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Module 8 Pharm

Terms in this set (34)

Allergy or hypersensitivity:
-May be a mild allergic reaction (rash, hives, pruritus)
-Treatment for mild is antihistamine such as diphenhydramine
-May be severe allergy such as anaphylactic shock (Bronchospasm, laryngeal edema, Vascular collapse, cardiac arrest)
-Treatment for severe is epinephrine, bronchodilator, corticosteroid (IV methylprednisolone) and antihistamine (IV diphenhydramine)

Superinfection:
-Secondary infection that occurs when normal flora killed
-Common sites: mouth, skin, respiratory tract, vagina, intestines
-Usually occurs when treated more than 1 week
-More common with broad spectrum antibiotics
-Examples: Thrush (oral candidiasis) or Clostridium difficile Associated Diarrhea-CDAD (bacteria in intestines, overgrowth causes severe diarrhea)
Treatment depends on organism: thrush is treated with nystatin and CDAD is treated with antibiotics such as vancomycin and fidaxomicin (which is a macrolide antibiotic)

Organ toxicity (which organ is affected depends on the antibiotic being used) These are the common toxicities associated with various antibiotics:
-Nephrotoxicity
-Hepatotoxicity
-Ototoxicity

-All antibiotics cause GI distress including anorexia, nausea, vomiting and diarrhea. Some antibiotics can be taken with food, which will help with the GI distress; however, some antibiotics must be taken on an empty stomach. Drinking a full glass of water with those antibiotics can help with the GI distress.

- Stevens-Johnson Syndrome is something that also occurs with antibiotics. It can occur with almost any medication, and perhaps you have noticed it written in bold red letters in the drug guide for almost every medication that we have studied this semester. Since it is fairly common with antibiotics, this is where we will discuss Stevens-Johnson's Syndrome.
Assessments should include:
-Assess renal function by checking urine output BUN, and creatinine as most antibiotics are cleared through the kidneys. Urinary output of less than 600 mL/day indicates impaired renal function
-Assess for allergy to prescribed antibiotics. Antibiotics are some of the most common allergies.
-Assess baseline CBC. Elevated white count occurs with infection. We want to be able to evaluate if the infection is improving. Many antibiotics also cause blood dyscrasias and having a baseline hemoglobin, hematocrit and platelet count can be useful.
-Obtain culture and sensitivity before any antibiotics are given. It will take up to 5 days to receive the finalized report. We do not delay treatment waiting on the results.
-Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of Clostridium difficile-associated diarrhea (CDAD)

Diagnosis:
-Infection related to invading bacterial organism.

Planning:
-Outcome for all antibiotics will be specific to infection.
WBC will trend down to within the normal range
-Patient's temperature will trend down to normal range.

Implementation:
-Fluid intake should be increased with all antibiotics. -Some will require more than others. This helps with renal excretion of the drug and can help prevent nephrotoxicity.
-Antibiotics should be given on time around the clock to help maintain consistent blood levels of the antibiotic. This can help prevent antibiotic resistance.

Patient Teaching:
-*Encourage patient to drink extra water
-Complete entire course of antibiotics. Do not share with others. Do not stop taking when you "feel better".
-There is a need to replace normal gastrointestinal flora that is being killed by antibiotics. This can be achieved with yogurt, butter milk, or OTC probiotics (they also have prescription probiotics available)
-Advise patient to report the signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul-smelling stools) and allergy to health care professional.
-Instruct patient to notify health care professional if fever and diarrhea develop, especially if stool contains pus, blood, or mucus. Advise patient not to treat diarrhea without consulting health care professional.
-Instruct patient to notify health care professional if symptoms do not improve.

Evaluation:
-Infection is better-WBC level decreasing to normal, fever is reduced, drainage from wound decreases.
-Whatever the infection was, we see that it is getting better.
-Structure and MOA: Beta-lactam structure, inhibition of bacterial cell wall synthesis, causing cell death (bactericidal effect)

-Contraindications: Allergy, gallbladder disease, pseudomembranous colitis

-Side effects: pancytopenia refers to all cells on a complete blood count being low (like a panoramic view of the CBC). This means that RBC, WBC, HGB, HCT, and platelets could all be low as a side effect of this medication, nephrotoxicity can occur (especially if the patient is on a medication like furosemide or has a pre-existing renal disorder).

-Drug Interactions: It is important to note the risk of nephrotoxicity with loop diuretics and that there is increased chance of bleeding with anticoagulants. The crystallization can occur if administered concurrently in the same IV line as calcium salts, like are found in TPN and LR. In adult patients and older pediatric patients, we can administer in the same line as long as we stop the infusion of the calcium containing product and "adequately flush the line with a compatible solution." This would mean that we place the infusion pump on hold, flush the line with saline (minimum of 10 mL, but may need more depending on length of IV tubing we are trying to flush), administer the cephalosporin, flush the line with saline again(minimum of 10 mL).
Neonates cannot have IV cephalosporins if they need treatment with TPN or LR (calcium salts). Autopsy has revealed crystalline material in the lungs and kidneys of neonates receiving cephalosporins and TPN.
--Examples of the fluoroquinolones include levofloxacin, moxifloxacin, and ciprofloxacin. I love the fluoroquinolones because their last name is fun to say "floxacin".

-The action: is that fluoroquinolones inhibit bacterial DNA synthesis by interfering with DNA gyrase. They are broad spectrum and bactericidal.

-Contraindications: include allergy, severe renal disease, myasthenia gravis, pregnancy, and lactation. Use caution in seizure disorders, renal dysfunction, children under 14, older adults, and patient's with cardiac dysrhythmias.

-Side effects: include tinnitus, photosensitivity, nephrotoxicity and crystalluria. Note the QT prolongation. QT prolongation can lead to torsade's de points and ultimately sudden cardiac arrest. This is true especially if the patient is on other medications that can cause QT prolongation (like ondansetron-Zofran) or if the patient has a history of cardiac dysrhythmias

-Please be aware of the black box warning. The patient needs to report heel pain or any pain where it might be a tendon issue. This most often will happen after the course of the antibiotic is completed and it can be any tendon in the body, but the Achilles' tendon is the most common tendon affected.
-Fluoroquinolones also cause CNS effects, exacerbation of myasthenia gravis, and peripheral neuropathy.
Because of this severe black box warning and risk to patients, the quinolones should only be used for severe infections that are not responding to other antibiotics. At one time, they were used as a first-line antibiotic for pneumonia and urinary infections. Now, caution is used in prescribing these drugs. These are still commonly used to treat healthcare associated infections.

-Drug interactions: include increase effects of oral hypoglycemics and theophylline and concurrent use with corticosteroids increases the chance of tendonitis and tendon rupture.
Assessments should include:
-Assess past medical history for cardiac dysrhythmias, severe renal disease, myasthenia gravis, pregnancy and lactation
-Obtain drug history: Increase the effects of oral hypoglycemics (which would cause hypoglycemia in diabetic patient); look for any drug that causes QT prolongation; look for concurrent use of corticosteroids

Diagnosis and planning are the same for all antibiotics, refer to antibiotic basics lecture.

Implementation:
*-Monitor intake and output. Urine output should be at least 750 mL per day. Pt should increase intake to >2000 mL/day to prevent crystalluria.
-Administer oral doses 2 hours before or after antacids and iron products to aid in absorption.
-For IV levofloxacin, administer over 60 minutes
**-Monitor blood sugar more closely in patients with diabetes who are on oral hypoglycemic agents.
*-Monitor Theophylline levels when taken concurrently with fluroquinolones because it can increase theophylline levels and predispose a patient to theophylline toxicity.
*-Monitor heart rate and rhythm, especially in patients with cardiac history or on other medications that can cause QT prolongation. A cardiac monitor should be applied to the patient.

Patient Teaching
*-Teach patient to drink 2000 mL per day.
-Encourage the use of sun block and to wear protective clothing if in the sun. It is best to avoid sunlight altogether.
-Teach to repot pain in their heel area or at other tendon locations due to the black box warning of tendonitis and tendon rupture. This is most likely to occur weeks after the antibiotic course is completed.
-Vancomycin is the drug of choice for MRSA. Because vancomycin is used frequently, we now see
vancomycin resistant organisms (Vancomycin resistant enterococci).

-Action: vancomycin inhibits cell wall synthesis. Treats gram positive infections and is bactericidal.

-Contraindicated: in renal impairment. A reduced dose is required if the Creatinine Clearance is less than or equal to 80 mL/min.

-Side effects: include red neck or red man syndrome. You prevent administering vancomycin slowly. It is not an allergic reaction. 500 mg should be diluted in 100 mL; 1 gram should be diluted in 200 mL. Give over 60-90 minutes. If red man still occurs with 90-minute infusion, the infusion can be slowed to 2-hours. Ototoxicity and nephrotoxicity can occur.
-Because of the risk of nephrotoxicity and ototoxicity, serum levels of vancomycin should be monitored periodically in therapy. Report high levels to the doctor in order to prevent permanent damage. Often, peak and trough levels are drawn, but the peak is not as accurate due to the longer infusion times. Trough shows the rate of excretion and is drawn right before the next dose is due. If the trough level is high, it indicates that the kidneys are not filtering the medication as well as they should. This will lead to toxicity. The trough should be checked every 3-4 dose. If you do not see an order for a trough and it has been greater than 4 doses, you should request a trough level to be drawn. Ideal trough values are between 10-20 mcg/mL.

-Drugs interactions: include increased risk of nephrotoxicity and antihistamines can mask the symptoms of ototoxicity.
Isoniazid:
-Side effects: Hepatotoxicity, peripheral neuropathy (Caused by depletion of B6)
-Prevention of peripheral neuropathy can be achieved with administration of pyridoxine (vitamin B6)
-Avoid other medications and substances that cause damage to the liver

Rifampin:
-Side effects: Hepatotoxicity, red-orange discoloration of body fluids
-Discoloration can cause staining to clothing and soft contact lenses
-Avoid other medications and substances that cause damage to the liver

-Isoniazid is the most commonly used antitubercular drug.
-Common treatment would include 4 drugs- isoniazid, rifampin, pyrazinamide, ethambutol.
-Drug therapy for tuberculosis lasts up to 24 months and compliance is critical to help decrease the cases of Multi Drug Resistant TB (MDR-TB). Patients must take the drugs exactly as ordered, at the same time every day, in order to keep the blood levels steady.
-An issue we are currently facing with tuberculosis is the increasing number of MDR-TB cases. MDR-TB is resistant to both INH and rifampin.
-Drug-resistant TB can occur when the drugs used to treat TB are misused or mismanaged.

Examples of misuse or mismanagement include:
-People do not complete a full course of TB treatment
Health care providers prescribe the wrong treatment (the wrong dose or length of time)
-Drugs for proper treatment are not available
-Drugs are of poor quality
-Drug-resistant TB is more common in people who
-Do not take their TB drugs regularly
-Do not take all their TB drugs
-Develop TB disease again, after being treated for TB disease in the past
-Come from areas of the world where drug-resistant TB is common
-Have spent time with someone known to have drug-resistant TB disease