I.

INTRODUCTION Background of the Study Osteomyelitis is a severe pyogenic infection of the bone and surrounding tissues that requires immediate treatment. Though the bone is affected site, normally root cause of such infection is not injuries caused to bone. Most often the infection is originated from some other body parts and is spread to bone through blood stream. If the bone has undergone trauma recently, such bone becomes predisposed to the infection. It is a bone inflammation caused by bacteria. Generally there are three routes where a bacterium enters the body such as in the bloodstream or hematogenous spread, adjacent soft tissue infection or contiguous focus and direct introduction of microorganisms. Chronic Osteomyelitis occurs due to loss of blood supply to bone. Such loss of blood supply is caused when bone tissues dies. As is suggestive from the nomenclature chronic (which means prolonged), the Osteomyelitis conditions persists for many years. People with diabetes, hemodialysis, people who have suffered trauma recently and people who abuse IV drugs are considered on higher risk of developing chronic Osteomyelitis. Fortunately, it is a rare health condition. According to the available statistics, one person among 5000 people gets affected with Osteomyelitis. Osteomyelitis is the medical term for an infection in a bone. Infections can reach a bone by traveling through your bloodstream or spreading from nearby tissue. Infections can also begin in the bone itself if trauma exposes your bone to germs. Bone infections commonly affect the long bones of your body, such as your leg bones and upper arm bone, as well as your spine and pelvis. Osteomyelitis often occurs in children as an acute condition. In adults, osteomyelitis may occur as either the acute and chronic form. Once considered incurable, osteomyelitis can be successfully treated today. Still, osteomyelitis is a serious condition, requiring aggressive treatment to prevent spread of your infection and to save the affected bone.

Etiology Osteomyelitis is caused by

Contiguous spread (from infected tissue or an infected prosthetic joint) Blood borne organisms (hematogenous osteomyelitis) Open wounds (from contaminated open fractures or bone surgery
Most common organisms S. aureus, Enterobacter species, and group A and B Streptococcus species S. aureus, group A Streptococcus species, Haemophilus influenzae, and Enterobacter species S. aureus (80%), group A Streptococcus species, H. influenzae, and Enterobacter species S. aureus and occasionally Enterobacter or Streptococcus species Salmonella species

Age group Newborns (younger than 4 mo) Children (aged 4 mo to 4 y) Children, adolescents (aged 4 y to adult Adult Sickle Cell Anemia Patients

CLINICAL MANIFESTATIONS Signs and symptoms of osteomyelitis depend on whether the condition is acute, lasting several months or less, or chronic, lasting several months to years. Signs and symptoms of acute osteomyelitis include: Fever that may be abrupt Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection

Signs and symptoms of chronic osteomyelitis include: Warmth, swelling and redness over the area of the infection Pain or tenderness in the affected area

Chronic fatigue Drainage from an open wound near the area of the infection Fever, sometimes Sometimes osteomyelitis causes no signs and symptoms or has signs and

symptoms that are difficult to distinguish from other problems. For instance, osteomyelitis of the hip, spine or pelvis may have few signs and symptoms. Osteomyelitis that occurs after a broken bone (fracture) or deep wound may cause pain and swelling that you may attribute to your injury, not an infection. RISK FACTORS An increased risk of infections

Certain situations allow germs more opportunities to access your body, putting you at an increased risk of infection, which can lead to osteomyelitis. Examples include people who illegally inject drugs, people on dialysis, people who use urinary catheters and people who have had tubes placed in their bodies to give doctors easier access to major veins (central lines) Poor circulation

People with poor circulation include those with diabetes, peripheral arterial disease and sickle cell disease. When the arteries are damaged or blocked, your body has difficulty distributing the infection-fighting cells needed to keep a small infection from growing larger. A recent injury

A broken bone that breaks the skin or a deep puncture wound exposes your body to germs that can cause infection and increase your risk of osteomyelitis. Carefully follow your doctors instructions on taking antibiotics and taking precautions to prevent infection. Orthopedic surgery

Surgery to repair broken bones or replace worn joints puts you at risk of infection. Follow your surgeon's instructions to help avoid infection after your surgery. PATHOPHYSIOLOGY Osteomyelitis may be localized or it may spread through the periosteum, cortex, marrow, and cancellous tissue. The bacterial pathogen varies on the basis of the patient's age and the mechanism of infection. The following are the 2 primary categories of acute osteomyelitis: hematogenous osteomyelitis and direct or contiguous inoculation osteomyelitis. Hematogenous osteomyelitis is an infection caused by bacterial seeding from the blood. Acute hematogenous osteomyelitis is characterized by an acute infection of the bone caused by the seeding of the bacteria within the bone from a remote source. This condition primarily occurs in children. The most common site is the rapidly growing and highly vascular metaphysis of growing bones. The apparent slowing or sludging of blood flow as the vessels make sharp angles at the distal metaphysis predisposes the vessels to thrombosis and the bone itself to localized necrosis and bacterial seeding. Vertebral osteomyelitis at any age is most often a secondary complication of a remote infection with hematogenous seeding. In approximately one half of vertebral osteomyelitis cases, a source can be identified such as urinary tract or skin, and approximately one third may be diagnosed with endocarditis.1 Acute hematogenous osteomyelitis, despite its name, may have a slow clinical development and insidious onset. Direct or contiguous inoculation osteomyelitis is caused by direct contact of the tissue and bacteria during trauma or surgery. Direct inoculation (contiguous-focus) osteomyelitis is an infection in the bone secondary to the inoculation of organisms from direct trauma, spread from a contiguous focus of infection, or sepsis after a surgical procedure. Clinical manifestations of direct inoculation osteomyelitis are more localized than those of hematogenous osteomyelitis and tend to involve multiple organisms.

Additional categories include chronic osteomyelitis and osteomyelitis secondary to peripheral vascular disease. Chronic osteomyelitis persists or recurs, regardless of its initial cause and/or mechanism and despite aggressive intervention. Although listed as an etiology, peripheral vascular disease is actually a predisposing factor rather than a true cause of infection. Disease states known to predispose patients to osteomyelitis include diabetes mellitus, sickle cell disease, acquired immune deficiency syndrome (AIDS), intravenous (IV) drug abuse, alcoholism, chronic steroid use, immune suppression, and chronic joint disease. In addition, the presence of a prosthetic orthopedic device is an independent risk factor, as is any recent orthopedic surgery or open fracture. DIAGNOSTIC PROCEDURES

ESR or C-reactive protein X-rays, MRI, or radio isotopic bone scanning Culture of bone, abscess, or both

MEDICAL MANAGEMENT Medical management for clients with Osteomyelitis are as follows:

Analgesics as prescribed. Antibiotics as prescribes. Dressing changes- use sterile technique. Maintain proper body alignment and change position frequently to prevent deformities Immobilization of affected part Incision ad Drainage of bone abscess. Sequestrectomy- removal of dead, infected bone and cartilage. Bone grafting is recommended after repeated infections

Surgery if needed:

II.ANATOMY AND PHYSIOLOGY Human musculoskeletal system

A musculoskeletal system (also known as the locomotors system) is an organ system that gives animals (including humans) the ability to move using the muscular and skeletal systems. The musculoskeletal system provides form, support, stability, and movement to the body. It is made up of the body's bones (the skeleton), muscles, cartilage, tendons, ligaments, joints, and other tissue that supports and binds tissues and organs together). The musculoskeletal system's primary functions include supporting the body, allowing motion, and protecting vital organs. The skeletal portion of the system serves as the main storage system for calcium and phosphorus and contains critical components of the hematopoietic system. This system describes how bones are connected to other bones and muscle fibers via connective tissue such as tendons and ligaments. The bones provide the stability to a body in analogy to iron rods in concrete construction. Muscles keep bones in place and also play a role in movement of the bones. To allow motion, different bones are connected by joints. Cartilage prevents the bone ends from rubbing directly on to each other. Muscles contract (bunch up) to move the bone attached at the joint.

The Skeletal System serves many important functions; it provides the shape and form for our bodies in addition to supporting, protecting, allowing bodily movement, producing blood for the body, and storing minerals. The number of bones in the human skeletal system is a controversial topic. Humans are born with about 300 to 350 bones; however, many bones fuse together between birth and maturity. As a result an average adult skeleton consists of 206 bones. The number of bones varies according to the method used to derive the count. While some consider certain structures to be a single bone with multiple parts, others may see it as a single part with multiple bones. There are five general classifications of bones. These are Long bones, Short bones, Flat bones, Irregular bones, and Sesamoid bones. The human skeleton is composed of both fused and individual bones supported by ligaments, tendons, muscles and cartilage. It is a complex structure with two distinct divisions. These are the axial skeleton and the appendicular skeleton. The Skeletal System serves as a framework for tissues and organs to attach themselves to. This system acts as a protective structure for vital organs. Major examples of this are the brain being protected by the skull and the lungs being protected by the rib cage. Located in long bones are two distinctions of bone marrow (yellow and red). The yellow marrow has fatty connective tissue and is found in the marrow cavity. During starvation, the body uses the fat in yellow marrow for energy. The red marrow of some bones is an important site for blood cell production, approximately 2.6 million red blood cells per second in order to replace existing cells that have been destroyed by the liver. Here all erythrocytes, platelets, and most leukocytes form in adults. From the red marrow, erythrocytes, platelets, and leukocytes migrate to the blood to do their special tasks. Another function of bones is the storage of certain minerals. Calcium and phosphorus are among the main minerals being stored. The importance of this storage "device" helps to regulate mineral balance in the bloodstream. When the fluctuation of minerals is high, these minerals are stored in bone; when it is low it will be withdrawn from the bone.

Functions: 1. BONE Bones have eleven main functions: Mechanical

1. Protection Bones can serve to protect internal organs, such as the skull

protecting the brain or the ribs protecting the heart and lungs. 2. Shape Bones provide a frame to keep the body supported.
3. Movement Bones, skeletal muscles, tendons, ligaments and joints function

together to generate and transfer forces so that individual body parts or the whole body can be manipulated in three-dimensional space. The interaction between bone and muscle is studied in biomechanics. Synthetic
1. Blood production The marrow, located within the medullary cavity of long

bones and interstices of cancellous bone, produces blood cells in a process called haematopoiesis. Metabolic
2. Mineral storage Bones act as reserves of minerals important for the body, most

notably calcium and phosphorus.

3. Growth factor storage Mineralized bone matrix stores important growth factors

such as insulin-like growth factors, transforming growth factor, bone morphogenetic proteins and others. 4. Fat Storage The yellow bone marrow acts as a storage reserve of fatty acids
5. Acid-base balance Bone buffers the blood against excessive pH changes by

absorbing or releasing alkaline salts.

6. Detoxification Bone tissues can also store heavy and other foreign elements,

removing them from the blood and reducing their effects on other tissues. These can later be gradually released for excretion. 7. Endocrine organ - Bone controls phosphate metabolism by releasing fibroblast growth factor - 23(FGF-23), which acts on kidney to reduce phosphate reabsorption CATEGORIES OF BONE

Short bones are roughly cube-shaped, and have only a thin layer of compact bone surrounding a spongy interior. The bones of the wrist and ankle are short bones, as are the sesamoid bones.

Flat bones are thin, flattened and generally curved; Most of the bones of the skull are flat bones, as is the sternum.

Irregular bones as implied by the name, their shapes are irregular and complicated. The bones of the spine and hips are irregular bones.

Long bones are characterized by a shaft, the diaphysis that is much greater in length than width. Most bones of the limbs, including those of the fingers and toes, are long bones.

STRUCTURE OF THE LONG BONE

The diaphysis, or shaft, is the long tubular portion of long bones. It is composed of compact bone tissue.

The epiphysis (plural, epiphyses) is the expanded end of a long bone. The metaph ys i s is the area w here the diaphys is mee ts the epiph ys is . It includes the epiphyseal line, a remnant of cartilage from growing bones.

The medullary cavity, or marrow cavity, is the open area within the diaphysis. The adipose tissue inside the cavity stores lipids and forms the yellow marrow.

Articular cartilage covers the epiphysis where joints occur. The periosteum is the membrane covering the outside of the diaphysis (and epiphyses where articular cartilage is absent). It contains osteoblasts (bone-forming cells), osteoclasts(bo ne- des tr oyin g cel ls ) , ner ve fibers , and blood and lymph at ic ve ss els . Lig ame nts an d tendons attach to the periosteum.

The endosteum is the membrane that lines the marrow cavity.

TYPES OF BONES

Compact bone or (Cortical bone) The hard outer layer of bones is composed of compact tissue, so-called due to its

minimal gaps and spaces. This tissue gives bones their smooth, white, and solid appearance, and accounts for 80%of the total bone mass of an adult skeleton. Compact bone may also be referred to as dense bone.

Trabecular bone Filling the interior of the organ is the bone tissue (an open cell porous

network also called cancellous or spongy bone), which is composed of a network of rod- and plate-like elements that make the overall organ lighter and allowing

room for blood vessels and marrow. Trabecular bone accounts for the remaining 20% of total bone mass but has nearly ten times the surface area of compact bone.

2. Joints Human synovial joint composition Joints are structures that connect individual bones and may allow bones to move against each other to cause movement. There are two divisions of joints, diarthroses which allow extensive mobility between two or more articular heads, and false joints orsynarthroses, joints that are immovable, that allow little or no movement and are predominantly fibrous. Synovial joints, joints that are not directly joined, are lubricated by a solution called synovia that is produced by the synovial membranes. This fluid lowers the friction between the articular surfaces and is kept within an articular capsule, binding the joint with its taut tissue. 3. Tendons A tendon is a tough, flexible band of fibrous that connects muscles to bones. Muscles gradually become tendon as the cells become closer to the origins and insertions on bones, eventually becoming solid bands of tendon that merge into the periosteum of individual bones. As muscles contract, tendons transmit the forces to the rigid bones, pulling on them and causing movement. 4. Ligaments A ligaments a small band of dense, white, fibrous elastic tissue. Ligaments connect the ends of bones together in order to form a joint. Most ligaments limit dislocation, or prevent certain movements that may cause breaks. Since they are only

elastic they increasingly lengthen when under pressure. When this occurs the ligament may be susceptible to break resulting in an unstable joint. Ligaments may also restrict some actions: movements such as hyperextension and hyper flexion are restricted by ligaments to an extent. Also ligaments prevent certain directional movement. Lower Limb The thigh, leg, and foot constitute the lower limb. The bones of the lower limbs are considerably larger and stronger than comparable bones of the upper limbs because the lower limbs must support the entire weight of the body while walking, running, or jumping. Illustrates features of the 30 bones of each lower limb.

III. PATHOPHYSIOLOGY Predisposing factors: vascular insufficiency disorders genitourinary infections respiratory infections IV drug use Immuno compromising diseases history of blood- stream infections Indwelling prosthetic devices Injury/ Trauma Invasion of pathogenic microorganism (staphylococcus aureus) Bacteria lodge in adjacent tissues Increase WBC and enters the affected area Bacteria release enzyme Leukocidins WBC engulf dead cell Pus formation Pus will spread in the bones and blood vessel impairing blood flow Hematoma Increase pressure Vascular compromise of the periosteum Infection through the bone cortex and marrow Cortical devascurization Necrosis Medullar cavity periosteum soft tissues and joints Pus (pain,swelling, redness and blisters Sequestrum form pain swelling

IV. DIAGNOSTIC PROCEDURES The following studies are indicated in patients with osteomyelitis:

CBC count: The WBC count may be elevated, but it is frequently normal.
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A leftward shift is common with increased polymorphonuclear leukocyte counts. The C-reactive protein level is usually elevated and nonspecific; this study may be more useful than the erythrocyte sedimentation rate (ESR) because it reveals elevation earlier. The ESR is usually elevated (90%); however, this finding is clinically nonspecific. CRP and ESR have limited roles in the setting of chronic osteomyelitis and are often normal

Culture: Superficial wound or sinus tract cultures often do not correlate with the bacterium that is causing osteomyelitis and have limited use. Blood culture results are positive in approximately 50% of patients with hematogenous osteomyelitis. However, a positive blood culture may preclude the need for further invasive procedures to isolate the organism. Bone cultures from biopsy or aspiration have a diagnostic yield of approximately 77% across all studies.

Imaging Studies

Radiography
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Radiographic evidence of acute osteomyelitis is first suggested by overlying soft-tissue edema at 3-5 days after infection. Examples of radiographic evidence of osteomyelitis are presented in the images below. Bony changes are not evident for 14-21 days and initially manifest as periosteal elevation followed by cortical or medullary lucencies. By 28 days, 90% of patients demonstrate some abnormality. Approximately 40-50% focal bone loss is necessary to cause detectable lucency on plain films.

MRI
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The MRI is effective in the early detection and surgical localization of osteomyelitis. Studies have shown its superiority compared with plain radiography, CT, and radionuclide scanning and is considered to be the imaging of choice. Sensitivity ranges from 90-100%.

Positron emission tomographic (PET) scanning has accuracy similar to MRI. Radionuclide bone scanning
o

Three phase bone scan, gallium scan and tagged WBC scan are considerations in patients who are unable to have MRI imaging. A three phase bone scan has high sensitivity and specificity in adults with normal findings on radiograph. Specificity is dramatically decreased in the setting of previous surgery or traumatized bone. In special circumstances, additional information can be obtained from further scanning with leukocytes labeled with gallium 67 and/or indium 111.

CT scanning
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CT scans can depict abnormal calcification, ossification, and intracortical abnormalities. It is not recommended for routine use for diagnosing osteomyelitis but is often the imaging of choice when MRI is not available

Ultrasonography
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This simple and inexpensive technique has shown promise, particularly in children with acute osteomyelitis. Ultrasonography may demonstrate changes as early as 1-2 days after onset of symptoms. Abnormalities include soft tissue abscess or fluid collection and periosteal elevation. Ultrasonography allows for ultrasound-guided aspiration. It does not allow for evaluation of bone cortex.

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V. MEDICAL MANAGEMENT PHARMACOLOGIC THERAPY The primary treatment for osteomyelitis is parenteral antibiotics that penetrate bone and joint cavities. Treatment is required for at least 4-6 weeks. After intravenous antibiotics are initiated on an inpatient basis, therapy may be continued with intravenous or oral antibiotics, depending on the type and location of the infection, on an outpatient basis. The following are recommendations for the initiation of empiric antibiotic treatment based on the age of the patient and mechanism of infection:

With hematogenous osteomyelitis (newborn to adult), the infectious agents include S aureus, Enterobacteriaceae organisms, group A and B Streptococcus species, and H influenzae. Primary treatment is a combination of penicillinaseresistant synthetic penicillin and a third-generation cephalosporin. Alternate therapy is vancomycin or clindamycin and a third-generation cephalosporin, particularly if methicillin-resistant S aureus (MRSA) is considered likely. Linezolid is also used in these circumstances. In addition to these abovementioned antibacterials, ciprofloxacin and rifampin may be an appropriate combination therapy for adult patients. If evidence of infection with gramnegative bacilli is observed, include a third-generation cephalosporin.

In patients with sickle cell anemia and osteomyelitis, the primary bacterial causes are S aureus and Salmonellae species. Thus, the primary choice for treatment is a fluoroquinolone antibiotic (not in children). A third-generation cephalosporin (eg, ceftriaxone) is an alternative choice.

When a nail puncture occurs through an athletic shoe, the infecting agents may include S aureus and Pseudomonas aeruginosa. The primary antibiotics in this scenario include ceftazidime or cefepime. Ciprofloxacin is an alternative treatment.

For patients with osteomyelitis due to trauma, the infecting agents include S aureus, coliform bacilli, and Pseudomonas aeruginosa. Primary antibiotics include

nafcillin and ciprofloxacin. Alternatives include vancomycin and a thirdgeneration cephalosporin with anti pseudomonal activity. SURGICAL MANAGEMENT Surgery Drain the infected area. Opening up the area around your infected bone allows your surgeon to drain any pus or fluid that has accumulated in response to the infection. Remove diseased bone and tissue. In a procedure called debridement, the surgeon removes as much of the diseased bone as possible, taking a small margin of healthy bone to ensure that all the infected areas have been removed. Surrounding tissue that shows signs of infection also may be removed. Restore blood flow to the bone.

Your surgeon may fill any empty space left by the debridement procedure with a piece of bone or other tissue, such as skin or muscle, from another part of your body. Sometimes temporary fillers are placed in the pocket until you're healthy enough to undergo bone graft or tissue graft. The graft helps your body repair damaged blood vessels and form new bone. Remove any foreign objects.

In some cases, foreign objects, such as surgical plates or screws placed during a previous surgery, may need to be removed. Antibiotics Once the bacterium or fungus causing your infection has been identified and you've undergone surgery, if necessary, your doctor selects the antibiotic most likely to be effective in fighting your particular type of infection. Antibiotics are administered most often through a vein in your arm (intravenously) or, in some cases, they can be taken orally. You typically take antibiotics for four to six weeks, or even longer. In some cases, you may need to take antibiotics for the rest of your life. Antibiotics carry a risk of side effects, including nausea, vomiting and diarrhea. Allergic reactions can also occur.

VI. DRUG STUDY

1. Generic Name: Nafcillin

Brand Name: Nafcil, Unipen Classification: Antibiotic Penicillinase- resistant penicillin Mechanism of Action: Bactericidal; Inhibits cell wall synthesis of sensitive organisms, causing cell death Dosage and Frequency: 500- 1000 mg q 4 hours for 14 days Route: IV Adverse Effects: Nausea/ vomiting Diarrhea Rash Fever Wheezing Pain Sore mouth Side Effects: Stomach upset Diarrhea DOB Fatigue Nursing Responsibilities 1. Culture the infection before treatment; re culture if response is not as expected.

2. Continue therapy for at least 2 days after signs of infection have disappeared, at last 14 days. 3. This drug must be given intravenously every 4 hours.

2. Generic Name: Ceftriaxone

Brand Name: Rocephin Classification: Antibiotic Cephalosporin (third generation) Mechanism of Action: Bactericidal; Inhibits cell wall synthesis of sensitive organisms, causing cell death Dosage and Frequency: Adult: 1- 2 g OD Pediatric: 50- 75 mg/kg/day q 12 hours Route: IV IM Adverse Effects: Nausea/ vomiting Diarrhea Abdominal pain Anorexia Flatulence Ranging from rash to fever Pain Side Effects: Stomach upset Fatigue Diarrhea

DOB Nursing Responsibilities 1. Protect drug from light. 2. Do not mix ceftriaxone with any other antimicrobial drug. 3. Monitor ceftriaxone blood levels in patients with severe renal impairment and patients with renal and hepatic impairment. 4. Have Vitamin K available in case hypoprothrombinemia occurs. 5. Discontinue if hypersensitivity occurs.

3. Generic Name: Cefazolin

Brand Name: Ancef Classification: Antibiotic Cephalosporin (first generation) Mechanism of Action: Bactericidal; Inhibits cell wall synthesis of sensitive organisms, causing cell death Dosage and Frequency: Adult: 250- 500 mg q 6- 12 hours Pediatric: 25- 50 mg/kg/day in three or four equally divided doses Route: IV IM Adverse Effects: Nausea/ vomiting Diarrhea Abdominal pain Anorexia Flatulence Ranging from rash to fever Pain

Side Effects: Stomach upset Loss of appetite Nausea Headache Dizziness Diarrhea Nursing Responsibilities 1. Inject IM doses deeply into large muscle group. 2. Solution is stable for 24 hours at room temperature, redissolve by warming to room temperature and agitating slightly 3. Have Vitamin K available in case hypoprothrombinemia occurs.

4. Generic Name: Ciprofloxacin

Brand Name: Cipro Classification: Antibacterial Fluoroquinolone Mechanism of Action: Bactericidal; Interferes with DNA replication in susceptible bacteria preventing cell rep[roduction Dosage and Frequency: Adult: 1g/day in 2- 4 divided doses for 7- 14 days Pediatric: not recommended for children < 12 yrs. old Route: Oral Adverse Effects: Headache Dizziness Nausea

Rash Pruritus Urticaria Perineal burning Side Effects: Nausea/ vomiting Abdominal pain Diarrhea Drowsiness Blurring of vision Dizziness Nursing Responsibilities 1. Do not mix with aminoglycoside solutions. Administer these drugs separately. 2. Powder and reconstituted solution darken with storage. 3. Have Vitamin K available in case hypoprothrombinemia occurs. 4. Discontinue if hypersensitivity occurs.
5. Generic Name: Ceftazidime

Brand Name: Fortaz, Ceptaz Classification: Antibiotic Cephalosporin (third generation) Mechanism of Action: Bactericidal; Inhibits cell wall synthesis of sensitive organisms, causing cell death Dosage and Frequency: Adult: 1g (range 250 mg -2 g) q 8- 12 hours

Pediatric: 0- 4 wks - 30 mg/ kg q 12 hours 1 mo. - 12 yrs- 30- 50 mg/ kg q 8 hours Route: IV IM Adverse Effects: Nausea/ vomiting Diarrhea Abdominal pain Anorexia Flatulence Ranging from rash to fever Pain Side Effects: Stomach upset Diarrhea Nursing Responsibilities 1. Continue therapy for 2 days after sign and symptoms of infection are gone. 2. Ensure that patient is well hydrated. 3. Give antacids at least 2 hours after dosing. 4. Monitor clinical response, if no improvement is seen or a relapse occurs, repeat culture and sensitivity. 5. Encourage patient to complete full course of therapy.

6. Generic Name: Clindamycin

Brand Name: Cleocin Classification: Lincosamide Antibiotic Mechanism of Action: Inhibits protein synthesis in susceptible bacteria causing cell death. Dosage and Frequency: Adult:150- 300 mg q 6 hours up to 300- 450 mg q 6 hours in severe infection Pediatric: 8- 20 mg/ kg/ day in 3 or 4 equal doses Route: Oral Adverse Effects: Hypotension Nausea/ vomiting Diarrhea Esophagitis Anorexia Rashes Pain Abdominal pain Side Effects: Nausea/ vomiting Super infection in the mouth, vagina Nursing Responsibilities 1. Administer oral drug with a full glass of water or with food to prevent esophageal irritation.

2. Do not use for minor bacterial or viral infections. 3. Monitor renal and liver function tests, and blood counts with prolonged therapy. 4. Take full prescribed course of oral drug. Do not stop taking without notifying health care provider. 7. Generic Name: Vancomycin Brand Name: Vancocin Classification: Antibiotic Mechanism of Action: Bactericidal; Inhibits cell wall synthesis of sensitive organisms, causing cell death Dosage and Frequency: Adult: 500 mg q 6 hours or 1 g q 12 hours Pediatric: 10 mg/ kg/ dose q 6 hours Route: IV Adverse Effects: Hypotension Ototoxicity Urticaria Nausea Nephrotoxicity Red neck or red man syndrome Side Effects: Nausea Changes in hearing Super infection in the mouth, vagina

Nursing Responsibilities 1. Observe the patient very closely when giving parenteral solution particularly the first doses, red neck syndrome can occur; slow administration decreases the risk of adverse effects. 2. Culture site of infection before beginning therapy. 3. Monitor renal function tests with prolonged therapy. 4. Evaluation for safe serum level, concentrations of 60- 80 mcg/ ml are toxic.