Lincosamides

By: Kriste Frasier RN

Overview

• Similar to effects of penicillins
• Penicillin substitute in patients who have an allergy

Mechanism of Action
Inhibits bacteria protein synthesis, causing cell death through bacteriostatic action. In higher doses can have bactericidal action.

Indication for use

• Strep and Staph infections
• Acne vulgaris
• BV

Other uses
Combination therapy for cerebral toxoplasmosis, toxigenic strep, and pneumocystis jirovecii

Examples
Clindamycin (Cleocin)
lincomycin (Lincocin)
 *Incompatible with certain drugs such as phenytoin, aminophylline, cefazolin/gent, ceftriaxone, ranitidine, and calcium gluconate.

Routes of administration
PO, IV, topically, and Intravaginally

Side effects
hypotension, abdominal pain, n/v, neutropenia, rashes, fatigue, headache, cardiac arrest (with rapid IV administration), pseudomembranous colitis (potentially fatal)

Contraindications
Prior history of allergic reaction to medication
Hx of asthma or any other respiratory
Hx of renal or hepatic dysfunction
Patients taking MAOI, SSRI, or tricyclic antidepressants
Hx of hematologic reactions
Pregnancy/breastfeeding

Dosing Considerations
Consider adjusting dosages for patients with renal and liver dysfunction
In pregnant patients, lincosamides can pass through the placenta and cumulate in the fetus' liver

Drug interactions
Digoxin
Warfarin
Estrogens

Nursing Interventions
Obtain health history including allergies and allergic reactions
Baseline blood work including renal and liver function
Vital signs
Assessment of wounds for infections - obtain C&S, rashes, lesions
Assess lung and bowel sounds

Client Teaching
Take oral antibiotic with a full glass of water
Take entire course of antibiotic treatment as prescribed
Report to health care provider if no change symptoms of infection
Report any symptoms such as persistent diarrhea, abdominal pain, or n/v
Topical solution - avoid contact with eyes and mucous membranes - flush with copious amount of cool water
Refrain from sexual intercourse during treatment for BV


References

Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2012). Macrolides, Tetracyclines, Aminoglycosides, and Fluoroquinolones. In Pharmacology: A nursing process approach (p. 428). St. Louis, MO: Elsevier Saunders.

Levison, M. E. (2009, July). Lincosamides, Oxazolidinones, and Streptogramins: Bacteria and Antibacterial Drugs: Merck Manual Professional. Retrieved March 2, 2014, from http://www.merckmanuals.com/professional/infectious_diseases/bacteria_and_antibacterial_drugs/lincosamides_oxazolidinones_and_streptogramins.html

Lincosamides - comprehensive review on Antibioticslist.com. (n.d.). Retrieved March 2, 2014, from http://www.antibioticslist.com/lincosamides.html

Penicillin

                                                                      Penicillin

By: Taylor DiDonato & Samantha Benjamin

                                                                    Background

•  A natural antibacterial agent obtained from the mold genus Penicillium
•  It was introduced to the military during World War ll
• Became widely used in 1945 and was labeled a “miracle” drug
•  “It was first introduced for the treatment of staphylococcal infections, but after a few years mutant strains of staphylococcus developed that were resistant to penicillins G and V because of the bacterial enzyme penicillinase, which destroys penicillin” (Kee, Hayes & McCuistion, 2012, p. 413)
• —Soldiers who would normally died from wound and respiratory infections were treated effectively with penicillin's.

—

                                            Broad-Spectrum Penicillins (Aminopenicillins)

• —Used to treat both gram positive and gram negative bacteria
• —They are not as “broadly” effective against all microorganisms as they once were considered to be.
• —Examples: ampicillin (Omnipen) and amoxicillin (Amoxil)

— 

                           Penicillinase-Resistant Penicillins (Antistaphylococcal Penicillins)

• Used to treat penicillinase-producing S. aureus
• —Dicloxacillin (Dynapen) is an oral preparation of these antibiotics
• nafcillin (Unipen) and oxacillin (Prostaphin) are IM and IV preparations
• Not effective against gram-negative organisms and less effective then penicillin G against gram-positive organisms

 

—                            Extended Spectrum Penicillins (Antipseudomonal Penicillins)

• Broad-spectrum penicillins
• Effective against Pseudomonas aeruginosa, a gram-negative bacillus
• Useful against gram-negative organisms such as Proteus spp., Serratia spp., Klebsiella pneumonia, Enterobacter spp., and Acinetobacter spp.
• —Antipseudomanal penicillins are not penicillinase resistant
• —Less toxic then aminoglycosides but their pharmacologic actions are similar

 

—

                                                     Beta-Lactamase inhibitors

• —Three beta-lactamase inhibitors: clavulanic acid, sulbactam , and tazobactam
• —These inhibitors are not given alone but in combination with penicillinase-sensitive penicillin such as amoxicillin, ampicillin, piperacillin, or ticarcillin

 

—

                                                                  Adverse Effects

• Possible secondary infection due to disruption of normal body flora
• —Nausea
• —Vomiting
• —Diarrhea
• Severe allergic reactions: laryngeal edema, bronchoconstriction, stridor, and hypotension.

 

—

                                                                Client Teaching

• —Teach clients to take the entire prescribed dosage.
• —Encourage clients to increase fluid intake; fluids aid in decreasing the body temperature and in excreting the drug
• —Medication should be take with food to avoid GI upset.
• —Patients should tell all providers if they have an allergy to penicillins.

 

— 

                                                                    Article

• Very Few Patients with Penicillin Allergy Histories Are Truly Allergic
• Approximately 8% of the US population claims to have an allergy to penicillin.
• The only true indicator to way to test for a penicillin allergy is by skin testing.
• —However many providers rarely order skin testing.

 

                                         

                                                                  References

Kee. , Hayes, , & McCuistion, (2012). Pharmacology: A nursing approach. (7th ed.). St. Louis, Missouri: Elsevier Saunders.

Amrol, D. (2013). Very few patients with penicillin allergy histories are truly allergic . New England Journal of Medicine, Retrieved from http://www.jwatch.org/na31567/2013/07/11/very-few-patients-with-penicillin-allergy-histories-are

Fluoroquinolones

Fluoroquinolones

Ray Masters RN

Elizabeth Mathes RN 

 

Overview

·         Antibacterial spectrum includes bactericidal action on both gram+ and gram- organisms

·         Effective against some gram+ organisms (Streptococcus pneumonia, Haemophilus influenzaep, aeruginosa, Salmonella, and Shigella).

Mechanism of Action

·         Interferes with the enzyme DNA gyrase, which is needed to synthesize DNA.

·         Contains a bactericidal action.

Indications

·         Urinary tract infections

·         Bone infections

·         Joint infections

·         Bronchitis

·         Pneumonia

·         Gastroenteritis

·         Gonorrhea

Examples

·         ciprofloxacin HCL (Cipro)

·         levofloxacin (Levaquin)

·         lomefloxacin (Mazaquin)

·         moxifloxacin (Avelox)

·         norfloxacin (Noroxin)

·         ofloxacin (Floxin)

·         chloramphenicol (Chloromycetin)

·         quinupristin (Synercid)

Routes

·         PO, IM, IV

Considerations

·         Fluid intake should be at least 2000ml/day

·         Antacids and iron preparations decrease absorption of fluoroquinolones such as levofloxacinj

·         Levofloxacin can increase the effects of theophylline and caffeine.

·         Levofloxacin can increase the effects of oral hypoglycemic.

·         When levofloxacin is taken with NSAIDs, CNS reactions such as seizures may occur.

Nursing Interventions

·         Obtain specimen from infected site for culture and sensitivity before initiating antibacterial therepy.

·         Monitor I&O. Urine output should be at least 750ml/day.

·         Client fluid intake should be >2000ml/day to prevent crystalluria.

·         Monitor BUN and serum creatinine. Elevated values may indicate renal dysfunction.

·         Administer levofloxacin 2 hours before or after antacids of iron products. If GI upset occurs, may be taken with food.

·         For IV levofloxacin dilute in an appropriate amount of solution and infuse over 60 minutes.

·         Monitor for signs and symptoms of superinfection (mouth ulcers, furry black tongue, anal or genital discharge/itching.)

·         Monitor serum theophylline.

·         Monitor blood glucose.

Client Teaching

·         Drink at least 6 to 8 glasses of fluid daily.

·         Avoid caffeinated products.

·         Avoid operating hazardous machinery or operating a motor vehicle while taking drug or until stability has occurred.

·         Use sunglasses, sun block, and protective clothing when in the sun.

Side Effects

·         Drug related dizziness

·         Photosensitivity

·         Nausea

·         Vomiting

·         Diarrhea/flatulence

·         Abdominal cramps

·         Tinnitus

·         Rash

·         Tendon rupture (rare)

References

Kee, J.L., Hayes, E.R., & McCuistion, L.E. (2012). Pharmacology: A nursing process approach. St. Louis: Elsevier Saunders.

Cephalosporins

Pharmacology Outline

Cephalosporins and generations 1-4

Diana Crane RN

Karen Daniels RN

Cephalosporins: In 1948 a fungus was discovered that was found to be active against gram positive and negative bacteria as well as resistant to beta –lactamase.  This Beta-lactam structure inhibits the enzyme necessary for cell wall synthesis, this leads to cell wall lysis, and cell death.  .  The beta-lactamases can destroy some forms of cephalosporins.  Cephalosporins have been altered to treat wider ranges of bacterium, and have grown to encompass four groups or generations.  Cephalosporins are used widely in healthcare.  Most forms of cephalosporins are used IV or IM, few are given PO.  They are protein bound and largely excreted unchanged in the urine. 

First Generation: Destroyed by beta-lactamases.  Effective against most gram positive and gram negative bacteria.  Examples of first generation cephalosporins are cefadroxil, cefazolin, cephalexin, and cephradine.  These antibiotics are used to treat infections including UTI, beta-hemolytic streptococcal infections, staphylococcal skin infections, otitis media, and bone infections. 

Second Generation: Some are affected by beta-lactamases.  Effective against most gram positive and gram negative bacteria.  Second generation is effective against more gram negative bacteria than first generation, and is also effective against some anaerobes.  Examples of second generation cephalosporins include cefaclor, cefotetan, cefoxitin, and cefuroxime.  These are used to treat infections including  septicemia, staphylococcus aureus, meningitis, and surgical prophylaxis. 

Third Generation:  Resistant to beta-lactamases.  Effective against fewer gram positive bacteria than first and second generations.  Effective against increased number of gram negative bacteria.  Examples of third generation cephalosporins include cefdinir, cefixime, cefpodoxime, and ceftazidime.  These are used to treat infections, including acute sinusitis, chronic bronchitis, Streptococcus pyogenes, Neisserie gonorrhoeae, Haemophilus influenza, and respiratory infections.  Cefditoren is safe to use with oral birth control. 

Fourth Generation:  resistant to beta-lactimases.  Broader gram positive effectiveness than third generation.  Resistant to most beta-lactamase bacteria.   An example of a fourth generation cephalosporin is cefepime which is effective in treating pneumonia, E. coli, Klebsiella, Proteus, and has broader gram positive coverage than third generation cephalosporins. 

Pharmokinetics:  Most given IM or IV, few PO options.  Protein bound.  60-80% excreted in urine.

Pharmodynamics:  Inhibit cell wall synthesis, causing cell lysis and cell death.  Onset of action is nearly immediate for IV, 30-60 minutes for PO. 

Side Effects:  GI disturbances such as nausea, vomiting and diarrhea.  Blood clotting time can be increased, causing increased bleeding.  Nephrotoxicity, when large doses are used, and when pt. has renal disorders.  Proteinuria, glycosuria, renal failure, nephrotoxicity.  . 

Drug interactions: When given with probenecid urine excretion of cephalosporins is decreased, Action of drug is increased.  Tetracycline or erythromycin can decrease effectiveness of cephalosporins.    Uricosuric medications can interfere with excretion of cephalosporins. 

Herbal interactions:  Do not use acidophilus, separate doses by several hours.  Angelica, anise, arnica, chamomile, clove, celery, garlic, ginger, ginseng, ginkgo and others can increase bleeding risk. 

Food interactions:  Do not use alcohol while using cephalosporins, this may cause dizziness, cramping, nausea and vomiting. 

Nursing considerations: Assess for allergies or sensitivities to PCN, and type of reaction.  Check laboratory studies, especially AST, ALT, BUN, and Creatine.  Bowel pattern, especially for diarrhea.  Bleeding risk, especially if pt. is on anticoagulants.  Nephrotoxicity, I & O.  If GI upset, give with food. 

Teaching: Teach patient signs of anaphylaxis, difficulty breathing or swallowing, hives, wheezing, and what to do incase these are evident.  To report to Doctor if increased bleeding occurs.  To take with food to decrease GI discomfort.  To eat yogurt or buttermilk to decrease chances of diarrhea and yeast infection.  Teach patient to finish full course of treatment, even if they feel well.  Teach patient the importance of discussing all other medications, and herbal supplements with prescribing Doctor.  Teach pt. to report diarrhea, or decreased urine output.   Teach pt. to report if infection symptoms are increasing or not decreasing while on antibiotic.  

References:

AHFS Consumer Medication Information. Bethesda (MD): American Society of Health-System Pharmacists, Inc. (2008). Cephalexin retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682733.html

 

Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2012). Pharmacology: A nursing process approach. St. Louis, MO: Elsevier.

Skidmore-Roth, L. (2008). Mosby's nursing drug reference. St. Louis, MO: Elsevier.

 

Aminoglycosides

Hello, we, byeolnim lee and Haeon lee, re-write about Aminoglycosides. And, we have a question. In the textbook, Gentamicin sulfate is effective against MRSA. But you stated,"One point to clarify is that aminoglycosides are not effective in treating MRSA." I wonder what is the correct information. 

Origin

• Streptomycin sulfate from the bacterium streptomyces griseus in 1944.

Actions

• Inhibition of bacterial protein synthesis; bactericidal effect

General Information

§  Serious infections, since good activity against multidrug-resistant Gram-negative pathogens, such as pseudomonas aeruginosa.

§  Active against both Gram-negative and gram-positive infections.

§  Not effective in MRSA.

§  Clinical application: bacteremia, endocarditis, nosocomial pneumonias, intra-abdominal infections.

Indication

• Respiratory tract
•  Bone and joint
• Skin, and soft-tissue infections
•  Pelvic inflammatory disease
•  Hepatic coma
• Decreases bacteria in the bowel
• Tuberculosis

Route & Dosage

·         Amikacin sulfate (Amikin)

—         A/: IM/IV: 10 to 15 mg/kg/d q8 to 12h; max: 15 mg/kg/d

—         C: IM/IV: 7.5 to 22.5mg/kg/d in divided doses; max:15 mg/kg/d

—         TDM: peak: 25 to 35 mcg/mL; trough: < 5 mg/ml

·         Gentamicin sulfate (Ganamycin)

—         A: IM/IV: 3 to 6 mg/kg/d in 2 to 3 in divided doses

—         C: IM/IV: 2 to 2.5mg/kg q8h

—         TDM: peak: 5 to 8 mcg/mL; trough: 0.5 to 2 mcg/mL

·         Kanamycin sulfate (Kantrex):

—         A/C: IM/IV: 10 to 15mg/kg/d in divided doses

·         Neomycin sulfate Myciguent (Neo-Fradin)

—         Bowel prep: A: PO: 1 g q1h for 4 doses; then 1 g q4h for 5 doses

—         Hepatic coma: A: PO: 1 to 3 g q6h for 5 to 6 d; max: 12 g/d

·         Streptomycin sulfate (Streptomycin)

—         A: IM: 1 to 2 g/d

—         C: IM: 20 to 40 mg/kg/d

—         TDM: peak: 20 to 35 mcg/mL; trough: <10 mcg/mL

·         Tobramycin sulfate (Nebcin):

—         A: IM/IV: 3 to 5 mg/kg/d in divided doses

—         C: IM/IV: 2.5mg/kg/d in divided doses

—         TDM: peak: 4 to 8 mcg/mL; trough: 0.5 to 2 mcg/mL

Interactions

§  With penicillins, efficacy ↓

§  With aminoglycosides, oral anticoagulants ↑

§  With ethacrynic acid, ototoxicity ↑

§  With beta lactams, efficacy ↑

§  With gentamicin, streptomycin, penicillin G and ampicillin, efficacy ↑  

Side  Effects

• Nephrotoxicity
• Ototoxicity                                        
• Photosensitivity             
• Nausea, Vomiting, tremors, tinnitus, pruitus, and muscle cramps           

Contraindications

• Hypersensitivity
• Severe renal disease
• Pregnancy, and breastfeeding

Nursing Intervention

• Record vital signs
•  Monitor intake/output.

• Check lab results (renal, liver function)

• Medical history related to renal or hearing disorders.
• Send sample from infected area.

• Check for hearing loss to observe ototoxicity.

Patient Teaching

• Unless fluids are restricted, encourage client to increase fluid intake.
• Instruct client never to take leftover antibiotics.
• Observe side effect.
• Concern about sun exposure.

Interesting Information

According to Pagkalis, Mantadakis, Mavros, Ammari andFalagas (2011),
1. The once-daily dosing schedule provide a longer time of administration until the threshold for nephrotoxicity is met.
2. Regarding ototoxicity, no dosing regimen appears to be less ototoxic than another.
3. Close monitoring need to minimize the toxicities and the clinical failures.

References

Kee, J., Hayes, E., & McCuistion, L. (2012). Pharmacology; a nursing process approach (7th ed.). St. Louis, MO: Elsevier.

Pagkalis, S., Mantadakis, E., Mavros, M.N., Ammari, C., & Falagas, M. E. (2011). Pharmacological consideration for the proper clinical use of aminoglycosides. Drugs, 71(17), 2277-2294. doi:10.2165/11597020-000000000-00000

Radigan, E. A., Gilchrist, N. A., & Miller, M. A. (2010). Management of Aminoglycosides in the Intensive Care unit. Journal Of Intensive Care Medicine (Sage Publications Inc.), 25(6), 327-342. doi:10.1177/0885066610377968