Week 9 Infectious Disease 總整理 (考20).docx

Let's begin with a few words from the CDC... - The majority of antibiotic use is in the outpatient setting, with **at least 28% of antibiotics not needed** - Most commonly prescribed outpatient antibiotics in US: amoxicillin and azithromycin - Most common in acute care settings vary...

Let's begin with a few words from the CDC... - The majority of antibiotic use is in the outpatient setting, with **at least 28% of antibiotics not needed** - Most commonly prescribed outpatient antibiotics in US: amoxicillin and azithromycin - Most common in acute care settings vary, but two big ones: vancomycin and piperacillin/tazobactam **Narrow vs Broad Spectrum** - 窄示好的 - As the name indicates, narrow-spectrum antibiotics are more selective. Always our preference, but bacterial cultures can take a couple days to grow - Broad-spectrum can kill wider range of bacteria (usually both gram+ and -), but as you might guess, causes increased risk of killing our normal flora and lead to secondary infection (super infection) - Yeast infection - C diff - Candidiasis, like the white fungal tongue - - - **Susceptibility** (~~Sensitivity~~) & Resistance(耐受性) - Antimicrobial resistance = microbes evolve mechanisms that protect them from antimicrobials (broader term that includes antibiotic resistance, antiviral, antifungal...etc) - You will hear term MDR for multi-drug resistant. These organisms are extremely difficult to treat, we have to resort to 2nd or 3rd--line meds with more toxicity, often less efficacy, and thus higher degree of mortality - When you hear that a bacteria is susceptible to an antibiotic, this is a good thing! It means the antibiotic is able to kill that bacteria. The bacteria is not resistant. - Poor adherence to antibiotic regimens increases risk of developing resistance (example of MDR-TB in former Soviet republic prisons) - Examples of highly resistant bacteria 課本上的圖， 考methnicillin- resistant (mrsa), ancineobactoer 熟悉這些名，知道影響哪， Main Hospital Acquired Infections (HAI) vs CAI \* put together with bacteria in last slide Hospital Acquired Infections :醫院裡的感染，細菌很強 Community Acquired Infections:社區感染,covid 1. Ventilator-associated [pneumonia] 2. Surgical site infections 3. Catheter-associated urinary tract infections 4. Central line-associated blood stream infections 5. C diff infections Often serious, drug-resistant infections that are difficult to treat Also seeing rise in community-acquired infections (CAI) like MRSA **Gram-positive vs Gram-negative** - Gram-[positive] bacteria's cell envelope [only has 2 layers]: cell membrane and thick cell wall - For fun: called gram-positive because thick cell wall is able to absorb purple/blue dye - Gram-negative bacteria's cell envelope has 3 layers: cell membrane, thin cell wall and additional outer layer - Whereas, gram-negative do not absorb the purple/blue dye because of their thin cell wall (not due to additional outer layer), so they look red/pink when counter-stained - What's important to the nurse? Knowing that certain meds, like penicillin, can treat gram-positive infections, but not gram-negative because unable to penetrate outer layer..p.12的圖補上，會考 Common bacteria: p.11 要背 **General SE or risks of all antibiotics** - GI: N/V and especially....Diarrhea - - Could choose to stop it with something like loperamide - Allergic reaction, take rash very seriously! Cross sensitivity between Antibiotics. This is especially important before starting Antibiotics (SHORT , 過敏，都要停藥，一樣也可用\"enprinine\" - [Super infection,] especially in places where more natural flora exists: vagina (risk of yeast infection) and GI tract (C diff infection) - Black hairy tongue (看到時，要把anitibody 停了)is rare & benign, but scary & may take wks/months to resolve - As always, keep an eye on liver and **kidneys**, will star\*\* any special cases **Teaching for all antibiotics** - Very important to keep at therapeutic levels, Take equally divided doses around the clock - Continue medication for entire time prescribed, even if symptoms resolve, super common NCLEX question: "I will stop taking my medication when I feel better." education required! - Encourage fluids, take Antibiotics with water (sometimes [fruit juice, dairy and alcohol c]an impact effect) PLUS, diarrhea common so best to [increase fluid] to prevent dehydration and helps with inflammatory healing process - In general, [avoid alcohol] while on Antibiotics, but (fun fact) technically one Antibiotics OK with EtOH = amoxicillin, and 2 very bad = [metronidazole] and [Bactrim] - Check expiration date, especially common for people to use old Antibiotics - If on oral contraceptive pills, some Antibiotics (especially rifampin) can decrease effectiveness of contraception through P450 induction; best to use back-up method，so have to change medication for UTI ***Clostridium difficile =C diff*** - **Treatment: Vancomycin!!** 很難治療 - **KNOW** the most common culprits listed by CDC - Hypothesized link to PPI, so **DON'T** give to high risk pt in acute care setting *P.15的圖很重要會考。( 已補上) 右下方的四個要要背起來* A close-up of a chart Description automatically generated Match the drug 💊 with the bug 🧫 - Swap wound or blood cultures x 2. When? [Before] starting treatment(antibotic) - \~10mL per bottle, one aerobic, one anaerobic - Antisepsis protocol very important! - Don't pull from a line, unless ordered; otherwise fresh stick p.17已補上 (太難，不用背，只是為了分類，分類只是為了好背) +-----------------------------------+-----------------------------------+ | **Overview of MOA for Antibiotic | **Representative Group or | | Drug Classes for Today** | Individual Antibiotic** | +===================================+===================================+ | Inhibitors of cell wall synthesis | Penicillins | | (bactericidal) | | | | Cephalosporins | | -cidal 殺 | | | (會直接殺菌的se都比較強) | Carbapenems | | | | | 這一個表格都是beta-lactam，都是破壞細胞壁 | Vancomycin (glycopeptide, not a | | | beta-lactam) | | | | | 破壞的比較廣 | | | | | | "細胞壁 | | | 是為了保護細菌的，沒了或被迫率，水會一職進入去破壞細菌，最後細菌會 | | | 因此死掉。 | | +-----------------------------------+-----------------------------------+ | Bacteri[cidal] | Aminoglycosides | | inhibitors of protein synthesis | | | | | | 殺 | | +-----------------------------------+-----------------------------------+ | Bacteri[ostatic] | Macrolides | | inhibitors of protein synthesis | | | | Tetracycline | | 抑制 蛋白質 | | | | (Doxycycline) | | \- [ ostatic 抑制 | | | 細菌複製的亮] | | | | | | [全都怕光] | | +-----------------------------------+-----------------------------------+ | Drugs that interfere with | Fluroquinolones | | synthesis or integrity of | | | bacterial DNA and RNA | Metronidazole | | | | | 避免或破讓組織DNA, RNA | Rifampin (TB med) | +-----------------------------------+-----------------------------------+ | Antimetabolites | Sulfonamides | | | | | 抗代謝，無法破 | Trimethoprim | +-----------------------------------+-----------------------------------+ | Drugs that disrupt the cell | Amphotericin | | membrane | | | | | | 讓細胞膜沒辦法達成 | | +-----------------------------------+-----------------------------------+  - **Beta-lactam, what is it?** - As you can see, all B-lactam Antibiotics have same chemical structure, allows them to impact the bacterial cell wall - We are going to focus on: - PCNs - Cephalosporins - Carbapenems **Penicillin (PCN)(technically Penicillin G)** - Weaken the cell wall and promote bacterial lysis because without wall, bacteria absorbs water and bursts - -How? Either inhibit cell wall synthesis or activate enzymes that break down wall. Fortunately, don't affect our mammalian cells which only have a cell membrane, no wall - Mostly active against [gram-positive] bacteria - Renal excretion: often need to [decrease dosage for elderly] or renally-compromised patients 考，不適不用，但減少用量 - [\#1 winner for allergic,] anaphylactic reactions, so review allergy list carefully and know that epi is your go to med in a serious allergic rxn and there can be cross-sensitivity to other beta-lactam Antibiotics (like cephalosporins and carbapenems) - Penicillin (PCN): Broad or narrow? 一張含有 文字, 螢幕擷取畫面, 字型, 數字 的圖片 自動產生的描述 - PCN info - Use: treatment of respiratory, skin, gastrointestinal, and urinary infections and of otitis media and gonorrhea - Take careful history of penicillin reaction; observe for 20 minutes post IM injection - PO for penicillin and ampicillin: take 1 hour ac or 2 hours pc to reduce gastric acid destruction of drug; not true for [amoxicillin] - Check for hypersensitivity to other drugs, especially cephalosporins - SE: Allergic reactions: fever, difficulty breathing, urticaria, skin rash - Renal, hepatic, hematologic abnormalities (Bone marrow suppression) - Usual GI: Nausea, vomiting, diarrhea **Beta lactamase** - Bacteria are able to [produce beta-lactamases,] enzymes that break down our valuable little beta-lactam ring in all our beta-lactam antibiotics - Penicillinase is a specific type of beta-lactamase enzyme that does what? Specifically breaks down the beta-lactam ring in PCNs - BUT some PCNs can resist this penicillinase and they are listed in the table in Slide 22. Please note that **nafcillin** is underlined MRSA - *Staphylococcus aureus* is a gram-positive bacteria that loves to colonize skin and wounds (not limited to these tissues, but most common) - By the 1960s, the organism become resistant to methicillin (which was the PCN of choice, but now obsolete) - [**(會考)Resistant to most beta lactam Antibiotics** (all PCN, most cephalosporins)] - [Used to be our most common HAI, now found as CAI & we have more HAI] - [Tx: Vanco or Trimethoprim-sulfamethoxazole \[Bactrim\]] Pip-Tazo (Piperacillin- Tazobactam) - Piperacillin is a PCN 屬於PCN - Tazobactam is a beta-lactamase inhibitor - So given together as brand name Zosyn, tazo [protects] the pip! - Give all the time in acute care for things like UTI, pneumonia, GI, skin, so much! - Similar med to know, more often oral: amoxicillin-clavulanate \[Augmentin\] (考"後面的都是為了保護前面的抗生素，免受" beta-lactamase"破壞掉) A client is prescribed penicillin for an ear infection. The nurse notices elevated BUN and creatinine levels when the morning lab results are posted. The nurse notifies the provider and anticipates: - Answer:\ For someone with compromised renal function, will need to order reduced dosage - So many Cef meds! - Remember, they are [all beta-lactam Antibiotics] - Remember another place we saw some Cef meds? On the C diff slide! Esp 3^rd^ gens like ceftriaxone, cefdinir, cefixime and the 4^th^ gen: cefepime **Generation of Cephalo-sporin** **Notes on generation** ---------------------------------- ------------------------------------------------------------- 1st Tx gram + 2nd Same as 1^st^, but less susceptible to beta lactamases 3rd Same as 2^nd^, but even less susceptible to beta lactamases 4th More broad spectrum because effective vs gram + and -- 5th Only ones effective against MRSA  - A patient is prescribed ceftriaxone for a bacterial infection. The nurse should be aware that which of the following is a possible cross-sensitivity reaction? - Answer:\ Cephalosporins, like ceftriaxone, can have a cross-sensitivity reaction with penicillin. Patients with a history of penicillin allergy may also be allergic to cephalosporins. Both are beta-lactam Antibiotics. **Use of Cephs** - Use: treatment of respiratory tract, urinary tract, skin, and bone infections - \*\*Some may cause false positive for urine glucose \-\-- glycosuria(glucosuria) - Possible cross allergy to penicillin because B lactam - SE: GI, hepatic and nephro, HA, rash and dyspnea more serious, may be sign of allergic rxn **Carbapenems (廣，有效)** - Meropenem, imipenem - MOA: weakens cell wall, similar to PCN, but what is the bonus? - **Resistant to nearly all beta-lactamses (考)** - SE: usual GI, rare seizure activity - What's special? Often saved for a second-line med because high risk of resistance because very broad antibiotics - But unfortunately, already seeing carbapenem-resistant Enterobacteriaceae **Vancomycin** **IV, NOT PO)** - We love vanco! - Effective against 2 of our most serious, resistant infections: MRSA & the diff - **Nephrotoxicity** - **Headache** - **Flushing** - **Ototoxicity** - **Dyspnea** - Originally called Red Man Syndrome, due to red flushing of skin, but has racist connotation to Indigenous Americans - And is it always obviously red? - Rate-related, meaning if you administer med slowly, less likely to happen, so that IV bag of 1g of vanco, we administer over an hour "go slow with vanco" - Action? Stop med! Second: administer anti-histamine (考) Nice paper from 2021 in NEJM: [*[https://www.nejm.org/doi/abs/10.1056/NEJMp2031891]*](https://www.nejm.org/doi/abs/10.1056/NEJMp2031891) Know the ototoxic meds! (要早點發現，才不會永久) - Often patients will experience tinnitus first, the "ringing in the ear" - If patient tells you this, stop the med & notify the provider. - Another reason to "go slow with vanco" - Rining the ear =\>馬上停藥，告訴provider - 熟悉malaria diug- quinine - Aminoglucoside (熟悉) - **C**: Cisplatin and Carboplatin - **A**: Aminoglycoside (Gentamycin & Tobramycin) - **L**: Loop Diuretics - **M**: Malaria drug - Quinine - **E**: Erythromycin - **A**: Aspirin - **R**: Redman Syndrome (Vancomycin) - 這些藥物有可能會對聽力造成影響，使用這個助記法可以幫助你快速記住它們。 Sure, here\'s an explanation of each drug listed in the mnemonic \"CALM EAR\" along with their indications: - **Cisplatin and Carboplatin** - **Classification**: Chemotherapeutic agents - **Indication**: Used to treat various types of cancers, including testicular, ovarian, bladder, and lung cancers. - **Aminoglycosides (Gentamycin & Tobramycin)** - **Classification**: Antibiotics - **Indication**: Used to treat serious bacterial infections, particularly those caused by gram-negative bacteria. - **Loop Diuretics** - **Classification**: Diuretics - **Indication**: Used to treat edema associated with heart failure, liver cirrhosis, and renal disease, as well as to manage hypertension. - **Malaria Drug - Quinine** - **Classification**: Antimalarial - **Indication**: Used to treat uncomplicated malaria caused by Plasmodium falciparum. - **Erythromycin** - **Classification**: Antibiotic (Macrolide) - **Indication**: Used to treat various bacterial infections, including respiratory tract infections, skin infections, and sexually transmitted infections. - **Aspirin** - **Classification**: Nonsteroidal anti-inflammatory drug (NSAID) - **Indication**: Used to reduce pain, fever, and inflammation. It is also used as an antiplatelet agent to prevent blood clots, reducing the risk of heart attack and stroke. - **Vancomycin (Redman Syndrome)** - **Classification**: Antibiotic (Glycopeptide) - **Indication**: Used to treat severe bacterial infections, including methicillin-resistant Staphylococcus aureus (MRSA) infections. Redman Syndrome is a side effect characterized by flushing and rash, typically due to rapid infusion of the drug. - - Phenytoin - Digoxin - Theophylline - **Vancomycin** - **Gentamycin** - Previously: Blood for peak test was drawn 60 min after giving med, and immediately prior to next dose for trough test. - Now: Specific intervals for peak levels; trough levels immediately before next dose. Bacteriostatic Inhibitors of Protein Synthesis: [Tetracyclines, Macrolides,] and Others Chapter 90 - Macrolides -- -- -- -- **Macrolides Info** - MOA: Inhibit bacterial protein synthesis through 50s ribosome - Broad spectrum - Use: treatment of mild to moderate respiratory and skin infections, chlamydia, and syphilis - Teaching: Take at equal intervals around the clock (really same with all Antibiotics), give with full glass of water (also same all Antibiotics), this one more reactive with fruit juice and **antacids**; although food can impact absorption, a little food helps relieve GI SE (same with tetracyclines) - Can be used in patients with compromised renal function, but be careful with liver failure - \*\*Monitor for signs of superinfection (sore throat, fever, fatigue) because broad spectrum - \*\*Increases effects of oral anticoagulants, will also see this with tetracyclines Additional Macrolides SE - GI: Nausea, vomiting, diarrhea - Hearing loss, see ototoxicity list - Dizziness, vertigo - Rash - Photosensitivity - Hepatotoxicity, Increased liver function tests - Vaginitis because broad spectrum - Angioedema - Anemia Tetracyclines as a class - MOA: Inhibit bacterial protein synthesis, not full killers like the aminoglycosides, but do prevent bacterial growth - Broad spectrum - (Fun fact: Named because have 4 HC rings) - Impact is also on ribosome, same with macrolides, but through 30S subunit instead of 50S - Used as first line med for conditions like: - Acne - ***\*\*H pylori* (usually with metronidazole)** - Chlamydia - Dental conditions - Outdoorsy infection like Lyme disease and Rocky Mt fever and Malaria prophylaxis SE of Doxycycline as prototype for Tetracyclines - Take with little food due to gastric irritation (Take with food to avoid stomach pain.), but not with milk because slows absorption, gastric irritation worse if taken too close to bed or reclining time - Increases effects of anticoagulants because decrease effect of Vit K, so increased risk of bleeding with Warfarin - [Photosensitivity so best to avoid sun exposure] - [No for pregnancy] (will see acronym at end of slides) and [even for kids up to 8yrs] discolors teeth (OK for adults) - Hepatic & renal issues **Aminoglycosides** - MOA: Inhibits protein synthesis in [gram-negative bacteria] - Use: Severe systemic infections, usually given 7-10 days - Gentamycin, streptomycin, neomycin, Tobramycin - SE: **Ototoxicity** and **nephrotoxicity** (plus GI like every other Antibiotics) - Let's look at ototoxic list again - Some can taken orally, bet generally poorly absorbed, so usually IV **Clindamycin** - Special! [Not an aminoglycoside, not a macrolide!] - A lincomycin - Useful for staph and strep - Gets it's own slide because: high risk for vaginitis and **[C diff ]** - Hepatic concerns, check for jaundice **TMP/SMX and tx for UTI** NYC Dept of Health Guidelines For symptomatic UTI: - Nitrofurantoin \[Macrobid\] 100 mg PO 2x/day x 5 days OR - TMP-SMX 160/800 mg PO (one DS tablet) x 3 days (Couple other options but these are top 2) **What's the most common bacterial cause of UTI? *E coli (*考*)*** Trimethoprim/Sulfame**thox**azole \[Bactrim\] - SULFA-meh-THOX-azole - Use: treatment of **urinary tract infections**, otitis media, chronic prostatitis, shigellosis, chancroid, and **traveler\'s diarrhea** - PO: with full glass water; if upset stomach occurs, take with food - PO: take at equal intervals around the clock - IV: infuse slowly over 60--90 minutes; flush lines at end of infusion to remove residue - Monitor for hypersensitivity reaction; stop med at first sign of skin rash - Never administer rapidly - [Encourage fluids to 8--10 glasses/day] See how there's really nothing new here? TMP/ SMX SE - Hypersensitivity reaction - Blood dyscrasias -- another way to include bone marrow suppressionso wbc low, risk of infection - Photosensitivity: need sun glassess - GI: Nausea, vomiting, anorexia, plus stomatitis, abdominal pain - Headache, fatigue - Increased BUN/creatinine (bed for kidney) - MOA: First undergoes enzymatic conversion to activate, then damages bacterial DNA - Use: Mostly UTI, check out NYC antibiogram, effective against most common cause of UTI [*[https://www.nyc.gov/assets/doh/downloads/pdf/csi/antibiogram2017-mn.pdf]*](https://www.nyc.gov/assets/doh/downloads/pdf/csi/antibiogram2017-mn.pdf) **Tuberculosis (TB)** 很多少會resist RIPE (考side efffec of each one) - Rifampin (RIF) - Impedes bacterial RNA synthesis - Also used to tx **meningitis** - **Urine color change is OK** - Isoniazid (INH) - Targets mycobacterium's cell wall - SE: **Hepatotoxicity** and peripheral neuropathy, **no alcohol** **(和 前的考試，複選題)** - Pyrazinamide (PZA) - SE: also hepatotoxicity, plus **hyperuricemia** - Ethambutol (ETH) - SE: **Optic toxicity** - Intensive 2M all, Continuation 4-7M RIF and INH (先吃兩個月，還是negitive就吃六個月 - ) Fluoro[quinolo]nes (FQ) - **Broad** spectrum, bactericidal by impacting bacterial DNA replication - Name comes from binding of element fluorine and med quinine (again, remember from Class I anti-dysrhythmic and malaria med, also found in tonic water) (不會考) - Do you remember the dangerous SE of quinine? Also a dangerous SE of FQ: \_\_\_\_**QT prolongation**\_\_\_ - Two main to know: Levofloxacin and Ciprofloxacin - Why do we like these meds? Can be taken orally and generally mild SE except for 2 big dangers: one mentioned above, the other other is possible rupture of the Achilles tendon SE Fluoro[quinolo]nes - Headache, nausea, vomiting, diarrhea, stomach pain - Dizziness - Vaginal itching and/or discharge - Tendon rupture or tendinitis - Photosensitivity, rash - Hepatotoxicity - **Can cross BBB:** Insomnia, Suicidal thoughts, Hallucination, paranoia - Encephalopathy - Chest pain, palpitations - [Check BG] - MOA: In it's own class of Antibiotics, that's why under miscellaneous; works by integrating into bacterial or **[parasitic DNA]** and inhibiting protein synthesis (through uncoupling oxidative phosphorylation in mitochondria) - Use: Bacterial infectious (所以可用在STI), plus first med with mentioned to treat parasitic and helminth (intestinal worms) infections like: STI trichomoniasis and GI giardia - [Do not drink alcohol] or preparations containing alcohol during and 48 hours after use; [disulfiram-like reactio]n can occur - SE: Besides GI, nephro, hepatic & neurotoxicity Antimicrobial use during pregnancy (pregnancy immunne sysyem become back, may cause c diff - **T**etracycline - **N**itrofurantoin \[Macrobid\] (UTI drugs, but cannot be used during pregnancy.) - **T**rimethoprim/sulfa \[Bactrim\] (UTI drugs, but cannot be used during pregnancy.) - - **P**CN like amoxicillin and ampicillin - Some **C**ephs (like cephaclor-2^nd^ gen, cephalexin-1^st^ gen) - **C**lindamycin (but careful with C diff) - **M**etronidazole \[Flagyl\] *"We know how to PCCM (pick em)!"* - Big finish: Switching over to\ **Anti-fungal and Anti-viral** +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | | | | +-----------------------+-----------------------+-----------------------+ | - Anti-viral | - Valacyclovir | - No need to | | | | distinguish the | | | | -acyclovirs | +-----------------------+-----------------------+-----------------------+ | - Anti-viral | - Acyclovir | - | +-----------------------+-----------------------+-----------------------+ **Amphotericin B (Not very selective, they can harm the body, so they are only used in emergency situations.)** - MOA: binds to [ergosterol] in the fungal cell membrane, which leads to the formation of pores, ion leakage and ultimately fungal cell death (but the way it pokes holes in fungal cells, can poke holes in our cells, too) - Use: To treat the most serious fungal infections. For example, would we use it to treat a localized candidiasis (like on tongue or vagina)? [No. But would we use to treat candidiasis (or other fungal infection) that has moved into blood stream? Yes. ] - Mnemonic: "Amphoteric" comes from the Greek \"ampho,\" meaning \"both", so Amphotericin B is doubly terrible - treats terrible life-threatening fungal infections and has terrible side effects. - Potential benefits must be balanced against serious side effects - Do not mix with other drugs - Monitor vital signs; report fever or change in function, especially nervous system - Severe risk to blood & renal system - \*\*Nursing Care: Meticulous care and observation of injection sites! **Phlebitis!!!** - I would add to H: hypokalemia and hypomagnesemia, these cause cardio problems - I would add to N, neurotoxicity & nephrotocxirt - Fluconazole, ketoconazole, and itraconazole - No need to distinguish between 3, look for suffiz, -azole - Good alternative to amphotericin because less toxic, but as you might have guessed, less effective, too - Useful from admin perspective because given orally and topically - MOA is also through ergosterol - Can treat: ringworm, skin/nails & oral fungal infections - MOA: taken up by virus into viral DNA strand & then suppresses synthesis of viral DNA synthesis from within - Use with mnemonic: a-cyclone against herpes - Herpes simplex virus (HSV) infections (genital herpes, cold sores, and herpes encephalitis) - Varicella-zoster virus (VZV) infections, such as shingles and chickenpox. - Antivirals Teaching and SE Teaching: Drink lots of fluid and no sex when lesions present - SE: Include usual GI (Nausea, vomiting, diarrhea, abdominal cramps) - Headache - Rash - Dizziness - Dysmenorrhea - Thrombocytopenic purpura - Increased hepatic labs - Answers - Client arrives to the ED with clear signs of infection. Blood cultures are sent. The nurse prepares to administer which of the following IV Antibiotics? Broad spectrum! Like vanco, amoxicillin, pip-tazo; tetracyclines and macrolides, FQ, carbapenems OR - Culture results return for the Client in Room 2. Results indicate + for *Staph aureus*. The nurse anticipates the administration of which of the following Antibiotics? Narrow spectrum! Nafcillin for staph, PCN for strep would be 2 examples There is debate about narrow v broad, so these are good examples for now. Most Antibiotics fall under broad. The nurse identifies which of the following clients in the ICU are at greatest risk for developing C diff? (Select all that apply.)