1

ANTI INFECTIVE DRUGS

REMEMBER: 1. 2. 3. 4. Microorganism must be isolated and isentified through culture. Susceptibility to various drugs must be determined. The location of the infection should be considered. Cost of drug must be considered.

ANTIBACTERIAL DRUGS

a. Aminoglycosides
Effects as BACTERICIDAL (kills bacteria) against Gram (-) bacilli Some aerobic gram (+) bacteria Mycobacteria Some protozoa

Drugs commonly Used

Amikacin sulphate Gentamicin sulphate Kanamycin sulphate neomycin sulphate paromomycin streptomycin tobramycin sulfate

Kills bacteria by binding to the bacterium 30S subunit, a specific ribosome in the microorganism, thereby interrupting protein synthesis and causing the bacterium to die. When some there is a resistant gram positive bacteria to aminoglycosides, PENICILLIN is used as combination therapy to aminoglycosides. This is to alter the bacterial cell wall and allowing aminoglycoside to penetrate the bacterial cell membrane.

Uses Caution!: Infections caused by Gram negative Bacteria Serious nosocomial infections UTI Infection of the CNS and the eye Treats gram positive bacteria such as staphylococcal or enterococcal infections( with the help of Penicillin) Patient with PTB

Don t mix penicillin and aminoglycoside drugs in the same container or IV line because of its reduced effectiveness.

Don t use aminoglycosides with neuromuscular blocker. It increases neuromuscular blockade. Renal toxicity will happen when given with Ampothericin B or acyclovir. Ototoxicity when given to pt using loop diuretic.(may be irreversible)

Side Effects - Neuromuscular reactions - Ototoxicity - Renal toxicity - N/V

Diarrhea

b. Penicillins
Most impotant and usefullantibacterials 4 Groups: 1. Natural Penicillins (Pen Gbenzathine, Pen G K, Pen G procaine, Pen G Na, Pen V K. 2. Penicillinase- resistant penicillins ( dicloxacillin, nafcillin, oxacilin 3. Aminopenicillins ( amoxicillin, ampicillin) 4. Extend- spectrum penicillins( carbanicillin, ticarcillin.) They Bind reversibly to several enzymes outside the bacterial cytoplasmic membrane. The penicillin Binding Proteins or the PBP s are involved in cell wall synthesis and cell devision. That causes distruction of the cell. It is used to treat infections caused by gram positive and negative,anaerobic organisms. Its given IM when pt. s compliance is questionable.

Uses Caution! -

It lessen the effectiveness of the Hormonal contaceptives. It increases the bleeding risk of anticoagulant.

Side Effects - Anaphylactic reactions - various rashes - Serum sickness - Drug fever - Tongue inflammation for oral meds - N/V - Diarrhea - Liver toxicity

c. Cephalosporins
1. 2. 3. 4. - Grouped in 4 Generations First Generation ( cefadroxil, cefazolin Na, Cephalexin monohydrate. Second Generation (Cepahalosporine like cefaclor, cefprozil, cefoxitin, cefuroxime,axetil, and cefuroxime Na. Third Generation ( cefdinir, cefixime, cefotaxime Na, cefpodoximeproxetil, ceftazidime, ceftibuten, ceftriaxone Na) Fourth Generation ( cefepimeHcl.) One who has allergy to penicillin has a great possibility that they could be allergic to cephalosporins too because thaey both have beta lactam molecular structure. Cephalosporines inhibit cell wall synthesis by binding to the bacterial Enzymes known as PBP s located on the cell membrane. After the drug damages the cell wall by binding with the PBP s, the body s natural defense mechanism destroy the bacteria.

USES 1st generations is used against gram positive organisms, alternative therapy to patient allergic to penicillin depending on how sensitive to penicillin he is. Patient with pneumonia, skin infections and bone infections. 2nd Generations is used to gram negative bacteria, and anaerobes. 3rd generations used for gram negative organisms for infections caused by Enterecobacter,P. aeroginosa , and anaerobic organism. 4th Generation used agains gram positive and negative bacteria.

3 Caution! -

Alcohol ingestion 72 hours after cephalosporin may experience alcohol intolerance (headache, flushing, dizziness, N/V or abdominal cramps 30 minutes of alcohol ingestion) Reaction occurs also 3 days after discontinuing the therapy. Can decrease the effect or hormonal contraceptives. Decreased excretion of cephalosporines when taken with anti gout.

Side Effects - Confusion - hive - itching - Seizures - measles type rash - Bleeding, - serum sickness - N/V - anaphylaxis - Diarrhea

d. Tetracyclines
Has 2 Classification 1. Intermediate acting demeclocycline 2. Long Acting doxycycline hyclate and minocycline hydrochloride. This is used to inhibit the multiplication and growth of bacteria by penetrating the bacterial cell by an energy dependent process. Within the cell they bind primarily to a subunit of the ribosome, inhibiting the protein synthesis needed to maintain the bacterial cell.

Uses. Used againsts gram positive and gram negative aerobic and anaerobic bacteria ( spirochetes, mycoplasma, ricketsiae,chlamydiae, and some protozoa.) Used to treat rocky mountain spotted fever, Q fever, and lyme disease, infection caused by Chlamydia and ureaplasma, treatment of brucellosis. In low dosage used to treat acne because it is effective in decreasing the fatty acid content of the sebum.

Caution! Reduced the effectiveness of the hormonal contraceptives Decrease the antibacterial effect of the penicillin, antacid decrease its effectiveness of the tetracylines.

Side Effectsn Superinfection - N/V Abdominal distress and distension Diarrhea Photosensitivity Liver and renal toxicity

e. Lincomycin derivatives
Used for many gram positive and anaerobic organism Less effective than clindamycin and it is rarely used Shouldn t be used to minor infections but for acute infections who s allergic to other antibiotics. Inhibits bacterial protein sentizies by inhibiting the binding of bacterial ribosome at therapeutic concentration. Clindamycin

USES Used against gram (+) bacteria, including staphylococci, streptococci except enterococcus fecalis and pneumococci. Effective to treat anaerobic intra-abdominal, pleural, or pulmonary infections caused by bactriodesfragilis. Used as alternative to penicillin andin treating clostridium perfringens infections.

Caution! Has neuromascular blocking effect. Don t use with other neuromuscular blocker. This can lead to respiratory depression.

Side Effects Pseudo membranous colitis (fatal, needs discontinuation and flid and electrolyte management, diarrhea may occur, stomatitis, n/v, hypersensitivity reaction.

f. Macrolides
Erythromycin estolate Erythromycin ethylsuccinate -erythromycin lactobionate - erythromycin stearate - azithromycin - clarithromycin

Is entericoated to protect from gastric acid distruction, beacause it needs to be absorbed in the dedounum. This drug inhibits the RNA dependent of ribosome, synthesis by acting on a small portion of the ribosome , much like clindamycin.

Uses - Used against gram positive and negative bacteria, inclusing mycobacterium Treponema, mycoplasma and, chlamydia. - Also effective in pneumococci and group A streptococci. Staphylococcus aureus. - Used to treat infections mycoplasma pneumonia and pneumonia caused by legionella pneumophila. - Used to pt with gonorrhoea and syphilis who can t tolerate Penicillin G. or tetracyclines. - Used to treat minor staphylococcal infection of the skin. - Used in many pneumococcal infections. Caution! May increase teophyllin effects that can lead to toxicity, and increase concentration of arbamazepin when used together.

Side Effects - Epigastric distress, N/V, diarrhea, rash, fever, eosinophilia, anaphylaxis.

g. Vancomycin
VancomycinHcl Used to treat methicillin resistant S. aureus. It should be used only when culture and sensitivity test results confirm the need for it. Oral and IV administration of this drugs should not be interchangeable. This drug inhibits bacterial cell wall synthesis, damaging the bacterial plasma membrane. When the bacterial cell wall is damaged, the body s natural defence can attack the organism.

Uses used against gram positive organism such as S. aureus, S. epidermidis, S. pyogenes, enterococcus and S. pneumoniae. Used to patient with serious resistant staphylococcal infection whoshypercensitive to penicillins. Oral route is used to treat pt. with clostridium defficile colitis who respond poorly to metronidazole. When used with aminoglycoside used as treatment for pt. infected with E faecalis endocarditis that is again allergic to penicillin.

Caution! Toxicity may occur when administered with other dug such as aminoglycosides, ampothericin B, bacitracin, cisplatin, colistin, and plymyxin B. Should be given very slow IV.

Side Effects Anaphylactic reactions, drug fever, eosinophilia, neutropenia, hearing loss in excessive use. Sever hypotension may occur when given rapid IV administration, accompanied with red rash with flat and raise lesions on the neck, face, chest and arms ( redman s syndrome).

h. Carbapenems
Uses. Side effects N/V, diarrhea, hypersensitivity reaction, Kidney problem. Effective against aerobic gram positive species such as streptococcus, S aureus, and S. epidermidis. Inhibits the enterobacter species, inhibits P. aeruginosa and most anaerobic species including B fragilis. Also treats serious health care acquired infections in immunocompromised patients. Abdominal infections and meningitis. Intra abdominal, skin, urinary tract, gynecologic infections, as well as CAP. Ertapenem Imipenemcilastatin Na Meropenem Used for serious or life threatening infection, especially gram positive and negative health care acquired infections. These drug inhibits the bacterial cell wall synthesis.

I.
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Monobactams
Aztreonam ( only one and currently available) Inhibits bacterial cell wall synthesis. It binds the PBP-3 of susceptible gram negative bacterial cells, inhibiting cell wall devision and resulting to lysis.

Uses

Effective against a wide variety of gram negative aerobic organisms, including P. aeruginosa, E coli, Ebterocobacter, klebsiella pneumonia, K. oxytoca, Proteus mirabilis, Serriatiamarcescens. H.influenzae, and citrobacter. Also used in UTI s, secpicemia, lower respiratory tract, skin, and skin structure, intra abdominal, andgynecologic infections.

Side Effects Diarrhea Hypersensitivity and skin reactions, hypotensions, N/V, Trancient ECG changes, transient incease in serum liver enzyme.

j.Flouroquinolones
- Ciprofloxacin - Levofloxacin -moxifloxacin - norfloxacin - ofloxacin

This interrupts DNA synthesis during bacterial replication by inhibiting DNA gyrase, an essential enzyme of replicating DNA. As a result bacteria can t reproduce.

Uses Treats UTI s, respiratory tract infection, infectious diarrhea, skin, bone and joint infections, acute bacterial sinusitis, mils CAP, prostatitis, selected STD s.

CAUTION! Side Effects Dizziniess, N/V, Diarrhea, abdominal pain. MODERATE to severe phototoxic reactions direct or indirect sunlight. Use cautiously to pt. under anti arrythmics Could cause toxicity if given with the same family of drug Antacids may decrease absorption of these drugs.

k. Sulfonamides
Cotrimoxazole - sulfadiazine Effective systemic antibacterial This is bacteriostatic, prevents bacterial growth by inhibiting folic acid production. The dcreae of folic acid syhtesis decrease also the number of bacterial nucleotides and inhibits bacterial growth.

Uses Treats acute UTI Also used to pt infected with gram positive and negative bacteria

Caution!

7 Side Effects Crystals in the urine, Hypersensitivity reaction Serum sickness, fever, joint pain, hives bronchospasm, leukopenia and photosensitivity. Has hypoglycaemia effect Can develop crystal in the urine Increase the anticoagulant effect of anticoagulants Increase riusk of kidney toxicity

L. Nitrofurantoin
- Usually bacteriostatic, nitrofurantoin may become bactericidal, depending on its urinary concentration and the susceptibility of the infecting organism. - Has unkbown mechanism of action. But it is said to disrupt bacterial cell wall formation. Uses Caution! Side Effects GI irritation, anorexia, N/V, diarrhea, dark yellow or brown urine, abdominal pain, chills fever, joint pain, anaphylaxis, headache and hypersensitivity reactions. Reducing efficacy and toxicity when given with sulfinpyrazone Effect of this drug is reduced with antacids Decrease effectiveness of other antibacterials such as norfloxacin. Treats UTI s, effective also in systemic infections

ANTI VIRAL DRUGS

USED TO TREAT AND PREVENT VIRAL INFECTIONS ranging from influenza, to HIV

a. Synthetic Nucleosides
Acyclovir, famciclovir, graniclovir, valacyclovir, valganciclovir. This drug enters virus infected cells where it is changes through series of steps. The acyclovir triphosphate inhibits virus specific DNA polymerase, an enzyme necessary for viral growth, thus disrupting viral replication. On cytomegalo virus ganciclovir once entered in the cell it is converted to ganciclovir triphosphate inhibits Viral DNA synthesis. Famiclovirenetersviaral cell and it inhibits DNA polymerase, viral DNA synthesis and thus viral replication, and the rest f the antiviral drug do the same thing.

Uses treats infections caused by herpes viruses, including HSV type 1 and 2 and the varicella zoater virus. Shingles, chickenpox, CMV, AIDS, HIV and encephalitis.

Caution! In taking these drugs to other drug such as probenecid this could cause toxicity. It inhibits replication of rapidly dividing cells in the bone marrow, GI tract, skin, and sperm producing cell specially when given with drugs that damage tissue cells such as dapsone, ampothericin B, cotrimoxazole. It could also cause seizure. And could cause anemia in long term use of zidovoudin.

Side Effects -

Kidney impairment when administered in fast IV, headache, nausea, vomiting and diarrheahypersensitivity reaction, anemia, insomnia, seizures,retinal detachment, sepsis, abdominal pain, anemia.

b. Pyrophospate analogues
- foscarnet - prevents viral replication by selectively inhibiting DNA polymerase. Uses Used in treating CMV retinitis in the pt. with AIDS. Used as combination therapy with cyclovir for the pt. who has relapsed with either drug.

Caution! Toxic to kidneys and can cause hypocalcemia.

Side Effects Fatigue, depression, fever, confusion, headache, numbness, tingling, dizziness, and seizures, n/v, diarrhea, abdominal pain, granulocytopenia, leukopenia, anemia, involuntary muscle contraction and neuropathy, breathing difficulties, coughing, rash, altered kidney function, electrolyte disturbances.,

c. Influenza A and syncytial virus drugs.

- amantadine -rimantadine - ribavirin

- amantadine appears to inhibit an early stge of viral replication, rimantdine inhibits RNA AND PROTEIN SYNTHESIS. The last inhibits viral DNA and RNA synthesis subsequently halting viral replication. Uses Used to prevent and treat respiratory infections caused strains of influenza A virus.

Ribavirin is used to treatsevere RSV infection in children, also used in adults in combination with interferon alfa 2B for treatment of chronic hepatic C. These also protects patient who has received the influenza vaccine during the first 2 weeks needed for immunity to develop as well as the pt. who can t take the influenza vaccine because of hypersensitivity.

Remember amantadine is also used to pt with parkinsonism and drug induced extrapyramidal reactions. Side Effects Anorexia, anxiety, confusion, depression, forgetfulness, dizziness, fatigue, hallucinations, hypersensitivity reactions, insomnia, irritability, nausea, nervousness, psychosis. (rimantidine has Less reaction.) ribavin: apnea, cardiac arrest, hypotension, nausea, pneumothorax, worsening of respiratory function.

d. Nucleoside analogue reverse transcriptase inhibitors

- abacavir, didanosine, emtricitabine,lamivudine, stavudine, zidovudin - Zidovudin is the first drug that receives FAD approval. - abacvir works by inhibiting the activity of HIV 1 transcriptase, by competing with the natural component and incorporating into the viral DNA. - Didanosine blocks HIV replication - Entricitabime inhibits Viral DNA replication - lamivudine and stavudin also inhibits viral DNA replication - zodovudine prevents viral DNA replication. Uses Caution - Can Cause hepatomegaly with steatosis and common in women. - Kidney toxicity, profound lethargy and drowsiness. Side Effects - Blood related reactions, headache dizziness, muscle pain, fever, rash, N/V, abdominal pain and diarrhea. - Stomatitis unusual tase loss, dry mouth, pancreatitis - Peripheral neuropathy, dizziness, muscle weakness, hair loss, and potentially hypersensitivity reaction. Used to treat HIV and AIDS.

e. Non nucleoside reverse transcriptase inhibitor

Uses Used in combination with other antiretrovirals in HIV treatment; nevirapine is specifically indicated for the patient whose clinical condition and immune status have deteriorated. Delavirdine -efavirenz -nevirapine Delavidine and nevirapineBinds to reverse transcriptase enzyme, preventing it from it from exerting its effect, and thus preventing HIV replication. Efavirenz competes for the enzyme through non-competitive inhibition.

Caution! - May cause allergic reaction and it may reduce the effect of hormonal contraceptive. - Decrease effectiveness of 1 NNRTI when used together at the same time. Side Effects - Headache, dizziness, asthenia, nausea and vomiting, diarrhea and rash.

f. Neuclotide analogue reverse transcriptase inhibitors

Uses Used in combination to treat HIV infection Tenofovir is the only drug in this class It competes with substrates and is subsequently incorporated into the DNA and halting HIV replication.

10 Caution! - Severe hepatomegaly with steatatosis, fatal lactic acidosis may occur. - Suspend treatment if patient has pre-existing and existing liver disease. Side Effects - N/V, diarrhea, anorexia, abdominal pain, severe hepatomegaly and lactic acidosis.

g. Protase inhibitors
Uses Caution! Used with combination with other antiretroviral agents for the treatment of HIV infection. Use cautiously with other drugs, because of the sensitivity for toxicity and may experience adverse reactions and it can cause vision changes. Amprenavir - atazanavir - darunavir - frosamprenavir Indinavir sulphate - lopinavir and ritonavir - squinavirmesylate -tipranavir Inhibits the activity of HIV protease and prevent the cleavage of viral polyproteins.

Side Effects - Abdominal discomfort, abdominal pain, acid regurgitation, anorexia, back pain, deep vein thrombosis, depression, diarrhea, dizziness, dry mouth, encephalopathy, fatigue, flank pain, headache, hemorrhagic colitis, hypercholesterolemia, hyperglycemia, hypertriglycerimia, leukopenia, insomnia, muscle weakness, n/v, pancreatitis, tastepervertion.

ANTI TUBERCULAR DRUGS

Rifampin Isoniazid Pyrazinamide Ethambutol Streptomycin These drugs are specific for mycobacteria. They inhibit the growth of M, tuberculosis, and arrest the multiplication, replication and cell death.

Uses Isoniazid usually used with ethambutolrefampin or pyrazinamide this because compbination therapy for TB and other MIcobacterialinfectuions can prevent or delay the development of resistance.

Remember! Patient may experiencebody weakness and poor appetite on the first 2 weeks of medication. But tell the patient that it is one of the effects of the drug. May advice to have small frequent feeding and never stop the medication. Once stopped patient will start medication from the beginning.

Side Effect Etambutol (itching, joint pain, GI distress, malaise, leukopenia, headache, dizziness, numbness and tingling of the extremities, optic neuritis, and confusion may occur. May produce rash and fever.

11 Caution! Isoniazid effect is decreased when taken together with corticosteroid. Isoniazid also increases the level of other drugs that may lead to toxicity like phenytoin, diazepam, theophylline and warfarin. Isoniazid (peripheral neuropathy, severe and occasional hepatitis may occur months after treatment has stopped. Rifampin(Epigastric pain, N/V, abdominal cramps, flatulence, anorexia and diarrhea. Pyrazinamide (Liver toxicity, GI disturbance, N/V, hyperuricemia, arthralgia, and anorexia.

ANTIMYCOTIC DRUGS
Used to treat fungal infections Amphotericin B Nystatin Amphotericin B works by binding to sterol (lipid) in the fungal cell membrane, altering cell permeability( ability to allow a substance to pass through) allowing intracellular components to leak out. Nystatin binds to sterols in fungal cell membranes and alters the permeability of the members, leading to loss of cell components.

a. Polyenes

Uses Amphotericin B treats systemic fungal infections and meningitis caused by fungi sensitive to the Drug. But it s never used for noninvasive forms of fungal disease because its highly toxic. Treats infection caused by Candida,Paracoccidioidesbrasiliensis, Blastomycesdermatitidis, coccidioideimmitis, Cryptococcus neoformans, and sporothrixachenkii. Also effective in Aspergillusfurmigatus. Microsporum, audoinii, rhizopus, candida glabrata, trichophyton, and rhodotorula Nystatinis used primarily to treat candidal skin infections. Mucous membrane infections such as oral thrush, diaper rash, vaginal and vulvar candidiasis, and candidiasis between skin folds. Oral Nystatin is used for GI infections.

Caution! Side Effect NYSTATINE may cause :Diarrhea, N/V, abdominal pain, bitter taste, skin irritation, hypersensitivity. Amphotericin B chills, fever, N/V, anorexia, muscle and joint pain, indigestion, anemia and kidney toxicity. Aminoglycosides , cyclosporine, acyclovir + Amphotericin B = Kidney toxicity Nondepolarizing skeletal muscle relaxants+ Amphotericin B = increased muscle relaxation

b. Flucytosine
Flucytosine is the only antimetabolite Penetrates fungal cells, where it s converted to its active metaboilite fluorouracil, then it is incorporated into the RNA of the fungal cells, altering their protein synthesis and causing cell death.

12 Uses Ampothericin B is used to treat candida and cryptococcal meningitis alone, flucytosine is given to reduce the dosage and the risk of toxicity. Combination therapy is used to treat cryptococcal meningitis. Flucytosine is used to treat candida infections of the lower urinary tract. Also effective in treating infections caused by T. Glabrata, phialophora, Aspergillus, and cladosporium.

Caution! Side effect Confusion, headache, drowsiness, vertigo, hallucinations, DOB, respiratory arrest, rash, N/V, abdominal distension, diarrhea, and anorexia. Watchout for toxicity. Cytarabine antagonize the effect of the antifungal drug.

c. imidazole
Ketoconazole, the most commonly used imidazole Interferes with the sterol synthesis, damaging, the cell membrane, and increasing its permeability. This leads to a loss of essential intracellular elements and inhibition of cell growth.

Uses Used to treat topical and systemic infections caused by susceptible fungi, which include dermatophytes and most other fungi.

Remember! When pt. is taking antacid and imidazole be sure to take imidazole 2 hours after taking antacids. Liver toxicity may occur to pt. taking liver toxic drugs. Hemorrhage can occur when pt is taking anticoagulants. Side Effects Anaphylaxis, joint pain, chills, fever, ringing in the ears, impotence, photophobia, liver toxicity after drug is stopped but it is reversible.

d. Synthetic triazoles
Fluconazole, Itraconazole Voriconazole Fluconazole Inhibits fungal cytochrome P-450, AN ENZYME RESPONSIBLE for fungal sterol synthesis, causing fungal cell walls to weaken. Itraconazole and voriconazol interfere with fungal cell wall synthesis by inhibiting the formation of ergosterol and increasing cell wall permeability, making the fungus susceptible to osmotic instability.

Uses Fluconazole Used to treat mouth, throat, and esophagial candidiasis and serious systemic candida infections, including UTI s, peritonitis, and pneumonia. Also used to treat cryptococcal meningitis.

13 Intraconazole is used to treat blastomycosis, non menongalhistoplasmosis, candidiasis, aspergillosis, and serious fungal infection,.

Caution! May increase bleeding when taken with anti coagulants. May increase possible toxicity when given to anti Tb drug and other anti viral drug such as zidovudin.

Side Effects Fluconazole = abdominal pain, diarrhea, dizzioness, headache, elevated liver enzyme level, N/V, rash. Itraconazole= dizziness, headache, hypertension, impaired liver function, nausea. Voriconazole= Vision disturbance, fever, chills, headaches, tachycardia, n/v, rash, elevated liver enzyme.

e. Glucan synthesis inhibitors

Caspofungin Used to ptwhos not responding to Ampothericin B treatment or itraconazole. Caspofungin inhibits the synthesis of beta (1,3) D glucan, an integral component of the fungal cell wall.

Uses Used to treat invasive aspergillosis in the patient wjo hasn t responded to, or can t tolerate, other antifungals. It hasn t been studied as an initial treatment for invasive aspergillosis.

Side Effcets Paresthesia, tachycardia, tachypnea, N/V, diarrhea, rash, facial swelling.

f. Synthetic allylamine derivatives

Terbinafine Thought to inhibit squaleneepoxidase, which blocks the biosynthesis of ergosterol, an essential component of fungal cell membranes.

Uses Side Effect Headache, visual disturbance, nausea, diarrhea, abdominal pain, neutropenia, Stevens Johnson syndrome. Used to treat tineaunguium fungal infections of the fingernail or toenail.

g. Drotrecoginalfa
Drotrecoginalfa, the first FDA- approved rhACP drug, is used to treat severe sepsis in adult patients with acute organ dysfunction when they are at risk for death.

14 It works by producing dose dependent reductions in D-dimer and interleukin-6. Activated protein C exerts anti thrombotic effect by inhibiting factors Va and VIIIa.

Uses Used to treat adults who have severe sepsis associated with acute organ dysfunction and who have a high risk of death. The drug has antithrombotic, and anti-inflammatory, and fibronolytic properties.

Caution! Contraindicated in patients who are hypersensitive to the drug or any of its components. It s also contraindicated in patients with active internal bleeding and those who have had hemorrhagic stroke in the Past 3 months or intracranial or intraspinal surgery in the past 2 months. In addition, the drug is contraindicated in patients with severe head trauma, trauma with increased risk of life threatening bleeding, an epidural catheter, an intracranial neoplasm or mass lesion, or cerebral herniation.

Side Effects Bleeding, ecchymosis and GI bleeding.