foreign guys uh we're going to talk today about antibiotics uh other drugs to fight infections and chemotherapy so I'm going to give you a common scenario that happens that somebody's grandma starts to feel a little sick who's the first person who always knows about Grandma being sick because usually your mom right because then if your mom's anything like my mom then she'll call me and say hey your grandma's sick you should call her right you should you should talk to your grandma right so a choose your mom who checks up on your grandma tells you she's sick anywho then a common scenario in the the hospital in medicine is uh your mom checks up on your grandma like two or three days later actually goes over to her house and then when she checks up on grandma grandma is minimally responsive meeting grandma is awake but grandma is not able to really talk and respond like she normally does to your mom your mom rightfully so freaks out takes grandma to the emergency room fast forward to the emergency room we check on Grandma she's running a temperature and we tell your mom you tell your mom you know thank God you brought her in why is that because if Mom Wonder brought Grandma to the ER um your grandma probably would have been dead in about anywhere from four to six more hours why she would have been septic she would have gone into septic shock and would have uh perished so very common scenario right I mean there's many others we could talk about but just think of that scenario so I want you to think about maybe you're working in that ER put yourself there when when that Grandma comes into the ER do we have a strong suspicion that she has an infection yes we do and since it's Grandma Odyssey being a female what type of infection do we probably suspect being the most likely we don't know but we suspect yeah it would probably be uh UTI and urinary tract infection and Udi as I call it so Grandma comes in without doing any tests we know we we strongly suspect based on our signs and symptoms that she have an infection we strongly suspect it's a urinary tract infection so what do we do to treat in the infection we give you Grandma antibiotics but here's the thing there's two different types or two different broad categories of antibiotics what are they there's broad spectrum and narrow Spectrum antibiotics so what's the difference between those you need to know the difference for the test difference is narrow Spectrum works against maybe one or just a very small handful of infections whereas broad spectrum works against many many many different types of bacteria you know could be hundreds could be thousands and there's thousands of different bacteria that could cause infections or things that could cause infections so when Grandma comes in think about it we strongly suspect she has an infection we don't know for sure we strongly suspect we know what type of infection is UTI probably but do we know what specifically the specific bacteria out of the thousands is causing the infection no we don't so what type of antibiotic do we initially Place grandma on would you anticipate that we initially would put this grandma on it has to be a broad spectrum antibiotic guys because if there's thousands of antibiotics and I said we don't give your your grandma antibiotic to kill that bacteria she'll be dead in four hours then if there's thousands of different bacteria if we're using narrow Spectrum what's the odds that we chose the correct antibiotic for that specific bacteria which again we don't know the specific bacteria yet yeah it's it's very unlikely so when a patient comes in when we have a strong indication that they have an infection we have to start them on broad spectrum or else the odds are unlikely that we're going to just randomly choose the correct narrow spectrum antibiotic so here's the thing how do we end up finding out what was the in fact the specific bacteria that caused Grandma's UTI infection so for the test you need to understand that we do a culture and sensitivity the culture and sensitivity will tell us which specific bacteria is causing the actual infection once we know the specific bacteria that's causing the infection for the test you need to understand that that's the point we switch from a broad spectrum to a narrow spectrum antibiotic for the test you need to know that we need to send off the sample the specimen as it were of our culture and sensitivity we need to get obtain that and send it off prior to starting any antibiotics so you get the culture and so on this is specific example guys Grandma came in we suspect a urinary tract infection what will we send to the lab for the culture and sensitivity we'd send off some of her urine we'd send some of Grandma's urine to the lab for to obtain a culture and sensitivity then we'd start the broad spectrum antibiotic then we'd wait for the results of that to come back then we'd switch to a narrow Spectrum antibiotics so here's the question for you how long does it normally take to get the results from a culture insensitivity well it the answer is it depends so it depends on the type of infection the type of bacteria and how how our our ability did and the quality of the sample we sent but in in Broad terms to get a final like uh conclusive result on the on the culture and sensitivity can take around 48 hours now we often will get per what we call preliminary results in about two to four hours depending on you know depending on how busy the lab is about four hours get preliminary results those are one like hey this is what it's looking like but the um final results the conclusive results aren't going to be you know for a day or two so um anyway let me let me go ahead and Advance our slides here so again antibiotics for the test you need to understand antibiotics work against bacteria only they don't work against funguses viruses Etc so bacteria is not going to do anything if you have the flu or covid or respiratory synthesisial virus or any other type of uh viral infection it's only against bacterial infection s Well antibiotics work so this isn't specifically tested but you just need to know the terms so that you don't select the wrong answer on the test so bacteria is an antibiotic that's bactericidal means it actually kills the bacteria and you'll hear this term also bacteriostatic so if an anti-antibiotic is bacteriostatic it means that it stops the antibiotic from replicating that so how do you Republic how does that stop the infection well it halts the growth of the bacteria to give the patient's bodies immune system time to peel off the infection so the bactrostatic works in conjunction with the patient's immune system so but what are what are really you know on a day-to-day basis what are the big categories or drugs we're talking about we're talking about broad spectrum versus narrow Spectrum if you're looking at the screen these little green guys here that would represent one type of bacteria let's just say it's like E coli so you can have a narrow spectrum antibiotic that really all it would kill off would be E coli those little green guys broad spectrum they could kill off not just those little green E coli but they may kill off the little pink MRSA they may kill off the uh the rods the purple guy and the the seediff the the turquoise guy there in other words again broad spectrum can kill off many many different types of bacteria so when we don't know exactly what's causing the infection we need to start off with broad spectrum so for the test again when a patient comes in with an infection what's the first action we take as a nurse is prior to you know when giving antibiotics to a patient with an infection once you know the first thing we do is we need to obtain the culture and sensitivity first for the test then after obtaining the culture and sensitivity and sending it off to the lab what antibiotics do we or what type of antibiotics do we give we're going to give broad spectrum antibiotics okay how do we tell the specific bacterias which specific bacteria is causing the problem that is the culture part of the culture and sensitivity that's found out in the lab how do we tell what works against that back specific bacteria that's the sensitivity part so when we get the results of the culture insensitivity when we find that out what changes for the test we need to understand guys we'll switch from a broad spectrum to a narrow spectrum antibiotic so if you're wondering what cultural sensitivity is let's say in the lab what do they do remember we sent our grandma's urine off to the lab for this culture and sensitivity thing well what they do is they'll dip a little sterile Q-tip basically into Grandma's urine and they'll wipe it back and forth across the inside of a petri dish then they put into a little kind of mini oven turn it up turn up the heat and they the culture part is they're actually trying to grow a bunch of that bacteria so if you look on your screen the little kind of white streaks up and down you see that that's where they kind of spread on the petri dish the Grandma's urine and those little white streaks are actually the bacterial growth of the the organism the bacteria that was causing Grandma's infection then the sensitivity part is after we've grown a bunch of the anime of the bacteria which by the way why are we growing a bunch because we need a bunch of it so that when we look at it with the microscope we can identify it right remember we're having to zoom in a lot so we need a bunch of it to be able to look in at it and identify the specific organism so the culture part is identifying the organism the next is the sensitivity is we put these little what you see is white dots on your screen we put those on a petri dish and why are we doing that well those little white dots are actually just little pieces of paper essentially but they're the paper is saturated with different types of antibiotics so then we come back our you know hours later and we look at our petri dish and we can tell visually which one of these is doing a really good job of killing this specific bacteria so that's the sensitivity so if you're looking at your screen clearly you see a couple white dots where there's uh you know the white dots itself were clearly it hasn't killed any bacteria you can still the bacteria are growing still right around it then you see a couple a couple other white dots where there's just this big kind of clear circle around them that means that that antibiotic was just killing off that that uh bacteria like no other so we'll say that this specific bacteria is sensitive to those antibiotics once we get the results of that that's when we uh switch from a narrow Spectrum to a broad spectrum all right so that's the general procedure guys the general procedure but what problems can arise out of that General procedure well the problems are there's some areas of infection bacterial infection that are really difficult to treat what are those so for the test doesn't this look like a select all that apply uh which of the following you know something like which of the following areas would be uh might be much more difficult to treat using back antibiotic therapy so what are some areas that are difficult to treat with antibiotics so first one we've talked about before is the Triple B that being the blood brain barrier so if you if Grandma had an infection in her brain or spinal cord what if we do the culture insensitivity but we find out that the antibiotic that that brain infection is sensitive to that that antibiotic doesn't cross into or doesn't cross the blood-brain Bearer could we then treat that infection it would be very yeah probably not with that antibiotics does that make sense what's another area that's difficult to treat well AB purely abscesses in the body you're wondering what a purulent abscess is you all have this in your in your memory it's think of Dr because you've all seen Dr pimple popper right and she goes in and like pops this gigantic pimple with all this pus of spring out so inside of that Lake of pus that abscess that Lake of pus makes it difficult for the antibiotic to reach that infection so that that pimple or that white head that's uh that big infection it's just difficult for the antibiotics to reach there which BT dubs that's why Dr pimple Popper's making the incision and popping it so she can get rid of all that Lake of of uh pus then you'll see she cuts it pops he gets over to like a puss she'll kind of wipe it out either with a gauze or a Q-tip and then she'll she'll put some topical antibiotics so now we can reach the actual bacteria some other areas where the antibiotic may have difficulty reaching and killing the bacteria would be on non-living tissue so some examples of non-living tissue in the body whereas the patient has a bunch of metal implants in their body like after a traumatic car accident or motorcycle accident what if the patient has some non-living implants in their body like someone who's had a heart valve replacement so those don't get good blood flow because they're not living tissue they don't have arteries delivering the uh antibiotic there in the amount it needs to to get to treat the kill off the bacterial infection so it's hard to treat uh bacterial infections where the bacteria is kind of growing and living on non-living things like metal or non-legal tissue what if the area itself is not getting good blood supply remember the antibiotics traveling around in the blood these would be disorders like Peripheral arterial disease the antibiotic is not being carried there or what about DM DMS diabetes mellitus remember diabetes mellitus kind of causes reduced blood flow and then what's the other problem with treating what's the problem with treating bacterial infections of patients with diabetes is that membrane diabetes their their blood sugar is really high what do bacteria like to grow they like sugar so it's hard to treat and kill bacteria while at the same time the in the diabetic the diabetics blood is basically giving them a buffet of food to eat so some difficult some areas in the body that may change you know our general approach of which antibiotic to give and how it could it could be that there's some locations that are hard to treat so that may change which antibiotic we select well something else you need to know for the test is what are some problems in general with pretty much all antibiotics or potentially with all antibiotics well some problems with all antibiotics could include that antibiotics taken as a whole are very allergenic substances meaning they cause allergic reactions so it's estimated between anywhere between 10 to 20 percent of the US population has an allergy to an antibiotic so they're very allergenic substances you need to be aware of that when you're given antibiotics they could go into an anaphylactic reaction potentially and that's just anybody so antibiotics in general they may not all but many of them may cause a kind of toxic reaction the body called Steven Johnson syndrome you're going to see us abbreviate that sjs so the Stephen Johnson syndrome that's commonly when they start to develop a very small rash and then suddenly that rash over the next couple of hours or days spreads to the rest of the patient's body then that rash turns into the skin melting off of their body essentially so um can be very much life-threatening uh ATM ATN you should know stands for acute tubular necrosis atan is just a fancy way of saying the patient's kidneys aren't working So the patient's suddenly going into kidney failure what you may see referred to in different texts is acute kidney injury or cute kidney failure so ATN means that the kidney is not working the main cause of ATN is we meaning the doctors and the nurses do it to our patients but that doesn't sound very nice like why would we kill off our patients kidney well it's the antibiotics a lot of the antibiotics we give in the hospital which are stronger antibiotics right makes sense a lot of the antibiotics we give in the hospital are very strong and they can start damaging the kidney that term of a drug damaging the kidney nephro toxic we say that the there's nephrotoxicity that's the cause of the acute tubular necrosis or the cause of the kidney not working we need to be aware of that with a lot of these antibiotics we give another issue that can arise when giving antibiotics is the issue of super infections what are some examples of this you've learned well you guys have learned oral thrush yes that kind of white uh kind of cheesy looking growth in a patient's mouth that's a result commonly of giving really strong antibiotics what's another example that you've learned C diff Clostridium difficile so we all have some C diff in our bodies but once we give you some strong antibiotics that can kind of pave the way for the C diff to start growing more relative to the other bacterial infections so um yes super infections like C diff like the oral thrush which is also um called the candida or you know candida infections candidiasis so other problems and again this is just this is the the same problems that the last slide just kind of writing out the problems I said again antibiotics can cause allergic reactions are very allergenic substances so things you need to understand for the test that I may ask you and and it relates to real life so what if in real life you ask your patient oh do you have any allergies and they say no then what if you're about to give them an antibiotic let's just say you're going to give them oh I don't know um Ceftriaxone as an IV infusion you say Oh Mr patient um we're about to give you the ceftrax when you ever received this before and they go oh yeah actually I have then you ask them which you should hey well did you have any issue with that they go no no no no problem I mean I had a little bit of a rash on one arm like I had some rash and some hives on one arm afterwards but it was fun so if the patient tells you that what should you do as an RN so if they have a previous reaction to that antibiotic you should confer with the provider I mean call the doctor why because anaphylactic or allergic reactions sometimes they happen the very first time a person gets a substance but sometimes it's the second or or later instance of them receiving the substance or being exposed to the substance that all of a sudden is what causes them to go anaphylactic so just think of this way that first time the patient got that Ceftriaxone antibiotic they had a little reaction but now the immune system is kind of primed going forward and it made me that next time you give it to when they go into full-on anaphylaxis uh the patient said they had some type of reaction like that before you definitely want to uh talk to the physician um and kind of come up with the plan the physician may switch antibiotics or they may they may say depending on their knowledge they may say you know what let's go ahead and give it give it you know they'll make prescribe some other meds along with it until you just to be vigilant for like the first 30 minutes while you give it but anyway it should be in consultation with your um the patient's position uh what if what if your patient says no I've never got it before I've never I'm totally fine and then you give the antibiotic and they start saying you know what I'm feeling dizzy when they start saying oh you know what I'm not getting short of breath so guys it's you know on a test it should be pretty obvious you give an antibiotic patients suddenly dizzy or short of breath those aren't expected things you should suspect they're going into an allergic reaction or anaphylaxis so that would be something again we need to that could be a potential emergency situation you need to call the doctor stay with your patient um Etc stop the stop the antibiotic that would be a reason we stopped in antibiotics we suspect they're going to an allergic reaction okay remember the toxic reaction what if the patient is getting antibiotics suddenly they have a new little rash this is a rash normally that the Stephen Johnson syndrome starts out as a rational about the size of a quarter so I tell you the patient's getting antibiotic and all of a sudden they have a new rash again that could that could be not always this but could be the development of Stephen Johnson syndrome we should sit there and uh or we should call the physician a report that and then the physician at that point that may be another reason that we stop the antibiotic confusion so notice normally we don't stop antibiotic confusions we don't stop and for the test guys we don't stop giving somebody antibiotics because they develop a super infection what we do stop giving the end to hold the antibiotic and consult The Physician for is hey they're getting short of breath they're saying they're dizzy hey they got a new suddenly developed a new rash or hey suddenly my patient's not making any urine or very little urine and oh they're they're abundant creatinine is going up those are reasons that we may hold the antibiotic consultant position and then take it from there make sure we know for the test something uh I believe we talked about before is peak and trough levels so this is a common reason why we're drawing Peak and trough levels is because we're giving an antibiotic that can damage the kidney if the patient gets too much so remember the peak and trough the trough trough levels are drawn to tell us if the patient's getting enough medication the peak levels are drawn to see if the patient's getting too much medication so for antibiotics that are highly nephrotoxic we'll talk about some of those or antibiotics that have a narrow therapeutic index or uh narrow therapeutic range we're going to be drawn Peak and trough levels as a reminder when do we draw Peak and trough levels when do we draw timing wise so remember the the trough is the easiest one to remember just 30 minutes within the 30 minute period right before we give the antibiotic we draw the trough levels send it off to the lab So the patient's scheduled to get their next antibiotic uh infusional IV infusion at let's say two in the afternoon we would draw that trough level between 1 30 in the afternoon and two be so that 30 minutes somewhere in that 30 minute period prior to administration of the antibiotic is when we draw the trough the peak is drawn within the 30-minute period after we've given the antibiotics so again trough the 30-minute period prior to giving the ad but before we give the antibiotic Peak 30 minute period after we've already given the antibiotic so the only thing make sure you remember for the peak when we so in our example I said oh we're going to give this this antibiotic at two o'clock when we pardon me when we draw the trough look we drop between 130 and 2 right before we give them in then when we redraw the peak the common thing that students get wrong in the test is we don't draw the peak between 2 and 230. well why don't we drop between 2 and 230 because remember if they're giving it you're receiving it IV infusion between 2 and 2 30 during that time the med is still going into them they haven't received all the medication so just remember when you're looking at the peak it's if we gave the med at two o'clock and let's say we ran it over two hours so when is the med after really finished it would be from two o'clock it runs over two hours would go from two o'clock to four o'clock it would have finished at four o'clock so we draw the peak after it's finished meaning between somewhere between four and four Thirty PM in that 30 minute period so it's after that 30 minute period after the drug has finished infusing right not while it's infusing so um for the test make sure you know signs of a super infection so we said candidiasis what was the sign for that that's right was that kind of white cheesy growth inside the mouth uh what's another sign of a super infection could be like a black furry tongue what's a what's a sign of a C diff super infection will this one be watery very smelly diarrhea so again for super infections guys for the test do we stop and hold the antibiotic and stop giving it no we don't stop giving you we'll notify and report it to the physician but we don't stop giving we only stop giving antibiotics for life-threatening things like an allergic reaction a toxic reaction where their kidneys are getting destroyed then then we'll stop stop it hold it call The Physician um and anticipate switching potentially to another antibiotic so what is those super infections look like oh here look Valentine's Day is coming up Valentine's Day is coming early so here's a mouth everyone wants to kiss right with that white this is the candidiasis or the oral thrush so for the test guys make sure you know what the treatment is for oral thrush the treatment is Nystatin with an N they do a Nystatin mouthwash and you need to know the patient teachings we teach them to swish it around in their mouth for at least three minutes so they're just kind of like swishing it around their mouth the doctor will will usually direct us whether they want him to just spit it out at that point or they can swallow it it's not going to hurt if they swallow it so they switch you teach them the tuition around in their mouth for at least three minutes and then after let's say they spit it out you need to teach them not to eat or drink anything for at least 15 minutes afterwards why yeah that's right because the drugs still in contact with their own mucil so it's still actually working there's another uh here's another mouth we want to kiss oh yeah with the black furry tongue so again Valentine's Day came early so if you saw that oral candidias you see this black furry tongue that's not a reason to hold the medication that's a reason we will tell the doctor about it and keep them informed you would expect that that oral candidiasis we're gonna keep rolling with the antibiotics and we'll just treat the candidiasis make sure you know that the oral candidiasis that's a fungal infection so the nice Statin we treat that with is an anti-fungal agent which we'll talk about a little later uh nice then also I'm going to say as an aside so that you want to remember later for the final is Nystatin is an anti-fungal that do not confuse that with the Statin meds that are heart meds like atorvastatin and simvastatin nystands anti-fungal also you know it is not a Statin cardiac event all right last thing we're going to kind of talk about regards to what can go wrong with antibiotics or just some problems that may occur um is antibiotic resistance so what is antibiotic resistance that's that's when bacteria that had previously been getting killed off by a specific specific antibiotic that now that bacteria no longer is killed off by that antibody the antibiotic no longer works for that so you've heard of this before you've all I assume have heard of MRSA what is MRSA that's methicillin resistant staph aureus so staph aureus used to be killed we used to treat it with this antibiotic called methicillin so but after a while suddenly the methistillins stopped killing that specific screen of staph aureus so we started calling that a MRSA infection the problem is that makes it harder to treat currently the way we treat MRSA is with vanco with the antibiotic Vancomycin real important antibiotic so for the test you need to understand what can cause or what contributes to antibiotic resistance what contributes to bacteria developing a resistance to antibiotics where the antibiotic doesn't work in them anymore there's a couple ideas here guys you need to understand this okay so for the test if you understand this you should get it right instead of memorizing it if you memorize it you're probably going to be having trouble first understanding is that the more often we give a patient or everybody the more often we use antibiotics the more likelihood that the bacteria will figure out a way to become resistant to them so think of it this way I like playing video games I got a PlayStation 5. um I like video games I wouldn't consider myself a gamer but I do like games and I think all of you sometimes you play games so you know when you play these video games even though there's even if the game is really hard and I start dying a bunch in the beginning if I keep playing the game long enough and I start playing the game day after day and I get to play it a lot eventually I'll figure out how to beat the game right it's just I just need to get opportunities to keep playing the game the more time and exposure I have to the game eventually I'll figure out how to beat it we all would right it's not that I'm special so think of this regarding bacteria playing the antibiotic video game the more often bacteria get to see and play the video game eventually they'll figure out how to beat it so if we use antibiotics too much the overuse of antibiotics the over prescription of antibiotics um that's giving the bacteria Time and Time and Time and all these opportunities to play the video game eventually they'll figure out how to beat the game so how do we try and avoid that well we don't want to give again we don't want to use antibiotics unless we have to so we don't want to give antibiotics to things that aren't a bacterial infection because for the test antibiotics only treat a bacterial infection so should we give should we administer or have a prescription for an antibiotic or somebody who has the flu or flu-like symptoms or has covid-like symptoms no those are viruses the antibiotic won't work so why would we use it why we give when we're given that the other bacteria in that patient's body gets to see the antibiotic and they can develop resistance okay um what about here's another concept you want to understand that if we use the antibody correctly hopefully they kill off all the bacteria so then that bacteria since it's dead it won't learn how to we won't figure out how to beat the video game but if we use the drug incorrectly and we don't kill off all the bacteria the survivors May potentially learn how to beat that antibiotic so if you understand that concept then then what do we need to worry about we need to teach the patient don't skip doses now why would this happen many antibiotics will prescribed there'll be a two-week course meaning for example say hey take this particular antibiotic take this tetracycline once a day for the next two weeks well when does the patient start feeling better when they're taking antibiotics most patients start reporting that they feel a lot better around 48 to 72 hours after we start them on antibiotics the problem is 48 to 72 hours so two to three days after we start the antibiotics they start to feel better the problem is they're supposed to continue taking those antibiotics for another week and a half if they stop because they feel better there's still some bacteria in their body and think about it that bacteria got to see the antibiotic they got to play the video game so then the problem is the next time we try to use that drug for their infection that in this example tetracycline that bacteria may not get killed off by it they may say oh I've seen this game before I know how to beat it so we teach the patient don't skip doses take the full course of the prescription as it's prescribed What If instead of skipping the dose what if the doctor doesn't prescribe enough of the drug well we prescribe we under dose or prescribe too small of a dose of the antibiotic it May kill some of the bacteria but it'll leave some survivors and again those survivors will have seen the video they've gotten a chance to play the video game so they can develop resistance so guys for the test students commonly missed if I say what can cause antibiotic resistance taking a large dose actually when we in terms of antibiotic resistance taking a large dose is a good thing it makes sure all the bacteria gets killed off now that large dose may increase the risk of the adverse effects or may increase the risk of damaging the kidney it might but regarding antibiotic resistance we like to err on the side of a larger dose versus a smaller dose because a smaller dose you run a huge risk of creating antibiotic resistance so how do we again how do we check that they're getting too small a dose is we that's why we're drawing a trough level if our trough level is below the mech the minimum effect of concentration if our trough level is below the mech what dosage adjustment do we need to recommend to the physician yeah we need to recommend it to the doc a with you know what do you think about increasing the dose on this uh increasing the amount the patient's getting on this because their their blood levels are below the mech um so again if the the trough level is below the mech that means in between doses that the amount of bacteria the amount of antibiotic that kills the bacterias is not having any effect so for the test though hey if the trough level is below the mech that means the drug is not having any effect it is not killing any bacteria there's not enough in there to do its job so we'd expect an increase in dose or rarely they may give the drug a little bit more frequently instead of giving it every six hours they may give it every four hours at the same dose so again how do we check that they're getting underdosed that's with the trough level and how do we check that they're getting too much that would be with the peak level and again know when you check those all right um we don't want to we don't want to stop in antibiotic suddenly unless it's for a real life-threatening reason why again because if we stop an antibiotics suddenly any of those bacterial survivors could have played the video game enough you could have played the antibiotic video game enough to develop antibiotic resistance so again a patient has a super infection we typically are not going to stop the giving the antibiotic or hold it we're just going to treat the super infection all right I'm gonna pause here