hey everyone welcome back we are going to discuss part two of our antibiotics chapter 39. I know I don't usually cover the objectives but again for the antibiotic sections there are a lot of antibiotics to know so the big thing here is you can't memorize every single thing about every single drug class well I mean you can but um really what you should know is going to be common adverse reactions so that you can provide patient education and you know that hesi is going to want to test you on any very unique type of reaction specific to a drug class and then jumping down to objective number five we want to make sure that we're able to outline the nursing considerations the nursing implementation for patients receiving each class of antibiotic again it's not just enough to know it we have to be able to apply it as well beginning of chapter 38 last chapter we discussed methods to prevent antibiotic resistance unfortunately as you know bacteria have a way of evading our natural and our developed defensive defenses including antibiotics so multi-drug resistant organisms these are highly problematic nowadays not just in the hospital setting but unfortunately community-wide as well so we have MRSA which we've had for quite a long time and that's methyl acillen resistant staphylococcus Aurorus we also have bre now those are our bugs that are vancomyosin resistant so Vancomycin resistant enterococcus we also have esbl which is organisms producing extended spectrum beta-lactamases and that is not going to be effective our antibiotics that have that beta-lactamase that's not going to be effective so things like Augmentin which is the combination of amoxicillin clavulate which again helps to break down that beta-lactamase ring not going to be effective and then yikes we now have crobopentum resistant enterobactinase orbectin a formerly C c r e so let's start with MRSA MRSA there is a threat of MRSA becoming resistant to all antibiotics that are available so MRSA as you know we don't just see that in the hospital setting unfortunately it's now spread to the community setting and approximately half of the staph infections that we see in the community do involve MRSA the next one that we have is our VRE and that's our vancou myosin resistant enterococci um VRE is most often seen in urinary tract infections particularly patients with chronic Foley um happy to say that we do have newer antibiotics that have been developed to successfully treat VRE and MRSA again unfortunately we know that as time goes on there's a strong likelihood that organisms are going to become resistant to even these newer drug classes and we'll talk about some of those in this lecture the germaphobe in me relates to the picture from Monsters Incorporated although actually after having been in n95 masks and full PPE for the past three years VRE and MRSA seems like highly anything to be concerned about okay so esbl again extended Spectrum beta-lactamase so that's an enzyme that's found in some strands of bacteria and the espl producing bacteria can't be killed by many of the antibiotics so again our penicillins and our cephalosporins are not effective so again resist them to our beta-lactum antibiotics resistant to as trinom can be treated with carbopenums or sometimes our quinolones and I'm going to refer to quinolones as fluoroquinolone simply because that's how I learned it with the use of carbopentum such as meropentum fear to pentum and Emma pentum that we learned about last chapter resistance has occurred so we now have this production of an enzyme carbapanimase which now renders our caropendums ineffective so we have a couple of medications that can be used for esbl oh and don't you love it when you get to a slide and realize that you did not finish adding all the drug classes to the slide so sincere apologies we're going to go over aminoglycosides fluoroquinolones and a whole bunch of other medications that you're going to see in the next several slides foreign class that we're going to cover is going to be our aminoglycosides so these include the most common ones that you're going to see are Gentamicin and Tobramycin you're going to note that these end in myosin however there's a little asterisk there because nothing can ever be that easy and we're going to cover one called Vancomycin which is not an aminoglycoside so our Amino glycosides is a group of exceptionally powerful antibiotics which are used to treat serious serious infections life-threatening infections caused by gram-negative aerobic bacilli these will inhibit the bacterial protein synthesis and again we use it for treatment of serious systemic infections caused by a rhombogram negative bacteria myobacteria and some protozoans we do have newer antibiotics with less toxicity but you may still see these and resultingly there's going to be some nursing considerations to be aware of so again inhibiting protein synthesis and susceptible strains of gram-negative bacteria causing cell death this drug class has very poor poabsorption so we really don't have any oral forms to speak of and a little little side note of neomyosin most of these are going to be given IV although technically I suppose they could be given I am again very potent antibiotics with serious toxicities they are bactericidal they will kill the bacteria so can be used in our immunocompromised it will prevent protein synthesis again pharmacokinetics poorly observed from GI tract but rapidly absorbed following IM or IV Administration reaching our Peak levels within one hour widely will be distributed throughout the body unfortunately crossing over placenta and entering breast milk it will be excreted in urine average Half-Life two to three hours since they depend on the kidney for excretion we should probably know that these are going to be nephrotoxic our big contraindications here these aminoglycosides very very tough on the kidneys and the ears so obviously again allergic don't take to it but if you have kidney disease in particular if you have any sort of hearing loss these could potentially worsen both of those and we should also pay attention to how your liver is doing now again I should go back and say IV or I am Administration usually IV is what you're going to see for systemic infection we could sometimes use these for eye drops or ear drops and that's a little bit different that's not the serious infection and we're not going to get systemic effects from those so if you ever get the Tobramycin eye drops you know don't panic that's not going to be something that'll take it out on your kidneys if you have a pink eye infection okay so um it can also be given by inhalation for the treatment of lung infections okay again our exception to being poorly absorbed is going to be our neomyosin which will give to decontaminate the GI tract before surgical procedures that's highly specific not something that you need to know for my exam okay it could be used as an enema again to decontaminate the GI tractor for surgical procedures we could also use neomyosin to treat hepatic encephalop again this drug class High toxicity so it has a narrow therapeutic index we need to monitor um drug levels our serum levels so we're going to be monitoring our Peaks and our troughs again most important adverse effect that you should know is ototoxicity ears nephrotoxicity kidneys we could of course get our typical headache or super infections of course but paresthesia fever vertigo really relating more to my ototoxicity we always need to be on the lookout for a Rasha Specialist of your rash we always keep Stephen Johnson in the back of our mind dizziness again similar to vertigo now one Curious Thing here muscle aches and cramping with our immunoglycosides is a quote normal and known effect so according to references this is not something that you have to notify the provider about our implementation we want to monitor Peak and trough levels to prevent nephrotoxicity and ototoxicity again monitoring our Peak and trough ototoxicity could be in the form of hearing loss dizziness tinnitus nephrotoxicity signs and symptoms we might have urinary casts discolored urine protein urea as well as an increase in our BUN and creatinine um because our Amino glycosides can cause GI upset we want small meals because they can be nephrotoxic we want to make sure that we have adequate and I dare say ample fluid intake we want to take safety measures for dizziness and vertigo we want to monitor for bone marrow suppression meaning that you should watch your CBC right because we'll get a decrease in our hemoglobin hematocrit maybe even our platelets and our white blood cells we need to watch for super infections again we're killing off not just the bad bacteria but also the good bacteria headache and rash again these are more toxic than a lot of our other antibacterial classes more systemic adverse effects Muscle X common on exciting finding don't need to stop the infusion or call the PCP so our aminoglycosides again we're using this for things like meningitis or peritonitis things that could be life-threatening serious infections and highly damaging to the ears and the kidneys prototype one that you might see in the hospital setting is going to be Gentamicin um it's going to be rapid onset peaking in 30 to 90 minutes a student was nice enough to send me a picture of her four-legged baby Cody all right um true or false because of the adverse effects of our Amino glycosides that should be a g it is important to teach the patient to restrict fluids and eat six small meals daily correct answer is going to be false we do not want to restrict fluids these are nephrotoxic to begin with if we restrict fluids we're going to become dehydrated and we're going to increase our creatinine not what we want to do patient teaching should be maintaining adequate or ample fluids maintaining nutrition though there might be nausea vomiting diarrhea we did say maybe some small meals we didn't necessarily say six of them though moving on to the next drug class our book refers to them as quinolones I learned them as fluoroquinolones or fqs so I'm going to refer to it as fluoroquinolones our fluoroquinolones good antibiotic less toxicities about one black box warning that we'll talk about in a second so it inhibits bacterial DNA synthesis causing bacteria death so these are bactericidal they will treat infections caused by susceptible strains of gram-negative bacteria which includes UTIs Uris upper respiratory tractin infections skin infections and Anthrax it was actually I think developed to fight Anthrax back in the 80s again we have a whole bunch of ones staphylococcus auroras um mycobacterium a whole bunch of ones that this will be effective against however unfortunately we're starting to see some bacterial resistance to our fluoroquinolones as well again they are bacteriocidal these are going to all have the common ending of floxacin as you'll see on the next slide so we have ciprofloxacin levofloxacin those are probably going to be the ones that you see the most a little mnemonic the one specifically for upper respiratory infections are going to be moxofloxacin avlox gemafloxacin which is effective I have never hung that one in my life and levofloxacin I included a link to look at the mechanism of action and resistance for our fluoroquinolones if you feel like deep diving in again not going to be on a test so used for gram-negative bacteria you don't need to know that for an exam such as pseudomonas as well urinary tract respiratory tract bone joint infections GI infections oh STIs will use it a lot skin as well as Anthrax contraindications here's some ones that you need to know this is not approved for patients under 18 years of age we will sometimes see it used outside of our FDA approval but in the NCLEX Hesse world it is not to be used for patients under 18 years old accordingly we do not want to use it for pregnant patients it's processed through the kidney so we will need a dose adjustment for patients with renal disease our added effects you're going to see a whole bunch of stuff in red here yes we're going to have our usual GI upset and again remember all antibiotics have the possibility of giving you nausea especially diarrhea we could see headache or dizziness the important ones are going to be our photosensitivity so this is a fun in the sun fluoroquinolone F fun in the sun medication so with that photosensitivity we're going to tell patients that they should stay out of direct sunlight they should wear protective clothing if they are going to be outside we don't want them going to tanning beds and they should be using an SPF something very very high when they go outside um next we need to worry about monitoring EKGs because fluoroquinolones could potentially cause some dysrhythmias we need to watch liver function because they could also cause hepatotoxicity the Black Box warning for these medications is really quite curious it's tendonitis if you watch CNN or Fox News late at night you will see commercials for 1 800 bad drug have you or a loved one had an Achilles tendon rupture with okay so that is true it's a black box warning I've only seen it maybe once and that was with an elderly patient we were treating prostatitis and he was on a long-term dose as prescribed by a serologist and by long term I mean like three or four weeks of Ciprofloxacin additionally we have to be concerned for patients who have a prolonged qt or who are on multiple medications which can prolong our QT interval okay in addition to being a fun in the sun medication if you watch nurse Mike this is also a move the food medication meaning food decreases the absorption so in an Ideal World we want patients to take fluoroquinolones on an empty stomach um are antacids other milk containing products magnesium containing iron containing preparations can also interact with our fluoroquinolin so again empty stomach no other Medicaid well at least not antacids so we want to take interacting drugs at least an hour before or two hours after all right example being Ciprofloxacin and avoid in children under 18 years old ah prototype summary our fluoroquinolones can be given orally again they are very well absorbed we also have fluoroquinolones available in IV form and if needed we can use them to drink treat eye infections such as pink eye or ear infections in the form of otofloxacin okay question for you during IV fluoroquinolone Therapy in an 88 year old patient which potential problem is of most concern when addressing for adverse effects well I don't love hepatotoxicity um but the big one here is going to be the Black Box morning of our tendon rupture again Black Box require Black Box warning as required by the FDA for all fluoroquinolones because of the increased risk of tendonitis and tendon rupture it is more common than our older patients patients with renal failure again we need to dose adjust and patients receiving concurrent uh glucocorticoid therapy like long-term steroids okay we're gonna go through next Vancomycin technically the drug class is glycopeptides I think it's the only drug in that class so our book is kind of just lumped it in with miscellaneous Vancomycin was and still is the treatment of choice for MRSA and other gram-positive infections we can use oral Vancomycin again make sure that you see the word oral there is indicated for the treatment of antibiotic-induced colitis C diff colitis and for the treatment of staphylococcal enter colitis all right um Vancomycin was introduced long long time ago shockingly 1958 and um on the horizon we have stronger versions of Vancomycin which is three two according to these notes 25 000 times stronger than the original Vancomycin because this has a narrow therapeutic index we need to monitor our Peaks and our troughs this again is going to cause ototoxicity and nephrotoxicity kind of like the other myosin drugs that we talked about in our immunoglycosides so again we're going to need to monitor our Peak and our trough dosing for Vancomycin is based both on weight and on renal function and we should be pushing fluids adequate fluids to peripheral toxicity something unique to Vancomycin given IV is a phenomenon called red man syndrome red man syndrome is something that can occur and it is Flushing of the face itching of the face head neck upper trunk really it's kind of the upper chest neck head face and this is caused by the Vancomycin being infused too quickly I can tell you the entire time that I have been a nurse I have never had a patient with red man syndrome but yet somehow uncolex and hessy find it to be very important again we have IV pumps that are programmed with time so maybe this was more of an issue when my mom was an ICU nurse I've never seen it but for some reason it seems to be highly important to the NCLEX um so um Vancomycin should be infused over 60 minutes or more all right um rapid infusions could cause hypotension hypotension is the most severe adverse effect of the red man syndrome all right so your question a 58 year old man is receiving vanco as part of a treatment for a severe bone infection after the infusion he begins to experience some itching flushing of the face neck and upper body most important no chills no difficulty breathing so we need to make sure that we are distinguishing the difference between red man syndrome and anaphylactic reaction so what do you suspect do you think that this is an allergic reaction do you think that this is an anaphylactic anaphylactic reaction do you think that the medication will not be effective for the bone infection or do you think the IV dose may have infused too quickly all right correct answer is going to be D or IV dose may have infused too quickly again this is red man syndrome occurred doing or after the infusion of vanco which is given a little too quickly again characterized by flush air itching of the head face neck and upper trunk can usually be alleviated by slowing the rate of the infusion it's bothersome but it's usually not harmful mind you rapid infusions can also cause hypotension so it's not like we're bolusing Vancomycin here continuing on with our miscellaneous antibiotics we've already covered Vancomycin there's a few more that we're going to cover in some detail and others that I'm going to kind of skip right over because I really don't think you need to memorize every detail of it we do have a newer drug class coming out within the past five years specifically indicated for community acquired pneumonia I'm not testing you on it continuing on with our miscellaneous antibiotics lingosamides otherwise known as clindamycin is really the one to know here and I love a text that pretty much said hey similar to our macrolides if you remember correctly those are like azithromycin erythromycin and chlorothromycin but are more toxic so our clindamycin has a whole bunch of uses including chronic bone infections GI intra-abdominal infections other serious infections I've also seen it used in dental procedures though again I think if we can get by with just amoxicillin for dental procedures that'd be the way to go one of the big things that we see is could cause a pseudomemembranous colitis antibiotic Associated colitis such as a C diff infection a couple of times when I have seen patients with C diff infection community acquired they have been unclindomycin recently effective but that is definitely a side effect of this medication it can be given orally I am or IV um depth of myosin only drug of the new class known as the lipto peptides I don't know that there's anything really here that I'm going to test you on continuing on again I don't think I am um I'm going to be testing you on this drug class similar we're just going to skip it continuing with our miscellaneous antibiotics um lines a lid this one is used in hospital settings I would not expect you to know it for an exam um I don't know that it's still as much in favor as it was say 10 years ago we would use it for sepsis or severe VRE um curiously enough this medication could cause hypotension and a few unique things about it if taken with other ssris we could get serotonin syndrome and reactions if taken with tyramine containing foods so here's the thing again I wouldn't expect you to memorize this but as a staff nurse I would strongly recommend referring to your nursing Drug Book and just kind of reviewing before hanging this in contrast I absolutely would expect you to know and be familiar with Metronidazole metronidazole we have in both pill and IV form it is used for a whole bunch of different infections this one's an antibiotic plus we can use it for our anaerobic organisms such as C difficulties treat C diff or we could also use the oral Vancomycin it can also be used for intra-abdominal and gynecologic infections we can use it to treat trichomyosis usually in an oral form but we can also use it as a vaginal suppository um metronidazole can also treat prozoll infections it is processed through the liver through that cytochrome p450 pathway so we do have to be careful because there is potential for several drug interactions you know that this is a medication that's used frequently if nurses make memes and silly comments about it and the first time that you will ever open the IV packaging for metronidazole you will understand why and I just love this one why is the packaging for Flagyl stronger than all of my relationships so this is the reason you should probably just carry scissors on you at all times is just to open the metronidazole Packaging foreign specific adverse effects of our metronidazole that you should be aware of patients especially I've taken orally could report a metallic or bitter taste now I'm headache and fatigue you're going to see we pretty much had that with all of our antibiotics the darkening of the urine is an adverse effect that we can have with our metronidazole this is not something that we have to report we are aware so you might want to give patient education so they're not calling the provider at two in the morning um it's processed again through the liver so we have to watch for hepatotoxicity similar to all of the others GI distress nausea vomiting diarrhea very specific to metronidazole no alcohol no alcohol within 48 hours after treatment we will get the disulfirm type vomiting profuse vomiting reaction if we mix alcohol and metronidazole so again no mouthwash no aftershave no deodorant what anyway specific to just UTIs um nitrofurantoin I often see the brand name of this one as macrobid um use carefully if renal function is impaired it'll concentrate the urine we need to watch our liver function as well um not testing you on that one but you're going to see it a lot in practice used for UTIs particularly in the outpatient setting because it's very very specific to the kidneys ureter and bladder and here is another medication that was included in our textbook but I am not testing you on still not testing you on it all right so um some of these are the same nursing implications that we spoke of at the end of the last chapter again you're always going to assess drug allergies kidney function liver function cardiac function especially with say our fluoroquinolones which prolong the QT I want to make sure we're monitoring other lab studies obtur obtain patient health history immune status again we worry about patients who are immunocompromised we have to use a bactericidal antibiotic not a bacteriostatic we want to assess for contraindications such as age or pregnancy liver impairment or kidney in fact preparement that would be contraindications or antibiotic use or just indicate that we need to monitor a little bit more closely we need to assess for potential interactions again we always want to get the cultures before before beginning antibiotic therapy we always need to tell patients to take their antibiotics exactly as prescribed for the duration of time prescribed they should not just stop taking it because they feel better assessed for signs and symptoms of our super infection things like thrush vaginal yeast infection look for fever peritoneal itching perineal itching sorry um cough lethargy unusual discharge a lot of our cephalosporins all sound exactly the same so always double check the name of medication carefully each drug class has specific address effects and drug interactions that should be assessed and monitored the most common for all antibiotics are going to be nausea vomiting diarrhea we can always tell patients to take a probiotic not at the same time as the antibiotic but at some other time during the day during the duration of their antibiotic treatment I also can tell the patients to eat yogurt with live inactive cultures all oral antibiotics are better absorbed if taken with at least six to eight ounces of water again we have the move the food antibiotics which should be taken on an empty stomach so that would be our macrolides such as our throw myosins azithromycin chlorothromyosin and erythromycin T is for our tetracyclines and doxycycline tetracycline will end in cyclins and F is for our fluoroquinolones which will end in floxacin those should be taken on an empty stomach please monitor for therapeutic effects meaning is it doing what we think it should be doing Improvement in signs and symptoms of infection is our white blood cell count returning to normal are lymphocytes and our neutrophils returning to normal do we are we coming back to normal vital signs repeat culture should be negative again disappearance of fever if we're treating cellulitis disappearance or resolution of drainage and redness we always want to monitor for our adverse reactions I'm going to add one more thing there that for our medications which have a narrow therapeutic index we need to make sure that we are monitoring our Peaks and our troughs our our serum levels and that's it I hope you all have a great week