MS14.pdf

10/19/23, 3:43 AM Realizeit for Student Acute Pharmacologic Therapy The ideal medication for treatment of UTI in women is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infect...

10/19/23, 3:43 AM Realizeit for Student Acute Pharmacologic Therapy The ideal medication for treatment of UTI in women is an antibacterial agent that eradicates bacteria from the urinary tract with minimal effects on fecal and vaginal flora, thereby minimizing the incidence of vaginal yeast infections. The antibacterial agent should be affordable and should have few adverse effects and low resistance. Because the organism in initial, uncomplicated UTIs in women is most likely E. coli or other fecal flora, the agent should be effective against these organisms. Various treatment regimens have been successful in treating uncomplicated lower UTIs in women: single-dose administration, short-course (3-day) regimens, or 7-day regimens (Freeman et al., 2017). The trend is toward a shortened course of antibiotic therapy for uncomplicated UTIs, because most cases are cured after 3 days of treatment. Medications commonly used to treat UTIs are listed in Table 49-1. Regardless of the regimen prescribed, the patient is instructed to take all doses prescribed, even if relief of symptoms occurs promptly. Longer medication courses are indicated for men, pregnant women, and women with pyelonephritis and other types of complicated UTIs. Men with UTIs should be evaluated for possible prostatitis (Eliopoulos, 2018). Hospitalization and intravenous (IV) antibiotics are occasionally necessary (Freeman et al., 2017). Long-Term Pharmacologic Therapy Although pharmacologic treatment of UTIs for 3 days is usually adequate in women, infection recurs in about 20% of women treated for uncomplicated UTIs. Infections that recur within 2 weeks of therapy do so because organisms of the original offending strain remain. Relapses suggest that the source of bacteriuria may be the upper urinary tract or that initial treatment was inadequate or given for too short a time. Recurrent infections in men are usually caused by persistence of the same organism; further evaluation and treatment are indicated (Eliopoulos, 2018). If infection recurs after completing antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may be prescribed. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 1/12 10/19/23, 3:43 AM Realizeit for Student A meta-analysis of nine studies reported the daily intake of cranberry, especially in the form of capsules, significantly reduced the rate of recurrent UTI compared to placebo with minor adverse effects such as rash and gastrointestinal symptoms (Tambunan & Rahardjo, 2019). The same meta-analysis reported that antibiotics were more effective for the treatment of recurrent UTI compared to cranberry capsules but had more severe adverse effects including gastrointestinal symptoms and Stevens–Johnson syndrome (Tambunan & Rahardjo, 2019). Medical Management Patients with acute uncomplicated pyelonephritis are most often treated on an outpatient basis if they are not exhibiting acute symptoms of sepsis, dehydration, nausea, or vomiting. Patients treated on an outpatient basis must be willing and able to take their medications as prescribed. For outpatients, a 2-week course of antibiotic agents is recommended because renal parenchymal disease is more difficult to eradicate than mucosal bladder infections. Commonly prescribed agents include many of the same medications prescribed for the treatment of UTIs. Following acute pyelonephritis treatment, the patient may develop a chronic or recurring symptomless infection persisting for months or years. After the initial antibiotic regimen, the patient may need antibiotic therapy for up to 6 weeks if a relapse occurs. A follow-up urine culture is obtained 2 weeks after completion of antibiotic therapy to document clearing of the infection. Hydration with oral or parenteral fluids is essential in all patients with UTIs when there is adequate kidney function. Hydration helps facilitate “flushing” of the urinary tract and reduces pain and discomfort. Sulfonamides Trimethoprim–sulfamethoxazole (TMP-SMZ) combination (Bactrim, Septra) is useful in UTIs due to Enterobacteriaceae and Pneumocystis jiroveci infection (in high doses), and it serves as the prototype. The combination of drugs demonstrates synergistic antimicrobial activity that is greater than the dose of either drug used alone. Other drugs in the class vary in extent of systemic absorption and clinical indications. Some sulfonamides are well absorbed and can be used in systemic infections; others are poorly absorbed and have more local effects. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 2/12 10/19/23, 3:43 AM Realizeit for Student Pharmacokinetics TMP-SMZ is rapidly and nearly completely absorbed in the GI tract, and the half-life of the medication is 6 to 11 hours. It enters the extracellular spaces, crosses the placental and blood– brain barriers, and appears in small amounts in breast milk. Metabolism occurs in the liver, and excretion takes place in the kidneys as metabolites and unchanged drug. Action TMP-SMZ and other sulfonamides act as antimetabolites of para-aminobenzoic acid (PABA), which microorganisms require to produce folic acid. In turn, folic acid is necessary for the production of bacterial intracellular proteins. Sulfonamides enter into the reaction instead of PABA, compete for the enzyme involved, and cause formation of nonfunctional derivatives of folic acid. Thus, sulfonamides halt multiplication of new bacteria but do not kill mature, fully formed bacteria. With the exception of the topical sulfonamides used in burn therapy, the presence of pus, serum, or necrotic tissue interferes with sulfonamide action because these materials contain PABA. Some bacteria can change their metabolic pathways to use precursors or other forms of folic acid and thereby develop resistance to the antibacterial action of sulfonamides. After resistance to one sulfonamide develops, cross-resistance to others is common. Use TMP-SMZ acts by inhibiting bacterial synthesis of essential nucleic acids and proteins. Uses include the treatment of P. jirovecii pneumonitis, severe UTIs, Shigella enteritis, and Enterobacteriaceae. Other organisms treated with TMP-SMZ are Viridans streptococcus, Staphylococcus epidermidis, Salmonella, Klebsiella, Nocardia, and Pseudomonas. Use in Older Adults TMP-SMZ may cause renal impairment. Therefore, when administering the drug to older adults, it is important to assess the patient's renal function. Older people are also at greater risk of hyperkalemia due to the effects of aging on renal function. Use in Patients With Renal Impairment Patients with renal impairment should probably avoid taking TMP-SMZ and other systemic sulfonamides if other effective drugs are available. Acute renal failure has occurred when the drugs or their metabolites precipitated in renal tubules and caused obstruction. Preventive measures include intake of 1.5 to 3 L of fluid daily to reduce the formation of crystals and stones in the urinary tract. Use in Patients With Hepatic Impairment https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 3/12 10/19/23, 3:43 AM Realizeit for Student Metabolism of TMP-SMZ occurs in the liver. Thus, patients with altered liver function should be administered the drug with caution. Adverse Effects TMP-SMZ has several adverse effects. These include the following: GI effects: abdominal pain, nausea, vomiting, diarrhea, anorexia, and pancreatitis Hematologic effects: aplastic anemia, agranulocytosis, eosinophilia, thrombocytopenia, and leukopenia Dermatologic effects: pruritus, urticaria, Stevens-Johnson syndrome, and skin photosensitivity Renal effects: increased BUN and serum creatinine, renal failure, and interstitial nephritis Contraindications Contraindications include a known hypersensitivity to any sulfa drug, trimethoprim, TMP-SMZ or any other of the sulfonamides, salicylates, or megaloblastic anemia related to folate deficiency. The drug is also contraindicated in infants less than two months of age. Nursing Implications Culture and sensitivity testing should be completed prior to administering the drug. When administering TMP-SMZ, it is important to monitor potassium levels as hyperkalemia may result particularly in the older adult and individuals with renal impairment or hypoaldosteronism. The drug should be discontinued at the first sign of a rash. Preventing Interactions Trimethoprim and sulfamethoxazole both inhibit specific cytochrome P450 enzymes, leading to concurrent multiple drug and herb interactions, increasing or decreasing the effects of TMPSMZ. The drug inhibits warfarin metabolism and is associated with a threefold increased risk of GI bleeding when compared with other antibiotics. Other interactions include sulfonylureas (hypoglycemia), anticonvulsants (toxicity), and methotrexate (pancytopenia). Administering the Medication In general, TMP-SMZ is commonly administered orally, with or without food. It is important to take it with a full glass of water. In patients with severe pneumonia caused by P. jirovecii, the drug is administered parenterally. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 4/12 10/19/23, 3:43 AM Realizeit for Student QSEN Alert: Safety When administering TMP-SMZ parenterally, it is important that the medication be diluted and administered over 60 to 90 minutes. The drug has variable stability in normal saline. The drug should not be administered intramuscularly. It is essential that the parenteral TMP-SMZ drug combination not be mixed with other drugs and that IV lines be flushed to remove any residual drug prior to administration. Assessing for Therapeutic Effects If the patient is taking TMP-SMZ for treatment of a UTI, the nurse assesses for decreased symptoms of this infection, such as the elimination of pain when voiding, cloudy urine, and fever. If the patient is taking TMP-SMZ for treatment of Pneumocystis pneumonia, it is necessary to assess for resolution of symptoms including nonproductive cough, shortness of breath, or fever. If the drug is given for prophylaxis of pneumocystosis, the nurse observes for development of symptoms. Assessing for Adverse Effects The nurse assesses the patient’s intake and output. If the intake is greater than the output, assessment of renal function is necessary. The nurse also assesses for hyperkalemia, anemia, and changes in the complete blood count that are indicative of blood dyscrasias. In addition, it is necessary to assess for signs and symptoms of superinfection or hypersensitivity reactions. Septra, an IV form of TMP-SMZ, contains sodium metabisulfite, which has the potential to produce allergic reactions in some patients. It is necessary to assess for hives, skin redness, itching, wheezing, shortness of breath, and possible anaphylaxis. Patient Teaching Take TMP-SMZ with 8 ounces of water. Take the drug before or after meals. Drink a minimum of 2 to 3 L of fluid per day. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 5/12 10/19/23, 3:43 AM Realizeit for Student Adjuvant Medications Used to Treat Urinary Tract Infections: Urinary Antiseptics The adjuvant medications used to treat UTIs are trimethoprim and the urinary antiseptic agents. Urinary antiseptics may be bactericidal for sensitive organisms in the urinary tract because these drugs are concentrated in renal tubules and reach high levels in urine. They are not used in systemic infections because they do not attain therapeutic plasma levels. The adjuvant medications include nitrofurantoin, phenazopyridine, and trimethoprim. Nitrofurantoin Nitrofurantoin (Macrobid, Macrodantin) is an anti-infective agent that is administered for the treatment and prophylaxis of UTIs. The drug is effective for UTIs caused by E. coli, S. aureus, Enterobacter, Enterococcus, and Klebsiella. Administration of nitrofurantoin with food aids in absorption and decreases the onset of adverse effects. The two formulations differ with regard to the size of crystals in the preparation. Older adults should not take the medication because of the risk of renal, pulmonary, and hepatic toxicities. Contraindications include renal insufficiency as well as pregnancy—in the first trimester, there is a risk of fetal malformations, and between week 38 and delivery, there is a risk of hemolytic anemia. Other significant adverse effects of nitrofurantoin include (1) nonspecific ST- and T-wave changes and bundle branch block and (2) CNS changes such as fever, malaise, depression, headache, lethargy, and vertigo. In addition, the nurse should inform patients that the drug may cause the urine to turn brown. Although few drugs interact with nitrofurantoin, magnesium-containing antacids may reduce absorption and subsequent urinary secretion. Concurrent use of fluconazole may lead to hepatic and pulmonary toxicities. Phenazopyridine Phenazopyridine hydrochloride (Azo-Standard, Pyridium) is a urinary analgesic that is administered to provide pain relief related to burning, urgency, frequency, and irritation of the lower urinary tract mucosa. The pain is a result of infection, trauma, cystoscopic examinations, surgery, or catheter insertion. Phenazopyridine, an azo dye, is a drug that acts directly on the urinary tract mucosa to provide analgesia. Metabolism occurs in the liver. It is necessary to administer the medication with food to decrease GI distress. The nurse should tell the patient that his or her urine will turn reddish orange. The FDA has issued a BLACK BOX WARNING cautioning that if the patient’s skin turns yellow, it is important to report this to the health care provider immediately. This is a sign that phenazopyridine is accumulating in the patient’s system. It is also necessary to report a sore throat, fever, bruising, or bleeding. Contraindications to phenazopyridine include renal insufficiency and hepatitis. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 6/12 10/19/23, 3:43 AM Realizeit for Student Trimethoprim Trimethoprim (Primsol) is a folate antagonist that is a urinary tract anti-infective. Most commonly administered in combination with sulfamethoxazole or as an adjuvant agent with the sulfonamides (see Sulfonamides), it is also given singly. Prescribers order it for susceptible infections and UTIs. The CDC has recommended that trimethoprim be used (unlabeled use) in the treatment of P. jirovecii pneumonia. This drug inhibits folic acid reduction to tetrahydrofolate, thus interfering with the bacterial cell growth. Contraindications include a known folate deficiency, fragile X syndrome, and a creatinine clearance less than 15 mL/minutes. Patient teaching should include taking the entire course of medication even if symptoms improve; having a sufficient fluid intake (2000–3000 mL/24 hours); and reporting symptoms such as sore throat, fever, bruising, or rash to the health care provider. Rash and pruritus are the most common adverse effects. There also have been occasional reports of nausea, vomiting, thrombocytopenia, and leukopenia. Fluoroquinolones Ciprofloxacin (Cipro) is the prototype. Newer fluoroquinolones have been developed with a broader spectrum of activity that provides improved coverage of gram-positive organisms and, in one case, anaerobes. Although the oral administration of fluoroquinolones has allowed ambulatory treatment of infections that previously required parenteral therapy and hospitalization, the extensive use of these antibiotics has led to antimicrobial resistance to the drug class. Pharmacokinetics Ciprofloxacin is well absorbed from the upper GI tract, like all quinolones; it achieves 70% bioavailability. Once absorbed, it achieves therapeutic concentrations in most body fluids. With immediate-release ciprofloxacin, concentrations peak in 30 minutes to 2 hours. Ciprofloxacin is partially metabolized in the liver; it forms four metabolites, which have limited activity. Hepatic conversion of ciprofloxacin to active metabolites is 10% to 20% of ciprofloxacin elimination. The kidneys are the main route of elimination, and approximately 30% to 60% of an oral dose is excreted unchanged in the urine. Additional excretion is achieved via the feces. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 7/12 10/19/23, 3:43 AM Realizeit for Student Action Fluoroquinolones are bactericidal agents that cause cell death. Ciprofloxacin acts by interfering with enzymes required for synthesis of bacterial DNA and is therefore necessary for bacterial growth and replication. Use Ciprofloxacin is the most potent fluoroquinolone against gram-negative bacteria. Like most fluoroquinolones, it is indicated for various infections caused by aerobic gram-negative and other microorganisms. Fluoroquinolones may be used to treat infections of the respiratory, genitourinary, and GI tracts, as well as infections of the bones, joints, skin, and soft tissues. The Centers for Disease Control and Prevention (CDC) no longer recommends the use of fluoroquinolones for gonococcal disease because resistance to this antimicrobial has developed. The 2015 Sexually Transmitted Diseases Treatment Guidelines, issued by the CDC, recommend dual treatment with ceftriaxone and azithromycin as the only regimen for treatment of gonorrhea. It is necessary to consult the CDC website on sexually transmitted diseases for the most current recommendations regarding gonococcal susceptibility. Ciprofloxacin has multiple indications and can be used for acute sinusitis, lower respiratory infections, pneumonia, skin and soft tissue infections, prostatitis, and urinary tract infections. The FDA has recommended that use of quinolones be limited to complicated infections in patients for whom there are no alternate treatment options. Currently, ciprofloxacin is also recommended as first-line treatment for suspected Bacillus anthracis infections (anthrax) until culture and susceptibility results are available. The drug class also shows promise in the treatment of pulmonary tuberculosis Use in Older Adults Ciprofloxacin use in older adults necessitates close monitoring. Decreased renal function, other disease processes, and concurrent drug therapies increase the risks of adverse effects in older adults. In older adults with normal renal function, fluoroquinolones should be accompanied by an adequate fluid intake and urine output to prevent drug crystals from forming in the urinary tract. In addition, urinary alkalinizing agents should be avoided because drug crystals form more readily in alkaline urine. In older adults with impaired renal function, a common condition in this population, caution and reduced dosages are warranted. Use in Patients With Renal Impairment Ciprofloxacin requires a dose adjustment in renal impairment because usual doses may produce high and prolonged serum drug levels. However, even in renal failure, moxifloxacin (Avelox) does not require a dose adjustment. Reported renal effects include azotemia, https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 8/12 10/19/23, 3:43 AM Realizeit for Student crystalluria, hematuria, interstitial nephritis, nephropathy, and renal failure. Crystalluria rarely occurs in acidic urine but may occur in alkaline urine. Guidelines for reducing nephrotoxicity include using lower dosages, having longer intervals between doses, receiving adequate hydration, and avoiding substances that alkalinize the urine. Use in Patients With Hepatic Impairment It appears that dosage adjustment is not necessary for hepatic impairment. However, ciprofloxacin should be used with caution in patients with hepatic diseases such as cirrhosis. Use in Patients With Critical Illness Ciprofloxacin is commonly used in the critical care setting because of its broad spectrum of coverage. However, resistance is emerging because of overuse of the fluoroquinolones. The rate of resistance in P. aeruginosa is increasing due to the increased use of this drug class. Most resistance to fluoroquinolone activity appears most frequent in methicillin-resistant strains of P. aeruginosa and Staphylococcus aureus. In the United States, increases in fluoroquinolone resistance with enteric bacteria in the critical care setting are often associated with resistance to other antimicrobials. Most activity of the fluoroquinolones is against aerobic gram-negative organisms, especially Enterobacteriaceae, Moraxella catarrhalis, Haemophilus, and Neisseria species. Levofloxacin and moxifloxacin have increased potency against gram-positive infections, and moxifloxacin has activity against anaerobic organisms. Some fluoroquinolones, including ciprofloxacin, ofloxacin, moxifloxacin, and levofloxacin, provide atypical pneumonia coverage as well. Use in Patients Receiving Home Care Ciprofloxacin is given in the home setting, as are other fluoroquinolones. The drug may be given with food to help minimize GI upset. Patients should space out ciprofloxacin administration 4 to 6 hours with any of the following: antacids, multivitamins, sucralfate, or other products containing calcium, iron, or zinc. Absorption of ciprofloxacin may be impaired when these substances are administered together with ciprofloxacin, resulting in a decreased antibiotic effect. Administration of the oral suspension of ciprofloxacin via feeding tubes should not occur, because the oil-based formulation tends to adhere to the feeding tube. The frequent use of fluoroquinolones in the community setting has contributed to overall resistance to P. aeruginosa. Adverse Effects Ciprofloxacin is generally well tolerated. The most frequent adverse effects are GI side effects and include nausea, vomiting, and abdominal discomfort. Some patients experience dizziness and mild headache. Allergic and skin reactions have occurred. Photosensitivity can occur while https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99af… 9/12 10/19/23, 3:43 AM Realizeit for Student taking ciprofloxacin with exposure to direct or indirect sunlight, and artificial light or sunlamps may also precipitate photosensitivity reactions. Tendon rupture and tendinitis are serious concerns with the fluoroquinolones. The FDA has expanded the current BLACK BOX WARNING for fluoroquinolones, alerting health professionals not only to the increased disabling risk of tendinitis and tendon rupture but also to the significant risk of peripheral neuropathy, central nervous system and cardiac effects, and dermatologic and hypersensitivity reactions. The risk is greater for people older than 60 years of age; those with heart, kidney, and lung transplants; and those taking corticosteroid medications. Adverse effects can occur up to weeks after beginning fluoroquinolones and may potentially be permanent. Discontinuation of the fluoroquinolone is necessary with the development of adverse effects. In addition, a BLACK BOX WARNING exists for fluoroquinolones, including ciprofloxacin, because the drug class may exacerbate muscle weakness in persons with myasthenia gravis; its use should be avoided in patients with this condition. QT interval prolongation may occur, and the degree of severity varies by agent. Contraindications Contraindications include hypersensitivity and concurrent use of tizanidine. Current data have shown that ciprofloxacin crosses the placenta and is found in amniotic fluid and cord blood. Ciprofloxacin is recommended for the prophylaxis and treatment of pregnant women with anthrax exposure. Fluoroquinolones should be used in pregnant women for the treatment of other infections only if safer, effective drug therapy is not available. Nursing Implications Preventing Interactions Many medications interact with ciprofloxacin, increasing or decreasing its effects. Fluoroquinolones have the potential to prolong the QT interval and may increase the risks of torsade de pointes and sudden death. Patients should not receive drugs such as the antidysrhythmic amiodarone, which prolongs the QT interval, in conjunction with fluoroquinolones. Ciprofloxacin reduces theophylline clearance by 30%. Reportedly, fatal reactions have occurred after concurrent use of ciprofloxacin and theophylline. Herbs and foods also interact with ciprofloxacin. Ciprofloxacin can chelate with cations, and drugs containing iron, multivitamins, calcium, magnesium, aluminum salt, and sucralfate may significantly reduce the absorption of ciprofloxacin. Therefore, patients should take oral ciprofloxacin 2 hours before or 6 hours after such agents. Patients should also avoid taking oral ciprofloxacin with dairy products or other calcium-containing foods. In addition, patients should https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99… 10/12 10/19/23, 3:43 AM Realizeit for Student not take didanosine and ciprofloxacin simultaneously. Enteral feedings should be discontinued for 1 to 2 hours prior to and after ciprofloxacin administration; enteral feedings decrease drug absorption by more than 30%. The nurse should also watch for severe hypoglycemia, which has developed in patients receiving concomitant glyburide and fluoroquinolones, including ciprofloxacin. Although most cases have affected patients with diabetes, severe cases of hyperglycemia have occurred in patients not previously diagnosed with the disease. Administering the Medication Severe hypersensitivity reactions have occurred with the administration of fluoroquinolones. The nurse should discontinue the antibiotic immediately if skin rash or other signs or symptoms of hypersensitivity occur. To reduce the risk of irritation to the veins causing burning, swelling, and pain, the nurse administers the IV formulation over 60 minutes through a verified patent IV line. If administration through a nasogastric tube is necessary, the nurse crushes immediate-release tablets and mixes them with water. Enteral feedings reduce the serum concentration of ciprofloxacin, and the nurse gives tube feedings 1 hour before and 2 hours after administering the drug. Patients should take fluoroquinolones, like all antibiotics, for the full prescribed course of treatment to prevent complications. Assessing for Therapeutic Effects Assessing for factors that increase the risk of adverse effects is important, for example, impaired renal function, inadequate fluid intake, concomitant use of multivitamins or antacids, or frequent exposure to sunlight in the usual activities of daily living. It is not necessary to take drug levels when administering ciprofloxacin or any of the fluoroquinolones. Serum creatinine and blood urea nitrogen (BUN) are recommended values to monitor when administering ciprofloxacin. Assessing for Adverse Effects The nurse assesses adverse effects, such as nausea, diarrhea, vomiting, abdominal pain, headache, increased liver enzymes, and injection site reactions. It may be necessary to stop ciprofloxacin therapy if a harmful effect is severe enough. Any rash warrants careful evaluation, and if a hypersensitivity reaction occurs, the nurse discontinues the drug immediately and notifies the prescriber. Patient Teaching Patient teaching guidelines are outlined in Box 19.5. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99… 11/12 10/19/23, 3:43 AM Realizeit for Student BOX 19.5 Patient Teaching Guidelines for the Fluoroquinolones General Considerations Avoid exposure to sunlight during and for several days after taking one of these drugs. Stop taking the drug, and notify the prescribing prescriber if skin burning, redness, swelling, rash, or itching occurs. Sunscreen lotions do not prevent photosensitivity reactions. Be very careful if driving or doing other tasks requiring alertness or physical coordination. These drugs may cause dizziness or light-headedness. If receiving a fluoroquinolone antibiotic in the home care setting, make sure to administer it at regular intervals. Put all needles and syringes in a “sharps” container. Self-administration Take norfloxacin (Noroxin), levofloxacin solution, and ofloxacin 1 hour before or 2 hours after meals on an empty stomach. Ciprofloxacin (Cipro) may be taken with food to decrease gastrointestinal upset. Levofloxacin tablets and moxifloxacin (Avelox) can be taken with or without regard to meals. Drink 2 to 3 quarts of fluid daily if you are able. This helps prevent kidney problems. Do not take antacids containing magnesium or aluminum (e.g., Mylanta or Maalox); any products containing iron, magnesium, calcium (e.g., Tums), or zinc (e.g., multivitamins); or sucralfate or buffered didanosine preparations at the same time or for several hours before or after a dose of the fluoroquinolone. (Consult product-specific information for individual drug recommendations.) https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IcdpKuauTn1W0lrWmCsonBYnaQIwEDgwdbmVgOEy99… 12/12