Infection and Immunity Students F24 PDF

INFECTION & IMMUNITY STUDENT LEARNING OBJECTIVES 1. Describe the general concept of immunity & infection (Giddens concept) 2. Explain the common pathophysiological mechanisms and impact of an altered immune response and infection 3. Describe the principles, practices and processes underlying health...

INFECTION & IMMUNITY STUDENT LEARNING OBJECTIVES 1. Describe the general concept of immunity & infection (Giddens concept) 2. Explain the common pathophysiological mechanisms and impact of an altered immune response and infection 3. Describe the principles, practices and processes underlying health assessment of an altered immune response and infection using exemplars 4. Apply the pharmacokinetics, pharmacodynamics, and pharmacotherapeutics of common therapy targeted to an altered immune response and common therapy targeted to infection using exemplars a) Penicillins b) Cephalosporins c) Aminoglycosides d) Tetracyclines e) Macrolides f) Sulfonamides g) Fluroquinolones h) Epinephrine 5. Apply the principles, practices and processes of non-pharmacological therapy targeted to altered immune response and infection using exemplars 6. Apply Nursing Process/Clinical Judgment to the patient experiencing an altered immune response and infection  IMMUNITY Photo credit: https://www.news-medical.net/health/How-to- Optimize-Your-Immune-System.aspx  Physiologic process that provides an individual with SLO #1:  protection or defense from disease  Accomplished through actions of the immune system IMMUNITY  Protects body from attacks from foreign antigens  Typically proteins  Microorganisms: Bacteria, viruses, parasites, fungi  Pollens  Food  Venom (spider, bee, snake)  Vaccines  Transfusions  Transplanted tissue/organs IMMUNITY FIGURE 22.3 IMMUNITY AND INTERRELATED CONCEPT  Innate Immunity (also referred to as natural or native): present at birth  Acquired immunity: protection gained after birth through either active or passive immunity  Natural active acquired immunity: After introduction of a foreign antigen results in formation of antibodies or sensitized T lymphocytes IMMUNITY  Artificial active acquired immunity: occurs with immunization PROTECTION  Artificial passive acquired immunity: occurs when receiving a specific transfusion. For example: immunoglobulin (Ig)  Natural passive acquired immunity: antibodies from a mother to fetus through the placenta or from the colostrum or breastmilk. (It is immediate but short lived) (Iggy, pg.40) NORMAL PHYSIOLOGICAL PROCESS  Protects the body from microorganisms and other antigens  Removes dead or damaged tissue and cells  Recognizes and removes cell mutations that have demonstrated abnormal cell growth and development Suppressed Optimal Exaggerated Immune Immune Immune Response Response Response  Older adults (normal aging process) Low SES Non-immunized RISK FACTORS Adults with Chronic illness FOR CHANGES IN IMMUNITY Adults with chronic drug therapy (corticosteroids, chemotherapy drugs) Persons with substance use disorders Persons with unhealthy lifestyles Those with genetic risk for excessive or decreased immunity SLO #3: THREE LINES OF DEFENSE Skin boundary surfaces Mucous membranes, enzymes, natural microbial flora, complement proteins Activities of T lymphocytes, granulocytes, macrophages Antibodies from T lymphocytes and B lymphocytes resulting in learned or acquired specific immunity CELLS OF THE IMMUNE RESPONSE  Derived from stem cells in the bone marrow  Myeloid progenitors-Accessory Cells  Neutrophils,  Monocytes (become macrophages in tissue),  Eosinophils  Basophils  Mast cells  Lymphoid progenitor cells  B lymphocytes-in liver in mid-fetal life and bone marrow later and after birth  Mature T lymphocytes-Thymus gland  Natural killer cells   Lymphoid organs spread throughout the body  Spleen, thymus gland, bone marrow, adenoids, tonsils, ORGANS OF THE appendix IMMUNE SYSTEM  Lymphocytes are formed, grow, mature and are released  Makes up the lymphatic system that along with blood connects the organs OVERVIEW OF IMMUNE RESPONSE CLONAL SELECTION Cellular Immunity T-lymphocytes Major role in attacking infected cells, fighting intracellular viruses, tumor cells, fungi T Cytotoxic (Killer) cells (CD8 cells)-directly kill foreign antigens and may kill cells of self Attach antigens on cell membrane of foreign pathogens and release cytolytic substances to destroy pathogen Helper T cells (CD4 cells) -75% of all T-Lymphocytes Regulate T cytotoxic and B cell responses-producing cytokine messengers (lymphokines) to intensify the immune response Memory T and B cells Suppressor T cells- suppress the function of both the helper and cytotoxic T cells to prevent hyperimmune responses Humoral immunity B-Lymphocytes Plasma cells or memory cells differentiated by exposure to an antigen Responsible for body’s response to invading bacteria and viruses Provide humoral immunity NORMAL SPECIFIC IMMUNE RESPONSE COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD.   Recognize and ingest foreign antibodies as they enter the body  Macrophages and neutrophils are the first line of defense  Promote proliferation and differentiation of helper T cells and Cytolytic T Lymphocytes (CTLs) PHAGOCYTES  Antibody-antigen complexes have rougher surfaces and are AND THE susceptible to phagocytosis COMPLEMENT  The complement system-circulates in the blood waiting for the antigen-antibody complex. SYSTEM  Responsible for dilation and leaking from vascular system-redness and swelling that are part of the inflammatory response  Dendritic cells  Promote proliferation of CTLs and Helper T cells by serving as antigen presenting cells ANTIBODY MEDIATED PROCESS  Secreted by There are nine classes of antibodies: B Lymphocytes IgG (4 forms)–in blood (80-85%), may enter tissue, selectively crosses placenta, binds to macrophages and neutrophils, predominates the secondary and late immune response. ANTIBODIES (OR IgD- Found in the cell membrane of B lymphocytes IMMUNOGLOBULINS) IgM –in blood. Kills bacteria. First antibody produced with initial immune (primary) response IgA (2forms) –Protects entrances to the body- found in high concentrations in body fluids. Primarily released in mucus secretions and is particularly useful in defending the airways. Also found in breast milk. IgE –forms a receptor on masts cells and basophils and triggers histamine release during allergic reactions (found in trace amounts). PRIMARY AND SECONDARY IMMUNE RESPONSE AGE RELATED DIFFERENCES In utero-maternal alloantigen Neutrophils, monocytes, macrophages and dendritic cells are immature but provide innate immunity Matures thru infancy Infancy and childhood Exposure to antigens and vaccinations Aging Immunity and response decline with age, predisposing elderly to higher risks of acute bacterial or viral infections Diminished immune response and more serious complications Lessened efficacy of vaccination Increased prevalence of autoimmune diseases-failure to recognize self-antigens in elderly SUPPRESSED IMMUNE RESPONSE Primary Entire immune defense system is inadequate Immunodeficiency Individual is missing some or all of the components for a complete immune response (PI) Loss of immune function as a result of treatment or Secondary illness Immunodeficiency E.g. because of treatment to avoid rejection of transplanted tissue, treatment for leukemia, cancer SLO #5: ASSESSMENT  History  Clinical findings  Suppressed Immune Function  Exaggerated Immune Function  Diagnostic Tests  Primary Tests  RBC, WBC  Screening Tests  C-reactive protein (CRP), erythrocyte sedimentation rate (ESR)  Disease specific Testing SLO #4: 4 TYPES OF HYPERSENSITIVITY REACTIONS: EXAGGERATED IMMUNE RESPONSE Abnormal condition characterized by an exaggerated response of the immune system to Hypersensitivity disorders an antigen Inappropriate and excessive A Type I-IgE mediated or Atopic (Allergic) B Type II-IgM/IgG + antigen Tissue specific or Cytotoxic- (antiBodies)-destruction of tissues C Type III-Immune Complex-mediated deposits in tissue D Type IV-Cell-mediated or Delayed hypersensitivity (tissue destruction by T-lymphocytes) HYPERSENSITIVITY TYPE I  24 ALTERED IMMUNE RESPONSE SLO #5: ALLERGY ASSESSMENT  History  Allergy Testing  Skin Test  Allergen-specific Immunoglobulin (IgE) blood test SLO #6: MANAGEMENT Primary Prevention Vaccination Modify risk factors Secondary Prevention Screening Treat problem Immunosuppression Pharmacotherapy Corticosteroids Chemotherapy NSAIDs Immunomodulators Pain Management NSAIDs Corticosteroids MEET MR HAYES (HE/HIM).. Mr Hayes is a 50-year-old male admitted to the hospital for a gallbladder removal surgery. Following his surgery, his nurse completes an assessment and a set of vital signs. Blood pressure: 132/60 mmHg Heart rate: 70 beats per minute Respiratory rate: 14 breaths per minute Oxygen Saturation: 98% on room air Temperature: 37.0 degrees Celsius History: HTN He starts complaining of abdominal pain and asks for pain relief. The nurse checks his MAR and notes morphine PRN as most appropriate. The nurse administers morphine and continues on with her assessments. Shortly after, Mr Hayes states he does not feel well. MEET MR HAYES (HE/HIM) His nurse completes an assessment and finds extensive urticaria on his back and swelling of his lips (angioedema). His nurses asks him if he has any allergies in which he states no. She then proceeds to ask if he has ever had morphine before in which he states "Once, about a month ago with one of my gallbladder attacks", https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/hives-%28urticaria%29-and-angioedema-overview  Clinical Manifestations of Type 1 Hypersensitivity Reaction  ANAPHYLAXIS Condition in which type 1 hypersensitivity reaction involves of all blood vessels and bronchiolar smooth muscle causing widespread blood vessel dilation, decreased cardiac output, and bronchoconstriction within seconds to minutes after allergen exposure Life threatening Anaphylactic Reaction: Minimum 2 systems involved https://www.allergy.org.au/patients /about-allergy Copyright © 2019 Elsevier Canada, a division of Reed Elsevier Canada, Ltd. 30 MEET MR HAYES (HE/HIM) Suddenly, Mr Hayes becomes tachypneic and has increased work of breathing. The nurse calls a code blue. As the team rushes in, the nurse completes another set of vital signs and finds him to be hypotensive, tachycardic, tachypneic and hypoxic and no longer responding to her questions. The nurse calls a code blue and the team arrives. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/hives-%28urticaria%29-and-angioedema-overview MANAGEMENT OF EXAGGERATED IMMUNE RESPONSE Anaphylaxis Specific Support airway, breathing, circulation Epinephrine Bronchodilators (Will learn this next week) Circulatory support (Blood pressure control) General Allergic Reaction Immunosuppression Pharmacotherapy Corticosteroids NSAIDS MEET MR HAYES (HE/HIM)  Mr. Hayes is stabilized by the team and the physician discontinues the ordered morphine. VACCINES GENERAL PRINCIPLES OF VACCINE ADMINISTRATION  Vaccines are preventative measures that improve immune response to infectious agents  Dosage, number of doses and timing of doses are important considerations  Scheduling developed by CDC  Vaccines are generally safe with few contraindications and adverse effects  Common adverse effects of vaccines  Redness, swelling at site of injection  Soreness, tenderness at site of injection  Fever  Fatigue  Poor appetite  headache  Precautions and contraindications  Immunocompromised patients – patients are unable to produce an active immune response  History or allergy/anaphylactic response to vaccine components (preservatives etc.)  Pregnancy – only inactivated vaccines are suitable during pregnancy   Antigen – a marker, usually a protein, found on the surface of infectious agents  Introduction of foreign antigens to trigger immune response, allowing immune system to react more effectively the next time it is exposed to antigen  Effective vaccination, to confer long-term immunity to a disease, sometimes requires “boosters” or follow-up doses Bacterial vaccines  Inactivated bacterial exotoxins e.g. Tetanus  Killed bacteria e.g. Pneumococcal VACCINATION  Live attenuated bacteria - ↑response, but ↑risk Viral vaccines  Live attenuated virus - ↑response, but ↑risk  Killed virus  Recombinant – cultured vaccine; needs booster  Live viral vaccines produce ↑ protection and longer immunity and production of IgAs, IgGs, and cellular immunity  Killed virus only produce IgGs. COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. 37 SLO #2: INFECTION INFECTION  Infection: Invasion and multiplication of harmful microorganisms (pathogens) in the body that cause disease or illness  May not notice clinically or may result in local cellular injury  Acute or Chronic  Acute: lasting a few day or weeks  Chronic: typically longer than 12 weeks or uncurable  Location: Localized or Systemic  Localized: limited to a specific area on the body  Systemic: affects body as a whole  Sepsis: systemic infection-with presence of pathogens in the blood or tissue throughout the body  Epidemic: more cases of infection than normal  Pandemic: worldwide epidemic  Giddens, 2021 p.231 COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD. 41 SLO #3: TRANSMISSION OF INFECTIOUS AGENTS METHODS OF TRANSMISSION  Contact transmission  Droplet transmission  Airborne Transmission  METHODS OF INFECTION CONTROL AND PREVENTION  Hand Hygiene  Standard Precautions  Transmission-Based Precautions  Isolation Precautions  Contact  MRSA  C.difficile  Droplet  Covid 19  Airborne  TB https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.army.mil%2Farticle%2F234793%2Flrmc_implements_covid_19_ppe_protocols_to_ensure_staff_ patient_safety&psig=AOvVaw1ydgMmhGkDkx_5vxhR4sNJ&ust=1693509217932000&source=images&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCMizy82 LhYEDFQAAAAAdAAAAABAE 4 MOMENTS OF HAND HYGIENE  STAGES OF INFECTIOUS DISEASES POTTER & PERRY P.680 Incubation: Entrance of pathogen, appearance of first symptoms Prodromal: Onset of nonspecific symptoms to more specific symptoms (spread risk) Illness: Patient manifests symptoms specific to the type of infection (peak) Convalescence: Acute symptoms disappear and body returns to homeostasis; recovery occurs https://www.coursehero.com/sg/microbiology/stages-of-disease/  RISK FACTORS  Natural immunity: congenital or acquired immune deficiencies (suppressed) – chronic disease  Normal flora: Alteration by antibiotic therapy  Age: infants and older adults  Hormonal factors: DM, steroids, adrenal insufficiency, stress  Phagocytosis: Neutropenia  Skin, mucus membranes: break in skin  Nutrition: Malnutrition or dehydration  Environmental factors: tobacco or alcohol, inhalation of toxins  Medical interventions: Endoscopy, catheters, IVs, steroids  CAUSES OF INFECTIOUS DISEASE (GIDDENS, 2021, P.232-242) Pathogens: Microbes capable of causing disease including viruses, bacteria, fungi, unicellular organisms (protozoans). May extend to infestations by multicellular animal such as fleas, mites, and worms. Pathogenicity: ability to cause disease, depends on microbes speed of reproduction and ability to bypass body defenses. Opportunistic pathogens: rely on a suppressed immune system for successful infection. COPYRIGHT © 2014 ELSEVIER CANADA, A DIVISION OF REED ELSEVIER CANADA, LTD.  CLINICAL MANIFESTATIONS OF INFECTION Local Signs: General Systemic Signs: 1) Signs of inflammation: Redness, pain, 1) Fever (or subnormal heat, swelling. temperatures with some viral infections). 2) Exudate may be present: Purulent (pus) in a bacterial infection, serous if viral. 2) Fatigue. 3) Lymphadenopathy (swollen and tender 3) Headache. lymph nodes). 4) Anorexia and nausea. 4) System-specific signs. Examples include: 5) Malaise and myalgia (ie. joint vomiting or diarrhea with GI infections; and muscle pain). sneezing, coughing and difficulty breathing with respiratory tract infections.  Severe, poorly responsive to therapy, or untreated challenge the body’s responses CONSEQUENCES OF INFECTION Can lead to septic shock and multiorgan dysfunction syndrome (MODS) Hypotension, tachycardia, tachypnea, oliguria or anuria, hypoxia, hypercapnia, coma and death  History Physical Examination SLO #5: ASSESSMENT Diagnostic Testing Laboratory Tests Help to visualize certain body tissues to Radiographic Tests gain insight into possibility of infection CXR, CT, MRI, PET scans, Indium scans  Antibiotics, Antimicrobials, Antivirals, Antifungals CLINICAL   Sanitation MANAGEMENT  Primary Prevention  Infection prevention and control  Hand Hygiene  Food Safety  Public Health Initiatives  Vaccination  Secondary Prevention  Screening LAB VALUES FOR INFECTION  Biochemistry  Sodium – dehydration  Potassium – GI infection (diarrhea/vomiting)  Creatinine – perfusion to kidneys (hypovolemia)  Lactate (sign of sepsis/MSOF)  Complete Blood Count  White Blood Cell Count  Elevated B and T lymphocytes, neutrophils, monocytes = bacterial or viral  Elevate basophils/eosinophils = parasitic  Culture and Sensitivity  Urine, sputum, throat, blood, wounds, spinal fluid  Equipment  Other  ESR  Antibody tests: Hepatitis, HIV GROWING BACTERIA Collaborative Interventions Antimicrobial drug therapy Fluids & Electrolytes Rest Nutrition Managing fever Treat cause If hyperthermic Cooling Ice packs, sponge bath, cooling blankets Remove clothing Antipyretics May mask fever therefore unless patient is uncomfortable, antipyretics not necessary all the time. If hypothermic Warming blankets Infection Control & Prevention  SLO #6: ANTI-INFECTIVE THERAPY FOCUS ON ANTIMICROBIALS ANTI-INFECTIVES Antibiotic Antiviral Anti-Infective Therapy Anthelmintics, Antiprotozoal Antifungal WE DO NOT USE ANTIBIOTICS ON PARASITES, VIRUSES, FUNGI….   Classification by Susceptible Organism Narrow Spectrum: active against a few specific CLASSIFICATION organisms OF ANTIBIOTIC Broad Spectrum: active against a wide variety of DRUGS organisms  Classification by Mechanism of Action  Bacteriostatic  Bactericidal HOW ANTIBIOTICS WORK: BACTERIO-STATIC VS BACTERIOCIDAL SUSPECTED INFECTION, PHYSICIAN ORDERS AND NURSE RETRIEVES THE SAMPLE: - WOUND SWAB - BLOOD CULTURES - URINE CULTURES  Lab technicians identify if the bacteria is Gram +ve or –ve & the shape http://laboratoryinfo.com/wp-content/uploads/2015/03/bacteria-types.jpg ANTIBIOTICS Selectively toxic: Attempt to kill the invading bacteria, but not the host. Achieved by exploiting the differences between human cells and bacteria. Bacteriocidal – kills bacteria Bacteriostatic – slows bacterial growth To be effective, antibiotics must be taken in the appropriate dose for an appropriate amount of time. Occasionally, an antibiotic is not tolerated well by the host: Immune reaction to the drug (ie. Allergy) Drug becomes toxic to the host in high doses With prolonged use, and metabolites of the drug may be toxic to the liver or kidney. ADMINISTERING ANTIBIOTIC THERAPY. WHAT DO WE NEED TO KNOW AS NURSES?  What bacteria does it impact? Penicillins  Mechanism of action? Cephalosporins  Narrow or broad spectrum? Aminoglycosides  Gram +ve or Gram –ve bacteria targeted? Tetracyclines  Assessment prior, during, after administration  Side effects Macrolides  Monitoring (e.g serum drug levels) Sulfonamides  Patient teaching Fluroquinolones   MOA: weaken cell wall causing bacteria to take up excessive amounts of water and rupture. (Bactericidal) PENICILLINS  Broad and narrow spectrum  Gram + bacteria, some gram -ve NARROW SPECTRUM/BETA- LACTAMASE)  Most common cause of drug allergy PENICILLIN G PENICILLIN V  Side effects: Superinfections (C.Diff), diarrhea, nausea, vomiting, NARROW SPECTRUM/ BETA- LACTAMASE RESISTANT abdominal cramping CLOXACILLIN DICLOXACILLIN  Contraindications: Allergy or anaphylaxis, renal impairment, BROAD SPECTRUM AMOXICILLIN  Nursing considerations: Assess allergies, monitor kidney function AMPICILLIN (lab value: creatinine) as renal impairment can cause penicillins to EXTENDED SPECTRUM accumulate to toxic levels, instruct to take full prescribed treatment CARBENICILLIN PIPERACILLIN (drug resistance), evaluate effects (reduction in ) PIPERACILLIN-TAZOBACTAM* (PIP/TAZ fever/pain/inflammation, monitor WBC) https://cdn.technologynetworks.com/tn/images/body/g- pos-g-neg-cell-wall-structure-final1566305996142.jpg   MOA: By disrupting the cell wall, these drugs produce bacterial lysis and death. (Bactericidal) CEPHALOSPORINS  Broad spectrum  5 generations (classes) with respect to antimicrobial spectrum CEFAZOLIN (ANCEF)  Contraindications: Allergies (1% of penicillin allergies react to CEFOXITIN cephalosporins), bleeding disorder, caution with CEFUROXIME anticoagulants/thrombolytics/antiplatelets/NSAID CEFTRIAXONE  Side effects: Bleeding (Reduce prothrombin levels), superinfections (C.diff), diarrhea, abdominal cramping, alcohol intolerance  Nursing considerations: Assess allergies or hx of bleeding disorders, monitor INR, instruct on no alcohol intake, instruct to take full prescribed treatment (drug resistance), evaluate effects (reduction in fever/pain/inflammation)   MOA: Inhibit bacterial protein synthesis (Bacteriostatic)  Broad spectrum  1st choice for pts with penicillin allergies  Side effects: epigastric pain, nausea, vomiting, diarrhea, superinfections (C.Diff), QT prolongation/sudden cardiac death, MACROLIDES hepatoxicity ERYTHROMYCIN  Contraindications: Congenital QT prolongation/arrhythmias, drug AZITHROMYCIN interactions with many drugs (calcium channel blockers/digoxin/warfarin), hepatoxicity  Nursing considerations: assess allergies, need to monitor drug levels/LFTs, assess for hx of heart disease, rashes (Steven-Johnson syndrome), do not take with grapefruit juice, instruct to take full prescribed treatment (drug resistance), evaluate effects (reduction in fever/pain/inflammation)   MOA: suppress bacterial growth by inhibiting protein/DNA/RNA synthesis (Bacteriostatic)  Broad spectrum  Gram +ve, gram -ve  Side effects: GI (nausea, vomiting, diarrhea), blood dyscrasias, SULFONAMIDES kernicterus (newborns), renal damage from crystalluria, photosensitivity, Steven Johnson syndrome (rash) TRIMETHOPRIM/SULFAME THOXAZOLE  Contraindications: drug interactions with warfarin/phenytoin/oral antihyperglycemics  Nursing considerations: Assess and monitor for anemia and other hematological disorders, avoid exposure to direct sunlight, monitor urine output/creatinine levels, monitor warfarin & phenytoin levels, instruct to take full prescribed treatment (drug resistance), evaluate effects (reduction in fever/pain/inflammation) STEVEN JOHNSON’S SYNDROME https://usercontent1.hubstatic.com/8571388.jpg   MOA: Suppress bacterial growth (Bacteriostatic)  Broad spectrum TETRACYCLINES:  Gram +ve and gram -ve DOXYCYCLINE  Side effects: epigastric burning, cramps, nausea, vomiting, diarrhea, superinfections (C.diff/Candida), teeth discoloration (binds to calcium) and hypoplasia of enamel(4m-8yr), hepatotoxicity, photosensitivity, bleeding  Contraindications: under 8yrs, liver or renal impairment, drug interactions with digoxin/anticoagulants/oral contraceptives, avoid milk products/calcium & iron supplements/magnesium laxatives/antacids  Nursing considerations: assess allergies, administer 1hr before or 2hrs after ingestion of milk/supplements, monitor creatinine/LFTs/INR/digoxin levels, instruct to take full prescribed treatment (drug resistance), evaluate effects (reduction in fever/pain/inflammation)  DEVELOPMENT OF A SUPERINFECTION   MOA: disrupt bacterial protein synthesis (Bactericidal)  Narrow spectrum  Gram -ve  Reserved for serious systemic infections  Side effects: ototoxicity, nephrotoxicity, superinfections (C.diff), AMINOGLYCOSIDES: neuromuscular blockade (flaccid paralysis/resp depression) GENTAMICIN  Contraindications: Impaired hearing, renal impairment, caution with nephrotoxic drugs, caution with ototoxic drugs: furosemide/vancomycin  Nursing considerations: assess for allergies & tinnitus (ringing of the ears), monitor blood work: creatinine clearance, BUN (kidney function) and serum drug troughs levels, monitor urine output, instruct to take full prescribed treatment (drug resistance), evaluate effects (reduction in fever/pain/inflammation)   MOA: Affects DNA synthesis by inhibiting to bacterial enzymes (bactericidal)  Narrow and Broad spectrum  Gram +ve, gram -ve FLUROQUINOLONES  Side effects: GI (nausea, vomiting, diarrhea, abdominal pain), CNS (dizziness, restlessness, confusion), superinfections (C.diff, Candida), tendinitis tendon rupture, phototoxicity, hepatotoxicity, Guillian-Barre CIPROFLOXACIN (CIPRO) syndrome LEVOFLOXACIN  Contraindications: under 18 yr old, Myasthenia gravis, renal impairment, drug interactions with antacids/minerals/vitamins/calcium components  Nursing considerations: assess allergies, monitor CNS/muscular effects, educate about sun exposure, monitor for tendon pain/swelling, monitor LFTs & INR if on warfarin, instruct to take full prescribed treatment (drug resistance), evaluate effects (reduction in fever/pain/inflammation) ANTIBIOTIC RESISTANT BACTERIA Antibiotic Resistance  Occurs when bacteria continue to grow in the presence of the drug  Innate Resistance: penicillin innately does not work very well on Gram-negative bacteria since these bacteria have very little cell wall.  Acquired Resistance: when penicillin can no longer kill Gram- positive cocci, this resistance is said to be acquired. This resistance is passed on to the cells progeny and creates a resistant strain. ACQUIRED ANTIBIOTIC RESISTANCE CONTINUED: How does a bacteria acquire resistance? Four common mutations are: 1. The bacteria decrease the concentration at the drug site of action 2. The bacteria produce a drug antagonist 3. The bacteria alter the structure of drug target molecules 4. The bacteria cause drug inactivation  S S S S RESISTANCE → SELECTION S R S S S S S S Resistance develops through random mutations S S S that are occasionally advantageous resulting in S Apply antibiotic: survival. Get Selection Selection: By killing susceptible strains of a bacterial population through excessive use of R antibiotics, resistant strains are allowed to survive and eventually dominate that bacterial population. R R Infections acquired in a hospital or other R R R healthcare setting, called nosocomial infections R R R are often resistant to common antibiotics. R R  SUPPRESSED IMMUNE SYSTEM EXEMPLAR: MRSA CELLULITIS https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.actasdermo.org%2Fes-an-update-on-treatment-management-articulo- S1578219019300137&psig=AOvVaw35NdiIoSS6keYmJ9caVyLz&ust=1693578184124000&source=images&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCODpv8OMh4EDFQAAAAAdAAAAABAJ https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.the-hospitalist.org%2Fhospitalist%2Farticle%2F125604%2Fwhat-best-empiric-therapy-community-acquired- cellulitis&psig=AOvVaw35NdiIoSS6keYmJ9caVyLz&ust=1693578184124000&source=images&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCODpv8OMh4EDFQAAAAAdAAAAABAE s MRS A... 80-year-old female seen in ER following a fall in her garden 2 days ago. She states she bumped her leg on her rake. She states her leg has been quite sore the past day and can barely walk on it. Upon her assessment, the wound on her right leg is red, warm and swollen. A slight blister has formed leaking exudate. Vital Signs: Blood pressure: 121/79 mmHg Heart rate: 85 beats per minute Respiratory rate: 18 breaths per minute Oxygen Saturation: 98% on room air Temperature: 37.5 degrees Celsius https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.sciencephoto.com%2Fmedia%2F252496%2Fview%2Fcellulitis-on-the-leg-of-elderly- woman&psig=AOvVaw3jXHPn6Y3u81yst18suqRM&ust=1693497732636000&source=images&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCIDy9ujghIEDFQAAAAAdAAAAABAK HEALTH CARE PROVIDER ORDERS  Laboratory tests: CBC, biochemistry  Blood and wound cultures (if open wound)  Ultrasound to leg Should we start the antibiotic before the  Trace outline of infection blood and wound  Follow NEWS protocol for VS cultures return?  Broad spectrum antibiotics (pip-tazo)  Blood culture: Negative for bacteria Wound culture: Positive for bacteria Ultrasound: No signs of DVT noted https://www.google.com/url?sa=i&url=https%3A%2F%2Fbassett.testcatalog.or g%2Fshow%2FLAB462&psig=AOvVaw2vorMWYviQXnDkJaHkfh0Z&ust=16935 78458535000&source=images&cd=vfe&opi=89978449&ved=0CBAQjRxqFwo TCODH4saNh4EDFQAAAAAdAAAAABAE https://www.google.com/url?sa=i&url=http%3A%2F%2Fcontent.oncopadi.com%2Fproduct%2 Fwound-swab- mcs%2F&psig=AOvVaw3GnlOb771gjjWEFjQk4bxi&ust=1693578402895000&source=image s&cd=vfe&opi=89978449&ved=0CBAQjRxqFwoTCIDs3quNh4EDFQAAAAAdAAAAABAI  MRS. A'S LABORATORY Complete Blood Count RESULTS Lab Test (Serum Blood Reference Range Normal Result Test) Hemoglobin (Adults) 120-160mmol/L females 124 Platelets 181-521 X 10 (9)L 230 Biochemistry Hematocrit 0.37-.47 (females).38 3 Lab Test Reference Result White Blood Cells (WBC) 4,000-10,500/mm 16,000 Range Neutrophils (segs) 3,000-5,800/ mm 3 11,000 3.6 Neutrophils (bands) 150-400/ mm 3 800 (K+) 3.5- 3 5 mmol/L Lymphocytes 1,500-3,000 mm 4,150 3 135- 143 Eosinophils 50-250/ mm 200 (Na+) 145mmol/L 3 Basophils 15-50 mm 35 3 Creatinine 44- 92 Monocytes 285-500 mm 400 97mcmol/L.. MRS A Mrs. A is diagnosed with cellulitis and prescribed penicillin for 7 days. When Mrs. A is able to walk, she can be discharged.   Mrs. A has been on antibiotic therapy for three days.  You are completing a H2T and she mentions she is not feeling well. Her cellulitis appears larger and she states BACK TO MRS A 9/10 pain. When completing a set of VS you note the following:  BP 100/60, P 110, T 39.1, RR 20, SpO2 93% room air  Did the bacteria change? Is there another MRS A HAS BEEN ON antibiotic we can use? ANTIBIOTICS BUT Are they experiencing any complications related to the cellulitis? Why are her vital APPEARS TO BE signs worsening? GETTING WORSE, Do we need to place Mrs A on isolation? Should we re-order her bloodwork and WHY? cultures?   New blood cultures return and show positive for MRSA as well as her wound culture  Mrs. A now presents with a systemic infection with a resistant bacteria MRS A  The health care provider will have to reorder an antibacterial appropriate to fight the resistant bacteria  Patient will have to be isolated for MRSA – Contact Precautions  Continue therapy and monitoring SUMMARY  Immunity refers to cells within our body and the various defences that manage exposure to pathogens  Immune reactions are usually protection, but may not always be helpful (allergic reactions, anaphylaxis)  The Immune system works to prevent or manage infection by various organisms  When infections evade the immune system, we may need medications to help the body fight an invading bacteria  We are focusing on antibacterial therapy for this course (generally called antibiotics)  Some organisms have developed resistance to antibacterial agents, which is a growing and serious problem