombolytic Drugs
Streptokinase (Streptase); Alteplase (tPa) ~ prototype (plasminogen to plasmin)
Drugs for Diabetes
Insulin
Oral Hypoglycemics
Types of Insulin
7 types available (differences are on how fast they act)
• Short duration: rapid acting (eat right away)
1. Insulin lispro (Humalog)
2. Insulin aspart (NovoLog)
3. Insulin glulisine (Apidra)
• Short duration: slower acting (you need a little more
time before eating after you take it)
4. Regular insulin (Humulin R, Novolin R)
• Intermediate duration
5. Neutral protamine Hagedorn (NPH) insulin
6. Insulin detemir (Levemir)
• Long duration (going to last a long time in the body for long term control)
7. Insulin glargine
Examples of Oral Hypoglycemics
• Biguanides ~ Metformin (Glucophage) (Prototype)
• Alpha-glucosidase inhibitors – Acarbose (Precose) - prototype drug
• Miglitol (Glyset) - delays absorption of carbohydrates
• Gliptins – enhance the action of incretin hormones (only usually released in the presence of food) Sitagliptin
(Januvia)
other injectable drugs
** Exenatide (Byetta) incretin mimetic (PROTOTYPE DRUG)
• Liraglutide (Victoza) – incretin mimetic
• Pramlintide (Symlin) supplement to mealtime insulin
4 groups of Analgesics
1. Opioid
2. Opioid Pure Antagonists
3. Opioid Agonist-Antagonist
4. Non-opioid Centrally acting analgesics
Examples of Opioids
Narcotic Analgesics

Morphine, Fentanyl (prototypes)

• Opioid Agonists: Codeine, Meperidine, + Morphine-like drugs
Examples of Opioid Pure Antagonists
Naloxone, naltrexone, + others
Examples of Opioid Agonist-Antagonist
pentazocine, nalbuphine, butorphanol, (Mu atagonist, Kappa Agonist) buprenorphine
(Mu partial agonist, Kappa antagonist)
Examples of Non-opioid Centrally Acting Analgesics
• Dexmedetomidine (Precedex)
• Tramadol (Ultram) opioid and non-opioid mechanisms
• Clonidine (Duraclon) Alpha2-adrenergic agonist
• Ziconotide (Prialt), Selective antagonist at N-type voltage-sensitive calcium channels on neuronsBlocks calcium
channels on primary nociceptive afferent neurons in dorsal horn of the spinal cord,
• Cyclooxygenase Inhibitors (COX)
• Aspirin Nonselective inhibitor of cyclooxygenase
• Non-aspirin first generation NSAIDs,
• Aspirin-like drugs with fewer GI, renal, and hemorrhagic effects than aspirin
• 20+ nonaspirin NSAIDs available,
• Ibuprophen and naproxen from this group
• Second-generation NSAID's
• Celecoxib (Celebrex) ~ last choice agent Second-generation COX-2 inhibitor—fewer adverse effects than
first-generation drugs,
• Acetaminophen (Tylenol) Therapeutic uses ~ Analgesic, antipyretic, Does not have any anti-inflammatory or
antirheumatic actions, Not associated with Reye’s syndrome
Anti-Microbial Drugs
-Penicillins
-Cephalosporins
-Carbapenems
-Bacterial Inhibitors of protein synthesis
-Vancoymycin
-UTI drugs
-Fluoroquinolones
-Cyclic Lipopeptides
-Additional Drugs
-Monobactams
Examples of Penicillins
• Penicillin G (Benzylpenicilin)
• Nafcillin, Oxacillin, Dicloxacillin - Penicilinase-resistant penicilins
• Ampicilin, Amoxicilin - Broad spectrum antibiotics
• Piperacilin - Broad spectrum, penicilinase sensitive
Examples of Cephalosporins
-most widely used group of antibiotics
• 1st gen: cefazolin (IV) and cephalexin (PO) ~ skin surgical prophylaxis
• 2nd gen: Cefaclor
• 3rd gen: cefoperazone
• 4th gen: Cafepime
Examples of Carbapenems
-give first (broad spectrum) before we know culture and sensitivity results
• Imipenem, meropenem, ertapenem, doripenem
Examples of Vancoymycin
-treat C. difficile
• PO form not absorbed, IV for system administration
• otoxicity risk, red man syndrome, thrombophlebitis (common), thrombocytopenia (rare)
Examples of Monobactams
• Aztreonam ~ binds to penicillin binding protein 3, parenteral only, (narrow spectrum antibiotic)
• Teicoplanin ~ MRSA and C. difficile, similar to vancomycin
• Fosfomycin ~ single dose for UTI
Examples of Bacterial Inhibitors of protein synthesis
• Teracylcine ~ common acne drug, broad spectrum, don’t take with dairy, risk for killing off GI flora and
damaging liver (don’t give too much)
• Macrolides
• Erythromycin ~ broad spectrum, bacteriostatic (prevents multiplication without destruction)/bactericidal, used
if pt. is allergic to penicillin
• clindamycin ~ topically used for acne
• Oxazolidines
• Linezolid ~ 1st member of this new class, active against multi drug resistant gram (+) bacteria
• Ketolide
• Telithromycin ~ 1st member of this new class, treats Streptococcus Pneumonia
• Streptogramins
• Dalopristin/Quinupristin ~ 1st members,
• Chloramphenicol ~ broad spectrum, only used for life-threatening illness when safer drugs don’t work or are
contraindicated, can cause fatal aplastic anemia, gray baby syndrome, reversible bone marrow depression
• Aminoglycosides
• Gentamicin
• narrow spectrum antibiotic, bactericidal, treat gram (-) bacteria
• dose 1 x day
• only used to treat serious infections
• same dose very different effects in pt.’s high trough levels causing toxicity problems (as opposed
to high peaks)
• Sulfonamides and Trimethoprim
• Trimethoprim ~ suppress bacteria growth by inhibiting terahydrofolic acid, was 1st drug for treating systemic
treatment of bacterial infection, more effective drugs now
• can cause stevens-johnson syndrome morality rate 25%, not common anymore
• Trimethoprim-sulfamethoxazole ~ combo called bactrim (IV or PO)
• treat pneumocystis pneumonia (in AIDS give daily as preventative), UTI, otitis media
Examples of UTI drugs
• Nitrofurantoin ~ bacteriostatic (low dose), bactericidal (high dose)
• methenamine ~ decomposes into ammonia and formaldehyde
Examples of Fluoroquinolones
• Ciprofloxacin (Cipro) ~ disrupts cell division, drug of choice for anthrax, respiratory infections, UTI, GI, bones
(too high levels can kill normal flora result in fungal overgrowth or C diff), also don’t take with dairy
• Metronidazole (Flagyl) ~ Bactericidal, protozoal infection, H. pylorie,
Examples of Cyclic Lipopeptides
• Daptyomycin ~ kills virtually all gram (-) bacteria, including MRSA, very specific use for this drug so hard to spot
if it causes widespread problems, 1 x daily IV, no laboratory work required
• no significant reactions detected to date
Examples of Additional anti-microbial drugs
• rifampin
• rifaximin
• bacitracin ~ cream (TAB)
• polymyxin B ~ cream (TAB), not used for systemic infection (toxic risk)
4 classes of Anti-fungal drugs
Polyene antibiotics
Azoles
echniocandins
pyrimidine analogs
Amphotericin B
Anti-Fungal

IV only drug (1st anti-fungal, before this there was nothing we could do), very toxic, infusion and
renal rx. always occurs, causes shake and bake syndrome, used for systemic mycoses, always flush kidneys
before and after with 1 L of saline (dose of > 4 g increases risk of residual kidney impairment)
Azoles
• Itraconazole ~ inhibits synthesis of ergosterol, inhibits fungal cytochrome P450, lower toxicity level, systemic
mycoses drug (alternative to amphotericin B), side effects well tolerated in usual doses (cardio suppression,
decrease in venticular ejection fraction, liver damage)
• fluconazole ~ fungistatic, same mechanism as itraconazole,
• voriconazole
• ketoconazole
Echinocandins
disrupt the fungal cell wall, oral dose for aspergillus and candida
Pyrimidine Analog
serious infection with susceptible strains of candida and cryptococcus neoformans, resistance
common, often used with ampho B, extreme caution in pt.’s with renal impairment or hematologic disorders
Drugs needed fot Superficial Mycoses
• Azoles ~ Clotrimaole (drug of choice for dermatophytic infections and candidiasis of skin, mouth, vagina),
Ketoconaole, Miconazole (drug of choice for dermatophytic infections and cutaneous/vulvovaginal
candidiasis)
• Griseofulvin ~ inhibits fungal mitosis
• Nystatin ~ polyene antibiotic, used only for candidiasis (drug of choice for intestinal candidiasis)
• OTC powders ~ tolfnaftate (tinactin), undecylenic acid, ciclopirox
Antiviral Agents (non-HIV viral infections)
Acyclovir
Valacyclovir
Famciclovir
Topical: Herpes Labialis (penciclovir, Docosanol) Ocular Herpes (Trifluridine, Vidarabine)
Ganciclovir
Cidofovir
Foscarnet
Acyclovir
-active only against herpes virus family (herpes is getting resistant), 1st choice for HSV or VZV infection
• IV ~ phlebitis, reversible nephrotoxicity
• PO ~ GI, Vertigo, Topical therapy with stinging sensations
Valacyclovir
-prodrug from of acyclovir (same effects)
• thrombotic purpura/hemolytic uremic syndrome in some immunocompromised pt.’s
• minimal adverse effects
Famciclovir
-prodrug used to treat acute HZV or genital herpes infection, similar effect to acyclovir, minimum
adverse effects
Ganciclovir
-synthetic antiviral agent, HSV, CMV
• can cause granulocytopenia, thromocytopenia, reproductive toxicity, nausea, fever, rash, anemia, liver
dysfunction, confusion, other CNS symptoms
Cidofovir
-IV for CMV pt.’s with AIDS and failed use of ganciclovir or fascarnet
• can cause nephrotoxicity, neutropenia, ocular disorders
Foscarnet
-IV active against all known HSV, more difficult to give, less well tolerated, very expensive
• CMV retinitis in AIDS
• Acyclovir-resistant mucocutaneous HSV and VZV in immunocompromised host
Statins
• - anything ending in statin
• most effective drugs for
lowering LDL (by up to 50%)
elevation of HDL (not greatly raised)
reduction of triglyceride levels
non-lipid beneficial
cardiovascular actions
Nicotinic Acid
• niacin
• can be used but doesn't
decrease LDL and TG levels
anywhere close to as well as statins
-does increase HDL levels better than any other drugs (maybe 5%) but no drug does this very well
Bile-Acid Sequestrants
• used to be first-line drugs
now primarily used as an
adjunct to statins
• colesevelam
• Ezetimibe (zetia)
Fibric Acid Derivatives
(Fibrates)
-Gemfibrozol is our prototype drug (for fibrates)
• Fenofibrate (tricor. Lofibra)
Fenofibric acid (TriLipix)
Isosorbide mononitrate and isosorbide
dinitrate
ORGANIC NITRATE

• Actions identical to those of
nitroglycerin
• Used for angina, taken orally, produce
headache, hypotension, and reflex
tachycardia
Amyl nitrite
ORGANIC NITRATE

• Ultrashort-acting agent used to treat
acute episodes of angina pectoris
• Used via inhalation – effects within 30
seconds lasts 3-5 minutes – often
abused
Ranolazine
• new drug with limited applications
• 1st new drug in a while (25 years
ago)
• in clinical trials reduced the number
of anginal episodes and increased
exercise tolerance
• better effect in men than woman
• can prolong QT interval (so multiple
drug interactions)
• exact mechanism unknown
• not used as first-line therapy
• combined with first-line therapy
• can be useful if bradycardia is a risk
for pt. because it doesn't cause
bradycardia
Propranolol
BETA BLOCKER

• 1st generation beta blocker so it
affects Beta1&2
• adverse: bronchoconstiriction,
inhibition of glycongenolysis, and has
CNS affects
• precautions
• severe allergies, diabetes, use in
pregnancy, cardiac, respiratory, and
psychiatric disorders
• very lipid soluble (can effect CNS and
fetus)
Metoprolol
BETA BLOCKER

• 2nd generation beta blocker so only
targets Beta1
• decreases HR
• primarily used for HTN (also used in
heart failure, angina, and MI)
• pro: it doesn’t affect Beta2 or
glycongenolysis
Nifedipine
CA CHANNEL BLOCKERS

-dilates arterioles
• significant blockade of Ca channels
in blood vessels
• minimal blockade of Ca channels in
the heart
• vasodilation
• blocks vascular smooth muscle
• less likely to exacerbate preexisting
cardiac disorders
• net effect
• lowered BP, increase HR, increased
contractile force
Verapamil and Diltiazem
CA CHANNEL BLOCKERS

-arterioles and
heart
• 5 direct hemodynamic effects
(blockade of:)
• peripheral arterioles - reduces arterial pressure
• arteries and arterioles of heart - increase coronary perfusion
• SA node - decrease HR
• AV node (most important) - decrease in AV nodal conduction
• myocardium - decrease force of contraction
Heparin (un-fractionated)
ANTICOAGULANT

• Enhances antithrombin which blocks clotting factors Xa and
thrombin
• only given IV or deep Sub Q (very painful)
• Activated partial thromboplastin time (aPTT) – check at
baseline before therapy and titrate until 1.5 to 2.0 times the
baseline aPTT
• we titrate aPTT until it's 1.5-2 x patients baseline
• get pt. to therapeutic level within 24 hrs.
• contraindicated for eye, spine, or brain surgery
• Antidote for OD: protamine sulfate
Heparin (low molecular weight)
ANTICOAGULANT

• very small molecules
• 3 common in US
• Enoxaparin (comes in pre-filledsyringe)
• Dalteparin (comes in vial - more pt. teaching)
• Tinzaparin
• smaller doses
Warfarin
ANTICOAGULANT

• monitor the PT - prothrombin time
• INR -international normalized ratio (what we use now)
• we want to get to a 2-3 level to prevent thrombosis development
• OD correct with IV or PO vitamin K
• we have to be careful because cabbage is high in vitamin K and can decrease effect
Aspirin
ANTIPLATELET

• Inhibition of cyclo-oxygenase
• Adverse effect - Increases risk for GI bleeding
use for:
• if pt. has had some type of ischemic stroke or
TIA's
• chronic stable/unstable angina
• coronary stenting (angioplasty)
• Acute MI
• previous MI
• primary prevention of MI
Ticlopidine (Ticlid)
ANTIPLATELET

• Inhibits ADP-mediated aggregation
• Adverse effects - Hematologic effects
Clopidogrel (plavix)
ANTIPLATELET

• ADP receptor antagonist
• very commonly used as a post stent replacement
• many patients leave catheterization lab on this
• was very expensive
• reduces thrombotic events in patients with acute
coronary syndromes
• MI, ischemic stroke, and vascular death
• similar adverse effects as aspirin
• use with caution in combination with other drugs
that promote bleeding
Streptokinase (streptase)
THROMBOLYTIC

• Major adverse effect – bleeding
(minor oozing to life-threatening amount)
• can be a problem because it is prepared from a streptococci bacteria culture
• very expensive $2500 a dose
• Therapeutic uses
• Acute coronary thrombosis (acute MI) Deep venous thrombosis (DVT)
• Massive pulmonary emboli

Adverse effects
• Bleeding – excessive fibrinolysis can be reversed with IV aminocaproic acid (Amicar)
• Antibody production – itching,urticaria
• This is prepared from cultures of streptococci (can be a problem for some people)
• Hypotension less than 10%
• Fever- 4%
• Likely sites of bleeding
• Recent wounds, needle puncture sites, invasive procedure sites
Alteplase (tPa)
THROMBOLYTIC

• Converts plasminogen to plasmin
• Given in accelerated schedule over
90 minutes
• Risk for intracranial bleeding higher
than with streptokinase
• Fever
Advantages
• Does not cause allergic reactions
Does not induce hypotension
Morphine
OPIOID NARCOTIC ANALGESICS

• Source: Seedpod of the poppy plant – named after Greek God
of sleep - Morpheus
• Overview: Receptors involvedPain relief, Drowsiness, Mental
clouding, Anxiety reduction, Sense of well-being
• Mechanism mimics the actions of the body’s natural opioid
type peptides
• Adverse Effects: Respiratory depression – worry when <12
breaths/minute; Infants and the elderly are especially sensitive
• Onset: IV 7 min; IM 30 min; subQ up to 90 min, may persist 4–
5 hr. Spinal injection—response may be delayed by hours,
• Pharmacokinetics Administered by several routes: PO, IM, IV,
subQ, epidural, and intrathecal
• Drug Interactions, CNS depressants, Anticholinergic drugs –
especially constipation, Hypotensive drugs, Monoamine
oxidase inhibitors, Agonist-antagonist opioids, Opioid
antagonists, Other interactions - amphetamines
• Toxicity: Clinical manifestations
• Classic triad, Coma, Respiratory depression, Pinpoint pupils
Treatment, Ventilatory support, Antagonist: naloxone (Narcan)
• Dosage and routes of administration, Oral, Intramuscular and
subcutaneous, Intravenous, Epidural and intrathecal,
Extended-release liposomal formulation (DepoDur), morphine
is put in a shell of liposomes (lipid particles) in order to slow
release
Fentanyl
OPIOID NARCOTIC ANALGESICS

(Sublimaze, Duragesic, Abstral, Actiq, Fentora,
Onsolis)
• 100 times the potency of morphine
• not more efficacious; simply you can get more done with less
• Five formulations in three routes; Parenteral (Sublimaze),
Surgical anesthesia, Transdermal (Duragesic), Patch—heat
acceleration, Iontophoretic system—needle-free,
Transmucosal, Lozenge on a stick (Actiq), Buccal film
(Onsolis), Buccal tablets (Fentora), Sublingual tablets (Abstral)
Codeine
OPIOID NARCOTIC ANALGESICS
Meperidine
OPIOID NARCOTIC ANALGESICS

• Short half-life
• Interacts adversely with several other drugs
• Toxic metabolite accumulation - normeperidine
Naloxone
OPIOID PURE ANTAGONIST

• Competitive antagonist
• Pharmacologic effects –
if given to an addict they
will go into withdrawal
• Pharmacokinetics – half
life @ 2 hours
• Reversal of opioid
overdose
• Drug of choice with pure
opioid agonist overdose
• Titrated cautiously with
physical dependence
• Reversal of
postoperative opioid
effects
• Titrated to achieve
adequate ventilation and
to maintain pain relief
• Reversal of neonatal
respiratory depression
• Opioids given during
labor and delivery may
cause respiratory
depression in neonate
• Opioid overdose 0.4mg
for adults
• Postoperative opioid
effects 0.1 – 0.2 mg
adults
• Neonatal respiratory
depression
• All doses are repeated
ay 3 minute intervals
until the respiratory rate
is satisfactory
Naltrexone
OPIOID PURE ANTAGONIST

• Methylnaltrexone
• Selective opioid
antagonist – approved in
2008Treatment of opioidinduced
constipation in
late-stage disease for
patients on constant
opioids
Pentazocine
OPIOID AGONIST/ANTAGONIST

Actions and uses – used for milder
pain – agonist at the Kappa and
antagonist at Mu receptor so it
produces little or no euphoria
Codeine
OPIOID AGONIST/ANTAGONIST

• 10% converts to morphine in liver
• Pain and cough suppression
• Usually oral (formulated alone or with
aspirin or acetaminophen)
• 30 mg produces same effect as 325 mg
acetaminophen
Oxycodone
OPIOID AGONIST/ANTAGONIST

• Analgesic actions equivalent to those of
codeineLong-acting analgesic
• Immediate-release
• Controlled-release (OxyContin)
• Abuse: crushes and snorts or injects
medication
• 2010 OP formulation much harder to crush
and does not dissolve into an injectable
solution to decrease risk of abuse
• an attempt to make it harder to abuse
Hydrocodone (Vicodin)
OPIOID AGONIST/ANTAGONIST

• Most widely prescribed drug in the United
StatesCombined with aspirin,
acetaminophen, or ibuprofen
Tapentadol
OPIOID AGONIST/ANTAGONIST

• Analgesic effects equivalent to
oxycodoneCauses less constipation than
traditional medications
Propoxyphene
OPIOID AGONIST/ANTAGONIST

• Analgesic effect equal to that of
aspirinCombined with aspirin or
acetaminophen
• Propoxyphene products, such as Darvon
and Darvocet, have been withdrawn owing
to limited efficacy and the risk of
potentially fatal dysrhythmias
• doesn't have as much efficacy as desired
Clonidine (Duraclon)
NON OPIOD CENTRAL ANTAGONIST
Alpha2-adrenergic
agonist
Ziconotide (Prialt)
NON OPIOD CENTRAL ANTAGONIST

Selective antagonist at N-type
voltage-sensitive calcium
channels on neuronsBlocks
calcium channels on primary
nociceptive afferent neurons
in dorsal horn of the spinal
cord
Cyclooxygenase Inhibitors (
COX)
NON OPIOD CENTRAL ANTAGONIST

• Aspirin
Nonselective inhibitor of
cyclooxygenase
Non-aspirin first
generation NSAIDs
NON OPIOD CENTRAL ANTAGONIST

Aspirin-like drugs with fewer
GI, renal, and hemorrhagic
effects than aspirin
20+ nonaspirin NSAIDs
available, Ibuprophen and
naproxen from this group
Second-generation NSAID's
NON OPIOD CENTRAL ANTAGONIST

• Celecoxib (Celebrex) ~
last choice agent
Second-generation COX-2
inhibitor—fewer adverse
effects than first-generation
drugs
Acetaminophen
NON OPIOD CENTRAL ANTAGONIST

(Tylenol) Therapeutic
uses ~ Analgesic,
antipyretic, Does not
have any antiinflammatory
or
antirheumatic actions,
Not associated with
Reye’s syndrome
Tramadol
NON OPIOD CENTRAL ANTAGONIST

Combination of opioid
and nonopioid
mechanisms
Penicillin G (Benzylpenicillin)
◦ Least toxic to bacteria of all antibiotics
◦ first type that was the product of a drug company copying the strain that Alexander Flemming discovered
• Allergies ~ 3 types Immediate (reaction in 2-30 minutes) ~ very violent, accelerated (rx. in 1-72 hours) late (reaction takes days or weeks to develop) very difficult to diagnose
• Drug interactions
◦ Aminoglycosides – penicillins in high concentrations can inactivate aminoglycosides – so do not mix in same IV
◦ Penicillin V - has now replaced PenG as it is more stable in stomach acid so it is used orally
Penicillinase-resistant penicillins ~ NafcillinOxacillin, Dicloxacillin
◦ Available in the United States – used for Staph infections (used to treat penicillin resistant bacteria)
Broad Spectrum Penicillins
◦ Ampicillin (Principen) Amoxicillin (Amoxil, DisperMox, Moxatag, Trimox)
◦ Adverse effects ~ RashDiarrhea
Extended-spectrum penicillins (antipseudomonal penicillins)
◦ Piperacillin Broad-spectrum, but penicillinase-sensitive
Penicillin Combinations
◦ Beta-lactamase inhibitors ~ Clavulanic acid, tazobactam, sulbactam
■ all added on to other agents to prevent beta-lactamase producing organisms from breaking down the antibiotic
◦ Extends antimicrobial spectrum when combined with penicillinase-sensitive antibiotics
■ Ampicillin/sulbactam (Unasyn)Amoxicillin/clavulanic acid (Augmentin)
■ Ticarcillin/clavulanic acid (Timentin)
■ Piperacillin/tazobactam (Zosyn) often hospital will pick just one of these and use them consistently, they also rotate per year to keep bacteria so to speak
Mechanism of Action for Cephlosporins
◦ Bind to penicillin-binding proteins (PBPs), disrupt cell wall synthesis, and cause cell lysis, Most effective against cells undergoing active growth and division
Drug Interactions of Cephalosporins
◦ Probenecid – can delay renal excretion of some cephalosporinsAlcohol- can cause nausea and vomiting in combo with
◦ Drugs that promote bleeding – can be additive
◦ Calcium and ceftriaxone – can cause precipitate so do not combine IV
Therapeutic Effects of Cephalosporins
◦ First- and second-generation agents rarely used for active infection
◦ Third-generation
■ Preferred therapy for several infections - meningitis
■ Highly active against gram-negative organisms
■ Able to penetrate to cerebrospinal fluid (CSF)
◦ Fourth-generation
■ Broad spectrum
■ Penetration to CSF is good
Carbapenems
• Beta-lactam antibiotics have an extremely broad antimicrobial spectrum with low toxicity
◦ what we would give first before C & S results from lab can narrow range
• Not active against methicillin-resistant Staphylococcus aureus (MRSA)
◦ Imipenem (Primaxin)
◦ Meropenem (Merrem IV)
◦ Ertapenem (Invanz)
◦ Doripenem (Doribax)
Vancoymycin
• oral is very expensive and is only used for C. difficile infection
• Action
◦ Inhibits cell wall synthesis
• Uses
◦ Severe infections only
◦ Methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis
◦ Oral dose used ONLY for Clostridium difficile if metronidazole was tried and found ineffective
◦ they will try a stool transplant if this doesn't work (take a relative's stool and implant it to help colonize with normal bacterial flora)
• Oral vancomycin is not systemically absorbed, it stays in the GI tract
◦ IV therapy required for system administration
◦ oral used for C. difficile
• Action
◦ Inhibits cell wall synthesis
• Uses
◦ Severe infections only
◦ Methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis
◦ Oral dose used ONLY for Clostridium difficile if metronidazole was tried and found ineffective
• Adverse effects
◦ Ototoxicity (reversible or permanent)
◦ Red man syndrome
■ people become very flushed and turn red (related to rate of delivery of vancomycin), treatment is to slow it down
◦ Thrombophlebitis (common)
■ very common inflammation of veins, its going through
◦ Thrombocytopenia (rare)
◦ Allergy
• if C. difficile occurs often they need to do a stool transplant
Aztreonam (Azactam)
MONOBACTAMS

◦ Binds to penicillin-binding protein 3 (PBP3)
◦ Narrow antimicrobial spectrum
◦ Gram-negative aerobic bacteria only
■ (bacteria that require oxygen to survive)
◦ Must be given parenterally
◦ Adverse effects similar to those of other beta-lactam antibiotics
Teicoplanin (Targocid)
MONOBACTAMS

◦ Similar in structure and actions to vancomycin
◦ Does not have beta-lactam ring
◦ MRSA and C. difficile are sensitive to drug
■ most common use for this drug
◦ Not approved in United States (approved in Japan and Europe)
◦ No infusion-related reactions
Fosfomycin (Monurol)
MONOBACTAMS

◦ Approved for single-dose therapy of uncomplicated urinary tract infection (UTI) caused by Escherichia coli or Enterococcus faecalis
◦ Disrupts the synthesis of peptidoglycan polymer strands that compose the cell wall
◦ Side effects
◦ Most common: diarrhea, headache, vaginitis, nausea
• most common side effects in antibiotics is usually diarrhea (other GI problems and dehydration issues because of normal destruction of GI flora)
Tetracycline
◦ Broad-spectrum antibiotics
■ Inhibit protein synthesis
■ Increasing bacterial resistance has emerged
◦ Uses
■ Rickettsial disease, Chlamydia trachomatis, Brucellosis, Cholera, Mycoplasma pneumoniae, Lyme disease, Anthrax, Helicobacter pylori, Acne (very commonly
used for this these days), Peptic ulcer disease, Periodontal disease
◦ Adverse effects
■ Gastrointestinal irritation
■ Effects on bone and teeth- can bind to developing teeth which will cause yellow/brownish teeth
■ Superinfection – overgrowth of drug resistant microbes
■ Hepatotoxicity
■ Renal toxicity
■ Photosensitivity – wear UV protective clothing and sunscreen
■ especially with kids taking these for their acne
■ great need to where UV protection, especially high SPF sunscreen (maybe also protective clothing)
◦ Summary of major precautions
■ Tetracycline and demeclocycline are eliminated primarily in urine and will accumulate in patients with kidney disease
■ Discoloration of deciduous and permanent teeth
■ Diarrhea may indicate a potentially life-threatening suprainfection of the bowel
■ we worry if too much because of risk for liver damage or killing off of too many GI flora bacteria
■ High-dose IV therapy has been associated with severe liver damage
◦ Drug and Food Interactions
■ Absorption of tetracyclines decreased if given with:
■ Milk products
■ Most antacids
■ Calcium supplements
■ Iron supplements
■ Magnesium-containing laxatives
Erythromycin
MACROLIDES

• Mechanism of action (MOA): inhibition of protein synthesis
• Usually bacteriostatic but can be bactericidal
• Use if allergic to penicillin
• Active against most gram-positive and some gram-negative bacteria
• Therapeutic uses
◦ Whooping cough, acute diphtheria, Corynebacterium diphtheriae, chlamydial infections, M. pneumoniae, group A Streptococcus progenies
• Drug interactions- inhibits CYP 450 enzymes – so increase effects of warfarin
• Adverse effects
◦ Gastrointestinal
◦ QT prolongation and sudden cardiac death- avoid in patients taking class IA or class III antiarythmics
◦ Superinfection
• Clarithromycin (Biaxin)- used for respiratory tract infection
• Azithromycin (Zithromax) – can increase adherence with this dosing schedule – Z Pac
Clindamycin (cleocin)
MACROLIDES

Inhibits bacterial protein synthesis
◦ Can induce severe Clostridium difficile–associated diarrhea (CDAD) (can be fatal)
◦ Active against most anaerobic bacteria (gram-positive and gram-negative)
◦ Indicated only for certain anaerobic infections located outside the central nervous system (CNS)
◦ topically used very commonly for Acne
◦ Adverse effects
■ Clostridium difficile–associated diarrhea (CDAD) Hepatic toxicity
■ Hypersensitivity reactions
■ Blood dyscrasias
■ Diarrhea
Linezolid (Zyvox)
MACROLIDES

• First member of a newer class of antibiotics: oxazolidinones
• Use
◦ Active against multidrug-resistant gram-positive pathogens (eg, vancomycin-resistant enterococci [VRE], methicillin-resistant Staphylococcus aureus [MRSA])
• Bacteriostatic inhibitor of protein synthesis
• Cross-resistance with other agents unlikely
◦ remember there is always bacteria striving to develop or increase resistance
◦ this may be good for now, doesn't guarantee anything
• Active against aerobic and facultative gram-positive bacteria
• VRE and MRSA
• Most common side effects
◦ Diarrhea
◦ Drug interaction with monoamine oxidase inhibitors (MAOIs)
◦ Nausea and vomiting
◦ Headache
◦ May also cause myelosuppression
Telithromycin
MACROLIDES

• First representative of ketolide class of antibiotics
• Use
◦ Effective against strains of Streptococcus pneumoniae
• Adverse effects
◦ GI effects
◦ Gray syndrome
◦ Visual disturbances
Dalfopristin/Quinupristin
MACROLIDES

• First members of streptogramins (new class of antibiotics)
• Inhibit bacterial protein synthesis
• Principal indication: VRE
• Adverse effects
◦ Hepatotoxicity
• Drug interactions
◦ CYP3A4
Chloramphenicol (Chloromycetin)
MACROLIDES

• Broad-spectrum antibiotic
• Inhibits protein synthesis
• Uses Only for life-threatening infections for which safer drugs are ineffective or contraindicated
• Adverse effects
◦ Reversible bone marrow depression
◦ Fatal aplastic anemia – why its not so commonly used
◦ Gray syndrome – originally called Gray baby syndrome
◦ GI effects – vomiting
◦ Peripheral neuropathy
Gentamicin, tobramycin, amikacin
AMINOGLYCOSIDES

◦ Narrow-spectrum antibiotics
◦ Bactericidal
◦ Use: aerobic gram-negative bacilli
◦ Can cause serious injury to inner ear and kidney
◦ Not absorbed from the GI tract – so given IV, IM or via inhalation
◦ Microbial resistance
• Adverse effects
◦ Nephrotoxicity
◦ Ototoxicity – inner ear (total cumulative and trough levels)
◦ Hypersensitivity reactions
◦ Neuromuscular blockade – risk of paralysis
◦ Blood dyscrasias
◦ Drug interactions
■ Beneficial
■ Adverse
• very important to monitor serum levels
◦ same dose can produce different levels in different patients
◦ Dosing
■ Single large dose each day or 2–3 smaller doses
◦ Monitoring of serum levels is common; the same aminoglycoside dose can produce very different plasma levels in different patients
◦ Peak levels must be high enough to kill bacteria; trough levels must be low enough to minimize toxicity\
◦ Interestingly toxicity with this class of drugs come from high trough levels versus high peak levels
■ the trough levels don't go low enough (so high low levels results in too much drug because not enough is cleared at any given time, resulting in toxicity)
■ dammage to inner ear and kidneys
■ ONCE A DAY DOSING ENDED UP BEING SAFER
■ gave pt. more time to clear drug out of system
■ initially they give large once/day dose and then take blood to see if pt. cleared it
Gentamicin (Garamycin) ~ prototypes
AMINOGLYCOSIDES

◦ Used to treat serious infections caused by aerobic gram-negative bacilli
■ Pseudomonas aeruginosa
■ Escherichia coli
■ Klebsiella
■ Serratia
■ Proteus mirabilis
◦ Adverse effects
■ Nephrotoxicity
■ Ototoxicity – impairs balance since it affects inner ear
• also know paromycim (Humatin) it is also oral and used for cryptosporidium
Sulfonamides and Trimethoprim
• Broad-spectrum antibiotics
• Have closely related mechanisms (reason why used together)
• Suppress bacterial growth by inhibiting tetrahydrofolic acid
• First drugs available for systemic treatment of bacterial infection
◦ More effective and less toxic drugs now available
• Inhibit the synthesis of folic acid (folate)
◦ Mammalian cells do not manufacture their own folate (not affected as bacteria are affected)
• Primary use now: for urinary tract infection
◦ Other uses: nocardiosis, Chlamydia trachomatis, conjunction therapy for toxoplasmosis/malaria, ulcerative colitis
◦ used for urinary tract infections because it is cleared by the kidneys
• Adverse effects
◦ Hypersensitivity reactions: Stevens-Johnson syndrome mortality rate ia 25% (big reason not as common)
◦ Hematologic effects
◦ Kernicterus
◦ Renal damage from crystalluria esp with older agents
• Drug interactions
◦ Metabolism-related interactions- can increase effect of warfarin
◦ Cross-hypersensitivity with other drugs with sulfonamide classes like thiazide diuretics,
◦ Hypersensitivity includes photo sensitivity use sunscreen
Trimethoprim (Proloprim, Trimpex)
◦ don't give to pregnant women (animal model problem)
■ Acute and uncomplicated urinary tract infections
◦ Uses
■ Inhibits dihydrofolate reductase
■ Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, Enterobacter, coagulase-negative Staphylococcus
◦ Adverse effects
■ Hematologic effects- rare – see anemias
■ Use in pregnancy and lactation – crosses placenta and have seen abnormalitis in animal models
Trimethoprim-Sulfamethoxazole
◦ Trimethoprim-sulfamethoxazole (TMP-SMZ) combo inhibits sequential steps in bacterial folic acid synthesis, making it much more powerful than TMP or SMZ alone
◦ This combo is called Bactrim – available IV or PO
◦ Therapeutic uses
■ Urinary tract infection, otitis media, bronchitis, Shigellosis, pneumonia by Pneumocystis jiroveci, Pneumocystis pneumonia, and GI infection
■ Pneumocystis is an opportunistic infection seen in AIDS
■ given daily as a preventative
◦ Adverse Effects
■ Adverse effects
■ Gastrointestinal
■ Nausea and vomiting
■ Rash
■ Hyperkalemia
■ Hypersensitivity reactions (Stevens-Johnson syndrome)
■ Blood dyscrasias
■ Kernicterus
■ Renal damage: crystalluria maintain adequate hydration
Drug Therapy of Urinary Tract Infections
• Drug Treatment
◦ Trimethoprim/sulfamethoxazole: frequently the treatment of choice for oral therapy of urinary tract infection
◦ So Bactrim is used very commonly unless there is resistance then we use a ciprofloxacin
• Acute Cystitis
◦ Single-dose therapy
■ usually for the 1st time we try this because its enough to take care of uncomplicated acute cystitis
◦ Short-course therapy (3 days)
◦ Conventional therapy (7 days)
◦ Urinary Tract Antiseptics
Nitrofurantoin (Furadantin, Macrodantin, Macrobid) (prototype)
Drug Therapy of Urinary Tract Infections

■ Bactericidal: high concentrations
■ Uses: lower UTIs, prophylaxis, recurrent lower UTIs
■ often used in combination with antibiotic
■ often used in nursing home pt. with urinary incontinence (we're trying to prevent infection)
■ side effects
■ Gastrointestinal effects
■ Pulmonary reactions
■ Hematologic effects - leukopenia
■ Peripheral neuropathy
■ Hepatotoxicity
■ Birth defects
■ Other
Methenamine (Mandelamine, Hiprex, Urex)
Drug Therapy of Urinary Tract Infections

■ Decomposes into ammonia and formaldehyde, which denature bacterial proteins
■ Therapeutic uses
■ Chronic lower UTIs (trimethoprim/sulfamethoxazole is preferred)
■ Adverse effects
■ Relatively safe and generally well tolerated
■ Contraindicated for renal and liver failure
■ These are all concentrated in the urine – usually second line agents or for prophylaxis of UTIs
Fluoroquinolones
• newer class of antibiotics (approved in last 20 years)
• Broad-spectrum agents with multiple applications
◦ very good applications
• Disrupt DNA replication and cell division
• All can be administered orally or IV
◦ very good oral absorption
◦ we can use IV but can readily switch to oral
• side effects
◦ generally mild but can cause tendon rupture (low risk)
◦ Usually affects Achilles tendon
◦ Avoid in patients younger than 18 years (because of tendon rupture problem)
■ risk although low, is still there for other patients (even elderly)
◦ Risk to all patients, especially those older than 60 years, those taking glucocorticoids, and those who have undergone kidney, heart, or lung transplantation
Ciprofloxacin (Cipro) - prototype
Fluoroquinolones

◦ disrupts cell division
◦ drug of choice for Anthrax
■ was bought up by government during anthrax scare
◦ Broad-spectrum antibiotic (gram-negative and some gram-positive)
◦ Inhibits bacterial DNA gyrase and topoisomerase II
◦ Uses: multiple systems
◦ Infections: respiratory, urinary tract (UTI - this drug does concentrate in urine), GI, bones,
■ respiratory and UT are very common employment for this drug
◦ adverse effects
■ dosages should be adjusted based on age and kidney function
■ to high levels can kill of intestinal flora resulting in C. difficile etc.
■ Mild
■ GI: nausea/vomiting, diarrhea, abdominal pain
■ Central nervous system (CNS): dizziness, headache, restlessness, confusion, rarely seizures
■ Candida infections: pharynx and vagina
■ fungal overgrowth because gram negative and positive organisms are suppressed leaving only fungal organisms to thrive
■ Older adult patients
■ Confusion, somnolence, psychosis, visual disturbances
◦ drug and food interactions
■ Cationic compounds
■ Absorption reduced by:
■ Aluminum antacids
■ Magnesium antacids
■ Iron salts
■ Zinc salts
■ Sucralfate
■ Milk and dairy products (tetracyclines are the others not to be taken with milk and diary)
■ Elevation of drug levels
◦ others (don't memorize)
■ Ofloxacin
Moxifloxacin
Norfloxacin
Levofloxacin
Gemifloxacin
Metronidazole (Flagyl) ~ bactericidal
• Bactericidal - class
◦ Uses
■ Protozoal infections
■ Infections caused by obligate anaerobes
■ Helicobacter pylori
◦ Adverse effects
■ Neurotoxicity
■ Allergy
■ Superinfections
Cyclic Lipopeptide
• Daptyomycin (Cubicin) ~ cyclic lipopeptide
• Cyclic lipopeptide (new class)
• Kills virtually all gram-positive bacteria, including methicillin-resistant Staphylococcus aureus (MRSA)
• No significant drug interactions
◦ very specific use for this drug so not widespread use (which reduces our ability to spot problems)
• Adverse effects: possible muscle injury
• Given only once daily IV: no laboratory work needed
◦ still monitor pt. but no specific lab test
Rifampin
◦ Broad-spectrum antibacterial used primarily for tuberculosis (TB)
◦ Also used for some meningitis: not monotherapy
Rifaximin
◦ Nonabsorbable PO form of rifampin used for traveler’s diarrhea
■ exposure to different types of water
■ exposure to pathogens you already have but exist in a different strain in another country
■ decreased incidence of traveler's diarrhea thanks to bottled water
■ also don't eat from street venders or eat ice (from unfiltered water)
◦ Nausea, flatulence, and defecation urgency (very uncomfortable for those who experience it)
◦ Newer indication: prevention of encephalopathy in patients with chronic liver disease
Bacitracin
~ antibiotic cream
◦ (TAB = triple antibiotic ointment NOT SODA story )
◦ Almost always used topically for bacterial infection
◦ Systemic; can cause serious toxicity, so not used
Polymyxin B
~ antibiotic cream
◦ (TAB = triple antibiotic ointment NOT SODA )
◦ Topical treatment for ears, eyes, and skin
◦ Skin treatment usually in combination
◦ Not used for systemic infection (because of toxicity risk)
Amphotericin B ~ IV only drug
Treatment of Fungi

Amphotericin B ~ IV only drug
◦ before we got this, there used to be nothing we could do
◦ Broad-spectrum antifungal agent (also used against some protozoa)
◦ Highly toxic
■ Infusion reaction and renal damage occur in all patients to varying degrees
■ Must be given IV; no oral administration
◦ Uses
■ Drug of choice for most systemic mycoses
■ Before ampho B, systemic fungal infections were usually fatal
◦ mechanism of action
■ Binds to ergosterol (much more than cholesterol) in fungal cell membrane
■ Bacterial cell membranes lack sterols
■ Fungi damaged more than human cells
■ Increases permeability
■ Cell leaks intracellular cations (especially potassium)
■ Fungistatic or fungicidal
◦ Adverse effects
■ Infusion reactions
■ (they used to call it shake and bake because of the shaking pt.'s experienced)
■ Benadryl and tylenol to help prevent shaking
■ Fever, chills, rigors, nausea, and headache
■ Caused by release of proinflammatory cytokines
■ Symptoms begin 1–3 hours after start of infusion and last for about 1 hour
■ Less intense with lipid-based ampho B formulations
■ Mild reactions: pretreatment options
■ Diphenhydramine plus acetaminophen
■ Aspirin can help but may increase renal damage
■ IV meperidine or dantrolene can be given if rigors occur
■ Hydrocortisone can be given with caution
■ Nephrotoxicity
■ give bolus of saline to increase excretion
■ monitor kidney function (flush kidneys after and even before)
■ Extent of kidney damage related to total dose administered over the full course of treatment
■ If total dose >4 g, residual impairment likely
■ Damage minimized by infusing 1 L of saline on days of treatment
■ not every patient can tolerate this much (it's okay to give them a little less)
■ Avoid concurrent use of other nephrotoxic drugs
■ Aminoglycosides, cyclosporines
■ Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided
■ Monitor serum creatinine every 3–4 days
■ dependent on the patient (severity of infection and how sick the patient is)
■ Reduce dosage if >3.5 mg/dL
■ Hypokalemia
■ Results from damage to the kidneys
■ Potassium supplements may be needed
■ Monitor serum levels
■ Hematologic effects
■ Can cause bone marrow suppression
■ Anemia: monitor hematocrit
◦ they've come up with new lipid based amphotericin B to reduce infusion reactions but its very expensive so few places have them
Azoles ~ oral possible
◦ Broad-spectrum antifungal drugs
◦ Alternative to ampho B for most systemic mycoses
◦ Lower toxicity
◦ Can be given orally (and nasal cavity, eye drops, etc.)
◦ Disadvantage
■ Inhibit P450 drug-metabolizing enzymes and can increase the levels of many other drugs
Itraconazole (Sporanox - prototype)
AZOLES

■ Azole group of antifungal agents
■ Lower toxicity level
■ Uses
■ Systemic mycoses (alternative to ampho B)
■ Mechanisms of action
■ Inhibits the synthesis of ergosterol
■ Inhibits fungal cytochrome P450–dependent enzymes
■ Side effects (well tolerated in usual doses)
■ Cardiosuppression
■ Transient decrease in ventricular ejection fraction
■ Liver damage
■ Watch for signs of liver dysfunction
■ Can inhibit drug-metabolizing enzymes
■ GI effects
■ Nausea, vomiting, diarrhea
Fluconazole (Diflucan) ~ prototype
AZOLES

■ Azole group of antifungal agents
■ Fungistatic
■ Same mechanism of action as itraconazole
■ Oral absorption good
■ IV and oral dosage the same
■ Adverse effects
■ Nausea
■ Headache
■ Vomiting
■ Abdominal pain
■ Diarrhea
Voriconazole (Vfend)
AZOLES

■ Azole group of antifungal agents
■ Broad spectrum of fungal pathogens
■ Uses
■ Candidemia
■ Invasive aspergillosis
■ Esophageal candidiasis
■ Scedosporium apiospermum–resistant infections
■ Mechanism of action
■ Suppresses synthesis of ergosterol
■ Adverse effects
■ Hepatotoxicity
■ Visual disturbances, hallucinations
■ Fetal injury
■ Hypersensitivity reactions
■ Nausea, vomiting, and abdominal pain
■ Headache
■ Drug interactions
Ketoconazole
AZOLES

■ Azole group of antifungal agents
■ Mechanism of action
■ Inhibits ergosterol
■ Uses: alternative to ampho B for systemic mycoses
■ Less toxic and only somewhat less effective
■ Slower effects
■ More useful in suppressing chronic infections than in treating severe, acute infections
■ Adverse effects (generally well tolerated)
GI (can be reduced if given with food)
Hepatotoxicity
Rare but potentially fatal hepatic necrosis
Effect on sex hormones
Can inhibit steroid synthesis in humans
Other adverse effects
Rash, itching, dizziness, fever, chills, constipation, diarrhea, photophobia, and headache
Echinocandins (know these as a class)
• Newest class of antifungal drugs
• Disrupt the fungal cell wall
• Oral dose effective treatment mainly for Aspergillus and Candida
• Caspofungin
• Micafungin
• Anidulafungin
Pyrimidine Analog
• Flucytosine (Ancobon)
• Uses
◦ Serious infection with susceptible strains of Candida and Cryptococcus neoformans
• Resistance common
◦ Often used with ampho B
• Extreme caution in patients with renal impairment or hematologic disorders
• Adverse effects
◦ Hematologic
◦ Bone marrow suppression
◦ Hepatotoxic
◦ Inhibits hepatic drug-metabolizing enzymes
Drugs for superficial Mycoses
• Mycoses caused by two groups of organisms
• Candida species
◦ Usually in mucous membranes and moist skin
◦ Chronic infections may involve scalp, skin, and nails
• Dermatophytic infections (eg, ringworm) especially in the nails
◦ Usually confined to skin, hair, and nails
◦ More common than Candida infections in nails
• Azoles
◦ Clotrimazole: topical is drug of choice for dermatophytic infections and candidiasis of skin, mouth, and vagina
◦ Ketoconazole: oral and topical therapy of superficial mycoses
◦ Miconazole: topical drug of choice for dermatophytic infections and for cutaneous and vulvovaginal candidiasis
■ New buccal tablet is used for oropharyngeal candidiasis
• Griseofulvin (Grifulvin)
◦ Uses
■ Superficial mycoses
■ Ineffective systemic mycoses
◦ Inhibits fungal mitosis
◦ Adverse effects
■ Transient headache
■ Rash
■ Gastrointestinal effects
■ Insomnia (disease itself more likely to blame)
■ Tiredness (disease itself more likely to blame)
• Nystatin (mycostatin) ~ S/S (swish and swallow)
◦ Polyene antibiotic
◦ Used only for candidiasis
◦ Drug of choice for intestinal candidiasis
◦ Also used for candidal infections in skin, mouth, esophagus, and vagina
◦ Can be administered orally or topically
• OTC powders
◦ Tolnaftate (tinactin)
◦ Undecylenic acid
◦ Ciclopirox
Acyclovir (zovirax) - prototype
Antiviral Agents I: Drugs for Non-HIV Viral Infections

◦ Active only against members of the herpesvirus family
◦ Agent of first choice for HSV or VZV infection
■ Herpes simplex genitalis
■ Mucocutaneous herpes simplex infections
■ Varicella-zoster infections (chicken pox)
■ works very well on chicken pox
◦ when these drugs were first available they were only indicated for patients with compromised immune system
◦ Herpes virus develops resistance to acyclovir
■ Decreased thymidine production
■ Alteration in thymidine kinase
■ Alteration of viral DNA polymerase
◦ Intravenous therapy
■ Phlebitis
■ Reversible nephrotoxicity
◦ Oral therapy
■ Gastrointestinal
■ Vertigo
■ Topical therapy
■ Stinging sensations
Valacyclovir (Valtrex)
Antiviral Agents I: Drugs for Non-HIV Viral Infections
◦ Prodrug form of acyclovir
■ Herpes zoster
■ Herpes simplex genitalis
■ Herpes labialis
◦ In some immunocompromised patients
■ Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS)
Famciclovir (Famvir)
Antiviral Agents I: Drugs for Non-HIV Viral Infections

◦ Prodrug used to treat acute herpes zoster or genital herpes infection
◦ Benefits are equivalent to those of acyclovir
◦ Adverse effects are minimal
Ganciclovir (Cytovene, Vitrasert)
Antiviral Agents I: Drugs for Non-HIV Viral Infections

◦ Synthetic antiviral agent
◦ Uses
■ Herpes simplex viruses, including CMV
■ Prevention and treatment of CMV infection in immunocompromised patients
◦ Serious side effects
■ Granulocytopenia
■ Thrombocytopenia
◦ Adverse effects
■ Granulocytopenia
■ Thrombocytopenia
■ Reproductive toxicity
■ Nausea, fever, rash, anemia, liver dysfunction, confusion, and other central nervous system (CNS) symptoms
■ can occur in anyone
Valgoaniclovir (Valcyte)
Antiviral Agents I: Drugs for Non-HIV Viral Infections

◦ Prodrug version of ganciclovir
◦ Used for CMV retinitis
◦ Oral is just as effective as IV
◦ Adverse effects
■ Blood dyscrasias
■ Bone marrow suppression
■ Granulocytopenia, anemia, thrombocytopenia
■ Diarrhea, nausea, vomiting
■ Potential for mutagenesis and carcinogenesis
■ Direct contact with broken tablet should be avoided
■ make sure you are wearing some gloves
■ Should be disposed of in the same manner as a cytotoxic drug (empty bags for oncology drugs aka. chemo)
Cidofovir (Vistide)
Antiviral Agents I: Drugs for Non-HIV Viral Infections

◦ IV with just one indication: CMV retinitis in patients with AIDS who have failed on ganciclovir or foscarnet
◦ Adverse effects
■ Nephrotoxicity
■ Neutropenia
■ Ocular disorders
Foscarnet (Foscavir)
Antiviral Agents I: Drugs for Non-HIV Viral Infections

◦ IV drug active against all known herpes viruses
◦ Compared with ganciclovir
◦ More difficult to give, less well tolerated, much more expensive
◦ CMV retinitis in patients with AIDS
◦ Acyclovir-resistant mucocutaneous HSV and VZV in immunocompromised host
. A postoperative patient has an epidural infusion of morphine sulfate (Astramorph). The patient’s respiratory rate declines to 8 breaths per minute. Which medication would the nurse anticipate administering?


A Naloxone (Narcan)
B Acetylcysteine (Mucomyst)
C Methylprednisolone (Solu-Medrol)
D Protamine sulfate
A
The nurse is planning care for a patient receiving morphine sulfate (Duramorph) by means of a patient-controlled analgesia (PCA) pump. Which intervention may be required because of a potential adverse effect of this drug?


A Administering cough suppressant
B Inserting a Foley catheter
C Administering an antidiarrheal
D Monitoring liver function tests
B
A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse, “Why am I receiving codeine? I don’t have any pain.” The nurse’s response is based on the knowledge that codeine also has which effect?


A Immunostimulant
B Antitussive
C Expectorant
D Decongestant
B
A patient takes oxycodone (OxyContin) 40 mg PO twice daily for the management of chronic pain. Which intervention should be added to the plan of care to minimize the gastrointestinal adverse effects?


A The patient should take an antacid with each dose.
B The patient should eat foods high in lactobacilli.
C The patient should take the medication on an empty stomach.
D The patient should increase fluid and fiber in the diet.
D
The nurse is teaching a patient with cancer about a new prescription for a fentanyl (Sublimaze) patch, 25 mcg/hr, for chronic back pain. Which statement is the most appropriate to include in the teaching plan?


A “You will need to change this patch every day, regardless of your pain level.”
B “This type of pain medication is not as likely to cause breathing problems.”
C “With the first patch, it will take about 24 hours before you feel the full effects.”
D “Use your heating pad for the back pain. It will also improve the patch’s effectiveness.”
C
Which agent is most likely to cause serious respiratory depression as a potential adverse reaction?


A Morphine (Duramorph)
B Pentazocine (Talwin)
C Hydrocodone (Lortab)
D Nalmefene (Revex)
A
The nurse is working on a postoperative unit in which pain management is part of routine care. Which statement is the most helpful in guiding clinical practice in this setting?


A At least 30% of the U.S. population is prone to drug addiction and abuse.
B The development of opioid dependence is rare when opioids are used for acute pain.
C Morphine is a common drug of abuse in the general population.
D The use of PRN (as needed) dosing provides the most consistent pain relief without risk of addiction.
B
A nurse administers naloxone (Narcan) to a postoperative patient experiencing respiratory sedation. What undesirable effect would the nurse anticipate after giving this medication?


A Drowsiness
B Tics and tremors
C Increased pain
D Nausea and vomiting
C
. The nurse assesses a patient who takes ibuprofen (Advil) on a regular basis. Which finding does the nurse know is an adverse effect of ibuprofen (Advil) therapy?


A Hives
B Hematemesis
C Dysmenorrhea
D Jaundice
B
A patient is scheduled to start taking aspirin for the treatment of rheumatoid arthritis. The nurse anticipates that which medication most likely will be prescribed?


A Docusate sodium (Colace)
B Ascorbic acid (vitamin C)
C Pantoprazole (Protonix)
D Furosemide (Lasix)
C
A nurse teaches a patient who takes daily low-dose aspirin for protection against myocardial infarction and stroke to avoid also taking which medication?


A Ibuprofen (Motrin)
B Zolpidem (Ambien)
C Loratadine (Claritin)
D Diphenhydramine (Benadryl)
A
A nurse should recognize that a patient who takes an angiotensin-converting enzyme (ACE) inhibitor while also taking high-dose aspirin is at risk of developing what complication?


A Congestive heart failure
B Liver toxicity
C Renal failure
D Hemorrhage
C
A nurse provides discharge instructions for a patient who is taking acetaminophen (Tylenol) after surgery. The nurse should instruct the patient to avoid which product while taking acetaminophen?


A Alcoholic drinks
B Leafy green foods
C Bananas
D Dairy products
A
A nurse instructs the parent of a child with influenza that which medication or medications may be used safely to reduce fever? (Select all that apply.)


A Ibuprofen (Advil)
B Naproxen (Aleve)
C Aspirin (Bayer)
D Acetaminophen (Tylenol)
E Indomethacin (Indocin)
D
After administering acetylcysteine (Mucomyst) to a patient who overdosed on acetaminophen (Tylenol), a nurse should recognize which outcome as an indicator of the therapeutic effects of acetylcysteine?


A Absence of jaundice
B Clear breath sounds
C Increased bowel sounds
D Palpable pedal pulses
A
A patient who has rheumatoid arthritis is scheduled to start taking celecoxib (Celebrex). A nurse should recognize which factor from the patient’s history as a contraindication to taking this medication?


A Hypothyroidism
B Recent heart bypass surgery
C Positive tuberculin skin test result
D Allergy to penicillin
B
Before administering celecoxib (Celebrex), it is most important for the nurse to assess the patient for a history of what?


A Allergy to sulfonamides
B History of hepatitis C
C Hypothyroidism
D Diabetes mellitus
A
A nurse instructs a patient to discontinue the scheduled use of high-dose aspirin before undergoing which procedures? (Select all that apply.)

A Routine dental cleaning
B Removal of a skin mole
C Cataract surgery
D Cholecystectomy
E Hysterectomy
D E
The nurse will include which statements when teaching a patient about the use of acetaminophen (Tylenol)? (Select all that apply.)

A “Acetaminophen is a useful drug for the treatment of inflammation, such as a rheumatoid arthritis.”
B “The most common side effect of treatment with the drug is kidney failure.”
C “Notify your healthcare provider if you notice that your skin or eyes are turning yellow.”
D “Do not routinely use acetaminophen to prevent vaccine-associated fever and pain.”
E “Use of this drug can prevent heart attack and stroke.”
C
Which statements about the care of a patient with aspirin poisoning does the nurse identify as true? (Select all that apply.)

A Warming blankets are routinely used to raise the patient’s temperature.
B Diuretics and fluid restrictions are needed to correct the fluid overload commonly seen with aspirin poisoning.
C Bicarbonate infusions are used to reverse acidosis and promote renal excretion of salicylates.
D Activated charcoal is contraindicated in the treatment of aspirin poisoning.
E Hemodialysis or peritoneal dialysis can accelerate salicylate removal.
C E
. An antimicrobial medication that has selective toxicity has which characteristic?


A Ability to transfer DNA coding
B Ability to suppress bacterial resistance
C Ability to avoid injuring host cells
D Ability to act against a specific microbe
C
The development of a new infection as a result of the elimination of normal flora by an antibiotic is referred to as what?


A Resistant infection
B Superinfection
C Nosocomial infection
D Allergic reaction
B
A microbe acquires antibiotic resistance by which means?


A Development of medication resistance in the host
B Over-riding of the minimum bactericidal concentration
C Incorrect dosing, which contributes to ribosome mutations
D Transfer of DNA coding to other bacteria
D
The nurse identifies which host factor as the most important when choosing an antimicrobial drug?


A Age
B Competent immune function
C Genetic heritage
D Previous medication reactions
B
What is the minimum bactericidal concentration (MBC)?


E The lowest concentration of an antibiotic needed to suppress bacterial growth completely
F The lowest concentration of an antibiotic needed to reduce the number of bacterial colonies by 99.9%
G The lowest concentration of an antibiotic needed to produce effects
H The lowest dose of an antibiotic needed to eradicate bacteria
F
Which test is the most widely used method for assessing drug sensitivity?


A Minimum inhibitory concentration (MIC)
B Minimum bacterial concentration (MBC)
C Broth dilution
D Disk diffusion
D
A nurse removes a central line access device once the patient no longer requires intravenous (IV) antibiotics. This action is an example of which strategy to prevent antimicrobial resistance established by the Centers for Disease Control and Prevention (CDC)?


A Preventing transmission
B Proper diagnosis
C Preventing infection
D Prudent antibiotic use
C
The nurse identifies what as the first step in the Campaign to Prevent Antimicrobial Resistance, established in 2002 by the CDC?


A Target the pathogen
B Access the experts
C Isolate the pathogen
D Vaccinate
D
A patient has acquired an infection while in the hospital. The nurse identifies this type of infection as what?


A Superinfection
B Suprainfection
C Nosocomial infection
D Resistant infection
C
A nurse is assessing the effects of antimicrobial therapy in a patient with pneumonia. The nurse should establish which outcomes when planning care? (Select all that apply.)

E Potassium level of 4 mEq/dL
F Reduction of fever
G Sterile sputum cultures
H Oxygen saturation of 98%
I Elastic skin turgor
FGH
Which are examples of the improper use of antibiotic therapy? (Select all that apply.)

A Using surgical drainage as an adjunct to antibiotic therapy
B Treating a viral infection
C Basing treatment on sensitivity reports
D Treating fever in an immunodeficient patient
E Using dosing that results in a superinfection
BE
A nurse should recognize that antibiotic prophylaxis is appropriate in patients with which medical conditions? (Select all that apply.)

A Aortic valve replacement
B Ruptured appendix
C Bronchitis
D Neutropenia
E Chickenpox
AD
The nurse identifies appropriate use of antimicrobials to prevent infection in which situations? (Select all that apply.)

A Cardiac surgery
B Recurrent urinary tract infections in women
C Anemia
D Treatment of fever of unknown origin
E Hysterectomy
ABE
Which medications does the nurse identify as having antibacterial properties? (Select all that apply.)

A Rifampin
B Zidovudine
C Imipenem
D Amphotericin B
E Amantadine
AC
. Before administering intravenous (IV) penicillin, the nurse should do what?


A Flush the IV site with normal saline.
B Assess the patient for allergies.
C Review the patient’s intake and output record.
D Determine the latest creatinine clearance result.
B
Thirty minutes after receiving an intramuscular (IM) injection of penicillin G (Pfizerpen), a patient reports itching and redness at the injection site. Which action should the nurse take first?


A Elevate the lower legs.
B Place an ice pack on the site.
C Make sure the patient stays calm.
D Administer subcutaneous epinephrine.
D
A patient is receiving penicillin G (Bicillin C-R). Which assessment should the nurse monitor as an indicator of an undesired effect?


A Cardiac rhythm
B Serum sodium level
C Lung sounds
D Red blood cell (RBC) count
A
A nurse should teach a patient to observe for which side effect when taking ampicillin (Polycillin)?


A Skin rash and loose stool
B Reddened tongue and gums
C Digit numbness and tingling
D Bruising and petechiae
.
A
Both IV ampicillin/sulbactam (Unasyn) and gentamicin (Garamycin) are ordered for a patient. When administering these medications, the nurse will do what?


A Ensure that separate IV solutions are used.
B Use two different peripheral IV sites.
C Administer the gentamicin first.
D There are no necessary precautions.
A
Which instructions should a nurse provide to a patient who is to start taking amoxicillin/clavulanate (Augmentin)?


A “Take Augmentin once per day and only at bedtime.”
B “Augmentin may be taken with food or meals.”
C “Avoid taking Augmentin with grapefruit juice.”
D “Use a minimal amount of liquid to swallow the Augmentin.”
B
An immunocompromised patient who is receiving piperacillin/tazobactam (Zosyn) develops oozing and bleeding from the gums. Which additional data should the nurse determine?


A Whether the patient has a fever above 100.5°F
B Whether the patient reports any painful teeth
C The most recent platelet count
D The last time mouth care was given
C
A patient is admitted to the hospital with a medical diagnosis of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). When taking the patient’s history, a nurse recognizes which information as the most important?


A Plays a contact sport and is an athlete
B Currently resides in a long-term care facility
C Did not complete the last course of antibiotics
D Had gallbladder surgery in the previous month
A
When performing a skin test for penicillin allergy, the nurse will do what? (Select all that apply.)

A Inject a tiny amount of the allergen subcutaneously.
B Observe for a local allergic response.
C Have epinephrine readily available.
D Have respiratory support readily available.
E Administer diphenhydramine (Benadryl) as the first-line agent should anaphylaxis occur
BCD
The nurse identifies which statements about penicillins as true? (Select all that apply.)

A Penicillins are the safest antibiotics available.
B The principal adverse effect of penicillins is allergic reaction.
C A patient who is allergic to penicillin always has a cross-allergy to cephalosporins.
D A patient who is allergic to penicillin is also allergic to vancomycin, erythromycin, and clindamycin.
E Penicillins are normally eliminated rapidly by the kidneys but can accumulate to harmful levels if renal function is severely impaired.
ABE
. A nurse observes a red streak and palpates the vein as hard and cordlike at the intravenous (IV) site of a patient receiving cefepime (Maxipime). Which assessment should the nurse make about the IV site?


A An allergic reaction has developed to the drug solution.
B The drug has infiltrated the extravascular tissues.
C Phlebitis of the vein used for the antibiotic has developed.
D Local infection from bacterial contamination has occurred.
C
A patient develops flushing, rash, and pruritus during an IV infusion of vancomycin (Vancocin). Which action should a nurse take?


A Reduce the infusion rate.
B Administer diphenhydramine (Benadryl).
C Change the IV tubing.
D Check the patency of the IV
A
A patient who is receiving vancomycin (Vancocin) IV for a methicillin-resistant Staphylococcus aureus (MRSA) infection asks a nurse, “Why can’t I take this medicine in a pill?” Which response should the nurse make?


A “The prescription could be changed, because vancomycin comes in two forms.”
B “You’re allergic to penicillin, and this is the only way this medication can be given.”
C “It will cause too much loss of appetite and nausea if given in the oral form.”
D “It is more effective by IV, because the pill form will stay in the digestive tract.”
D
A patient who is receiving cefotetan (Cefotan) has all of these medications ordered. The nurse monitors the patient for an adverse effect related to an interaction with which medication?


A Regular insulin
B Ampicillin (Polycillin)
C Naproxen (Naprosyn)
D Bisacodyl (Dulcolax)
C
A patient is receiving vancomycin (Vancocin). The nurse identifies what as the most common toxic effect of vancomycin therapy?


A Ototoxicity
B Hepatotoxicity
C Renal toxicity
D Cardiac toxicity
C
Before administering a cephalosporin to a patient, it is most important for the nurse to assess the patient for an allergy history to what?


A Soy products
B Peanuts
C Penicillins
D Opioids
C
The cephalosporins are beta-lactam antibiotics similar in structure and actions to the penicillins. They are contraindicated in patients with a history of severe allergic reactions to penicillins. The use of soy products, peanuts, and opioids is unrelated to cephalosporins. 


A High blood pressure
B Cardiotoxicity
C Red man syndrome
D Seizures
D
It is most important for the nurse to assess a patient receiving a cephalosporin for the development of which manifestation of antibiotic-associated pseudomembranous colitis (AAPMC)?


A Rigidity
B Ileus
C Ascites
D Diarrhea
D
When ceftriaxone is administered intravenously, it is most important for the nurse to avoid mixing it with what?


A Ringer’s lactate
B Normal saline
C Sterile water
D D5 0.45% NS
A
Which statements about vancomycin (Vancocin) does the nurse identify as true? (Select all that apply.)

A Vancomycin is the most widely used antibiotic in U.S. hospitals.
B Vancomycin is effective in the treatment of Clostridium difficile infection.
C Vancomycin is effective in the treatment of MRSA infections.
D Patients who are allergic to penicillin are also allergic to vancomycin.
E The major toxicity of vancomycin therapy is liver failure.
ABC
Which instructions will the nurse include when teaching a patient about cephalosporin therapy? (Select all that apply.)

A “Notify your healthcare provider if you develop diarrhea.”
B “Take aspirin if you develop a headache.”
C “Notify your healthcare provider if you develop a rash.”
D “Cephalosporins may not be taken with food.”
AC
. Which instruction should a nurse include in the discharge teaching for a patient who is to start taking tetracycline (Sumycin)?


A “You may stop taking the pills when you begin to feel better.”
B “Use sunscreen and protective clothing when outdoors.”
C “You’ll have to come back to the clinic for weekly blood work.”
D “Take the medication with yogurt or milk so you won’t have nausea.”
B
A nurse assessing a patient who is 12 years old should associate which complication with the patient’s receiving tetracycline (Sumycin) as a younger child?


A Delay in long bone growth
B Early onset of puberty
C Severe face and body acne
D Discoloration of the teeth
D
Which laboratory result should a nurse monitor more frequently when a patient is receiving clarithromycin (Biaxin) and warfarin (Coumadin)?


A Activated partial thromboplastin time (aPTT)
B Platelet count
C Erythrocyte sedimentation rate (ESR)
D International normalized ratio (INR)
D
A patient who has a vancomycin-resistant enterococci (VRE) infection is receiving linezolid (Zyvox). Which laboratory result indicates that the patient is having an adverse effect?


A White blood cell (WBC) count of 1200 units/L
B Hemoglobin (Hgb) level of 18 g/dL
C Potassium level of 3.0 mEq/dL
D Glucose level of 200 mg/dL
A
Which cardiovascular finding does the nurse identify as a possible adverse effect of erythromycin (Ery-Tab) therapy?


A Heart rate of 52 beats per minute
B Prolonged QT interval
C Jugular vein distention
D Grade III diastolic murmur
B
What does the nurse identify as an adverse effect of clindamycin (Cleocin) therapy?


A Cyanosis and gray discoloration of the skin
B Frequent loose, watery stools with mucus and blood
C Reduction in all blood cells produced in the bone marrow
D Elevated bilirubin, with dark urine and jaundice
B
The nurse identifies tigecycline (Tygacil) as a derivative of what?


A Penicillins
B Cephalosporins
C Tetracyclines
D Macrolides
C
The nurse identifies which drug as a short-acting tetracycline?


A Sumycin
B Declomycin
C Vibramycin
D Minocin
A
Which statements about CDAD associated with clindamycin therapy does the nurse identify as true? (Select all that apply.)

A Leukopenia commonly occurs.
B It is a potentially fatal condition.
C Patients usually experience abdominal pain.
D Anticholinergics are effective in treating the diarrhea.
E Clindamycin therapy should be discontinued and vancomycin started.
BCE
The nurse should include which instructions when teaching a patient about tigecycline therapy? (Select all that apply.)

A “Use sunscreen when you are outside.”
B “If you have diarrhea more than five times a day, notify your healthcare provider.”
C “Avoid using this drug if you are pregnant.”
D “Stop taking the drug if you experience nausea.”
E “Stop taking the drug if you experience vomiting.”
ABC
. nurse is administering a daily dose of tobramycin (Nebcin) at 1000. At which time should the nurse obtain the patient’s blood sample to determine the trough level?


A 0800
B 0900
C 1130
D 1200
B
A patient who is receiving an aminoglycoside (gentamicin) has a urinalysis result with all of these findings. Which finding should a nurse associate most clearly with an adverse effect of gentamicin?


A White blood cells (WBCs)
B Glucose
C Ketones
D Protein
D
A patient is receiving an aminoglycoside (tobramycin) antibiotic. A nurse asks the patient to choose daily meal selections, to which the patient responds, “Oh, dear, I don’t want another IV.” The nurse makes which assessment about the patient’s response?


A Some hearing loss may have occurred.
B The confusion is due to the hospital stay.
C A nutrition consult most likely is needed.
D The patient has a family history of dementia.
A
A nurse monitors a patient who is receiving an aminoglycoside (gentamicin) for symptoms of vestibular damage. Which finding should the nurse expect the patient to have first?


A Unsteadiness
B Vertigo
C Headache
D Dizziness
C
The nurse knows that there is an increased risk of ototoxicity in a patient receiving an aminoglycoside if which level is high?


A Concentration
B Trough
C Peak
D Dose
B
When administering an aminoglycoside to a patient with myasthenia gravis, it is most important for the nurse to assess what?


A Deep tendon reflexes
B Breath sounds
C Eyelid movement
D Muscle strength
B
A patient who is receiving an aminoglycoside develops flaccid paralysis and impaired breathing. Which medication does the nurse anticipate administering?


A Magnesium sulfate (Epsom salt)
B Potassium chloride (K-Dur)
C Sodium bicarbonate (Citrocarbonate)
D Calcium gluconate (Kalcinate)
D
Which enteral aminoglycoside would the nurse expect to be ordered preoperatively for a patient having intestinal surgery?


A Gentamicin
B Tobramycin
C Amikacin
D Neomycin
D
Before administering an aminoglycoside, it is most important for the nurse to assess the patient for a history of what?


A Myasthenia gravis
B Asthma
C Hypertension
D Diabetes mellitus
A
Which statements about ototoxicity and aminoglycosides does the nurse identify as true? (Select all that apply.)

A The risk of ototoxicity is related primarily to excessive peak levels.
B The first sign of impending cochlear damage is headache.
C The first sign of impending vestibular damage is tinnitus .
D Ototoxicity is largely irreversible.
E Use of aminoglycosides for less than 10 days is recommended to avoid ototoxicity.
DE
Which statements about serum drug levels does the nurse identify as true? (Select all that apply.)

A With once-daily dosing, only trough levels need to be drawn.
B Peak levels for intramuscular (IM) injections should be drawn 30 minutes after administration of the medication.
C The trough level ideally should be close to zero.
D For patients receiving once-daily doses, the sample should be drawn 2 hours before the next dose.
ABC
For patients receiving divided doses, trough levels should be drawn 1 hour before the next dose.
. The nurse is assessing a patient who is receiving a sulfonamide for treatment of a urinary tract infection. To monitor the patient for the most severe response to sulfonamide therapy, the nurse will assess for what?


A Diarrhea
B Skin rash and lesions
C Hypertension
D Bleeding
B
A patient is receiving local applications of mafenide (Sulfamylon) to burn areas. Before application, it is most important for the nurse to do what?


A Administer a pain medication.
B Obtain a set of vital signs.
C Auscultate the lung fields.
D Obtain a signed consent form.
A
A nurse should recognize that which sulfonamide, applied topically, has the greatest therapeutic benefit for burns?


A Sulfadiazine
B Trimethoprim (Trimpex)
C Sulfacetamide (Isopto Cetamide)
D Silver sulfadiazine (Silvadene)
D
A patient taking a sulfonamide is breast-feeding an infant. Which complication in the infant would the nurse associate with kernicterus?


A Hemolytic anemia
B Neurologic deficits
C Hepatocellular failure
D Ophthalmic infection
B
When providing patient teaching for oral sulfonamide therapy, the nurse should instruct the patient to take the sulfonamide in what way?


A At mealtime, when food is available
B With soy or nonmilk products
C Between meals with a full cup of water
D On awakening before breakfast
C
Before administering trimethoprim, it is most important for the nurse to assess the patient for a history of what?


A Heart failure
B Alcoholism
C Diabetes
D Emphysema
B
A patient who has acquired immunodeficiency syndrome (AIDS) is receiving trimethoprim/sulfamethoxazole (Bactrim). Which response should a nurse expect if the medication is achieving the desired effect?


A Increase in CD4 T cells
B Increased appetite and weight gain
C Resolution of pneumonia
D Decrease in joint pain
C
When caring for a patient receiving mafenide (Sulfamylon) for treatment of a severe burn, it is most important for the nurse to monitor which laboratory value?


A Blood glucose level
B Acid-base status
C Sodium level
D Peak mafenide level
B
The nurse identifies which statements about Stevens-Johnson syndrome as true? (Select all that apply.)

A Patients with Stevens-Johnson syndrome have a mortality rate of about 25%.
B Toxemia is associated with Stevens-Johnson syndrome.
C Short-acting sulfonamides do not induce Stevens-Johnson syndrome.
D Patients with Stevens-Johnson syndrome usually are hypothermic.
E Lesions of the mucous membranes are a characteristic of Stevens-Johnson syndrome.
ABE
Which manifestations does the nurse associate with the development of hemolytic anemia? (Select all that apply.)

A Urticaria
B Fever
C Pallor
D Jaundice
E Diarrhea
BCD
. Most cases (more than 80%) of uncomplicated, community-acquired urinary tract infection (UTI) are caused by which bacteria?


A Klebsiella pneumoniae
B Escherichia coli
C Enterobacter spp.
D Pseudomonas spp.
B
A patient who has acute cystitis is receiving treatment with trimethoprim/sulfamethoxazole. Which manifestation should indicate to a nurse that the patient’s condition is worsening?


A Incontinence
B Flank pain
C 3+ pedal edema
D Hyperactive bowel sounds
B
A patient is taking nitrofurantoin (Macrodantin). Which finding should a nurse recognize as an indication that the treatment is having an undesired effect?


A Hyperpigmentation of the palms
B Dyspnea with chills
C Gum irritation with bleeding
D Scalp tenderness and thinning hair
C
A patient is to begin taking nitrofurantoin (Macrodantin). The nurse should teach the patient that which manifestation should be the priority to report to the healthcare provider?


A Headache and drowsiness
B Brown-colored urine
C Nausea and vomiting
D Muscle weakness and tingling
D
A patient is taking nalidixic acid (NegGram) and experiencing photophobia and diplopia. Which instruction should a nurse provide the patient?


A Wear prescription sunglasses.
B Restrict driving temporarily.
C Wear nonskid footwear.
D Avoid daytime activities.
B
The nurse is working with a patient who has a UTI. Because patient adherence to a medication regimen is a concern, the nurse anticipates use of which medication?


A Fosfomycin
B Amoxicillin
C Cephalexin
D Trimethoprim
A
Which outcomes should a nurse establish when planning care for a patient taking methenamine (Mandelamine)? (Select all that apply.)

A Maintains a urine pH of 5.5 or lower
B Consumes 3000 mL of liquid daily
C Uses an enteric-coated formulation
D Avoids sulfonamide medications
E No elevation in liver enzymes
ACD
A nurse assesses the history of a patient who has had multiple complicated UTIs for which risk factors? (Select all that apply.)

A Female gender, child-bearing age
B Indwelling catheter
C Prostate hypertrophy
D Fair skin tone
E Urinary tract stones
BCE
The nurse identifies which statements about frequent urinary tract reinfections as true? (Select all that apply.)

A Reinfections are considered frequent if the individual has three or more a year.
B Prophylactic therapy should continue for at least 2 months.
C If reinfection is associated with sexual intercourse, the risk can be reduced by instructing the patient to void after intercourse.
D Single-dose nitrofurantoin 50 mg taken 1 hour before intercourse has been found to reduce the rate of reinfection.
E If a symptomatic episode occurs, the standard therapy for acute cystitis should be used.
CE
. After completing a course of ciprofloxacin (Cipro) for a skin infection, the patient says, “I took the whole bottle of pills, but my infection hasn’t gotten any better.” Which additional information should the nurse recognize as most significant?


A The patient takes antacids on a daily basis.
B The medication was stored in a cool, dry area.
C The patient did not use sunscreen while taking the ciprofloxacin (Cipro).
D The patient took two doses of diphenhydramine (Benadryl) while on ciprofloxacin (Cipro) therapy.
A
The nurse identifies which medication as posing a significant risk of causing confusion, somnolence, psychosis, and visual disturbances in elderly patients?


A Metronidazole (Flagyl)
B Rifampin (Rifadin)
C Ciprofloxacin (Cipro)
D Daptomycin (Cubicin)
C
Which approach should a nurse take when administering an oral dose of levofloxacin (Levaquin)?


A Give the medication with or without food.
B Administer the drug with an oral dose of a magnesium-based antacid.
C Premedicate the patient with diphenhydramine (Benadryl).
D Administer the drug with milk products.
A
A patient who takes ciprofloxacin (Cipro) and runs 6 miles daily tells a nurse about heel and calf tenderness. The nurse instructs the patient to take which action?


A No action is needed, because this is a temporary but expected side effect.
B Continue the antibiotic with an anti-inflammatory medication.
C Slow the running pace and walk more.
D Discontinue the medication, because severe damage can result.
D
A patient is taking daptomycin (Cubicin). The nurse should obtain a creatine phosphokinase (CPK) level when the patient shows what?


A Increased urination and urinary urgency
B Muscle pain and weakness
C Abdominal bloating and diarrhea
D Headache and visual disturbances
B
A patient who takes multiple antibiotics starts to experience diarrheal stools. The nurse anticipates administration of which antibiotic if a stool sample tests positive for Clostridium difficile?


A Rifaximin (Xifaxan)
B Metronidazole (Flagyl)
C Daptomycin (Cubicin)
D Gemifloxacin (Factive)
B
The nurse identifies rifampin as useful in the treatment of which disorders? (Select all that apply.)

A Tuberculosis
B Active meningococcal infection
C Leprosy
D Prophylaxis of meningitis caused by Haemophilus influenzae
E C. difficile infection
ACD
. A nurse is teaching a patient who is scheduled to start taking itraconazole (Sporanox). Which statement by the patient would indicate understanding of the teaching?


A “I’ll take diphenhydramine (Benadryl) before this medication so I don’t have a reaction.”
B “It’s important to remember to wear sunscreen while taking this medicine.”
C “I’ll avoid citrus foods, such as oranges and grapefruits, while taking this medication.”
D “If I notice my skin turning yellow or feel any nausea, I’ll notify my healthcare provider.”
D
A nurse planning care for a patient who is receiving nystatin (Mycostatin) should establish which outcome on the care plan?


A Relief of nasal congestion
B Decrease in mouth pain
C Productive cough
D Absence of urticaria
B
A patient is scheduled to receive intravenous amphotericin B. Which medication should a nurse administer as pretreatment before the infusion?


A 10 units of regular insulin intravenously
B 20 mg famotidine (Pepcid) in 50 mL of 5% dextrose
C 50 mg of diphenhydramine (Benadryl) and 650 mg of acetaminophen
D 1 g of calcium gluconate in 100 mL of normal saline
.
C
Which antifungal agent is used as a one-time oral dose to treat vaginal yeast infections?


A Nystatin (Mycostatin)
B Caspofungin (Cancidas)
C Voriconazole (Vfend)
D Fluconazole (Diflucan)
D
A nurse is administering an oral dose of itraconazole (Sporanox) to a patient at 10:00 AM. The nurse should administer a prescribed dose of famotidine (Pepcid) at which time?


A 9:00-9:30 AM
B 10:00 AM
C 10:30 AM
D 11:00 AM
A
It is most important for the nurse to assess a patient taking itraconazole (Sporanox) for the development of what?


A Hair loss
B Skin rash
C Pedal edema
D Joint pain
C
A patient is receiving amphotericin B. It is most important for the nurse to monitor which laboratory result?


A Serum pH
B Protein level
C Glucose level
D Creatinine level
D
When providing teaching for a patient starting flucytosine (Ancobon) therapy, the nurse identifies what as the priority concern?


A “You will have weekly blood draws to monitor your liver function.”
B “Another very strong medication may be needed in addition to this one.”
C “You’ll need to report any symptoms of bruising, fever, and fatigue.”
D “The dose is 10 pills, so take a few at a time over a 15-minute interval.”
C
A patient is receiving amphotericin B. The nurse identifies which medication as useful in preventing adverse effects of amphotericin B?


A Furosemide (Lasix)
B Insulin
C Vitamin K
D Potassium
.
C
The nurse identifies terbinafine (Lamisil) as useful for treating which conditions? (Select all that apply.)

A Onychomycosis
B Tinea corporis
C Oropharyngeal candidiasis
D Vulvovaginal candidiasis
E Tinea pedis
ABE
. A nurse develops a plan of care for a patient who has an outbreak of recurrent genital herpes and is taking oral acyclovir (Zovirax). Which outcome should be included?


A Minimal scarring from lesions
B Less frequent eruption of lesions
C Prevention of transmission to contacts
D Complete eradication of the virus
B
Which approach should a nurse take to administer intravenous (IV) acyclovir (Zovirax) to an immunocompromised patient?


A Infuse IV fluids during administration of the dose and for 2 hours afterward.
B Administer IV acyclovir diluted in 20 mL normal saline (NS) over 10 minutes.
C Only infuse the drug if the white blood cell (WBC) count is above 2500/mm3.
D Ask the provider to change the route to subcutaneous (subQ) injection.
A
A nurse is preparing to administer ganciclovir (Cytovene) to a patient for treatment of Cytomegalovirus (CMV) pneumonitis. Which laboratory result should the nurse recognize as a contraindication to use of this drug?


A Neutrophil count below 500/mm3
B Platelet count of 350,000/mm3
C Serum calcium level of 9.5 mg/dL
D Reduced forced vital capacity (FVC)
A
A patient is receiving weekly subcutaneous injections of peg-interferon-alfa-2a (Pegasys) for chronic hepatitis C. A nurse teaches the patient that which adverse effect will diminish with continued therapy?


A Black, sticky, tarry stools
B Lower leg muscle weakness
C Dyspnea and wheezing
D Flulike symptoms
D
What is the priority instruction a nurse gives to a male patient who is scheduled to receive ribavirin (Rebetol) combined with peg-interferon-alfa-2a for treatment of hepatitis C?


A “Combining these two medications will greatly increase response rates.”
B “An antidepressant can be prescribed to alleviate symptoms of depression.”
C “If you are sexually active, use two reliable forms of birth control to prevent pregnancy.”
D “It is very important that you have blood counts checked every 2 weeks.”
C
A nurse should recognize that for maximum therapeutic effects against the influenza virus, oseltamivir (Tamiflu) should be taken when?


A Two days or more after symptom onset
B When lung crackles are present
C Within 12 hours of symptom onset
D Only when fever is above 102°F
C
A nurse is providing teaching to a group of patients regarding flu season in the United States. Which statement should the nurse include in the teaching?


A In the United States, flu season usually peaks in October or November.
B To insure full protection, the best time to vaccinate is September.
C For people who missed the best time, vaccinating as late as April may be of help.
D The influenza vaccine may not be administered at the same time as the pneumococcal vaccine.
C
The nurse identifies which medication as the drug of choice for most infections caused by herpes simplex viruses and varicella-zoster virus?


E Ganiciclovir
F Amantadine
G Acyclovir
H Oseltamivir
C
.
A nurse administering flu vaccines at an annual clinic should recognize that which individuals should be vaccinated, as recommended by the Advisory Committee on Immunization Practices (ACIP)? (Select all that apply.)

A Women who will be pregnant during flu season
B All children 6 months and older and older adults
C Those who report severe allergy to chicken eggs
D Those who have a history of Guillain-Barré syndrome
E Those 6 months to 18 years old receiving aspirin therapy
ABE
A patient has been diagnosed with respiratory syncytial virus. The nurse anticipatates administration of which drug(s)? (Select all that apply._

A Ganciclovir
B Oseltamivir
C Ribavirin (inhaled)
D Palivizumab
E Entecavir
CD
When teaching a patient about therapy with Famciclovir, which statement(s) does the nurse include? (Select all that apply.)

A Famciclovir is generally well tolerated.
B Famciclovir is safe to use during pregnancy.
C Famciclovir is administered intravenously.
D Famiciclovir is used in the treatment of acute herpes zoster.
E Famiciclovir is contraindicated in the treatment of herpes simplex genitalis.
AD
. A patient who has type 2 diabetes has a glycated hemoglobin A1c (HbA1c) of 10%. The nurse should make which change to the nursing care plan?


A Refer the patient to a diabetes educator because the result reflects poor glycemic control.
B Glycemic control is adequate; no changes are needed.
C Hypoglycemia is a risk; teach the patient the symptoms.
D Instruct the patient to limit activity and weekly exercise.
A
A patient who has type 2 diabetes is taking nateglinide (Starlix). Which response should a nurse expect the patient to have if the medication is achieving the desired therapeutic effect?


A Inhibition of carbohydrate digestion
B Promotion of insulin secretion
C Decreased insulin resistance
D Inhibition of ketone formation
B
Which instruction should the nurse provide when teaching a patient to mix regular insulin and NPH insulin in the same syringe?


A “Draw up the clear regular insulin first, followed by the cloudy NPH insulin.”
B “It is not necessary to rotate the NPH insulin vial when it is mixed with regular insulin.”
C “The order of drawing up insulin does not matter as long as the insulin is refrigerated.”
D “Rotate subcutaneous injection sites each day among the arm, thigh, and abdomen.”
A
A patient is scheduled to start taking insulin glargine (Lantus). On the care plan, a nurse should include which of these outcomes related to the therapeutic effects of the medication?


A Blood glucose control for 24 hours
B Mealtime coverage of blood glucose
C Less frequent blood glucose monitoring
D Peak effect achieved in 2 to 4 hours
A
A patient who took NPH insulin at 0800 reports feeling weak and tremulous at 1700. Which action should the nurse take?


A Take the patient’s blood pressure.
B Give the patient’s PRN dose of insulin.
C Check the patient’s capillary blood sugar.
D Advise the patient to lie down with the legs elevated.
C
A teaching plan for a patient who is taking lispro (Humalog) should include which instruction by the nurse?


A “Inject this insulin with your first bite of food, because it is very fast acting.”
B “The duration of action for this insulin is about 8 to 10 hours, so you’ll need a snack.”
C “This insulin needs to be mixed with regular insulin to enhance the effects.”
D “To achieve tight glycemic control, this is the only type of insulin you’ll need.”
A
A patient newly diagnosed with type 1 diabetes asks a nurse, “How does insulin normally work in my body?” The nurse explains that normal insulin has which action in the body?


A It stimulates the pancreas to reabsorb glucose.
B It promotes the synthesis of amino acids into glucose.
C It stimulates the liver to convert glycogen to glucose.
D It promotes the passage of glucose into cells for energy.
D
A patient is taking glipizide (Glucotrol) and a beta-adrenergic medication. A nurse is teaching hypoglycemia awareness and should warn the patient about the absence of which symptom?


A Vomiting
B Muscle cramps
C Tachycardia
D Chills
C
A nurse assesses a patient who is taking pramlintide (Symlin) with mealtime insulin. Which finding requires immediate follow-up by the nurse?


A Skin rash
B Sweating
C Itching
D Pedal edema
B
Before administering metformin (Glucophage), the nurse should notify the prescriber about which laboratory value?


A Creatinine (Cr) level of 2.1 mg/dL
B Hemoglobin (Hgb) level of 9.5 gm/dL
C Sodium (Na) level of 131 mEq/dL
D Platelet count of 120,000/mm3
A
A nurse caring for a patient who has diabetic ketoacidosis recognizes which characteristics in the patient? (Select all that apply.)

A Type 2 diabetes
B Altered fat metabolism leading to ketones
C Arterial blood pH of 7.35 to 7.45
D Sudden onset, triggered by acute illness
E Plasma osmolality of 300 to 320 mOsm/L
BDE