Antibiotic Therapy: Mycobacterial, Fungal, Antiprotozoal
Chp. 47
Anti-Mycobacterial: Selective Antituberculosis
• Prototype: Isoniazid [INH]
• Highly specific for mycobacteria
• OTHERS
• Inhibit growth of mycobacteria by
preventing synthesis of mycolic acid in
cell wall
• Rifampin [RIF]
• Pyrazinamide [PZA]
• Ethambutol [ETH]-bacteriostatic
• Streptomycin
• Rifapentin
Uses
AE
•
Active and latent tuberculosis
•
ALL CAUSE HEPATOXICITY
•
Active: 4 med regimen
•
Hyperglycemia & decreased glucose control
•
•
Latent
•
•
•
INH [C], RIF [C], PZA [C], ETH [c]
•
INH: 9 months or INH with rifapetine once weekly for 3
months
Elevate glucose levels and lower glucose control
INH: PERIPHERAL NEURITIS/NEUROPATHY
•
Tingling, numbness, burning, pain from lack of
pyridoxine [Vit B-6]
•
Must take DAILY DOSE PYRIDOXINE-B6
Contra: children under 2 y; HIV clients, pregnant women
•
RIF: Body fluids reddish-orange,
pseudomembranous colitis
•
PZA: Hyperuricemia
•
•
Baseline and periodic Uric acid levels
ETH: Optic neuritis, altered color perception,
blindness
CONTRA
• Acute LIVER DISEASE
INTERACTIONS
• INH: Concurrent use of tyramine foods, alcohol,
rifampin and pza increase risk for hepatotoxicity
• Nursing
• Tell client to a avoid food w/high levels of
tyramine
• Instruct to avoid alcohol
• Rifampin: inhibits metabolism of phenytoin
= buildup=toxicity [Ataxia & incoordination]
• Nsg
• Monitor phenytoin levels
• Adjust based on med levels
• Monitor Liver function: ALT/AST
Nursing
•
Baseline Liver Function, vs, lung assessment, uric acid levels, glucose level
•
Must take exactly as ordered as same time each day
•
INH/RIF: 1 hour before or 2 hours after meals with full glass water. Any discomfort take w/meals
•
Monitor for liver involvement: jaundice, dark urine, anorexia, n/v, fatigue, malaise
•
Notify if visual acuity changes, altered color perception: report immediately esp. ETH
•
Ensure patient with active TB hospitalized is on AIRBORNE ISOLATION,
•
Ensure patient is observed taking the medication if hospitalized with active TB
•
Obtain sputum specimen for M. tuberculosis first morning sample, three consecutive mornings
•
Advise to use backup methods of contraception
•
MUST COMPLETE COURSE OF THERAPY for time prescribed
Antiprotozoals
• Prototype: Metronidazole [B]
• AE:
• Action: Broad spectrum with bactericidal
properties
• GI discomfort: n/v, dry mouth, metallic taste
• Route: PO, IV
• Uses: protozoal infections: intestinal
amebiasis, giardiasis, trichomoniasis, C.
DIFFICILE, prophylaxis for surgical
procedures: vaginal abdominal, colorectal,
high risk anaerobic infections, treat H. pylori
with tetracycline and bismuth subsalicylate
in clients who PUD
• Darkens urine: harmless effect-tell patient
• Neurotoxicity, CNS effects: stop if numbness,
ataxia, seizures
• THROMBOCYTOPENIA: WATCH CBC: PLTS
• PSEUDOMEMBRANOUS Colitis
• Nsg:
•
Instruct to report fever, diarrhea, abd. Pain, or blood
stool
•
Stop medication
Contra/Caution
• FIRST TRIMESTER PREGNANCY
• ACTIVE CNS disorders, blood
dyscrasias, during lactation
• Cautious use in clients with kidney,
cardiac, fungal, candida infections or
seizures
• Cautious use: older adults, 2nd and 3rd
trimester
Interaction
• ALCOHOL: DISULFIRAM-LIKE
REACTION; FACIAL FLUSHING,
VOMITING, DYSPNEA, TACHYCARDIA
• NSG: AVOID ALCOHOL, ALCOHOLCONTAINING PRODUCTS
• NO ALCOHOL 24 H BEFORE AND 36-72
hours post completion of regimen
• Inhibits activation of Warfarin, phenytoin,
lithium
• NSG: Monitor PT/INR. Adjust accordingly
Nursing
• Administer as directed either via PO or IV
• Must complete full course
• Advise client to use condoms if using this medication for treatment of
trichomoniasis.
• MUST AVOID ALCOHOL 24 HRS BEFORE INITIATION & FOR AT LEAST
36-72 HOURS POST COMPLETION OF LAST DOSE TAKEN
Antiprotozoal
Chp. 47
Antiprotozoal
• Prototype: Metronidazole
• Route: PO/IV
• Action: Broad-spectrum w/bactericidal activity against anaerobic-organisms
• Use: protozoal infections: intestinal amebiasis, giardiasis, trichomoniasis, CDifficile, STDs
• Prophylactic tx: surgical procedures
• Treat H.pylori in combo with tetracycline, bismuth subsalicylate [PUD]
Interactions
• ALCOHOL: disulfiram-like reaction
[facial flushing, vomiting, dyspnea,
tachycardia]
• NSG: Teach to AVOID ALCOHOL OR
ALCOHOL containing products
• Inhibits inactivation of warfarin, lithium,
phenytoin
• Nsg: Monitor PT/INR and phenytoin,
lithium levels. Adjust accordingly
AE
• Pseudomembranous colitis: STOP.
Monitor/report fever, diarrhea,
abdominal pain or blood stool
• Neurotoxicity, CNS effects:
numbness, ataxia, seizures: STOP
medication
• Darkening of urine: Harmless effect
• GI discomfort: n/v, metallic taste, dry
mouth-Observe & notify. Take with
meals to reduce
Contra
• Active CNS disorders, blood
dyscrasias, lactation
• First trimester
• Caution: 2nd or 3rd trimester
Nursing
• Monitor CBC: can cause reversible neutropenia & thrombocytopenia
• Teach to AVOID alcohol for 24 hours before start of therapy and for 36 hours after last dose
take
• Ask about alcohol intake
• Assess for allergies
• Baseline assessments: CNS, GI, GU
• Advise to complete full course of therapy
• Teach to abstain from sexual intercourse until medication is finished, manifestations have
resolved and partners treated: FOR STD USE
• For trichomoniasis: Teach to use Condom
ANTIFUNGALS
CHP. 48
Antifungals
•
Prototype: AMPHOTERICIN B [polyene AB systemic
mycoses] BBW
• Ampho B: acts on fungi cell membrane
to cause cell death
•
Ketoconazole: treat both superficial and systemic
mycoses
• Fungistatic or fungicidal: depends on
concentration
•
Others
• Use: Drugs are treatment of choice for
system fungal infections: candiasis,
aspergillosis, cryptococcosis
•
Fluconazole
•
Nystatin
•
Clotrimazole
•
MIconazole
•
Terbinafine
•
Griseofulvin, Flucytosine
• Other: treat superficial fungal infections:
tinea pedia [athletes food], tinea cruris
[ringworm groin-jock itch], candida
infections of skin, mucous membranes
and fungal infections of nails
[onchomycosis
Antifungals
• Ampho B: acts on fungi cell membrane to cause cell death
• Fungistatic or fungicidal: depends on concentration
• Use: Drugs are treatment of choice for system fungal infections: candiasis,
aspergillosis, cryptococcosis
• Other: treat superficial fungal infections: tinea pedia [athletes food], tinea
cruris [ringworm groin-jock itch], candida infections of skin, mucous
membranes and fungal infections of nails [onchomycosis]
AE
•
Ampho B: SHAKE AND BAKE EFFECT
•
FEVER, CHILLS, RIGORS, HEADACHES 1-3 H POST
INITIATION
•
Cardiac dysrhythmias
•
NSG; TEST DOSE OF 1 MG AMPHO B INFUSED
SLOWLY IV, ASSESS FOR REACTION
•
PRETEAT WITH DIPHENHYDRAMINE, ACETAMINOHEN,
CORTICOSTEROID [PREDNISONE]
•
Administer meperidine, dantrolene or hydrocortisone for
rigors
•
Thrombophlebitis
•
Observe infusion site
•
Rotate injection sites. Use large vein for administration
• Electrolyte imbalances: POTASSIUM & MG
LOSS [HYPOKALEMIA,
HYPOMAGNESEMIA]
• NSG: Supplement if needed
• Bone marrow suppression: Obtain baseline
CBC, hematocrit and monitor weekly
• Ketoconazole: Heptotoxic
• Effects on sex hormones
• Men-gynecomastia, decreased libido, ED
• Women: irregular menses
Nursing
• Infuse slowly over 2-4 hours IV
• Monitor vs every 15 minutes when infusion
started or as indicated
• Use filter
• Do not administer if cloudy or precipitates
• Cover IV bag with paper bag
• Assess for adverse reactions
• Severe: STOP
• NS 1 L on day of Ampho B to lessen
kidney injury
• Premedicate to lessen the shake &
bake effect
• Baseline e-lyte panel, CBC
• Monitor IV site: heat, pain, redness
• Baseline EKG
• Monitor I&O: report decreasing urine
output
• Gain of 2 lb in 24 h or 5 lbs in 1 week:
medication-induced renal damage
FLUCANAZOLE
NYSTATIN
• Better choice than Ampho B
• Polyene antifungal
• Excellent coverage
• Topically for diaper rash
• ROUTE: PO, IV
• PO/Vaginal: candidial infections
• Single oral dose: 150 mg for vaginal
candidiasis infection
• Route: PO prophylactically oral
candidiasis infection
• IV: protect from light & moisture-Keep in foil
wrap until ready to hang for infusion
• Monitor liver enzymes & renal function
• Use infusion pump & infuse over 1 hour
• SWISH around oral cavity AND
SWALLOW FOR ORAL CANDIDIASIS
Terbinafine
• Uses: superficial dermatologic fungus: athlete’s foot
[tinea pedia], tinea cruris [jock itch], tinea corporis
[ringworm]
• PO tablet: treat nail fungus [onchyomycosis]
Antivirals
Chp. 48
Antivirals
• Prototype: ACYCLOVIR: topical/IV/PO, Ganciclovir: IV/PO
• Others:
• Oseltamivir, ribavirin [X], zanamivir, amantadine
• Action: Impaired viral replication by preventing reproduction of viral DNA to interrupt
cell replication
• Uses
• Herpes & varicella-zoster virus: Acyclovir
• Prevent and treat cytomegalovirus [CMV]: Ganciclovir
• Influenza A & B: oseltamivir
• Respiratory syncytial virus [Aerosolization/inhalation], hepatitis C [Ribavirin]: PO
AE
• Acyclovir
• Phlebitis & inflammation at site of infusion
• Nsg: Rotate sites; Monitor site for swelling and
erythema
• Nephrotoxicity
• Nsg: IV slowly over 1 hour; adequate
HYDRATION during & 2 hours post infusion;
increase PO fluid intake as indicated. Caution
w/renal insufficiency
• Mild discomfort w/PO therapy: N/D, headache
• Nsg: Observe & report
• Ganciclovir:
• Bone marrow suppression:
leukocytopenia/thrombocytopenia
• Nsg: Baseline labs; administer Growth factors
[Granulocyte-stimulating factors], monitor
WBC, ANC, PLT during treatment. Teach to
report signs of infection, avoid crowds or sick
people
• Fever, headache, N/D: Give w/food
• Nsg: teach to report
Contra
Nursing
• Acyclovir
• Infuse slowly over 1 hour or more on pump
• No sexual activity should occur
when lesions are present
• Dilute IV in D5W or NS
• ANC <500/mm3 or PLT <
25,000mm3
• PO: Take with meals-minimize GI
• Encourage hydration
• Assess vs, pain level [associated lesions]
• Teach to use condom with healed herpetic lesions to
prevent viral transmission
• Instruct that it does NOT cure, only relieves s/s
Nursing
• Use rubber gloves or finger cot for topical administration to avoid transfer of virus to
other areas of body
• Wash affected area w/soap/water 3-4x per day; keep lesions dry
• REFRAIN from sexual contact while lesions are present
• Ribavirin: NOT to be handled by pregnant female or female of childbearing age
• Ganciclovir
• Use safety gear: Gloves, goggles when handling & preparation
• Avoid exposure of drug to eyes & mucous membranes and skin
• Monitor CBC [bone marrow toxicity]
Antiretroviral: NRTI: Nucleoside Reverse
Transcriptase Inhibitor
• Prototype: Zidovudine [AZT]
• Route: PO/Injectable
• Action: Reduces HIV by inhibiting DNA synthesis and viral replication
• Use
• 1st line anti-retroviral to teat HIV infection
• HIV-infected pregnant women to prevent maternal transmission of virus to infant;
newborns
• AE: major dose limiting effect: BONE MARROW SUPPRESSION [watch for
anemias], Lactic acidosis [hyperventilation], N/V/D, Hepatomegaly/fatty liver
Nursing
• Monitor for bone marrow suppression
• Baseline CBC/PLT @ start and throughout
• Treat anemia: Epoetin or transfusion
• Treat neutropenia: Growth factor: Filgrastim
• Teach to take exactly as indicated
• Notify immediately if pregnancy is suspected: increases risk lactic acidosis,
hepatomegaly and fatty liver
• Can take with meals or milk
• Teach to remain upright for 30 minutes
Fusion Entry Antiretroviral
• Prototype: Enfuvirtide
• Route: SQ
• Action: Decreases & limits spread of HIV by blocking virus from attaching to
and entering CD4 T cell
• Use: Treat HIV: unresponsive to other antiretrovirals
• AE: Local injection site reaction, Bacterial pneumonia, fever, chills, rash,
hypotension
• Nsg: Administered SQ only, monitor for bacterial pneumonia, teach to notify if
pregnancy is suspected; teach to take as prescribed
Protease Inhibitors
Nursing
• Prototype: Ritonavir and others
• Take w/food to increase absorption
• Action: act against HIV-1 and HIV-2 to
alter and inactivate virus by inhibiting
enzymes needed for replication of virus
• Report use of all medications: OTC,
Herbals, illicit
• Uses: HIV infection; combined with one
or two reverse transcriptase inhibitors
• Monitor glucose levels; adjust diet;
administer diabetic meds as prescribed
• Usually given with other PI to increase
their effect
• Monitor lipid panel; adjust diet
• AE: BONE LOSS/OSTEOPOROSIS,
HYPERGLYCEMIA [DM];
HYPERLIPIDEMIA/CHOLESTERAL,
Altered distribution of fat
[Lipodystrophy]
• Use barrier method of contraceptive
• Warn client of lipodystrophy/altered fat
distribution
• Treat prophylactically bone loss
• Teach consume diet high in Calcium and
Vit. D
Preexposure Prophylaxis (PrEP) &
Post-exposure
• What is PrEP?
• What is the FDA approved Prep medication and how often should patients take it?
• Who does CDC define as high-risk for HIV acquisition?
• When should Post-Exposure prophylaxis be initiated?
• PREP Regimen:
• Tenofovir DF 300mg +
• Emtricitabine 200mg daily +
• Raltegravir 400mg BID or dolutegravir 50 mg once daily.
Influenza
• What are the three different kinds of influenza vaccine?
• What is the most common adverse effects of Live-attenuated flu vaccine?
• Who should be vaccinated against Flu?
• Who do we NOT give live influenza vaccine to?
• Is Tamiflu used for the prevention or treatment of the Flu?
• Who should receive prophylactic therapy for Flu, when should it be initiated?
Hepatitis Infections
• What is the most common side effect that occurs in 50%
taking an Alfa-Interferon?
• What is the black box warning for alfa interferons?
• Why is Ribavirin combined with Interferon for treatment of
Hep C?
• What is the black box warning for Ribavirin?
• With Ribavirin use in combination with protease inhibitor how
long after treatment is stopped may cause birth control to be
ineffective?