CH 7

Chapter 7
Antimicrobial Agents
Anti-infective Therapy
Modern age
Discovery of sulfanilamide in 1936 Commercial introduction of penicillin in 1941
7-2
Copyright 2007 Thomson Delmar Learning, a division of Thomson Learning Inc. All rights reserved.
Antimicrobial Therapy
Original antimicrobials: derived from microorganisms Newer agents: chemically synthesized
7-3
Factors Leading to Infection
Age: young and elderly Increased exposure to pathogenic organisms Disruption of the normal barriers Inadequate immunological defenses Impaired circulation Poor nutritional status
7-4
Sources of Infection
Bacteria Fungi Viruses
7-5
Administering Antimicrobial Agents
Consider the following:
Location of the infecting organism in the body Status of the clients organ function
7-6
(continues)
(continued)
Administering Antimicrobial Agents
Consider the following:

Age of the client Pregnancy and/or lactation Likelihood of developing organisms resistant to the antimicrobial agent
7-7
Overuse
Overuse of antimicrobial agents can lead to the development of severely resistant organisms.
Promoted the development of organisms that are not affected by any of the available therapies
7-8
Resistant Organisms
MRSA/VRSA: methicillin/vancomycinresistant Staphylococcus aureus VRE: vancomycin-resistant Enterococcus ORSA: oxacillin-resistant Staphylococcus aureus
7-9

Prevent infections. Use Universal Precautions.
7 - 10
Classifications
Antimicrobial agents are classified based on the following factors:

Bactericidal or bacteriostatic Site of action Narrow or broad spectrum Adverse effects
7 - 11
Antimicrobial Classes
Sulfonamides Penicillins Cephalosporins Tetracyclines Macrolides
Aminoglycosides Fluoroquinolones Carbapenem Ketolides
7 - 12
Sulfonimides
First group of antibiotics
General action

Bacteriostatic effect Inhibit para-aminobenzoic acid (PABA)
PABA is essential for bacterial growth
Broad spectrum
7 - 13
Sulfonamides: Therapeutic Uses

Treatment of urinary tract infections Otitis media Certain vaginal infections Some respiratory infections
7 - 14
Sulfonamides: Adverse Effects
Hypersensitivity Renal dysfunction Hematological changes
7 - 15
Sulfonamides: Nursing Implications

Consume at least 1 liter of fluid/day Avoid sunlight and tanning beds Reduce the effectiveness of oral contraceptives
7 - 16
Sulfonamide Combinations
Sulfonamides also combined with:
Antimicrobials, diuretics, oral hypoglycemics, and carbonic anhydrase inhibitors
7 - 17
Penicillins
Part of a large group of chemically related antibiotics
Derived from fungus or mold
Cephalosporins currently used instead of the penicillins
7 - 18
Penicillins: Action
Inhibit synthesis of the bacterial cell wall
Most effective on newly forming and actively growing cell walls Some of the penicillins are rapidly destroyed in the stomach.
Given IM or IV
7 - 19
(continues)
(continued)
Action of penicillin on bacteria (from Medicines and You, U.S. Department of Health and Human Services)
7 - 20
Resistance to Penicillins
Frequent early use of penicillin caused:
Penicillinase

The bacteria to produce penicillin-destroying enzymes Potassium clavulanate inhibits penicillinase: combined with penicillin
7 - 21
Penicillins: Therapeutic Uses
Prevention and treatment of gram (+) bacterial infections:
Enterococcus, Streptococcus, and Staphylococcus bacteria
7 - 22
Penicillins: Adverse Effects
Hypersensitivity Gastrointestinal symptoms Neurotoxicity Renal dysfunction
7 - 23
Cephalosporins
Chemically and pharmacologically related to penicillins Action: prevent bacterial cell wall synthesis
7 - 24
Cephalosporins: Action
Either bactericidal or bacteriostatic; depends on:

Susceptibility of organism Dose of drug Tissue concentration Rate of bacteria multiplication
7 - 25
Classes of Cephalosporin
Include several generations:
First: good gram-positive coverage Second: good gram-positive coverage; some gram-negative coverage Third: less gram-positive coverage; more gram-negative coverage Fourth: good gram-negative coverage
7 - 26
Treatment with Cephalosporins
Treat infections of:
Skin Bone Heart Blood Respiratory tract Gastrointestinal tract Urinary tract
7 - 27
Cephalosporins: Adverse Effects
Hypersensitivity Cross-sensitivity reaction to penicillin Thrombophlebitis (when given IV) Sterile abscess (when given IM) Nephrotoxicity
7 - 28
Tetracyclines
Action: inhibit protein synthesis in the bacterial cell; bacteriostatic Broad spectrum Bacteria: gram and gram + Effective against: protozoa, Mycoplasma, Rickettsia, Chlamydia, syphilis, Lyme disease
7 - 29
Tetracyclines: Nursing Implications
Bind to Ca2+, Mg2+, and Al3+ ions and form insoluble complexes Do not give tetracycline with:
Dairy products, antacids, or iron salts
7 - 30
Tetracyclines: Toxic Effects
Do not give to children. Affects tooth development from:
Fourth month of fetal development to 8 years old Temporary and permanent discoloration of developing teeth
Photosensitivity Superinfection
7 - 31
Macrolides
Action
Bacteriostatic: inhibits protein synthesis in the bacterial cell
Primarily used for respiratory, gastrointestinal, urinary, skin, and soft tissue infections
7 - 32
Treatment with Macrolides
Treat both gram + and some gram organisms
Erythromycin: preferred (pertussis)
Primarily metabolized by the liver and excreted in the urine
7 - 33
Macrolides: Adverse Effects
Hypersensitivity Gastrointestinal effects Hepatotoxicity Jaundice
7 - 34
Aminoglycosides
Poor oral absorption
Given intravenously, not orally

Bactericidal: inhibit cell wall protein synthesis Effective: gram and some gram + Narrow therapeutic range
Action
Potent antibiotics with serious toxicities!
7 - 35
Aminoglycosides: Toxicities
Serious toxicities: caution

Nephrotoxicity Ototoxicity Block neuromuscular action, which can lead to respiratory paralysis
Monitor drug levels, both peak and trough
7 - 36
Fluoroquinolones
First oral antibiotics effective against gram-negative bacteria Excellent oral absorption
7 - 37
Fluoroquinolones: Action
Bactericidal: alter DNA Broad spectrum: effective against gramnegative organisms and some grampositive organisms
7 - 38
Treatment with Fluoroquinolones
Treat infections of:

Lower respiratory tract Bone and joint Infectious diarrhea Urinary tract Skin Sexually transmitted diseases
7 - 39
Fluoroquinolones: Nursing Implications
Consume at least 1 liter of fluid/day
7 - 40
Carbapenems
Action: Inhibit synthesis of the bacterial cell wall Broad spectrum Effective:

Gram negative Gram positive
Treat community acquired pneumonia
7 - 41
Carbapenems: Nursing Considerations
Given intravenously and intramuscularly Cross-sensitivity to penicillins Advantage
Given once every 24 hours
7 - 42
Carbapenems: Adverse Effects
Hypersensitivity Diarrhea Local reactions at intramuscular and intravenous sites
7 - 43
Ketolides

FDA approved in 2004 New class
Developed from macrolides

Semisynthetic Treat macrolide-resistant strep pneumonia
7 - 44
Ketolides: Adverse Effects
Hypersensitivity Headache Diarrhea
7 - 45
Urinary Tract Anti-infectives
Trimethoprim
Most common Blocks the synthesis of folate in bacteria, thus inhibiting formation of nucleic acid and protein
7 - 46
(continues)
(continued)
Urinary Tract Anti-infectives

Methenamine products: produces local bactericidal effect Nitrofurantoin: stops CHO metabolism
Others
Produces yellow-brown urine
7 - 47
General nursing implications Instructions take as prescribed:
Length of time: do not stop before antimicrobials are gone
Assess for signs and symptoms of returning infection
7 - 48
Antimicrobials: Nursing Implications
Obtain cultures from appropriate sites before beginning therapy.
7 - 49
Antitubercular Agents
Tuberculosis (TB)
Mycobacterium tuberculosis
An aerobic bacillus Requires oxygen to survive
Antitubercular agents treat all forms of Mycobacterium
7 - 50
Tuberculosis
TB close to eradication; new resistant strain developed in immunocompromised individuals and immigrants to the U.S. Drug therapy is given in two forms:
Preventive therapy Active therapy
7 - 51
TB: Preventive Therapy
Preferred agent
INH (Isoniazid) Known as chemoprophylaxis

Safest Low cost Action: tuberculostatic and tuberculocidal Treatment: 18 months to 2 years
7 - 52
Isoniazid
INH
Action: inhibits the synthesis of mycolic acid

Hepatotoxicity: jaundice Peripheral neuritis Nausea Skin rashes
Adverse effects of INH
7 - 53
Multiple Drug Therapy
Required: combination of two or three agents Helps prevent development of resistant strains
7 - 54
Antitubercular Therapy
Effectiveness depends on:

Where Strain Effective drug combination Sufficient duration Effective drug compliance
7 - 55
Antitubercular Agents: Nursing Implications

Client education is critical. Therapy may last for up to 24 months. Take medications exactly as ordered. Emphasize the importance of strict compliance.
7 - 56
Antitubercular Agents: Nursing Implications

Do not consume alcohol. Diabetic: monitor blood glucose levels INH and rifampin:
Oral contraceptives ineffective
7 - 57
Lyme Disease
Spirochete Borrelia burgdorferi
Transmitted from a deer tick
Symptoms

Rash Flulike symptoms, followed by arthritis and fatigue
7 - 58
Treatment for Lyme Disease
Oral doxycycline

Adults: 100 mg b.i.d Length: 10 to 14 days Photosensitivity
Adverse effect
7 - 59
Fungi
Contracted

Air Skin to skin Antibiotics Corticosteroid therapy Antineoplastic agents Suppressed immune system
Due to normal flora being killed off:

7 - 60
Mycotic Infections
Three general types
Cutaneous Subcutaneous Systemic (can be life threatening)
7 - 61
Antifungal Agents
Treatment

Antibiotic therapy will not work. Requires prolonged treatment
Human cell structure resembles fungi cell structure.
Action
Antifungal agents take advantage of the slight differences of the cell structures.
7 - 62
Antifungal Agents: General Adverse Effects

Topical: irritation and redness Oral: nausea, vomiting, and diarrhea May potentiate antihistamines
7 - 63
Antifungal Agents: Adverse Effects
IV: hepatotoxicity, renal toxicity, and phlebitis IV drugs must be diluted and administered slowly: amphotericin B
7 - 64
Antifungal Agents: Nursing Implications
IV
Monitor vital signs every 15 to 30 minutes. Monitor input and output. Monitor urinalysis findings.
7 - 65
Antiviral Agents
Viruses cause many infectious disorders:
Acute: common cold Chronic: herpes Slow growing: AIDS

Polio, rabies, and smallpox
Available vaccines
7 - 66
Viral Replication
A virus cannot replicate on its own. It must attach to and enter a host cell.
Uses the host cells energy to synthesize protein: DNA and RNA
7 - 67
(continues)
(continued)
Life cycle of a virus

7 - 68
Interferons
Normally, interferons protect the cells from infecting viruses.
Interferon: continuous research
Recent antifungal agents end in vir
7 - 69
Antiviral Agents: Key Characteristics
Inhibit viral replication by interfering with:

Viral nucleic acid synthesis and/or regulation Ability of virus to bind to cells
Interferon: stimulates immune system
7 - 70
Treatment with Antiviral Agents
Antiviral agents treat:
Influenzae A Herpes simplex RSV AIDS, HIV
7 - 71
Antiviral Agents: Adverse Effects

Bone marrow suppression Nephrotoxicity Hepatotoxicity Gastrointestinal effects Central nervous system effects
7 - 72
Antiviral Agents: Nursing Implications
Be sure to teach proper application:
Ointments Aerosol powders
Emphasize handwashing. Wear gloves for topical application.
7 - 73
(continues)
(continued)
Antiviral Agents: Nursing Implications

Replications cease: remain in nerve fibers
Range from delayed progression of AIDS and ARC to decrease in flulike symptoms Frequency of herpes-like flare-ups decrease
Usually not a cure
Therapeutic effects vary
7 - 74

CH 7

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CH 7

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Chapter 7

Discovery of sulfanilamide in 1936 Commercial introduction of penicillin in 1941

Original antimicrobials: derived from microorganisms Newer agents: chemically synthesized

Factors Leading to Infection

Bacteria Fungi Viruses

Administering Antimicrobial Agents

Consider the following:

Administering Antimicrobial Agents

Consider the following:

Prevent infections. Use Universal Precautions.

Antimicrobial agents are classified based on the following factors:

Bactericidal or bacteriostatic Site of action Narrow or broad spectrum Adverse effects

Sulfonamides Penicillins Cephalosporins Tetracyclines Macrolides

Aminoglycosides Fluoroquinolones Carbapenem Ketolides

First group of antibiotics

Bacteriostatic effect Inhibit para-aminobenzoic acid (PABA)

PABA is essential for bacterial growth

Sulfonamides: Therapeutic Uses

Sulfonamides: Adverse Effects

Hypersensitivity Renal dysfunction Hematological changes

Sulfonamides: Nursing Implications

Sulfonamides also combined with:

Antimicrobials, diuretics, oral hypoglycemics, and carbonic anhydrase inhibitors

Part of a large group of chemically related antibiotics

Derived from fungus or mold

Cephalosporins currently used instead of the penicillins

Inhibit synthesis of the bacterial cell wall

Frequent early use of penicillin caused:

Penicillins: Therapeutic Uses

Prevention and treatment of gram (+) bacterial infections:

Enterococcus, Streptococcus, and Staphylococcus bacteria

Penicillins: Adverse Effects

Hypersensitivity Gastrointestinal symptoms Neurotoxicity Renal dysfunction

Either bactericidal or bacteriostatic; depends on:

Susceptibility of organism Dose of drug Tissue concentration Rate of bacteria multiplication

Include several generations:

Treatment with Cephalosporins

Treat infections of:

Cephalosporins: Adverse Effects

Tetracyclines: Nursing Implications

Dairy products, antacids, or iron salts

Tetracyclines: Toxic Effects

Do not give to children. Affects tooth development from:

Bacteriostatic: inhibits protein synthesis in the bacterial cell

Treatment with Macrolides

Treat both gram + and some gram organisms

Erythromycin: preferred (pertussis)

Primarily metabolized by the liver and excreted in the urine

Macrolides: Adverse Effects

Hypersensitivity Gastrointestinal effects Hepatotoxicity Jaundice

Poor oral absorption

Given intravenously, not orally

Potent antibiotics with serious toxicities!

Serious toxicities: caution

Monitor drug levels, both peak and trough

Treatment with Fluoroquinolones

Treat infections of:

Fluoroquinolones: Nursing Implications

Consume at least 1 liter of fluid/day

Gram negative Gram positive

Treat community acquired pneumonia

Carbapenems: Nursing Considerations

Given intravenously and intramuscularly Cross-sensitivity to penicillins Advantage