PHARMACOLOGY: ANTI-INFECTIVES

Compiled by Precautions
ROQUEE HOSPICIO H. PARAGOSO, RN 1) Culture & susceptibility testing FIRST
JRMSU College of Nursing and Allied Health Sciences 2) Modify dosage in pts w/ hepatic & renal insufficiency
3) Use cautiously in pregnant & lactating women
ANTIBACTERIALS 4) Prolonged inappropriate broad-spectrum use superinfection
of fungi or resistant bacteria
General Use
Treatment & prophylaxis of various bacterial infections Interactions
1) Penicillins & aminoglycosides chemically inactivate each
General Action other – DO NOT MIX
• Kill (bactericidal) or inhibit the growth of (bacteriostatic) 2) Erythromycin -  metabolism of other drugs
susceptible pathogenic bacteria 3) Probenecid -  serum levels of penicillins
• NOT ACTIVE AGAINST VIRUSES OR FUNGI 4) Sulfonamides & other highly protein-bound anti-infectives –
• Categories depend on CHEMICAL SIMILARITIES and displaces other highly bound drugs
ANTIMICROBIAL SPECTRUM 5) Extended spectrum penicillins (ticarcillin, piperacillin) & some
cephalosporins (cefoperazone, cefotetan) -  R/F bleeding w/
Examples anticoagulants, thrombolytics, antiplatelet, NSAIDs
1. Aminoglycosides (-micin, -mycin) 6) Antacids, bismuth subsalicylate, iron salts, sucralfate, zinc
Amikacin Gentamicin Kanamycin salts -  fluoroquinolone absorption
Neomycin Streptomycin Tobramycin
Nursing Implications
2. Carbapenems (-penem) Assessment
Doripenem Ertapenem 1) S/Sx of infection pre- & intra-therapy
Imipenem/Cilastatin Meropenem 2) Previous hypersensitivities to penicillins or
cephalosphorins
3. First-Generation Cephalosporins 3) Obtain C&S specimens pre-therapy; may give 1st dose
Cefadroxil Cefazolin before results are in
Cephalexin Cephadrine
Potential Nursing Diagnosis
4. Second-Generation Cephalosporins 1) Risk for infection
Cefaclor Cefotetan Cefoxitin 2) Deficient knowledge r/t disease process & medication
Cefprozil Cefuroxime regimen
3) Noncompliance
5. Third-Generation Cephalosporins
Cefdinir Cefditoren Cefixime Implementation
Cefoperazone Cefotaxime Cefpodoxime Administer RTC to maintain therapeutic serum drug levels
Ceftazidime Ceftibuten Ceftizoxime
Ceftriaxone
Patient/Family Teaching
6. Extended Spectrum Penicillins 1) Continue taking meds RTC until completely finished even
Piperacillin Piperacillin/Tazobactam if feeling better
Ticarcillin Ticarcillin/Clavulanate 2) Report signs of superinfection
a. *black, furry overgrowth on tongue
7. Fluoroquinolones (-floxacin) b. *vaginal itching or discharge
Ciprofloxacin Gemifloxacin c. *loose or foul-smelling stools
Levofloxacin Moxifloxacin 3) Notify HCP if fever & diarrhea develop especially if stool
Norfloxacin Ofloxacin has pus, blood or mucus; DON’T SELF-MEDICATE for
LBM
8. Macrolides (-thromycin) 4) If symptoms persist, call the HCP
Azithromycin
Clarithromycin Evaluation
Erythromycin Resolution of S/Sx of infection; length of time depends on
organism & site of infection
9. Penicillins (-cillin, -cycline)
Amoxicillin Amoxicillin/Clavulanate ANTIVIRALS
Ampicillin Ampicillin/Sulbactam
Benzathine penicillin G General Use
Procaine penicillin G • Mgt of viral infections
Cloxacillin Dicloxacillin Herpes – acyclovir, famciclovir, valacyclovir
Nafcillin Oxacillin Chickenpox – acyclovir
Penicillin G Penicillin V Cytomegalovirus retinitis – cidovir, ganciclovir,
Doxycycline Minocycline valganciclovir, foscarnet
Tetracycline Opthalmic – vidarabine
Oral-facial herpes simplex – penciclovir, docosanol
10. Miscellaneous Influenza A prevention – oseltamivir, zanamivir
Trimethoprim/sulfamethoxazole
Cefepime Clindamycin General Action
Daptomycin Drotrecogin Most agents inhibit viral replication
Linezolid Metronidazole
Mupirocin Nitrofurantoin Contraindications
Quinupristin/dalfopristin Previous hypersensitivity
Rifaximin Telithromycin
Tigecycline Trimethoprim Precautions
Vancomycin • Renal impairment – adjust dose except zanamivir
• Acyclovir – renal impairment, CNS toxicity
Contraindications
• Foscarnet -  R/F seizures
• Known hypersensitivity
• Cross-sensitivity among related agents may occur Interactions
Acyclovir – additive CNS & nephrotoxicity w/ drugs causing 6. Integrase strand transfer inhibitor
similar adverse reactions Raltegravir

Nursing Implications 7. Non-nucleoside reverse trancriptase inhibitors

Assessment Delavirdine Efavirenz
1) S/Sx of infection pre- & intra-therapy Etravirine Nevirapine
2) Eye lesions pre- & intra-therapy QD
3) Skin lesions pre- & intra-therapy QD Contraindications
1) Hypersensitivity
Potential Nursing Diagnoses 2) Highly varying toxicities among agents!
1) Risk for infection
2) Impaired skin integrity Precautions
3) Deficient knowledge R/T disease process & medication 1) Renal impairment – adjust dosage
regimen 2) Hyperglycemia – protease inhibitors; use cautiously in DM pts
3) Bleeding – protease inhibitors; use cautiously in hemophiliacs
Implementation
Administer RTC to maintain therapeutic serum drug levels Interactions
1) Many serious drug-drug interactions among antiretrovirals
Patient/Family Teaching 2) Affected by drugs that alter metabolism
1) Continue taking meds RTC until completely finished even 3) May affect metabolism
if feeling better
2) Antivirals & antiretrovirals don’t prevent transmission to Nursing Implications
others; take precautions to prevent spread of virus Assessment
3) Instruct on correct technique for topical or ophthalmic 1) Change in severity of HIV symptoms & opportunistic
preparations infections intra-therapy
4) If symptoms persist, notify HCP 2) LAB TEST: Monitor viral load & CD4 counts pre- &
periodically intra-therapy
Evaluation
Resolution of S/Sx of infection; length of time depends on Potential Nursing Diagnoses
organism & site of infection 1) Risk for infections
2) Deficient knowledge, R/T disease process & medication
Examples regimen
Acyclovir Amantadine 3) Noncompliance
Cidofovir Docosanol
Entecavir Famciclovir Implementation
Foscarnet Ganciclovir Administer doses RTC
Imiquimod Lamivudine
Oseltamivir Penciclovir Patient Teaching
Ribavirin Valacyclovir 1) Take meds EXACTLY as directed RTC even if sleep is
Valganciclovir Zanamivir interrupted
2) Comply. Don’t double-dose/overdose. Don’t D/C w/o
ANTIRETROVIRALS consulting with AP
3) Take missed doses as soon as remembered UNLESS
General Use almost time for next dose
• Mgt of HIV infetion 4) Inform long-term effects are currently UNKNOWN
Goal:  CD4 cell counts &  viral load 5) Don’t share meds w/ others
(+) effects:  dse progression,  quality of life,  opportunistic 6) Inform that these DO NOT CURE HIV & does NOT
infections REDUCE risk of HIV transmission w/ others (Use a
• Perinatal use: prevents viral transmission to fetus condom. Avoid sharing needles or donating blood.)
• Post-exposure prophylaxis 7) Avoid taking Rx, OTC or herbal products w/o consulting
AP
General Action 8) Regular ff up exams & blood counts determine progress
& monitor for S/E
• HIV is managed by combo of agents due to  resistance &
toxicities of solo agents
Evaluation
• Selections & doses based on individual toxicities, underlying
 In viral load, CD4 counts in patients w/ HIV
organ system dse, concurrent drug therapy, severity of illness
• Up to 4 agents may be used simultaneously
Selected References:
Examples
1. CCR5 co-receptor antagonist
Deglin, J. and Vallerand, A. (2008). Davis’ Drug Guide for Nurses
Maraviroc
Eleventh Edition. F.A. Davis.
Abrams, A. (2009). Clinical Drug Therapy for Nursing. F.A. Davis.
2. Fusion inhibitor
Enfuvirtide

3. Metabolic inhibitor
Lopinavir/ritonavir

4. Nucleoside reverse trancriptase inhibitors

Abacavir Didanosine Emtricitabine
Lamivudine Stavudine Zidovudine
Tenofovir disoproxil fumarate

5. Protease inhibitors
Atazanavir Darunavir Indinavir
Nelfinavir Ritonavir Saquinavir
Tipranavir Lopinavir/ritonavir
Fosemprenavir calcium
ANTI-FUNGALS • Act by many different mechanisms (see table at the end of
this section)
General Use • Action may not be limited to neoplastic cells
• Treatment of fungal infections
Skin/Mucous Membrane – Topical/vaginal preparations Contraindications
Systemic – oral/parenteral therapy • Previous bone marrow depression or hypersensitivity
*Amphotericin – lipid encapsulation technology (new • Contraindicated in pregnancy & lactation
formulation)  toxicity
Precautions
General Action 1. Use cautiously in pts w/ active infections,  bone marrow
• Kill (fungicidal) or stop growth of (fungistatic) by affecting reserve, radiation therapy or other debilitating illnesses
permeability of the fungal cell membrane or protein synthesis 2. Use cautiously in pts w/ childbearing potential
w/in the fungal cell itself
Interactions
Examples • Allopurinol -  metabolism of mercaptopurine
1. Systemic • Nephrotoxic drugs & NSAIDS -  toxicity of methotrexate
Amphotericin B Fluconazole Ketoconazole • Bone marrow depression could increase

2. Topical/Local Nursing Implications

Clotrimazole Ketoconazole Miconazole Assessment
Nystatin Sulconazole Tioconazole 1. Monitor for BM depression (check for bleeding,
avoid IM injections & rectal temp, apply pressure to
Contraindications injection sites, assess for signs of infection, anemia,
• Previous hypersensitivity fatigue, dyspnea & hPN)
2. Monitor I/O, appetite & nutritional intake
Precautions 3. Give prophylactic antiemetics
1. Use cautiously in pts w/ bone marrow suppression 4. Monitor IV site carefully & ensure patency; D/C if
2. Renal impairment – Amphotericin, Fluconazole extravasation/infiltration occurs
3. More severe A/R in HIV (+) pts 5. Monitor for S/Sx of gout;  OFI, alkalinize urine,
allopurinol given to  uric acid
Interactions
• Differs greatly among various agents Potential Nursing Diagnoses
1. Risk for Infection
Nursing Implications 2. Imbalanced Nutrition: Less than Body Requirements
Assessment 3. Deficient Knowledge r/t disease process &
1. Assess for signs of infection & involved skin & medication regimen
mucous membranes pre- & post-therapy
2. D/C meds if w/  skin irritation Implementation
1. Wear gloves, gown, mask while preparing & handling
Potential Nursing Diagnoses meds
1. Risk for Infection 2. Check dose carefully
2. Impaired Skin Integrity
3. Deficient Knowledge r/t disease process & Patient/Family Teaching
medication regimen 1. Caution to avoid crowds & persons w/ known
infections
Implementation 2. Report STAT for S/Sx of infection
1. Available in various drug forms 3. Report unusual bleeding
2. Cleansing technique before applying meds 4. Meds may cause infertility & are teratogenic; report if
3. Wear gloves during application pregnancy is suspected
4. NO occlusive dressings unless specified by AP 5. Discuss possibility of hair loss
6. Inspect oral mucosa for erythema & ulceration;
Patient/Family Teaching manage stomatitis
1. Instruct on proper use of medication form 7. NO VACCINATIONS while therapy is ongoing
2. Instruct to continue medication as directed even if 8. Follow-up medical check-up & frequent lab tests
feeling better
3. Advise to report  irritation or lack of therapeutic Evaluation
response to AP 1.  in size & spread of tumor
2. Improvement in hematologic status in pts w/
Evaluation leukemia
1. Resolution of S/Sx of infection
2. Length of time for complete resolution depends on
organism & site of infection Selected References:
3. Prolonged therapy for deep-seated infections
4. Recurrent fungal infections – serious systemic Deglin, J. and Vallerand, A. (2008). Davis’ Drug Guide for Nurses
illness Eleventh Edition. F.A. Davis.

ANTI-NEOPLASTICS

General Use
• Treatment of various solid tumors, lymphomas, leukemias
• Treatment of some autoimmune disorders such as
rheumatoid arthritis (RA) – Cyclophosphamide, Methotrexate
• Used in combination to minimize individual toxicities &
maximize response
• May be combined w/ surgery & radiation therapy
• Newer lipid-encapsulated drugs have less toxicity &  efficacy

General Action