Antibiotics and Tuberculosis Student PDF

Antibioti cs MATTHEW MOEHL, PHARMD Introduction to antibiotics AN IDEAL ANTIBIOTIC REALITY… - kill 100% of bacteria - antibiotic resistance - only kills the intended target - harm to local flora likely - no harm done to patient - simple to administer - side effects, allergies - complex moni...

Antibioti cs MATTHEW MOEHL, PHARMD Introduction to antibiotics AN IDEAL ANTIBIOTIC REALITY… - kill 100% of bacteria - antibiotic resistance - only kills the intended target - harm to local flora likely - no harm done to patient - simple to administer - side effects, allergies - complex monitoring, IV compatibility Monitoring the patient Immediate (within 1 hour) Anaphylaxis ◦ Rash, itching, dyspnea, edema ◦ Monitor every 15 minutes ◦ Stop infusion, get antihistamine Delayed Stephen Johnson Syndrome (toxic epidermal necrosis) aka “SJS.” SJS Pseudomembranous colitis (aka C. diff or CDAD) HTTPS://WWW.MAYOCLINIC.ORG/DISEASES-CONDITIONS/ STEVENS-JOHNSON-SYNDROME/SYMPTOMS-CAUSES/SYC20355936 General Outline Part 1: Beta-Lactams ◦ Prototype ◦ Clinical key points Part 2: Aminoglycosides and Fluoroquinolones ◦ Prototype ◦ Clinical key points Part 3: Tetracyclines, sulfonamides ◦ Prototype ◦ Clinical key points HTTPS://WWW.LEARNODO-NEWTONIC.COM/PENROSESTAIRS-EXPLANATION-IMPOSSIBLE-STAIRS Part 1: Beta-Lactams MULTIPLE PROTOTYPES… HTTPS://BLOG.CSIRO.AU/CAN-AI-HELP-FIGHT-ANTIBIOTIC-RE SISTANT-SUPERBUGS/ Overview Beta-lactamase Penicillins Cephalosporins ◦5 generations Carbapenems Monobactam *Allergies especially important* KNOWYOURMEME.COM A beta-lactam ring (just FYI)  Beta-lactams and Cross-allergenicity If client has had a reaction to one, is it safe to give them a different one? Penicillins Allergic Less than 1% Considere d safe Other penicillins Cephalosporins Carbapenems Monobactam Antibiotic drug card • Prototype • Mechanism of action: • Use(s) • Infection… • Spectrum of activity • (what is it effective against?) • Nursing implications • Renal dose adjustments Penicillins (-cillin) • Prototype: ampicillin (Principen) • Mechanism of action: inhibit bacterial cell wall synthesis • Use(s) • Spectrum of activity • Strong gram positive • Weak gram negative • Nursing implications • Allergies, hypersensitivity • Inactivates aminoglycosides Piperacillin / tazobactam (Zosyn) • Combination drug • Penicillin + beta-lactamase inhibitor = adds gram negative activity! • Spectrum of activity: gram positive and gram negative. Cephalosporins (cef- or ceph-) 5 generations… • Prototype: cefazolin (Ancef, Kefzol) • Mechanism of action: inhibits bacterial cell wall synthesis • Use(s): Surgical prophylaxis • Spectrum of activity • Strong gram positive • Weak gram negative • Nursing implications • Give 60 minutes prior to first incision Ceftriaxone (Rocephin) • Very common antibiotic • Can be given via deep • Spectrum of activity • moderate gram IM injection • Very painful… reconstitute with 1% lidocaine • Only beta-lactam that does not require https://mms.mckesson.com/product/1110475/WG-Critical-Care44567070025 renal dose adjustment positive and gram negative Carbapenems (-penem) • Prototype: • Spectrum of imipenemcilastatin (Primaxin) activity • Very broad • Mechanism of spectrum • Nursing action: inhibit bacterial cell wall synthesis • Use(s): https://www.pinterest.com/pin/255579347578533169/ Pseudomonas aeruginosa implications • Saved for “critical” illness • Preexisting seizures Monobactam • Prototype: aztreonam (Azactam) • Mechanism of action: inhibit bacterial wall synthesis • Use(s) • “safe” in PCN allergy • Spectrum of activity • Lacks gram positive • Strong gram negative • Nursing implications • Limited crossallergenicity • Saved for “critical” illness Beta Lactams Case Study Part 2: Aminoglycosides & Fluoroquinolones Aminoglycosides • Prototype: gentamicin (Garamycin) • Mechanism of action: destroy bacteria’s ribosomes • Use(s): empiric therapy for serious infections • Typically not monotherapy (has synergy) • Spectrum of activity • Strong gram negative • Nursing implications • BBW for ototoxicity and nephrotoxicity • Monitor “peak” Fluoroquinolones (floxacin) • Prototype: ciprofloxacin (Cipro) • Mechanism of action: interfere with production of bacterial DNA • Use(s): many common infections • First line for Bacillus anthracis (anthrax) • Spectrum of activity • Moderate gram negative • Some gram positive • Nursing considerations • Can take orally • Gets its own slide… Nursing Considerations • Generally well tolerated, but… • BBW’s • Tendonitis / tendon rupture • Exacerbate weakness in myasthenia gravis • QT prolongation • Separate from iron, multivitamins, calcium, dairy products • Take 2 hours before, or 6 hours after • Avoid exposure to sunlight Antibiotics case study #1 Part 3: Tetracyclines, Sulfonamides, and Urinary Antiseptics Tetracyclines (-cycline) • Prototype: tetracycline hydrochloride • Mechanism of action: interfere with microbial protein synthesis • Spectrum of activity • Broad spectrum • Nursing implications • Use(s) • Mycoplasma, Chlamydia, and Rickettsia. • Lyme disease https://www.asmileabove.ca/blog/tetracycline-stained-teeth/ • Renal failure • Diminished contraceptive effects • Teeth discoloration • Must be > 8 years old Key points • Mainly used for some odd gram negatives • May need supplemental contraception • Not for patients under 8 years old due to teeth and bone interactions • Doxycycline treats anthrax Sulfonamides (sulfa-) • Prototype: trimethoprim – sulfamethoxazole (Bactrim, Septra) • Spectrum of activity • Broad spectrum • Mechanism of action: • Nursing implications stop multiplication of new bacteria • Not to be used during • Use(s) • Pneumocystis jiroveci breastfeeding • Also decreases contraception • Not for renal failure • Allergies seem common Urinary Antiseptics • Prototype: nitrofurantoin (Macrobid, Macrodantin) • Mechanism of action: • Use(s): • Adjuvant for Urinary tract infections (UTI) • Spectrum of activity • Nursing implications • Contraindicated in: • Pregnancy • Poor renal function • Urine may turn brown Part 4: Macrolides & Misc. Macrolides • Prototype: erythromycin • Mechanism of action: binds to bacterial ribosomes, stopping protein synthesis. • Use(s) • Penicillin substitute • Prevent conjunctivitis in newborns (eye oint.) • Spectrum of activity • Gram positive and negative • Nursing implications • Hepatic failure • No renal adjustments • Changing mood • Several GI effects • Pseudomembranous colitis Pseudomembranous colitis • Swelling of intestines due to overgrowth of clostridium difficile (C. diff). • CDAD • Causes severe diarrhea, dehydration • Has a particularly strong odor https://giphy.com/gifs/spongebob-spongebob-squarepants-mr-krabs-eugeneJ2gHlRQQvFamqOWlJF clindamycin (Cleocin) • Mechanism of action: similar to macrolides • Use(s): • Penicillin alternative • Used against Bacteroides fragilis (anaerobic bacteria) • Spectrum of activity: similar to macrolides • Nursing considerations • BBW for Pseudomembrano us colitis metronidazole (Flagyl) • Mechanism of action: disrupts DNA • Use(s) • C. diff treatment • Spectrum of activity • Mostly anaerobic bacteria • Nursing considerations • No alcohol during treatment and 3 days after vancomycin (Vancocin) • Mechanism of • Spectrum of activity action: inhibit bacterial wall synthesis • Only gram positive • Use(s) • MRSA, MSSA • C. diff (oral only) • Nursing considerations • Slow IV over 1-2 hours • Flushing, “red man syndrome” • Renal dose adjustments • Requires monitoring of troughs https://www.youtube.com/watch?v=AyViFdd5Zl0 Other Important Definitions… Monitoring of Specific Drug Levels • Peak: Highest serum drug level • Trough: Lowest serum drug level • Check 15-30 minutes After dose given • Check 15-30 minutes Before next dose • Measured when dosing Vancomycin and/or aminoglycosides (i.e. gentamicin) • Measured when dosing Vancomycin and/or aminoglycosides (i.e. gentamicin) linezolid (Zyvox) • Mechanism of action: inhibit bacterial protein synthesis • Use(s): • VRE, MRSA • Spectrum of activity • Only gram positive • Nursing considerations • BBW for https://www.pinterest.com/pin/282389839113903925/?nic=1 interaction with serotonergic drugs • Serotonin syndrome Antibiotics case study #2 Part 5: Tuberculosis …where’s Antarctica??? HTTPS://WWW.RESEARCHGATE.NET/FIGURE/ESTIMATED-TBINCIDENCE-RATES-FOR-2014-WHO-2015_FIG10_319040012 Tuberculosis Overview Mycobacterium tuberculosis Initial symptoms – an “acid fast” bacteria ◦ Low-grade temperature 4 stages of illness and progression ◦ Transmission ◦ Primary infection ◦ Latent TB infection ◦ Active TB ◦ Weight loss ◦ Cough ◦ Fatigue ◦ Night sweats ◦ Coughing up blood (hemoptysis) Mantoux skin testing Multidrug-resistant Tuberculosis HTTPS://WWW.CDC.GOV/TB/PUBLICATIONS/LTBI/ DIAGNOSIS.HTM HTTPS://WWW.CDC.GOV/TB/EDUCATION/CORECURR/PDF/CH APTER3.PDF ; Treatment regimens and Directly Observed Therapy (DOT) R.I.P.E. ◦ rifampin, isoniazid, pyrazinamide, ethambutol May need to take multiple medications for several months Dosing schedules can be difficult to follow D.O.T. highly recommended HTTP://QI.UCSD.EDU/NEWS-ARTICLE.PHP? ID=2211&GO=NEWER Rifamycins • Prototype: rifampin (Rifadin) • Mechanism of action: inhibits RNA synthesis • Use(s): • Alone for latent TB • Combo for active TB • Spectrum of activity: • Broad spectrum • Nursing considerations: • Hepatotoxicity • Renal failure • Red-orange body fluids • Enzyme inducer (CYP450) https://www.webmd.com/drugs/2/drug-1744/rifampin-oral/details What is a CYP inducer? Activ e Drug Activ e Drug Metaboliz ed drug CYP This is what normally happens enzym es Metaboliz ed drug What is a CYP inducer? This is what happens when CYP inducers (like rifampin) come into play… Lower plasma drug levels = decreased therapeutic effects CY ind P3A uc 4 er Activ e Drug Metaboliz ed drug CYP enzym es Metaboliz ed drug Metaboliz ed drug Anti-TB Drugs • Prototype: isoniazid • Spectrum of activity (INH) • Mechanism of action: inhibit bacterial cell wall formation • Selective for mycobacteria • Nursing considerations • Use(s): • alone or in combination for treatment of TB • ALWAYS combo if active TB https://aidsinfo.nih.gov/drugs/123/isoniazid/11/professional • Hepatotoxicity • Jaundice • elevated liver function tests (LFTs) • Peripheral neuropathy • Counter with pyridoxine (vit B6) Other drugs used in TB treatment • Pyrazinamide • Hepatotoxicity… again • Ethambutol • Optic neuritis https://marvelcinematicuniverse.fandom.com/wiki/ Guardians_of_the_Galaxy_Vol._2 R.I.P.E Increasing adherence Simplify regimen if possible D.O.T. Educate patients and family ◦ Especially for latent TB Promote communication HTTPS://WWW.THETIMES.CO.UK/ARTICLE/REVIEW-TOOMANY-PILLS-BY-JAMES-LE-FANU-STOP-TAKING-THE-TABLETSK272552PJ Tuberculosis Case Study The End When did you become an expert in bacteria and antibiotics? …Last night