Chapter 27 Antituberculars, Antifungals, and Antivirals Copyright © 2021, Elsevier Inc. All Rights Reserved. Tuberculosis Etiology Transmission Mycobacterium tuberculosis • Acid-fast bacillus Person to person via droplets • Coughing, sneezing, talking Patients at risk Immunocompromised Living or working in high-risk residential settings Injecting illegal drugs Health care workers with high-risk patients Copyright © 2021, Elsevier Inc. All Rights Reserved. 2 Tuberculosis Symptoms Symptoms Cough Fever Night sweats Anorexia Weight loss Chest pain Positive acid-fast bacilli in the sputum or bloody sputum Copyright © 2021, Elsevier Inc. All Rights Reserved. 3 Prophylaxis Prophylaxis recommended for: Latent TB infection Immunocompromised Positive tuberculin skin test Positive IGRA results Converted from negative to positive TB Prophylactic therapy contraindications Liver disease Copyright © 2021, Elsevier Inc. All Rights Reserved. 4 Antitubercular Drug Therapy Antitubercular drugs First line drugs Those used in drug resistant TB Combination therapy phases Phase 1 - Duration: 2 months Phase 2 - Duration: 4-7 months Copyright © 2021, Elsevier Inc. All Rights Reserved. 5 Antitubercular Drug Side Effects Side effects and adverse reactions Headaches GI distress Paresthesias Hyperglycemia Hypocalcemia Ocular toxicity, ototoxicity, hepatotoxicity Thrombocytopenia Rifampin: turns body fluids orange • Soft contact lens may be permanently discolored Copyright © 2021, Elsevier Inc. All Rights Reserved. 6 Tuberculosis in Special Populations Special populations Pregnancy HIV Pediatrics Others Copyright © 2021, Elsevier Inc. All Rights Reserved. 7 Nursing Process: Antitubercular Drugs (1 of 2) Concept Assessment Assess for hearing changes if drug regimen includes streptomycin. Patient problems Drug adherence Pulmonary infection Planning The patient’s sputum test for acid-fast bacilli will be negative 2-3 months after prescribed antitubercular therapy. Copyright © 2021, Elsevier Inc. All Rights Reserved. 8 Nursing Process: Antitubercular Drugs (2 of 2) Nursing interventions Administer INH 1 hour before or 2 hours after meals. Give pyridoxine (vitamin B6) as prescribed with INH to prevent peripheral neuropathy. Monitor hepatic function tests. Emphasize importance of complying with drug regimen. Encourage eye exams for patient taking INH and ethambutol. Evaluation Copyright © 2021, Elsevier Inc. All Rights Reserved. 9 Fungal Infections Fungal infections (candidiasis) Local infections • Mucous membranes, hair, nails, and moist skin areas • Mild • Examples: Oral candidiasis or thrush, Vaginal candidiasis Systemic infections • Severe • Affects lungs, abdomen, central nervous system • Examples: fungal lung infection, fungal meningitis Copyright © 2021, Elsevier Inc. All Rights Reserved. 10 Classification of Fungal Infections Opportunistic infections Candidiasis, aspergillosis, mucormycosis, pneumocystis pneumonia Usually occur in immunocompromised or debilitated population, or those taking antibiotics, corticosteroids, chemotherapy, or other immunosuppressives Acquired by contact with infected person Primary infections Blastomycosis, histoplasmosis, coccidioidomycosis, cryptococcosis, and paracoccidioidomycosis Usually occur in immunocompetent Acquired from inhaled spores Copyright © 2021, Elsevier Inc. All Rights Reserved. 11 Antifungal Drug Groups Polyenes Azoles Flucytosine Echinocandins Fluconazole Antimetabolic Amphotericin B, nystatin Caspofungin Miscellaneous antifungals Griseofulvin Copyright © 2021, Elsevier Inc. All Rights Reserved. 12 Polyenes Amphotericin B Treats severe, systemic fungal infections Action • Binds to fungal cell membranes, causing cell permeability, and leakage of cellular contents Side effects/adverse reactions • Flushing, fever, chills, headache, dizziness • Tachypnea, shortness of breath, hypotension, GI distress • Paresthesia, thrombophlebitis • High doses: nephrotoxicity, hypokalemia, hypomagnesemia • Reactions usually begin 1-3 hours after initiating drug • Avoid reactions: pretreat 30-60 minutes before drug with: Acetaminophen, diphenhydramine, hydrocortisone Copyright © 2021, Elsevier Inc. All Rights Reserved. 13 Azoles Route Action Oral, IV, vaginal, topical Increases cell permeability and leakage by interfering with ergosterol formation Side effects Headache, rash GI distress Hypokalemia, dysrhythmias Hepatotoxicity, nephrotoxicity Copyright © 2021, Elsevier Inc. All Rights Reserved. 14 Antimetabolites Action Selectively penetrates the fungal cell which disrupts fungal DNA and RNA synthesis Well-absorbed from the GI tract Used in combination with other antifungals such as amphotericin Side effects Renal and hepatic impairment Copyright © 2021, Elsevier Inc. All Rights Reserved. 15 Echinocandins Echinocandins Route • IV Action • Inhibits biosynthesis of essential components of fungal cell wall which interferes with growth and reproduction of Candida and Aspergillus species Side effects • Injection site reaction • Elevated hepatic enzymes • Histamine-mediated reactions Copyright © 2021, Elsevier Inc. All Rights Reserved. 16 Nursing Process: Antifungals (1 of 2) Concept Assessment Assess patient’s hepatic and renal function tests. Patient problems Drug adherence Decreased tissue integrity Planning The patient will list potential complications and when to call the medical provider. Copyright © 2021, Elsevier Inc. All Rights Reserved. 17 Nursing Process: Antifungals (2 of 2) Nursing interventions Advise the patient to take drugs as prescribed. Advise the patient not to consume alcohol. Encourage the patient to report side effects. Monitor patient’s urinary output. Evaluation Copyright © 2021, Elsevier Inc. All Rights Reserved. 18 Viruses Viruses Method of transmission • Droplets: coughing, sneezing, talking Process of replication Common viral infections • Influenza, herpes, hepatitis Copyright © 2021, Elsevier Inc. All Rights Reserved. 19 Influenza (1 of 2) Influenza (flu) Highly contagious Droplets enter into respiratory tract Seasonal, more prevalent from fall to spring Antigen types • Influenza A Moderate to severe viral infection • Influenza B Mild viral infection usually in children • Influenza C Mild respiratory, viral infection Copyright © 2021, Elsevier Inc. All Rights Reserved. 20 Influenza (2 of 2) Influenza (flu) Signs and symptoms • High fever, headache • Fatigue, weakness, myalgia • Watery nasal discharge • Red watery eyes • Photophobia • Chills, sore throat, nonproductive cough Copyright © 2021, Elsevier Inc. All Rights Reserved. 21 Herpes Viruses Herpes simplex virus type 1 (HSV-1) Herpes simplex virus type 2 (HSV-2) Causes chickenpox and shingles Epstein-Barr virus (HHV-4 or EBV) Causes lesions on genitalia Varicella-zoster viruses (HSV-3 or VZV) Causes with cold sores Causes mononucleosis Cytomegalovirus (HHV-5 or CMV) Causes weakened immune system Copyright © 2021, Elsevier Inc. All Rights Reserved. 22 Hepatitis Hepatitis virus Serious liver infection Bloodborne pathogens spread via blood and body fluids Signs and symptoms • Fatigue, malaise • Nausea, abdominal pain • Jaundice Copyright © 2021, Elsevier Inc. All Rights Reserved. 23 Non-HIV Antivirals Non-HIV antivirals Prevent or delay spread of viral infection Action • Inhibits viral replication Antivirals Influenzas A and B Herpesviruses HBV, HCV HIV Copyright © 2021, Elsevier Inc. All Rights Reserved. 24 Influenza Antivirals Influenza antivirals Decrease viral spread Shorten duration of signs and symptoms Side effects • Dizziness, headache • Insomnia, fatigue • GI distress • Abnormal behavior Copyright © 2021, Elsevier Inc. All Rights Reserved. 25 Herpes Antivirals Herpes simplex antivirals Action • Interferes with DNA synthesis Effective in treating initial and recurrent episodes of genital herpes Copyright © 2021, Elsevier Inc. All Rights Reserved. 26 Cytomegalovirus Antivirals Cytomegalovirus antivirals Use—CMV retinitis in people with AIDS Action • Inhibits DNA polymerase to suppress viral replication Side effects • Headache, dizziness, GI distress • Rash, pruritus, hematuria • Local irritation, renal dysfunction • Leukopenia, thrombocytopenia, granulocytopenia Copyright © 2021, Elsevier Inc. All Rights Reserved. 27 Nursing Process: Antiviral: Acyclovir (1 of 2) Concept Assessment Obtain patient’s medical history including hepatic and renal disease. Patient problems Infection Decreased immunity Planning The patient’s signs and symptoms of the viral infection will be diminished or eliminated. Copyright © 2021, Elsevier Inc. All Rights Reserved. 28 Nursing Process: Antiviral: Acyclovir (2 of 2) Nursing interventions Observe the patient for evidence of side effects. Check the patient for superinfections. Monitor the patient’s CBC for evidence of leukopenia, thrombocytopenia, low hemoglobin, and hematocrit. Record the patient’s urinary output. Dilute the antiviral drug in appropriate amount of solution. Evaluation Copyright © 2021, Elsevier Inc. All Rights Reserved. 29 Hepatitis Antivirals Hepatitis antiviral Delays progression of liver disease. Action • Inhibit viral replication Side effects—Mild to life-threatening • Fatigue, flu-like symptoms, depression, alopecia • Photosensitivity, anorexia, dysgeusia, arthralgia, myalgia • Thyroid and ophthalmic dysfunction • Hepatotoxicity, renal impairment • Lactic acidosis, pancytopenia Copyright © 2021, Elsevier Inc. All Rights Reserved. 30 Practice Question #1 (1 of 2) Which teaching for the patient who is taking fluconazole is a priority for the nurse? A. Take concurrent vitamin B6 to prevent peripheral neuropathy. B. Take 1 hour before or 2 hours after meals. C. Advise that hypoglycemia may occur with concurrent oral sulfonylureas. D. Warn that gingival hyperplasia may occur with prolonged use. Copyright © 2021, Elsevier Inc. All Rights Reserved. 31 Practice Question #1 (2 of 2) Answer: C. Advise that hypoglycemia may occur with concurrent oral sulfonylureas. Copyright © 2021, Elsevier Inc. All Rights Reserved. 32 Practice Question #2 (1 of 2) A patient has developed active tuberculosis and is prescribed isoniazid and rifampin. Which information will the nurse include in teaching the patient about taking this drug? (Select all that apply.) A. Isoniazid should be given 1 hour before or 2 hours after meals. B. Have periodic eye examinations as ordered by the health care provider. C. Compliance with drug regimen is essential. D. Report numbness, tingling, and burning of hands and feet. E. Warn patient that rifampin may turn body fluids a harmless green color. Copyright © 2021, Elsevier Inc. All Rights Reserved. 33 Practice Question #2 (2 of 2) Answer: A. Isoniazid should be given 1 hour before or 2 hours after meals. B. Have periodic eye examinations as ordered by the health care provider. C. Compliance with drug regimen is essential. D. Report numbness, tingling, and burning of hands and feet. Copyright © 2021, Elsevier Inc. All Rights Reserved. 34 Practice Question #3 A middle-aged adult is diagnosed with tuberculosis. Which is true of treatment for this diagnosis? A. B. C. D. Treatment may take about 10 days to 2 weeks. Usually two to three agents are needed. The bacteria is usually resistant to treatment therapy. Treatment for tuberculosis is usually without side effects. Copyright © 2021, Elsevier Inc. All Rights Reserved. 35 Practice Question #4 When teaching a patient about isoniazid (INH) and rifampin drug therapy, which statement will the nurse include? A. “Take isoniazid with meals.” B. “Double the amount of vitamin C in your diet to prevent the peripheral neuropathy associated with isoniazid therapy.” C. “Notify the primary health care provider immediately if your urine turns a red-orange color.” D. “Avoid exposure to direct sunlight.” Copyright © 2021, Elsevier Inc. All Rights Reserved. 36 Practice Question #5 A patient is diagnosed with a Candida infection in the mouth. The nurse anticipates that the patient will be treated with A. B. C. D. metronidazole. amphotericin B. isoniazid. nystatin. Copyright © 2021, Elsevier Inc. All Rights Reserved. 37 Practice Question #6 When caring for a patient receiving amphotericin B, it is most important for the nurse to assess the patient for the development of A. B. C. D. hypokalemia. hypernatremia. hypocalcemia. hypermagnesemia. Copyright © 2021, Elsevier Inc. All Rights Reserved. 38 Practice Question #7 Which nursing intervention is the priority when a patient is receiving antiviral drugs? A. B. C. D. Promoting hydration Enhancing bowel function Increasing tidal volume Promoting circulation Copyright © 2021, Elsevier Inc. All Rights Reserved. 39
