Chapter 40 Fall 2012
description
Transcript of Chapter 40 Fall 2012
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 40Antibiotics Affecting Protein
Synthesis
Chapter 40Antibiotics Affecting Protein
Synthesis
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Aminoglycosides Aminoglycosides
• The aminoglycosides have been in use since 1944.
• Effective antibiotics for treating severe infections.
• General use is limited because of the potential for serious adverse effects which are :
Ototoxicity and nephrotoxicity
• Prototype drug: gentamicin.
• Usually given intravenously : onset rapid
duration 6- 8 hrs.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gentamicin: Core Drug Knowledge Gentamicin: Core Drug Knowledge
• Pharmacotherapeutics
– Serious infections (such as urinary tract infections, peritonitis, endocarditis, sepsis, osteomyelitis)
– Effective against gram negative bacilli
• Pharmacokinetics
– Distribution: throughout the body (except CSF).
– Higher concentration in kidneys than serum.
• Pharmacodynamics
– Affects protein synthesis within the cell
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gentamicin: Core Drug Knowledge (cont.)Gentamicin: Core Drug Knowledge (cont.)
• Contraindications
– Pregnancy and lactation
Precautions – known allergy to any aminoglycoside
renal or hepatic disease, pre-existing hearing loss
• Adverse effects
– Neurotoxicity, nephrotoxicity, & ototoxicity
• Drug interactions
– Acyclovir, amphotericin B, cephalothin, cisplatin, cyclosporine, loop diuretics, and vancomycin
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gentamicin: Core Patient Variables Gentamicin: Core Patient Variables
• Health status
– Past medical and any kidney problems.
• Life span and gender
– Ototoxic to fetus, assess pregnancy status.
• Lifestyle, diet, and habits
– Assess the nutritional status of the patient. Dehydrated patients have an risk of nephrotoxicity
• Environment
– Assess environment where drug will be given.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gentamicin: Nursing Diagnoses and Outcomes Gentamicin: Nursing Diagnoses and Outcomes
• Risk for Injury related to potential drug-related allergic reactions or suppression of bone marrow function
– Desired outcome: the patient will remain free of injury and will contact the prescriber if unusual adverse effects occur.
• Diarrhea related to drug effects
– Desired outcome: the patient will avoid dehydration, maintain fluid intake, and contact the prescriber if diarrhea persists.
• Excess Fluid Volume related to potential nephrotoxicity
– Desired outcome: the patient will report any weight gain exceeding 3 lb to the health care prescriber.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gentamicin: Planning & InterventionsGentamicin: Planning & Interventions• Maximizing therapeutic effects
– Make sure that patients receive the full course as prescribed at around-the-clock intervals.
– Do not give at the same time as some forms of penicillin (space the drugs 2 hrs. apart )
• Minimizing adverse effects
– Maintain blood levels of gentamicin within a therapeutic margin that is very narrow.
– Monitor for signs of ototoxicity and nephrotoxicity.
– Monitor peak and trough blood levels
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Peak and Trough LevelsPeak and Trough Levels
• Certain drugs require peak and trough levels
• These measure the amount of drug within the blood
• Peak levels are those that are the highest levels in the blood
• Peak levels are drawn 30 minutes after the completion of a 30 minute IV administration of Gentamycin
• Peak levels are drawn 30- 60 minutes after completion of IV administration of Vancomycin
• Trough Level is the lowest level of the drug in the blood
• Trough Levels are drawn just before the next dose of the drug is to be administered
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Gentamicin: Teaching, Assessment & EvaluationsGentamicin: Teaching, Assessment & Evaluations• Patient and family education
– Patient should not take drug if pregnant or breastfeeding.
– Teach patients how to identify, report, and manage signs and symptoms of allergic reaction and adverse effects.
– If pt. has experienced an allergic reaction , they should not take any drug that has “micin” in it.
• Ongoing assessment and evaluation
– Discuss the addition of other potentially nephrotoxic or ototoxic drugs
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
• Gentamicin is effective against what organism(s)?
– A. Pseudomonas aeruginosa
– B. Proteus mirabilis
– C. Klebsiella
– D. Enterobacter
– E. All of the above
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
RationaleRationale
• Gentamicin is effective against what organism (s)?
– E. All of the above
– Gentamicin is effective in managing infections caused by gram-negative bacilli.
• Susceptible organisms include Pseudomonas aeruginosa, Proteus mirabilis, Escherichia coli; Klebsiella, Enterobacter, Serratia, and Citrobacter species; and staphylococci.
• Gentamicin must be transported across the cell membrane in order to enter the cell and disrupt protein synthesis.
• This process requires oxygen; therefore, gentamicin and other aminoglycosides are ineffective against anaerobes.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clindamycin: Core Drug Knowledge Clindamycin: Core Drug Knowledge
• Pharmacotherapeutics
– Aerobic gram-positive cocci and several anaerobic gram-negative and gram-positive organisms.
• Pharmacokinetics
– Varies with route of administration.
– Metabolized: liver. Excreted: bile and urine.
• Pharmacodynamics
– Enters the bacterial cell and binds to bacterial ribosomes, suppressing protein synthesis.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clindamycin: Core Drug Knowledge Clindamycin: Core Drug Knowledge
• Contraindications
pregnancy, and lactation
hypersensitivity
renal or hepatic dysfunction
• Adverse effects
– Pseudomembranous colitis{Black Box warning} maculopapular rash, erythema, and pruritus , nausea and vomiting
• Drug interactions are numerous
• Very toxic drug
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clindamycin: Core Patient Variables Clindamycin: Core Patient Variables
• Health status
– Assess for allergy to medication.
• Life span and gender
Used in pregnancy only if benefit outweighs the risk
– Assess the growth and developmental level of the child or infant ( use cautiously in infants and children)
• Lifestyle, diet, and habits
– Assess lifestyle to ensure that drug will be given properly.
• Environment
– Assess environment where drug will be given.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clindamycin: Nursing Diagnoses and Outcomes Clindamycin: Nursing Diagnoses and Outcomes
• Risk for Injury related to allergic reactions
– Desired outcome: the patient will stop drug therapy and immediately report symptoms of allergic reaction to the prescriber.
• Diarrhea related to drug effects
– Desired outcome: the patient will avoid dehydration and report persistent diarrhea to the provider.
• Risk for Injury related to possible blood dyscrasias
– Desired outcome: the patient will remain injury free throughout drug therapy.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clindamycin: Planning & InterventionsClindamycin: Planning & Interventions
• Maximizing therapeutic effects
– Make sure that the patient receives the full course of clindamycin as prescribed.
– Coordinate the administration of drugs to decrease potential undesired interactions.
• Minimizing adverse effects
– Clindamycin should be administered on an empty stomach with a full glass of water.
– Report diarrhea to the provider immediately.
– Always check that C & S reports indicate sensitivity to Clindamycin
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Clindamycin: Teaching, Assessment & EvaluationsClindamycin: Teaching, Assessment & Evaluations
• Patient and family education
– Advise patients to contact the prescriber immediately if they experience diarrhea.
– Teach patients to recognize and report symptoms of allergic reaction and superinfection.
• Ongoing assessment and evaluation
– Monitor the patient for the onset of diarrhea.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
QuestionQuestion
• What is the most serious adverse reaction of clindamycin administration?
– A. Respiratory arrest
– B. Pseudomembranous colitis
– C. Ventricular tachycardia
– D. Ototoxicity
Answer : B
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Macrolide Antibiotics Macrolide Antibiotics
• The macrolide antibiotics have been in use since 1952.
• They are characterized by molecules made up of large-ring lactones.
• Macrolides are bacteriostatic or bactericidal in susceptible bacteria.
• Prototype drug:
erythromycin ( E-mycin, Erythrocin Stearate)
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Erythromycin: Core Drug Knowledge Erythromycin: Core Drug Knowledge Pharmacotherapeutics
• More effective against gram positive organisms
• Used for patients that are allergic to penicillin
– Treating Legionnaire disease, Mycoplasma pneumoniae pneumonia, diphtheria,and chlamydial infections
• Pharmacokinetics
– Drug is easily inactivated by gastric acid ( various formulations are available to prevent this)
– Peak 1–4 hours ( orally) : 1 hour ( intravenously)
– Metabolized: liver.
– Excreted: urine & bile.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Erythromycin: Core Drug Knowledge (cont.)Erythromycin: Core Drug Knowledge (cont.)
• Pharmacodynamics
– Inhibiting protein synthesis
• Contraindications and precautions
– Allergy to medication
• Adverse effects
– GI symptoms, urticaria, maculopapular rash, erythema, and interstitial nephritis
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Erythromycin: Core Patient Variables Erythromycin: Core Patient Variables
• Health status
– Assess medical history and allergies.
• Life span and gender
– Assess pregnancy and lactation status.
– ( excreted in breast milk at about 50% of maternal plasma concentrations which can cause diarrhea or superinfection in the infant)
• Lifestyle, diet, and habits
– Avoid Grapefruit juice increases the serum concentration of erythromycin and may cause toxicity /side effects
– Take medication 1 hr. before or 2 hrs. after a meal
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Erythromycin: Nursing Diagnoses and Outcomes Erythromycin: Nursing Diagnoses and Outcomes
• Risk for Injury related to possible allergic reactions
– Desired outcome: the patient will stop drug therapy and report any signs of allergic reaction immediately to the prescriber.
• Diarrhea related to drug-induced GI upset
– Desired outcome: the patient will avoid dehydration, maintain fluid intake, and contact the prescriber if diarrhea persists.
• Risk for Infection related to potential for superinfection following drug therapy
– Desired outcome: the patient will contact the provider if any signs of superinfection occur, for example, sore throat or fever.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Erythromycin: Planning & InterventionsErythromycin: Planning & Interventions
• Maximizing therapeutic effects
– Reconstitute IV Erythromycin with sterile water only.
– Prepared infusion solutions that are stored at room temperature must be used within 8 hours.
• Minimizing adverse effects
– Because erythromycin can be very irritating to veins, it is important to administer IV infusions over 30 to 60 minutes.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Erythromycin: Teaching, Assessment & EvaluationsErythromycin: Teaching, Assessment & Evaluations
• Patient and family education
– Encourage patients to take the complete course of antibiotics.
– Advise patients to take erythromycin on an empty stomach (unless GI distress is unbearable)
• Ongoing assessment and evaluation
– Monitor for signs of allergic reactions, resolution of presenting signs and symptoms of infection, and signs of superinfection.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
RationaleRationale
• Grapefruit juice will decrease the serum concentration of erythromycin.
- A. True
– B. False
Answer : B
– Instruct the patient to avoid grapefruit or grapefruit juice because it increases the serum concentration of erythromycin and may cause adverse effects or toxicity.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chloramphenicol: Core Drug Knowledge Chloramphenicol: Core Drug Knowledge
• Antibiotic that also affects protein synthesis
• Pharmacotherapeutics
– True broad-spectrum antibiotic (effective against gram negative and gram positive organisms; not fungi)
• Pharmacokinetics
– Administered: oral and IV. Peak 1–3 hours.
– Passes through the blood brain barrier
• Pharmacodynamics
– Inhibiting the protein synthesis of bacterial cells.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chloramphenicol: Core Drug Knowledge Chloramphenicol: Core Drug Knowledge • Precautions
This drug is relatively toxic and has a Black Box Warning
To be used only in serious infections in which no other drug is effective or in patients with resistance or allergies
• Adverse effects
– Aplastic anemia, thrombocytopenia, and granulocytopenia ( depressed bone marrow function)
• Drug interactions
– Many different types of drugs
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chloramphenicol: Core Patient Variables Chloramphenicol: Core Patient Variables
• Health status
– Assess medical history. Establish baseline labs, CBC , hepatic and renal function
• Life span and gender
– Contraindicated in pregnancy since it can cause bone marrow depression or gray baby syndrome in the neonate.
• Environment
– Assess environment where drug will be given.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chloramphenicol: Nursing Diagnoses and Outcomes Chloramphenicol: Nursing Diagnoses and Outcomes
• Risk for Injury related to drug-induced adverse effects, such as blood dyscrasias, gray baby syndrome, and CNS effects, including optic or peripheral neuritis, headache, depression, confusion, or delirium
– Desired outcome: regular and careful monitoring will protect the patient from permanent drug-related adverse effects.
• Risk for Impaired Skin Integrity, rash and pruritus, related to topical drug use
– Desired outcome: the nurse and patient will observe for and report signs of unusual skin reaction and contact the prescriber.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chloramphenicol: Planning & InterventionsChloramphenicol: Planning & Interventions
• Maximizing therapeutic effects
– Oral chloramphenicol should be administered on an empty stomach 1 hour before or 2 hours after meals.
• Minimizing adverse effects
– Monitor plasma concentrations at least weekly or more often in patients with hepatic or renal impairment.
Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chloramphenicol: Teaching, Assessment & EvaluationsChloramphenicol: Teaching, Assessment & Evaluations
• Patient and family education
– Explain the importance of completing therapy.
– Teach patients the importance of measuring fluid intake and output accurately.
• Ongoing assessment and evaluation
– For patients receiving systemic therapy, coordinate serial monitoring of chloramphenicol plasma concentrations. ( peak and trough levels can be done)