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Miscellaneous Anti-infectives

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Miscellaneous Anti-infectives
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  100 Miscellaneous Anti-infectives 11 chapter  anaerobic blood dyscrasias hypoglycemia hypotension  Key TermsChapter Objectives  On completion of this chapter, the student will:   Discuss the uses, general drug actions, adverse reactions, contraindi-cations, precautions, and interactions of the drugs presented in thischapter.  Discuss preadministration and ongoing assessments necessary with theadministration of the drugs presented in this chapter.  Identify nursing assessments that are performed when a drug is poten-tially nephrotoxic or ototoxic.  List some nursing diagnoses particular to a patient taking the anti-infective drugs presented in this chapter.  Discuss ways to promote optimal response to therapy and importantpoints to keep in mind when educating patients about the use of theanti-infectives presented in this chapter. ADVERSE REACTIONS  Serious and sometimes fatal blood dyscrasias (pathologiccondition of blood; disorder of cellular elements of blood)are the chief adverse reaction seen with the administrationof chloramphenicol. In addition to blood dyscrasias, super-infection, hypersensitivity reactions, nausea, vomiting,and headache may be seen. It is recommended thatpatients receiving oral chloramphenicol be hospitalized sothat patient observation and frequent blood studies can beperformed during treatment with this drug. CONTRAINDICATIONS, PRECAUTIONS,AND INTERACTIONS  Chloramphenicol is contraindicated in patients withknown hypersensitivity to the drug. This drug is used cau-tiously in patients with severe liver or kidney disease, ingeriatric patients, in individuals with glucose-6-phosphatedehydrogenase (G6PD) deficiency (see Chap. 1), and dur-ing pregnancy (Category C) or lactation. Newborns are atincreased risk for experiencing adverse reactions due totheir inability to metabolize and excrete chloramphenicol. T he anti-infectives discussed in this chapter (seeSummary Drug Table: Miscellaneous Anti-infectives)are singular drugs, that is, they are not related to eachother and do not belong to any one of the drug groupsdiscussed in Chapters 6 through 10. Some of thesedrugs are used only for the treatment of one type of infection, whereas others may be limited to the treat-ment of serious infections not treatable by other anti-infectives. CHLORAMPHENICOLACTIONS AND USES  Chloramphenicol (Chloromycetin) interferes with orinhibits protein synthesis, a process necessary for thegrowth and multiplication of microorganisms. This is apotentially dangerous drug (see below), and thereforeits use is limited to serious infections when less poten-tially dangerous drugs are ineffective or contraindi-cated.   The effects of oral hypoglycemic drugs, oral anticoag-ulants, and phenytoin may be increased when adminis-tered with chloramphenicol. Phenobarbital or rifampinmay decrease chloramphenicol blood levels. LINEZOLIDACTIONS AND USES  Linezolid (Zyvox) is the first of a new classification, anoxazolidinone, that acts by binding to a site on a specificribosomal RNA and preventing the formation of acomponent necessary for the bacteria to replicate. It isboth bacteriostatic (ie, to enterococci and staphylococci)and bacteriocidal (ie, against streptococci). The drug isused in the treatment of vancomycin-resistant entero-coccus (VRE), nosocomial (hospital acquired) and com-munity acquired pneumonia, pneumonia, and in thetreatment of skin and skin structure infections, includ-ing those caused by methicillin-resistant Staphylococcus aureus (MRSA). ADVERSE REACTIONS   The most common adverse reactions include nausea,vomiting, diarrhea, headache, and insomnia. The drugmay also cause fatigue, depression, nervousness, and CHAPTER 11   Miscellaneous Anti-infectives  101 GENERIC NAMETRADE NAME*USESADVERSE REACTIONSDOSAGE RANGES chloramphenicol Chloromycetin,Serious, susceptibleSerious to fatal blood dyscrasias,50 mg/kg/d PO, IV in klor-am-fen’-i-kolegeneric  infections in which superinfections, hypersensitivity,divided dosesother less potentially nausea, vomiting, headachedangerous drugs areineffective or contraindicatedlinezolid ZyvoxInfections due to Nausea, diarrhea, headache,600 mg PO or IV q12h lah-nez’-oh-lid  vancomycin-resistant insomnia, pseudomembranous Enterococcus  sp faecium;  colitispneumonia due to Staphylococcusaureus  and penicillin-susceptible Streptococcus pneumoniae; skin andskin structure infectionsmeropenem Merrem IVIntra-abdominal and soft Headache, diarrhea, abdominal1 g IV q8h meh-row-pen’-em  tissue infections caused pain, nausea, pain and by multiresistant gram- inflammation at injection site,negative organismspseudomembraneous colitismetronidazole Flagyl, Protostat,Infections caused byNausea, diarrhea, anorexia, 7.5—15 mg/kg me-troe-nid’-uh-generic  susceptible anaerobic seizures, numbness,IV q6h; 7.5 mg/kg zole  microorganisms,hypersensitivity reactions, PO q6hamebiasis, trichomonasdisulfiram-like reactions with alcohol ingestionpentamidine NebuPent, Pneumocystis carinii  Nausea, anxiety, anorexia, 4 mg/kg IM, IV once a isethionate Pentam 300pneumonia (PCP) (IM, IV);headache, metallic taste in day; 300 mg once every pen-tam’-ih-deen  prevention of PCP mouth, chills, severe hypotension,4 wk by nebulizer ice-uh-thigh’-uh-  (inhalation)leukopenia, hypoglycemia, nate  thrombocytopeniaspectinomycin TrobicinGonorrheaSoreness at injection site,2 g IM as single dose; up spek-tin-oe-mye’-cin  urticaria, dizziness, rash, to 4 g IMchills, fever, hypersensitivity reactionsvancomycin Vancocin, Serious susceptible gram-Nephrotoxicity, ototoxicity, 500 mg to 2 g/d PO in van-koe-mye’-cin  Vancoled, positive infections notnausea, chills, fever, urticaria,divided doses; 500 mg generic  responding to treatment sudden fall in blood pressure, IV q6h or 1 g IV q8—12hwith other antibioticsredness on face, neck, arms, and back *The term generic  indicates the drug is available in generic form. SUMMARY DRUG TABLE MISCELLANEOUS ANTI-INFECTIVES  photosensitivity. Pseudomembranous colitis and throm-bocytopenia are the more serious adverse reactionscaused by linezolid. CONTRAINDICATIONS, PRECAUTIONS,AND INTERACTIONS   The drug is contraindicated in the presence of an allergyto the drug, pregnancy (Category C), lactation, andphenylketonuria (oral form only). Linezolid is used cau-tiously in patients with bone marrow depression,hepatic dysfunction, renal impairment, hypertension,and hyperthyroidism.When linezolid is used with antiplatelet drugs such asaspirin or the NSAIDs (see Chap. 18) there is anincreased risk of bleeding and thrombocytopenia. Whenadministered with the MAOIs (see Chap. 31) the effectsof the MAOIs are decreased. There is a risk of severehypertension if linezolid is combined with large amountsof food containing tyramine (eg, aged cheese, caffeinatedbeverages, yogurt, chocolate, red wine, beer, pepperoni). MEROPENEMACTION AND USES  Meropenem (Merrem IV) inhibits synthesis of the bacter-ial cell wall and causes the death of susceptible cells. Thisdrug is used for intra-abdominal infections caused by Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneu- moniae, and other susceptible organisms. Meropenem alsois effective against bacterial meningitis caused by Neisseria meningitidis, Streptococcus pneumoniae, and Hemophilus influenzae. ADVERSE REACTIONS   The most common adverse reactions with meropeneminclude headache, nausea, vomiting, diarrhea, anorexia,abdominal pain, generalized pain, flatulence, rash, andsuperinfections. This drug also can cause an abscess orphlebitis at the injection site. An abscess is suspected if theinjection site appears red or is tender and warm to thetouch. Tissue sloughing at the injection site also may occur. CONTRAINDICATIONS, PRECAUTIONS,AND INTERACTIONS  Meropenem is contraindicated in patients who areallergic to cephalosporins and penicillins and in patientswith renal failure. This drug is not recommended in children younger than 3 months or for women dur-ing pregnancy (Category B) or lactation. Meropenem isused cautiously in patients with central nervous sys-tem (CNS) disorders, seizure disorders, and in patientswith renal or hepatic failure. When administered withprobenecid, the excretion of meropenem is inhibited. METRONIDAZOLEACTIONS AND USES   The mode of action of metronidazole (Flagyl) is not wellunderstood, but it is thought to disrupt DNA and proteinsynthesis in susceptible organisms. This drug may beused in the treatment of serious infections, such as intra-abdominal, bone, soft tissue, lower respiratory, gyneco-logic, and CNS infections caused by susceptible anaero-bic (able to live without oxygen) microorganisms. ADVERSE REACTIONS   The most common adverse reactions seen with thisdrug are related to the gastrointestinal tract and mayinclude nausea, anorexia, and occasionally vomitingand diarrhea. The most serious adverse reactions areassociated with the CNS and include seizures andnumbness of the extremities. Hypersensitivity reactionsalso may be seen. Thrombophlebitis may occur withintravenous (IV) use of the drug. CONTRAINDICATIONS,PRECAUTIONS, AND INTERACTIONS   This drug is contraindicated in patients with knownhypersensitivity to the drug and during the first trimesterof pregnancy (Category B). This drug is used cautiouslyin patients with blood dyscrasias, seizure disorders, andhepatic dysfunction. Safety in children (other than orallyfor amebiasis) has not been established. The metabolism of metronidazole may decrease whenadministered with cimetidine. When administered withphenobarbital, the effectiveness of metronidazole maydecrease. When metronidazole is administered with war-farin, the effectiveness of the warfarin is increased. PENTAMIDINE ISETHIONATEACTIONS AND USES  Pentamidine isethionate (Pentam 300, the parenteralform; NebuPent, the aerosol form) is used in the treat-ment (parenteral form) or prevention (aerosol form) of  102 UNIT II   Anti-infectives   Pneumocystis carinii  pneumonia, a pneumonia seen inthose with acquired immunodeficiency syndrome. Themode of action of this drug is not fully understood. ADVERSE REACTIONS  More than half of the patients receiving this drug by theparenteral route experience some adverse reaction.Severe and sometimes life-threatening reactions includeleukopenia (low white blood cell count), hypoglycemia (low blood sugar), thrombocytopenia (low plateletcount), and hypotension (low blood pressure).Moderate or less severe reactions include changes insome laboratory tests, such as the serum creatinine andliver function tests. Other adverse reactions include anx-iety, headache, hypotension, chills, nausea, and anorexia.Aerosol administration may result in fatigue, a metallictaste in the mouth, shortness of breath, and anorexia. CONTRAINDICATIONS, PRECAUTIONS,AND INTERACTIONS   This drug is contraindicated in individuals who havehad previous hypersensitivity reactions to pentamidineisethionate. Pentamidine isethionate is used cautiouslyin patients with hypertension, hypotension, hyper-glycemia, renal impairment, diabetes mellitus, liverimpairment, bone marrow depression, pregnancy(Category C), or lactation.An additive nephrotoxicity develops when pentami-dine isethionate is administered with other nephrotoxicdrugs (eg, aminoglycosides, vancomycin, or amphotericinB). An additive bone marrow depression occurs when thedrug is administered with antineoplastic drugs or whenthe patient has received radiation therapy recently. SPECTINOMYCINACTIONS AND USES  Spectinomycin (Trobicin) is chemically related to butdifferent from the aminoglycosides (see Chap. 10). Thisdrug exerts its action by interfering with bacterial pro-tein synthesis. Spectinomycin is used for the treatmentof gonorrhea. ADVERSE REACTIONS  Soreness at the injection site, urticaria, dizziness, rash,chills, fever, and hypersensitivity reactions may be seenwith the administration of this drug. CONTRAINDICATIONS, PRECAUTIONS,AND INTERACTIONS   This drug is contraindicated in known cases of hyper-sensitivity to spectinomycin. In addition, the drugshould not be given to infants. If another sexually trans-mitted disease is present with gonorrhea, additionalanti-infectives may be needed to eradicate the infectiousprocesses. Safe use during pregnancy (Category B) orlactation or in children has not been established.No known significant drug or food interactions forspectinomycin are known. VANCOMYCINACTIONS AND USES  Vancomycin (Vancocin) acts against susceptible gram-pos-itive bacteria by inhibiting bacterial cell wall synthesis andincreasing cell wall permeability. This drug is used in thetreatment of serious gram-positive infections that do notrespond to treatment with other anti-infectives. It alsomay be used in treating anti-infective–associated pseudo-membranous colitis caused by Clostridium difficile. ADVERSE REACTIONS  Nephrotoxicity (damage to the kidneys) and ototoxicity(damage to the organs of hearing) may be seen with theadministration of this drug. Additional adverse reactionsinclude nausea, chills, fever, urticaria, sudden fall in bloodpressure with parenteral administration, and skin rashes. CONTRAINDICATIONS, PRECAUTIONS,AND INTERACTIONS   This drug is contraindicated in patients with knownhypersensitivity to vancomycin. Vancomycin is usedcautiously in patients with renal or hearing impairmentand during pregnancy (Category C) and lactation.When administered with other ototoxic and nephro-toxic drugs, additive effects may be seen.  The Patient Receiving a Miscellaneous Anti-infective ASSESSMENT Preadministration Assessment  Before administering these drugs, the nurse takes andrecords the patient’s vital signs and identifies and records NURSING PROCESS CHAPTER 11   Miscellaneous Anti-infectives  103  the symptoms of the infection. It is very important to takea thorough allergy history, especially a history of drugallergies. When culture and sensitivity tests are ordered,these procedures must be performed before the first doseof the drug is given. Other laboratory tests such as renaland hepatic function tests, complete blood count, and uri-nalysis also may be ordered before and during drug ther-apy for early detection of toxic reactions. Ongoing Assessment   The nurse should monitor the patient’s vital signs every4 hours or as ordered by the primary health care provider.It is important to notify the primary health care providerif there are changes in the vital signs, such as a significantdrop in blood pressure, an increase in the pulse or respi-ratory rate, or a sudden increase in temperature. The nurse observes the patient at frequent intervals,especially during the first 48 hours of therapy. It is impor-tant to report any adverse reaction to the primary healthcare provider before the next dose of the drug is due. NURSING DIAGNOSES Drug-specific nursing diagnoses are highlighted in theNursing Diagnoses Checklist. Other nursing diagnosesapplicable to these drugs are discussed in Chapter 4. PLANNING  The expected outcomes for the patient depend on thereason for administration of the anti-infective but mayinclude an optimal response to drug therapy, manage-ment of adverse drug reactions, a decrease in anxiety,and an understanding of and compliance with the pre-scribed drug regimen. IMPLEMENTATION Promoting an Optimal Response to Therapy  Monitoring each patient for response to drug therapyand for the appearance of adverse reactions is an inte-gral part of promoting an optimal response to therapy. The nurse immediately reports serious adverse reac-tions, such as signs and symptoms of a hypersensitivityreaction or superinfection, respiratory difficulty, or amarked drop in blood pressure. INTRAMUSCULAR ADMINISTRATION.  To promote anoptimal response to therapy when giving these drugsintramuscularly (IM), the nurse inspects previous injec-tion sites for signs of pain or tenderness, redness, andswelling. In addition, the nurse reports any persistentlocal reaction to the primary health care provider. It alsois important to develop a plan for rotation of injectionsites and to record the site used after each injection. INTRAVENOUS ADMINISTRATION. When giving thesedrugs IV, the nurse inspects the needle site and areaaround the needle at frequent intervals for signs of extravasation of the IV fluid. More frequent assessmentsare performed if the patient is restless or uncooperative. The rate of infusion is checked every 15 minutes andadjusted as needed. This is especially important whenadministering vancomycin because rapid infusion of thedrug can result in severe hypotension and shock. Thenurse inspects the vein used for the IV infusion every 4to 8 hours for signs of tenderness, pain, and redness(which may indicate phlebitis or thrombophlebitis). If these symptoms are apparent, the nurse restarts the IVin another vein and brings the problem to the attentionof the primary health care provider. SPECIAL CONSIDERATIONS FOR SPECIFIC DRUGS.  Topromote an optimal response to therapy, the nurseshould know the following special considerations forspecific drugs. Chloramphenicol. When the drug is given orally, the nursegives it to the patient whose stomach is empty, 1 hourbefore or 2 hours after meals. If gastrointestinal distressoccurs, it is acceptable to give the drug with food.Chloramphenicol is also given IV. The drug should beadministered around the clock to maintain therapeuticblood levels of the drug. 104 UNIT II   Anti-infectives  ❊ Nursing Alert The blood dyscrasias may occur with the administration of chloramphenicol during either short- or long-term therapy.The nurse observes patients closely for signs and symptoms that may indicate a blood dyscrasia—fever, sore throat, sores in the mouth, easy bruising or bleeding (even several weeks after the drug regimen is completed) and extreme fatigue.It is important to monitor closely serum blood levels of chloramphenicol, particularly in patients with impaired liver or kidney function or when administering chloramphenicol with other drugs metabolized by the liver. Blood concentra- tion levels exceeding 25 mcg/mL increase the risk of the patient developing bone marrow depression. Nursing Diagnoses Checklist  Anxiety related to infection, seriousness of illness, route ofadministration, other factors (specify)  Diarrhea related to adverse drug reaction, superinfection  Pain related to intramuscular injection  Risk for Disturbed Sensory Perception:Auditory relatedto adverse drug effects (ototoxicity)  Risk for Impaired Urinary Elimination related to adversedrug effects (nephrotoxicity) Linezolid.  The drug is given orally or intravenously (IV).When the drug is taken orally, it is administered every12hours and may be taken with or without food. If nausea develops, the drug may be taken with food. Foods
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