Pharmacology and Pathogens Quiz

Antiinfections

• Pathogens include bacteria (TB, pneumonia, cellulitis, bronchitis, STDs, UTIs, traveler's diarrhea, URIs), viruses (hepatitis, HIV, shingles, flu, COVID, norovirus, herpes simplex), fungi (candidiasis, pneumocystis pneumonia, histoplasmosis), and parasites (tapeworms, lice, mosquitoes, bedbugs, scabies).
• Antiinfection agents either kill the pathogen or stop its reproduction.

Sepsis Triggers

• Elevated white blood cell count (WBC)
• Fever, chills, weakness, fatigue
• Elevated lactic acid
• Hypotension
• Tachycardia
• Hypercapnia
• Hypoxia
• Inflammation
• Positive blood cultures

Sepsis Treatment

• Fluid resuscitation is the priority.
• Obtain blood cultures immediately.
• Initiate broad-spectrum antibiotics within one hour.
• Iatrogenic sepsis examples for UTI and abdominal infections include Zosyn/Tazobactam 3.375g q8h and Vancomycin 15mg/kg q12h.
• For pneumonia, add Levofloxacin 750mg IV q24h.
• For simple sepsis or community-acquired pneumonia, Ceftriaxone (Rocephin) 1g IV q24h, plus Doxycycline 100mg IV q12h or Levofloxacin 750mg IV q24h.
• Narrow treatment is adjusted based on culture results and sensitivities.

Four Basic Mechanisms of Antibiotic Action

• Interference with bacterial cell wall synthesis (penicillins, cephalosporins)
• Inhibition of bacterial protein synthesis (aminoglycosides, tetracyclines)
• Interruption of nucleic acid synthesis (fluoroquinolones)
• Interference with bacterial metabolism (sulfonamides, trimethoprim)

Knowing Antibiotics

• Some antibiotics are bactericidal, while others are bacteriostatic.
• Broad-spectrum antibiotics are effective against both gram-positive and gram-negative bacteria.
• No antibiotics are effective against viruses.
• Avoid giving IV antibiotics concurrently with antacids.
• Monitor for allergic reactions (rash, hives), especially after the first dose.
• Metronidazole (Flagyl) is unique in treating protozoal infections.

Classes of Antibiotics

• Penicillins (Ampicillin, Amoxicillin)
• Cephalosporins (Cephalexin, Cefepime, Ceftriaxone)
• Tetracyclines (Doxycycline, Tetracycline)
• Macrolides
• Aminoglycosides
• Fluoroquinolones (Ciprofloxacin, Levofloxacin)
• Sulfonamides (Bactrim, Septra, Sulfasalazine)

Treating Tuberculosis

• Mycobacterium tuberculosis is slow-growing.
• It commonly infects the lungs.
• Treatment involves intensive and continuation phases.
• Latent TB treatment is 9 months of Isoniazid (INH).
• Active TB requires a 6-12-month treatment regimen combining Isoniazid, Rifampin, Pyrazinamide, and Ethambutol.
• Diagnostic methods include Mantoux skin test, Quantiferon tests, sputum culture, and CXR.

Isoniazid (INH)

• Route: Oral (PO) and intramuscular (IM) injection (rare).
• Administration: avoid giving it within two hours of antacids (aluminum).
• Adverse effects include peripheral numbness, tingling, and hepatotoxicity.
• Contraindicated with disulfiram.
• Consider concurrent pyridoxine (vitamin B6) administration. Monitor liver enzymes regularly.
• Complete the full treatment course.

Adverse Effects of Antibiotics

• Severe allergic reactions (anaphylaxis)
• Severe watery/bloody diarrhea (Clostridium difficile infection)
• Stomach cramps
• Yeast infections (mouth or vagina)

Nursing Care for Patients on Antibiotics

• Verify allergies before starting antibiotics.
• Monitor vital signs (especially temperature).
• Watch for adverse reactions in the first two hours.
• Maintain adequate hydration.
• Provide patient teaching about the medication dose, schedule, and possible side effects.
• Offer probiotics (yogurt) with oral antibiotics to maintain the gut flora.
• Consider sensitivities if antibiotic doesn't work, consider changing to another antibiotic.
• Inquire about any OTC medications, or contraceptives and monitor accordingly.

Classes of Antiretrovirals

• Nucleoside/Nucleotide reverse transcriptase inhibitors (NRTIs) (Abacavir, Trizivir, Biktarvy)
• Non-nucleotide reverse transcriptase inhibitors (efavirenz, etravirine, nevirapine)
• Protease inhibitors (Atazanavir, Lopinavir)
• Entry inhibitors (Maraviroc)
• Integrase inhibitors (Biktarvy, Dolutegravir)
• Combination therapy is necessary for HIV-infected patients

Pharmacotherapy with Antiretrovirals

• Establish baseline CBC, BMP, CD4, viral load, liver, and kidney studies.
• Monitor for concurrent infections.
• Monitor for hepatic, renal, and neurotoxicity.
• Monitor glucose and lipid levels.
• Emphasize adherence to the drug regimen.
• Assess for body image issues.
• The therapy goal is to reduce viral load and prevent opportunistic infections.

NRTIs

• Abacavir, Emtricitabine, Lamivudine, Zidovudine
• Inhibit the HIV enzyme that makes copies of itself.

Prototype Drug: Acyclovir

• Therapeutic class: antiviral for herpesviruses
• Pharmacologic class: nucleoside analog
• Treatment for herpes viruses, prevents viral DNA synthesis, decreases duration and severity of episodes.
• May reduce frequency of herpes recurrences (does not cure)
• Adverse effects can occur with IV administration: nephrotoxicity and neurotoxicity, and resistance can develop.

Nursing Considerations during Antiretroviral Therapy

• Monitor kidney and liver function, heart function
• Manage side effects (skin rash, weight gain, fever, fatigue, joint pain, headache, eye swelling).
• Patient education.
• Teach patients about managing HIV medications as a required lifetime treatment.
• Monitor for side effects and complications.
• Genetic testing before initiation, especially for NRTIs such as Trizivir or Ziagen.
• Avoid non-nucleoside reverse transcriptase inhibitors (NNRTIs) like doravirine in patients with mental illness.

Parasites

• Protozoa (malaria, dysentery, giardiasis); Malaria is a serious worldwide disease with significant mortality and morbidity.
• Helminths (wormlike creatures); Examples: tapeworms, roundworms, Enterobius vermicularis (pinworm).
• Arthropods (ticks, lice, mites); can be vectors for other diseases like bubonic plague.

Pharmacotherapeutic Management of Pain

• Pain is a sensory or emotional experience
• Opioid analgesics include Morphine, Codeine, Hydrocodone, Fentanyl, Oxycodone, Methadone, Tramdol.
• Non-opioid analgesics include Acetaminophen (for mild-moderate pain and fever) and Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ASA, Ibuprofen, Naproxen.
• Antidepressants (Duloxetine, Amitriptyline)
• Antiepileptics (Gabapentin, Pregabalin)
• Local anesthetics (lidocaine patch)

Side Effects of Pain Medications

• Opioids: respiratory suppression, sedation, mental instability, abnormal EKG
• NSAIDs: GI upset
• Lidocaine: arrhythmias, seizures, loss of consciousness
• Duloxetine: serotonin syndrome, tachycardia, seizures, coma
• Acetaminophen: overdose can cause liver damage

Medications for End-of-Life Care

• Goal: palliative care, managing anxiety and pain.
• Medications like morphine sulfate, acetaminophen, haloperidol, lorazepam, atropine sulfate, bisacodyl, and antidepressants.

End-of-Life Quiz Questions

• Specific question about which medications are appropriate for a patient experiencing symptoms in end-of-life.

Febrile Actively Dying Patient Needs

• Acetaminophen (PR or PO) is suggested.

Haloperidol Use

• For agitation and anxiety

Impending Death and Anxiety

• Lorazepam, diazepam, xanax, and clonazepam as appropriate.

Gurgling Breathing Sounds

• Sublingual atropine drops

Death Rattle Management

• Atropine

Dyspnea and Air Hunger Management

• Morphine Sulfate

Nausea Management in Dying Patients

• Ondansetron, Prochlorperazine, Metoclopramide (excluding Dronabinol)

Comfortable Laxative for Dying Patients

• Bisacodyl suppository

IV Fluids for Actively Dying Patients

• Contraindicated, May prolong suffering; Isotonic fluids are preferred.