Transcript Pharmacology and Pathophysiology II

Pharmacology and
Pathophysiology II
Anti - infectives
Review of the Pathophysiology Basics
Non Specific Resistance (First Line of Defense)
Intact Skin
Non Specific Resistance (Second Line)
Specific Resistance (Third Line)
Mucous Membranes
Phagocytic WBC
Normal Flora
Inflammation
Specialized Lymphocytes
Fever
Antibodies
Antimicrobial Substances
Non Specific Resistance (Second Line)
– Phagocytic WBC
– Inflammation
• 5 Signs
– Fever
• Hypothalamus
• Interleukin I (released by phagocytes)
– Hypothalamus releases prostaglandins
– Antimicrobial Substances
• Antibiotics
Specific Immunity
• Antigens
– Provoke a specific response
• Antibodies
– Proteins (immunoglobulins) made in response to
an antigen
• IgG, IgM, IgA, IgD, IgE
Lymphocytes
• Granulocytes
– Neutrophils
– Basophils
– Eosoniphils
• Agranulocytes
– Monocytes
– Macrophages
• Lymphocytes
– T Cells
– B Cells
Review of Nursing Procedures
• Blood Cultures
REMEMBER: NEVER START IV ANTIBIOITICS
UNTIL YOU HAVE COLLECTED YOUR BLOOD
CULTURES!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
• Stool Cultures
• Sputum Cultures
• Urine Cultures
• Wound Cultures
Lab Work
• Blood Smear (slide)
– Wright stain applied for WBC
– Parasites may be found
• CRP (C – Reactive Protein)
– Produced by liver
– Increases with generalized inflammation
• ESR (Erythrocyte Sedimentation Rate)
– Indirectly measures how much inflammation is present
• Governed by pro-sedimentation factors (fibrinogen) and negatively
charged erythrocytes (resisting sedimentation)
• Inflammation causes high proportion of fibrinogen in blood
Lab Work
Lab Work
Lab Work
Lab Work
LabWork
• Left Shift
– Probable bacterial infection
– Absolute increase in neutrophils with an increase
in bands, and sometimes an increase in immature
forms such as metamyelocytes or myelocytes
Lab Work
Types of Infections
• MDRO
– Multi – Drug Resistant Organisms
– MRSA
• Methicillin Resistant Staph. Aureus
– VRE
• Vancomycin Resistant Enterococcus
– KPC
• Klebsiella Pneumoniae Carbapenemase Producer
– ESBL
• Extended Spectrum Beta Lactamase
MDRO Infection and Colonization
• Colonized
– Bacteria present, but no active infection
• Infected
– Signs of Infection
Vaccinations
• Attenuated Whole Agent Vaccine
– Living, but attenuated microbes
– Good ‘teachers’ for the immune system
– MMR, Chickenpox
– Not for immunosuppressed patients
– Need to be refrigerated
Vaccinations
• Inactivated Whole Agent Vaccine
– Microbes have been killed, usually by formalin or
phenol
– More stable and safer than attenuated whole
vaccines
– Do not always need to be refrigerated
– Influenza, Hepatitis A
Vaccinations
• Subunit Vaccine
– Antigenic fragments of a microorganism that best stimulate an
immune response
– Some use epitopes
• Variable part of the antigen
• Lower risk of adverse reactions
• May contain 1 – 20, or more, antigens
– Created by using chemicals to break apart and gather antigens
OR recombinant DNA technology to manufacture the antigens
– Hepatitis B
• Made by inserting hep. B gene codes for antigens into bakers yeast
– Research is looking for recombinant subunit vaccine for
Hepatitis C
Vaccinations
• Toxoids
– Inactivated toxins produced by a pathogen
– For toxins excreted by bacteria
– Inactivated with formalin
– Tetanus
– Diphtheria
• TDap
Vaccinations
• Conjugated Vaccine
– Polysaccharide coating on certain bacteria
• Disguises antigens
– Immature immune systems can’t recognize it
– Poor immune system of children
• Do not respond well to T-independent antigens of the
vaccines with capsular polysaccharides until 15-24
months of age
• Haemophilus influenza type B
– Combined with diptheria toxoid (protein)
Types of Super Infections
• MDRO
– Multi – Drug Resistant Organisms
– MRSA
• Methicillin Resistant Staph. Aureus
– VRE
• Vancomycin Resistant Enterococcus
– KPC
• Klebsiella Pneumoniae Carbapenemase Producer
• pneumonia, bloodstream infections, wound or surgical site
infections, and meningitis.
– ESBL
• Extended Spectrum Beta Lactamase
• urinary tract, lungs, skin, blood, or abdomen.
Sulfonamides
• Sulfadiazine
• Trimethoprim (TMP) and Sulfamethoxazone
(SMZ)
– Bactrim
• Silvadene
• Septra
Sulfonamides
– UTI
– Acute Otitis Media
– Treatment and Prevention of Infection for 2nd and
3rd Degree Burns
– MRSA (Bactrim)
Sulfonamides
• Adverse Reactions
– Anorexia
– N/V/D
– Abdominal Pain
– Stomatitis
– Pruitis
– Toxic Epidermal Necrolysis (TEN)
– Stevens-Johnson Syndrome (SJS)
Sulfonamides
• Contraindications
– Lactation
– Less than 2 years old
– Term pregnancy
– Diabetic Patients
Penicillins
• Aminopenicillins
– Narrow Spectrum
– Amoxil
• Amoxicillin
– Ampicillin
• Extended Spectrum Penicillins
– Used for Pseudomonas
– Piperacillin
– Ticarcillin
• Penicillin Beta Lactamase Inhibitor
Combinations
– Augmentin (amoxicillin and clavulanic acid)
– Timentin (ticarcillin and clavulanic acid)
– Unasyn (ampicillin and sulbactam)
– Zosyn (piperacillin and tazobactam)
Penicillins
• Uses
– UTI
– Septicemia
– Meningitis
– Intra-Abdominal Infections
– STDs
• Syphilis
– PNA and other respiratory infections
Penicillins
• Adverse Reactions
– Glossitis (if given orally)
– Stomatitis
– Dry mouth
– Gastritis
– N/V/D
– Abdominal Pain
Penicillins
• Contraindications and Precautions
– Lactation
– Pregnancy
– Renal Disease
– Asthma
– Bleeding Disorders
Cephalosporins
Sensitivity
• Four Generations
• Bacetericidal
• Similar action to
PCN
1st Gen.
Sensitivity to Gram Negative
Bacteria
2nd Gen.
Sensitivity to Gram Positive
Bacteria
3rd Gen.
4th Gen.
Cephalosporins
• Remember: CEF- First Generation
– Ancef (cefazolin), Keflex(cephalexin)
• Second Generation
– Ceftin (cefuroxime), cefaclor
• Third Generation
– Omnicef (cefdinir), Fortaz (ceftrazidime), Rocephin
(ceftriaxone)
• Fourth Generation
– Maxipime (cefepime)
Cephalosporins
• Uses
– Respiratory Infections
– Otitis Media
– Bone / Joint Infections
– GU Infections
Cephalosporins
• Adverse Reactions
– N/V/D
– HA
– Dizziness
– Malaise
– Nephrotoxicity
– CONNECTED WITH PCN ALLERGY
Tetracyclines
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Remember: CYCLINE
Doxycycline (Vibramycin)
Tetracycline (Sumycin)
Tigecycline (Tygacil)
Tetracyclines
• Uses
– Rickettsial Diseases
• Rocky Mountain Spotted Fever, Typhus fever
– Skin and Soft Tissue Infections
– Uncomplicated urethral, endocervical or rectal
infections
– H. pylori
• Treated in combination with metronidazole and
bismuth subsalicylate
Tetracyclines
• Adverse Reactions
– N/V/D
– Epigastric Distress
– Somatitis
– Sore Throat
– Sin Rash
Tetracyclines
• Contraindications
– Pregnancy
– Lactation
– Children under 9
• Permanent discoloration of teeth
– Impaired renal function
Aminoglycosides
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Remember: CIN*
Amikacin (Amikin)
Gentamicin
Neomycin
Streptomycin
• * - can be confused with macrolides and
lincosamides
Aminoglycosides
• Uses
– Hepatic Coma (encephalopathy)
• Reduces ammonia forming bacteria in intestinal tract
– Prior to surgery
• Reduction in flora
Aminoglycosides
• Adverse Reactions
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N/V/D
Anorexia
Rash
Urticaria
Ototoxicity
• Tinitis
• Vertigo
• Hearing loss
– Neurotoxicity
• Numbness
• Circumoral or peripheral paresthesia
– Nephrotoxicity
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Proteinuria
Hematuria
Increased BUN and Creatinine
Decreased Urinary Output
Aminoglycosides
• Contraindications
– Myasthenia Gravis
– Parkinsonism
– Preganancy
– Lactation
Aminoglycosides
• Interactions
– Cephalosporin
• Increased risk of nephrotoxicity
– Loop Diuretics
• Increased risk of ototoxicity
– Pavulon and Anectine (anesthesia)
• Increased risk of neuromuscular blockade
Macrolides
• Azithromycin
– Z-Pack
• Erythromycin base
Macrolides
• Uses
– Acne Vulgaris
– Skin Infections
– Upper Respiratory Infections caused by
Hemophilus influenzae (Hib)
• In conjunction with sulfonamides
Macrolides
• Contraindications
– Preexisting liver disease
– Myasthenia Gravis
– Pregnancy
Case Study
• Jason Williams is a 75-year-old African American man. He is diagnosed
with an acute exacerbation of chronic bronchitis. The physician would like
to give Mr. Williams a sulfonamide to treat his exacerbation.
• Discussion:
• 1. What information should the nurse obtain from Mr. Williams before
the physician sees him?
• 2. The physician diagnoses Mr. Williams with an acute exacerbation of
chronic bronchitis. The physician would like to give Mr. Williams Bactrim
DS one tablet every 12 hours for 14 days. What should the nurse tell Mr.
Williams about the prescription before letting him leave the physician’s
office?
• 3. Mr. Williams calls the physician’s office after 2 days of taking the
medication. He complains of red bumps on his face, neck, and extremities.
What should the nurse tell Mr. Williams?
Case Study
• Lori Jenkins is a 6-year-old Caucasian girl. She presents to the physician’s
office today with bilateral ear pain, nasal congestion, cough, and a lowgrade fever. Her mother reports she is not taking any medications and has
no allergies that she is aware of at this point. The physician writes a
prescription for amoxicillin 250 mg/5 mL, give 2 teaspoonfuls 3 times a
day for 10 days.
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• Discussion:
•
• 1. Lori’s mother is concerned that Lori may have an allergic reaction to
the amoxicillin. What signs or symptoms should the nurse tell Lori’s
mother to look for that may indicate an allergic reaction has occurred?
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• 2. What should the nurse tell Lori’s mother about oral suspensions?
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• 3. What should the nurse tell Lori’s mother about the prevention of
anti-infective resistance?
Case Study
• Luis Labra is a 65-year-old Hispanic man. He presents to the emergency
department today with increased shortness of breath, cough, and a lowgrade fever. His current medications are warfarin (Coumadin) 5 mg take as
directed and metoprolol 50 mg twice daily. He is admitted to the hospital
and the physician writes an order for Mr. Labra to receive ceftriaxone
(Rocephin) 1 g every 12 hours via IV infusion.
•
• Discussion:
•
• 1. Before administering the ceftriaxone to Mr. Labra what information
should the nurse obtain from the patient?
•
• 2. He reports upset stomach after taking penicillin a long time ago. Is
this a true allergy, and should Mr. Labra not receive the ceftriaxone?
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• 3. Mr. Labra is feeling better but is to continue to receive cefdinir
(Omnicef) 300 mg by mouth twice daily for 7 days. What should the nurse
tell Mr. Labra and his family about the Omnicef?
Case Study
• Maria Lopez is a 24-year-old Hispanic woman. She presents
to the physician’s office today seeking treatment for her
acne. Her only medication is Ortho Tri-Cyclen Lo. The
physician writes Ms. Lopez a prescription for doxycycline
(Doryx) 150 mg once daily.
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• Discussion:
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• 1. What should the nurse tell Ms. Lopez about taking oral
contraception with Doryx?
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• 2. What adverse reactions should the nurse discuss with
Ms. Lopez?
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• 3. How should the nurse tell Ms. Lopez to take the Doryx?