Chapter 44. Medication for Infection
Antibiotics Affecting the Bacterial Cell Wall
Penicillins
Penicillin G potassium, narrow-spectrum, IM or IV use
Others:
Narrow-spectrum
Penicillin G benzathine for IM use
Penicillin V for PO use
Broad-spectrum
Amoxicillin for PO use
Amoxicillin-clavulanate for PO use
Ampicillin for PO or IV use
Antistaphylococcal: Nafcillin for IM or IV use
(nafcillin, oxacillin)
Antipseudomonal (extended spectrum)
Ticarcillin-clavulanate for IV use
Piperacillin tazobactam for IV use
Complications
Allergies, anaphylaxis
1) For prior allergy interview
2) Observe for allergic reaction 30 min following parenteral
administration.
Renal impairment
Hyperkalemia, dysrhythmias, hypernatremia
Cephalosporins
Interactions
Inactivates with aminoglycoside
Probenecid delays the excretion of penicillin
SELECT PROTOTYPE MEDICATION: Cephalexin,
first generation
OTHER MEDICATIONS
First generation: Cefazolin for IM or IV use
Second generation: Cefaclor, cefotetan for PO use
Third generation: Ceftriaxone, cefotaxime for
IM or IV use
Fourth generation: Cefepime for IM or IV use
Fifth generation: Ceftaroline for IV use- only
cephalosporin that is effective against MRSA
Complications
1) Allergy, hypersensitivity, anaphylaxis,
2) Bleeding tendencies from cefotetan and ceftriaxone
3) Thrombophlebitis with IV infusion
4) Renal insufficiency
5) Pain with IM injection
6) Antibiotic-associated pseudomembranous colitis
Diarrhea, notify the provider
Interactions
1) Disulfiram reaction (intolerance to alcohol) occurs
with simultaneous use of alcohol and either cefotetan
or cefazolin.
CLIENT EDUCATION: Do not consume alcohol while taking
these cephalosporins.
2) Probenecid delays renal excretion.
NURSING ACTIONS: Monitor I&O.
3) Calcium and ceftriaxone interaction
Do not administer together. Can cause the solutions to
precipitate and lead to serious complications.
Carbapenems
Vancomycin
Aztreonam,
Fosfomycin
Antibiotics
Affecting Protein
Synthesis
SELECT PROTOTYPE MEDICATION: Imipenem-cilastatin
for IM or IV use
OTHER MEDICATIONS: Meropenem for IV use
Complications
 Allergy, hypersensitivity, possible cross-sensitivity
to penicillin or cephalosporins
 Gastrointestinal upset (nausea, vomiting, diarrhea)
 Suprainfection
Interactions
Imipenem-cilastatin can reduce blood levels of valproic
acid. Breakthrough seizures are possible.
Vancomycin for PO, IV, or rectal use. Commonly used
in hospitals.
Aztreonam, a monobactam, for IM or IV use
Used to treat C. difficile infections
Diarrhea common during use
Fosfomycin for PO use
Given as a single dose for UTIs
Can cause diarrhea, headaches, vaginitis, drowsiness,
and abdominal pain
Vancomycin Complication
Ototoxicity (rare and reversible)
Infusion reactions
Red man syndrome
Administer vancomycin slowly over 60 min
IM and IV injection-site pain, thrombophlebitis
Renal toxicity
Interaction
Increased risk for ototoxicity when taking vancomycin concurrently with
another medication that causes ototoxicity (loop diuretics, erythromycin
acid, aminoglycoside antibiotics).
Tetracyclines
SELECT PROTOTYPE MEDICATION: Tetracycline
OTHER MEDICATIONS
Doxycycline
Minocycline
Demeclocycline
Complications
1) Yellow or brown tooth discoloration,
hypoplasia of tooth enamel
--- avoid children <8 yrs, no pregnant
2) Hepatotoxicity (lethargy, jaundice)
3) Photosensitivity (intense sunburn)
4) Superinfection
--- pseudomembranous colitis (diarrhea), yeast infections
Contraindications/precautions
1) Pregnancy Risk D
2) Liver and kidney disease.
3) Interaction with milk products, calcium and iron supplements.
4) Decrease the efficacy of oral contraceptives
5) Both minocycline and doxycycline increase the risk of digoxin
toxicity
Macrolides
SELECT PROTOTYPE MEDICATION: Erythromycin
OTHER MEDICATION: Azithromycin
Complications
1) GI discomfort (nausea, vomiting, epigastric pain)
2) Prolonged QT intervals
--- dysrhythmias and possible sudden cardiac death
3) Ototoxicity with high-dose therapy
Contraindications/precautions
Erythromycin and azithromycin are Pregnancy Risk
Category B.
Liver disease and QT prolongation are contraindications.
Interaction
1) Erythromycin inhibits the metabolism of antihistamines,
theophylline, carbamazepine, warfarin, and digoxin, which can
lead to toxicity.
2) Verapamil, diltiazem, HIV protease inhibitors, antifungal
medications, and nefazodone inhibit the metabolism of
erythromycin, which can lead to toxicity and cause
tachydysrhythmias and possible cardiac arrest.
SELECT PROTOTYPE MEDICATION: Gentamicin
OTHER MEDICATIONS
Tobramycin
Neomycin
Streptomycin
Paromomycin
Amnioglycosides
Complications
1) Ototoxicity
--- Monitor for tinnitus, headache, hearing loss, nausea, dizziness,
vertigo
2) Nephrotoxicity
acute tubular necrosis (proteinuria, casts in the urine, dilute urine, elevated
BUN, elevated creatinine)
NURSING ACTIONS
Monitor I&O, BUN, and creatinine. Report hematuria and cloudy urine.
Intense neuromuscular blockade
Resulting in respiratory depression, muscle weakness
NURSING ACTIONS:
Closely monitor use in clients who have myasthenia gravis, clients taking
skeletal muscle relaxants, and clients receiving general anesthetics.
3) Hypersensitivity
4) Streptomycin: Neurologic disorder
 Peripheral neuritis, optic nerve dysfunction, tingling/
numbness of the hands and feet.
Interaction
1) Penicillin inactivates aminoglycosides when in the same IV
solution.
NURSING ACTIONS: Do not mix aminoglycosides and penicillins in the
same IV solution.
2) Concurrent administration with other ototoxic medications (loop
diuretics) increases the risk for ototoxicity.
NURSING ACTIONS: Assess frequently for hearing loss with concurrent
medication use.
Urinary Tract
Infections
Sulfonamides and
trimethoprim
SELECT PROTOTYPE MEDICATIONS
Trimethoprim-sulfamethoxazole
Sulfadiazine
Trimethoprim
Complications
1) Hypersensitivity
Including Stevens-Johnson syndrome
NURSING ACTIONS
Do not administer trimethoprim-sulfamethoxazole to clients who have
allergies to the following.

Sulfonamides (sulfa)

Thiazide diuretics (hydrochlorothiazide)

Sulfonylurea-type oral hypoglycemics (glipizide,
glyburide)

Loop diuretics (furosemide)
Stop trimethoprim-sulfamethoxazole at the first indication of
hypersensitivity (rash).
Urinary tract
antiseptics
2) Blood dyscrasias
Hemolytic anemia, agranulocytosis, leukopenia, thrombocytopenia,
aplastic anemia
3) Crystalluria
Crystalline aggregates in the kidneys, ureters, and bladder, causing
irritation and obstruction that causes acute kidney injury
4) Kernicterus
NURSING ACTIONS: no pregnant or breastfeeding, or to infants
younger than 2 months (due to the risk of kernicterus).
5) Hyperkalemia
Monitor Potassium levels
Contraindications/precautions
1) Pregnancy Risk Category D.
2) Folate deficiency is a contraindication
3) The neonate can develop kernicterus if taken in the last trimester.
4) impaired kidney function (give lower dosages).
5) adults older than 65 years who take ACE inhibitors or angiotensin
II receptor blockers because of the risk for hyperkalemia.
Interaction
Increased effects of warfarin, phenytoin, sulfonylurea oral hypoglycemics
SELECT PROTOTYPE MEDICATION: Nitrofurantoin
OTHER MEDICATIONS: Methenamine
Complications
1) GI discomfort
Anorexia, nausea, vomiting, diarrhea
NURSING ACTIONS
Administer nitrofurantoin with milk or meals.
Reduce dosages, and use macrocrystal capsules.
2) Hypersensitivity reaction
With fever, chills, severe pulmonary manifestations
(dyspnea, cough, chest pain, alveolar infiltrations)
CLIENT EDUCATION
Stop taking the medication and to report these reactions.
Pulmonary manifestations should subside within several days after
stopping nitrofurantoin.
Do not take nitrofurantoin again.
3) Blood dyscrasias
4) Peripheral neuropathy
Contraindications/precautions
1) Impaired kidney function increases the risk of
toxicity because of the inability to excrete nitrofurantoin.
2) Nitrofurantoin is a Pregnancy Risk category B.
3) Nitrofurantoin should not be administered during the third
trimester of pregnancy because the medication can cause
hemolytic anemia.
Fluoroquinolones
Mycobacterial,
Fungal, and
Parasitic
Infections
4) Nitrofurantoin should not be administered to an infant under 1
month of age.
5) Older adults with renal impairment should not receive
nitrofurantoin.
Client Education
 Nitrofurantoin turns urine rust-yellow to brown and can stain
teeth.
 Take medication with food if adverse GI effects occur.
 Complete the entire course of therapy, even if manifestations
resolve sooner.
 Avoid crushing, chewing, or opening capsules because of
the possibility of tooth staining.
 Avoid nitrofurantoin while pregnant (can cause birth defects).
SELECT PROTOTYPE MEDICATION: Ciprofloxacin
OTHER MEDICATIONS
Ofloxacin
Moxifloxacin
Levofloxacin
Gemifloxacin
Complications
1) GI discomfort
2) Achilles tendon rupture
3) Sufrainfection
4) Phototoxicity (severe sunburn)
Interactions
Cationic compounds (aluminum- or magnesium containing
antacids, iron salts, sucralfate, dairy products) decrease the absorption of
ciprofloxacin.
NURSING ACTIONS: Administer cationic compounds 6 hr before or 2
hr after ciprofloxacin.
Plasma levels of theophylline can increase with
concurrent use of ciprofloxacin.
NURSING ACTIONS: Monitor levels, and adjust dosages.
Plasma levels of warfarin can increase with concurrent
use of ciprofloxacin.
NURSING ACTIONS: Monitor prothrombin time and INR,
and adjust dosages.
Antimycobacterial
(selective¢antituberculosis)
SELECT PROTOTYPE MEDICATION: Isoniazid
OTHER MEDICATIONS
Pyrazinamide
Ethambutol (bacteriostatic only to M. tuberculosis)
Rifapentine
Complication
1) Peripheral neuropathy
2) Hepatotoxicity
3) Hyperglycemia and decreased glucose control
Contraindication
Isoniazid is contraindicated for clients who have
liver disease.
Interactions
1) Isoniazid inhibits metabolism of phenytoin, leading to buildup of
medication and toxicity. Ataxia and incoordination can indicate
toxicity.
2) Concurrent use of tyramine foods (aged cheeses, cured meats),
alcohol, rifampin, and pyrazinamide increases the risk for
hepatotoxicity
Broad-spectrum
SELECT PROTOTYPE MEDICATION: Rifampin
antimycobacterial Complications
(antituberculosis)
1) Discoloration of body fluids
2) Hepatotoxicity
3) Mild GI discomfort
4) Pseudomembranous colitis
Interactions
1) Rifampin accelerates metabolism of warfarin, oral contraceptives,
protease inhibitors, and non-nucleoside reverse transcriptase
inhibitors (NNRTIs) for HIV, resulting in diminished
effectiveness.
2) Concurrent use with isoniazid and pyrazinamide increases risk of
hepatotoxicity.
Antiprotozoals
SELECT PROTOTYPE MEDICATION: Metronidazole
Complications
1) GI discomfort
2) Darkening of urine
3) Neurotoxicity, CNS effects
4) Pseudomembranous colitis
Interactions
Alcohol causes a disulfiram‑like reaction (facial flushing,
vomiting, dyspnea, tachycardia).
CLIENT EDUCATION: Avoid alcohol consumption.
Metronidazole inhibits inactivation of warfarin,
phenytoin, and lithium.
NURSING ACTIONS: Monitor prothrombin time and INR,
phenytoin and lithium levels. Adjust dosages accordingly.
Antifungals
SELECT PROTOTYPE MEDICATIONS
Amphotericin B (a polyene antibiotic for systemic mycoses)
Ketoconazole (an azole for treating both superficial and
systemic mycoses)
OTHER MEDICATIONS
Flucytosine
Nystatin
Miconazole
Clotrimazole
Terbinafine
Fluconazole
Griseofulvin
Complications
1) Infusion reactions
2) Thrombophlebitis
3) Nephrotoxicity
4) Electrolyte imbalance
5) Bone marrow suppression
Ketoconazole Complications
1) Hepatotoxicity
2) Effects on sex hormones
Interactions
 Aminoglycosides (gentamicin, streptomycin, cyclosporine)
have additive nephrotoxic risk when used concurrently with
antifungal medications.
 Antifungal effects of flucytosine are potentiated with
concurrent use of amphotericin B.
 Azole antibiotics increase levels of multiple medications,
including digoxin, warfarin, and sulfonylurea antidiabetic medications.
Viral Infections,
HIV, and AIDS
Antivirals
SELECT PROTOTYPE MEDICATIONS
Acyclovir (oral, topical, IV)
Ganciclovir (oral, IV)
OTHER MEDICATIONS
Interferon alfa-2b
Lamivudine
Oseltamivir
Ribavirin
Amantadine
Boceprevir
Telaprevir
Acyclovir Complications
1) Phlebitis and inflammation at the site of infusion
NURSING ACTIONS
Rotate IV injection sites.
Monitor IV sites for swelling and redness.
2) Nephrotoxicity
NURSING ACTIONS
 Administer acyclovir infusion slowly over 1 hr.
 Ensure adequate hydration during infusion and 2 hr after to
minimize nephrotoxicity by administering IV fluids and
increasing oral fluid intake as prescribed.
 Use with caution in clients who have renal impairment
or are dehydrated.
3) Mild discomfort associated with oral therapy Nausea, headache,
diarrhea
NURSING ACTIONS: Observe for manifestations and notify the
provider.
Ganciclovir Complications
1) Suppressed bone marrow
Including leukocytes and thrombocytes
NURSING ACTIONS
Obtain baseline CBC and platelet count.
Administer granulocyte colony-stimulating factors.
Monitor WBC, absolute neutrophil, and platelet counts
frequently during treatment.
CLIENT EDUCATION: Report manifestations of infection
and bleeding, and avoid crowds or individuals who have
respiratory infections.
2) Fever, headache, nausea, diarrhea
NURSING ACTIONS: Administer with food.
CLIENT EDUCATION: Report these findings.
Acyclovir Interactions
1) Probenecid can decrease elimination of acyclovir
2) Concurrent use of zidovudine can cause drowsiness
Ganciclovir Interactions
Cytotoxic medications can cause increased toxicity