Anti infective agents

Chapters 37,38,39 & 41

Antibiotics: Definition
Medications used to treat bacterial infections Ideally, before beginning antibiotic therapy, the suspected areas of infection should be cultured to identify the causative organism and potential antibiotic susceptibilities

Antibiotics: Classes

Sulfonamides Penicillins Cephalosporins Tetracyclines Macrolides

Aminoglycosides Quinolones

Figure 37-1 Bacterial morphologies. (From Murray, P.R., Rosenthal, K.S., Kobayashi, G.S., & Pfaller, M.A. (2002). Medical microbiology. St. Louis, MO: Mosby.)

Figure 37-3 Gram-stain morphology of bacteria. The crystal violet of Gram stain is precipitated by Gram iodine and is trapped in the thick peptidoglycan layer in gram-positive bacteria. The decolorizer disperses the gram-negative outer membrane and washes the crystal violet from the thin layer of peptidoglycan. Gram-negative bacteria are visualized by the red counterstain. (From Murray, P.R., Rosenthal, K.S., Kobayashi, G.S., & Pfaller, M.A. (2002). Medical microbiology. St. Louis, MO: Mosby.)

Figure 37-4 Gram-positive and gram-negative bacteria. A gram-positive bacterium has a thick layer of peptidoglycan (left). A gram-negative bacterium has a thin peptidoglycan layer and an outer membrane (right). Structures in parentheses are not found in all bacteria. (From Murray, P.R., Rosenthal, K.S., Kobayashi, G.S., & Pfaller, M.A. (2002). Medical microbiology. St. Louis, MO: Mosby.)

Antibiotic Therapy
Empiric therapy: treatment of an infection before specific culture information has been reported or obtained Prophylactic therapy: treatment with antibiotics to prevent an infection, as in intraabdominal surgery

Antibiotic Therapy (contd)

Therapeutic response
Decrease in specific signs and symptoms of infection are noted (fever, elevated WBC, redness, inflammation, drainage, pain)

Subtherapeutic response
Signs and symptoms of infection do not improve

Antibiotic Therapy (contd)

Four common mechanisms of action Interference with cell wall synthesis Interference with protein synthesis Interference with DNA replication Acting as a metabolite to disrupt critical metabolic reactions inside the bacterial cell

Actions of Antibiotics
Bactericidal: kill bacteria Bacteriostatic: inhibit growth of susceptible bacteria, rather than killing them immediately; will eventually lead to bacterial death

Antibiotics: Sulfonamides
One of the first groups of antibiotics sulfadiazine Sulfamethoxazole (Bactrim) sulfisoxazole

Sulfonamides: Mechanism of Action

Bacteriostatic action Prevent synthesis of folic acid required for synthesis of purines and nucleic acid Do not affect human cells or certain bacteriathey can use preformed folic acid

Sulfonamides: Indications

Treatment of UTIs caused by susceptible strains of:

Enterobacter spp., Escherichia coli, Klebsiella spp., Proteus mirabilis, Proteus vulgaris, Staphylococcus aureus

Nocardiosis Pneumocystis carinii pneumonia (PCP) Upper respiratory tract infections Other uses

Sulfonamides: Combination Products

trimethoprim/sulfamethoxazole
Used to treat UTIs, PCP, otitis media, other conditions

erythromycin/sulfisoxazole
Used to treat otitis media

sulfisoxazole
Used to treat otitis media, UTIs, other conditions

Beta-Lactam Antibiotics
Penicillins Cephalosporins Carbapenems Monobactams

Penicillins
Natural penicillins Penicillinase-resistant penicillins Aminopenicillins Extended-spectrum penicillins

Penicillins (contd)
Natural penicillins

penicillin G, penicillin V potassium

Penicillinase-resistant penicillins

Cloxacillin
amoxicillin, ampicillin, pivamicillin piperacillin sodium

Aminopenicillins

Anti-pseudomonal penicillins

Penicillins (contd)
First introduced in the 1940s Bactericidal: inhibit cell wall synthesis Kill a wide variety of bacteria Also called beta-lactams

Penicillins (contd)
Bacteria produce enzymes capable of destroying penicillins These enzymes are known as beta-lactamases As a result, the medication is not effective

Penicillins (contd)

Chemicals have been developed to inhibit these enzymes:

Clavulanic acid (Clavulin) Tazobactam Sulbactam

These chemicals bind with betalactamase and prevent the enzyme from breaking down the penicillin

Penicillins: Mechanism of Action

Penicillins enter the bacteria via the cell wall Inside the cell they bind to penicillin-binding protein Once bound, normal cell wall synthesis is disrupted Result: bacteria cells die from cell lysis Penicillins do not kill other cells in the body

Penicillins: Indications

Prevention and treatment of infections caused by susceptible bacteria, such as:

Gram-positive bacteria Streptococcus, Enterococcus, Staphylococcus spp.

Penicillins: Adverse Effects

Allergic reactions occur in 0.7% to 8% of cases

Urticaria, pruritus, angioedema

10% of allergic reactions are life threatening 10% of these are fatal

Penicillins: Side Effects

Common side effects

Nausea, vomiting, diarrhea, abdominal pain

Other side effects are less common

Cephalosporins
First generation Second generation Third generation Fourth generation

Cephalosporins (contd)
Semisynthetic derivatives from a fungus Structurally and pharmacologically related to penicillins Bactericidal action Broad spectrum Divided into groups according to their antimicrobial activity

Cephalosporins: First Generation

cephalexin (Keflex) cefazolin (Ancef) cefadroxil(Duricef)

Good

gram-positive coverage Poor gram-negative coverage

Cephalosporins: First Generation (contd)

Used for surgical prophylaxis, URIs, otitis media

cefazoline: IV or PO (Ancef) cephalexin: PO (Keflex)

Cephalosporins: Second Generation

Good gram-positive coverage Better gram-negative coverage than first generation

cefaclor cefprozil cefoxitin cefuroxime cefotetan

Cephalosporins: Second Generation (contd)

cefoxitin: IV and IM
Used prophylactically for abdominal or colorectal surgeries Also kills anaerobes

cefuroxime: PO
Surgical prophylaxis Does not kill anaerobes

Cephalosporins: Third Generation

Most potent group against gram-negative Less active against gram-positive cefixime cefotaxime ceftizoxime ceftriaxone ceftazidime

Cephalosporins: Third Generation (contd)

cefixime

Only oral third-generation agent Best of available oral cephalosporins against gramnegative Tablet and suspension IV and IM, long half-life, once-a-day administration Easily passes meninges and diffused into CSF to treat CNS infections

ceftriaxone

Cephalosporins: Fourth Generation

cefepime
Newest cephalosporin agents Broader spectrum of antibacterial activity than third generation, especially against gram-positive bacteria

Cephalosporins: Side Effects

Similar to penicillins

Macrolides
erythromycin azithromycin clarithromycin

Macrolides: Mechanism of Action

Prevent protein synthesis within bacterial cells Bacteria will eventually die

Macrolides: Indications

Strep infections Streptococcus pyogenes (group A beta-hemolytic streptococci) Mild to moderate URI Haemophilus influenzae Spirochetal infections Syphilis and Lyme disease Gonorrhea, Chlamydia, Mycoplasma

Macrolides: Side Effects

GI effects, primarily with erythromycin

Nausea, vomiting, diarrhea, hepatotoxicity, flatulence, jaundice, anorexia Newer agents, azithromycin and clarithromycin: fewer side effects, longer duration of action, better efficacy, better tissue penetration

Tetracyclines
demeclocycline oxytetracycline tetracycline doxycycline minocycline

Tetracyclines (contd)
Natural and semisynthetic Obtained from cultures of Streptomyces Bacteriostaticinhibit bacterial growth Inhibit protein synthesis Stop many essential functions of the bacteria

Tetracyclines (contd)
Bind to Ca2+ and Mg2+ and Al3+ ions to form insoluble complexes Thus, dairy products, antacids, and iron salts reduce absorption of tetracyclines

Tetracyclines: Indications

Wide spectrum
Gram-negative, gram-positive, protozoa, Mycoplasma, Rickettsia, Chlamydia, syphilis, Lyme disease

demeclocycline is also used to treat SIADH, and pleural and pericardial effusions

Tetracyclines: Side Effects

Strong affinity for calcium

Discoloration of permanent teeth and tooth enamel in fetuses and children May retard fetal skeletal development if taken during pregnancy

Tetracyclines: Side Effects (contd)

Alteration in intestinal flora may result in:

Superinfection (overgrowth of nonsusceptible organisms such as Candida) Diarrhea Pseudomembranous colitis

Tetracyclines: Side Effects (contd)

May also cause:

Vaginal moniliasis Gastric upset Enterocolitis Maculopapular rash

Aminoglycosides
gentamicin neomycin streptomycin tobramycin amikacin

Aminoglycosides (contd)
Natural and semisynthetic Produced from Streptomyces Poor oral absorption; no PO forms Potent antibiotics with serious toxicities Bactericidal; prevents protein synthesis Kill mostly gram-negative; some gram-positive also

Aminoglycosides: Indications
Used to kill gram-negative bacteria such as Pseudomonas spp., E. coli, Proteus spp., Klebsiella spp., Serratia spp. Often used in combination with other antibiotics for synergistic effect

Aminoglycosides: Indications (contd)

All aminoglycosides are poorly absorbed through the GI tract, and given parenterally Exception: neomycin

Given orally to decontaminate the GI tract before surgical procedures Also used as an enema for this purpose

Aminoglycosides: Agents
Three most common (systemic): gentamicin, tobramycin, amikacin Cause serious toxicities

Nephrotoxicity (renal failure) Ototoxicity (auditory impairment and vestibular [eighth cranial nerve])

Must monitor drug levels to prevent toxicities

Aminoglycosides: Side Effects

Ototoxicity and nephrotoxicity are the most significant

Headache Paresthesia Neuromuscular blockade Dizziness Vertigo Skin rash Fever Superinfections

Quinolones
ciprofloxacin norfloxacin ofloxacin levofloxacin gatifloxacin

Quinolones (contd)
Excellent oral absorption Absorption reduced by antacids First oral antibiotics effective against gram-negative bacteria

Quinolones: Mechanism of Action

Bactericidal Effective against gram-negative organisms and some gram-positive organisms Alter DNA of bacteria, causing death Do not affect human DNA

Quinolones: Indications
Lower respiratory tract infections Bone and joint infections Infectious diarrhea Urinary tract infections Skin infections Sexually transmitted diseases Anthrax

Quinolones: Indications
Lower respiratory tract infections Bone and joint infections Infectious diarrhea Urinary tract infections Skin infections Sexually transmitted diseases Anthrax

Quinolones: Side Effects

Body System CNS
restlessness GI

Effects Headache, dizziness, fatigue, depression,

Nausea, vomiting, diarrhea, constipation, thrush, increased liver studies

function

Quinolones: Side Effects (contd)

Body System Integumentary Effects Rash, pruritus, urticaria, flushing, photosensitivity (with lomefloxacin) Fever, chills, blurred vision, tinnitus

Other

Other Antibiotics
clindamycin (MRSA) Metronidazole(anaerobes) nitrofurantoin (uncomplicated UTI)

Other Antibiotics (contd)

vancomycin
Natural, bactericidal antibiotic Destroys cell wall Treatment of choice for MRSA, and other gram-positive infections Must monitor blood levels to ensure therapeutic levels and prevent toxicity May cause ototoxicity and nephrotoxicity

Other Antibiotics (contd)

vancomycin (contd)
Should be infused over 60 minutes Monitor IV site closely Redmans syndrome may occur
Decreased BP, flushing of neck and face Antihistamine may be ordered to reduce these effects

Ensure adequate hydration (2 L fluids/ 24 hr) if not contraindicated to prevent nephrotoxicity

Antibiotics: Nursing Implications

Before beginning therapy, assess drug allergies; hepatic, liver, and cardiac function; and other lab studies Be sure to obtain thorough client health history, including immune status Assess for conditions that may be contraindications to antibiotic use or that may indicate cautious use Assess for potential drug interactions

Nursing Implications
It is recommended to obtain cultures from appropriate sites BEFORE beginning antibiotic therapy

Nursing Implications (contd)

Clients should be instructed to take antibiotics exactly as prescribed and for the length of time prescribed; they should not stop taking the medication early when they feel better Assess for signs and symptoms of superinfection: fever, perineal itching, cough, lethargy, or any unusual discharge

Nursing Implications (contd)

For safety reasons, check the name of the medication carefully because there are many agents that sound alike or have similar spellings

Nursing Implications (contd)

Each class of antibiotics has specific side effects and drug interactions that must be carefully assessed and monitored The most common side effects of antibiotics are nausea, vomiting, and diarrhea All oral antibiotics are absorbed better if taken with at least 180 to 240 mL of water

Nursing Implications (contd)

Each class of antibiotics has specific side effects and drug interactions that must be carefully assessed and monitored The most common side effects of antibiotics are nausea, vomiting, and diarrhea All oral antibiotics are absorbed better if taken with at least 180 to 240 mL of water

Nursing Implications (contd)

Each class of antibiotics has specific side effects and drug interactions that must be carefully assessed and monitored The most common side effects of antibiotics are nausea, vomiting, and diarrhea All oral antibiotics are absorbed better if taken with at least 180 to 240 mL of water

Nursing Implications (contd)

Sulfonamides

Should be taken with at least 2000 mL of fluid per day, unless contraindicated Due to photosensitivity, avoid sunlight and tanning beds These agents reduce the effectiveness of oral contraceptives Oral forms should be taken with food or milk to reduce GI upset

Nursing Implications (contd)

Penicillins

Any client taking a penicillin should be carefully monitored for an allergic reaction for at least 30 minutes after its administration The effectiveness of oral penicillins is decreased when taken with caffeine, citrus fruit, cola beverages, fruit juices, or tomato juice

Nursing Implications (contd)

Cephalosporins

Orally administered forms should be given with food to decrease GI upset, even though this will delay absorption Some of these agents may cause a disulfiramlike reaction when taken with alcohol

Nursing Implications (contd)

Macrolides

These agents are highly protein-bound and will cause severe interactions with other protein-bound drugs The absorption of oral erythromycin is enhanced when taken on an empty stomach, but because of the high incidence of GI upset, many agents are taken after a meal or snack

Nursing Implications (contd)

Tetracyclines

Milk products, iron preparations, antacids, and other dairy products should be avoided because of the chelation and drug-binding that occurs All medications should be taken with 180 to 240 mL of fluid, preferably water Due to photosensitivity, avoid sunlight and tanning beds

Nursing Implications (contd)

Aminoglycosides

Monitor peak and trough blood levels of these agents to prevent nephrotoxicity and ototoxicity Symptoms of ototoxicity include dizziness, tinnitus, and hearing loss Symptoms of nephrotoxicity include urinary casts, proteinuria, and increased BUN and serum creatinine levels

Nursing Implications (contd)

Quinolones

Should be taken with at least 3 L of fluid per day, unless otherwise specified Intake of alkaline foods and drugs, such as antacids, dairy products, peanuts, and sodium bicarbonate should be limited

Understanding Viruses
Viral replication

A virus cannot replicate on its own It must attach to and enter a host cell It then uses the host cells energy to synthesize protein, DNA, and RNA

Figure 38-1 Virus replication. Some viruses integrate into host chromosomes with development of latency. (Modified from Brody, T.M., Larner, J., & Minneman, K.P. (1998). Human pharmacology: molecular to clinical (3rd ed.). St. Louis, MO: Mosby.)

Understanding Viruses (contd)

Viruses are difficult to kill because they live inside human cells Any drug that kills a virus may also kill human cells

Viral Infections
Competent immune system: Best response to viral infections A well-functioning immune system will eliminate or effectively destroy virus replication

Viral Infections (contd)

Immunocompromised clients have frequent viral infections

Cancer clients, especially leukemia or lymphoma Transplant clients, due to pharmacological therapy AIDS clients, disease attacks immune system

Antivirals
Viruses killed by current antiviral therapy Cytomegalovirus (CMV) Hepatitis viruses Herpes viruses Human immunodeficiency virus (HIV) Influenza viruses (the flu) Respiratory syncytial virus (RSV)

Antivirals (contd)
Key characteristics of antiviral drugs Able to enter the cells infected with virus Interfere with viral nucleic acid synthesis and/or regulation Some agents interfere with ability of virus to bind to cells Some agents stimulate the bodys immune system

Antiviral Medications

Antiviral agents
Used to treat infections caused by viruses other than HIV

Antiretroviral agents
Used to treat infections caused by HIV, the virus that causes AIDS

Antiviral Agents: Nonretroviral

Mechanism of action
Inhibit viral replication

Used to treat non-HIV viral infections

Influenza viruses HSV, VZV (another herpes virus) CMV Hepatitis A, B, C (HAV, HBV, HCV)

HIV

Human immunodeficiency virus infection ELISA (enzyme-linked immunosorbent assay)

Detects HIV exposure based on presence of human antibodies to the virus in the blood

Retrovirus Transmitted by:

Sexual activity, intravenous drug use, perinatally from mother to child

Natural History of HIV Infection

Primary acute infection Asymptomatic infection Early symptomatic infection Advanced immunodeficiency with opportunistic complications

Opportunistic Infections

Protozoal
Toxoplasmosis of the brain, others

Fungal
Candidiasis of the lungs, esophagus, trachea PCP, others

Viral
CMV disease, HSV infection, others

Opportunistic Infections (contd)

Bacterial
Various mycobacterial infections, others

Opportunistic neoplasias
Kaposis sarcoma, others

Others

Antiretroviral Agents (contd)

Reverse transcriptase inhibitors (RTIs)

Block activity of the enzyme reverse transcriptase, preventing production of new viral DNA

Protease inhibitors (PIs)

Inhibit the protease retroviral enzyme, preventing viral replication

Fusion inhibitors
Inhibit viral fusion, preventing viral replication

Antiretroviral Agents: Side Effects

Numerous and vary with each agent Drug therapy may need to be modified because of side effects Goal is to find the regimen that will best control the infection with a tolerable side effect profile Medication regimens change during the course of the illness

Antivirals: Nursing Implications

Before beginning therapy, thoroughly assess underlying disease and medical history, including allergies Assess baseline VS and nutritional status Assess for contraindications, conditions that may indicate cautious use, and potential drug interactions

Nursing Implications

Be sure to teach proper application technique for ointments, aerosol powders, etc. Emphasize handwashing before and after administration of medications to prevent site contamination and spread of infection Clients should wear a glove or finger cot when applying ointments or solutions to affected areas

Nursing Implications (contd)

Instruct clients to consult their physician before taking any other medication, including OTCs Emphasize the importance of good hygiene Inform clients that antiviral agents are not cures but do help to manage symptoms

Nursing Implications (contd)

Instruct clients on the importance of taking these medications exactly as prescribed and for the full course of treatment Monitor for side effects

Effects are varied and specific to each agent

Nursing Implications (contd)

Monitor for therapeutic effects

Effects will vary depending on the type of viral infection Effects range from delayed progression of AIDS and ARC to decrease in flulike symptoms, decreased frequency of herpeslike flare-ups,or crusting over of herpetic lesions

Antituberculous Agents

Tuberculosis (TB) Caused by Mycobacterium tuberculosis Antituberculous agents treat all forms of Mycobacterium

Tuberculosis
Tuberculosis (abbreviated as TB for Tubercle Bacillus is a common and deadly infectious disease caused by the mycobacterium tuberculosis Symptoms include a productive, prolonged cough of more than three weeks duration, chest pain, and coughing up blood. Systemic symptoms include fever, chills, night sweats, appetite loss, weight loss, paling, and those afflicted are often easily fatigued

Mycobacterium Infections
Common infection sites Lung (primary site) Brain Bone Liver Kidney

Mycobacterium Infections (contd)

Aerobic bacillus Passed from infected:

Humans Cows (bovine) Birds (avian)

Mycobacterium Infections (contd)

Tubercle bacilli are conveyed by droplets Droplets are expelled by coughing or sneezing, then gain entry into the body by inhalation Tubercle bacilli then spread to other body organs via blood and lymphatic systems Tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue

Antituberculous Agents
First-Line Agents isoniazid* INH ethambutol pyrazinamide (PZA) rifampin streptomycin
*Most frequently used

Second-Line Agents capreomycin cycloserine ethionamide kanamycin para-aminosalicyclic acid (PAS)

Mechanism of Action
Three groups

Protein wall synthesis inhibitors (streptomycin, kanamycin, capreomycin, rifampin, rifabutin) Cell wall synthesis inhibitors (cycloserine, ethionamide, isoniazid) Other mechanisms of action

Isoniazid (INH)
Drug of choice for TB Resistant strains of Mycobacterium emerging Metabolized in the liver through acetylationwatch for slow acetylators Used alone or in combination with other agents

Indications
Used for the prophylaxis or treatment of TB

Antituberculous Therapy
Effectiveness depends upon:

Type of infection Adequate dosing Sufficient duration of treatment Drug compliance Selection of an effective drug combination

Antituberculous Therapy (contd)

Problems

Drug-resistant organisms Drug toxicity Client noncompliance

Side Effects
INH Peripheral neuritis, hepatotoxicity Ethambutol Retrobulbar neuritis, blindness Rifampin Hepatitis, discoloration of urine, stools

Nursing Implications

Obtain a thorough medical history and assessment Perform liver function studies in clients who are to receive isoniazid or rifampin (especially in elderly clients or those who use alcohol daily) Assess for contraindications to the various agents, conditions for cautious use, and potential drug interactions

Nursing Implications (contd)

Client education is critical

Therapy may last for up to 24 months Take medications exactly as ordered, at the same time every day Emphasize the importance of strict compliance to regimen for improvement of condition or cure

Nursing Implications (contd)

Client education is critical (contd)

Remind clients that they are contagious during the initial period of their illness instruct in proper hygiene and prevention of the spread of infected droplets Emphasize to clients to take care of themselves, including adequate nutrition and rest

Nursing Implications (contd)

Clients should not consume alcohol while on these medications or take other medications, including OTC, unless they check with their physician Diabetic clients taking INH should monitor blood glucose levels because hyperglycemia may occur INH and rifampin cause oral contraceptives to become ineffective; another form of birth control will be needed

Nursing Implications (contd)

Clients who are taking rifampin should be told that their urine, stool, saliva, sputum, sweat, or tears may become reddish orange; even contact lenses may be stained Pyridoxine may be needed to combat neurologic side effects associated with INH therapy Oral preparations may be given with meals to reduce GI upset, even though recommendations are to take them 1 hour before or 2 hours after meals

Nursing Implications (contd)

Monitor for side effects

Instruct clients on the side effects that should be reported to the physician immediately These include fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, jaundice

Nursing Implications (contd)

Monitor for therapeutic effects

Decrease in symptoms of TB, such as cough and fever Laboratory studies (culture and sensitivity tests) and CXR should confirm clinical findings Watch for lack of clinical response to therapy, indicating possible drug resistance

Antifungal Agents: Definition

Drugs used to treat infections caused by fungi

Systemic Topical

Fungi
Large and diverse group of microorganisms Broken down into yeasts and moulds Fungal infections also known as mycosis Some fungi are part of the normal flora of the skin, mouth, intestines, vagina

Yeasts
Single-cell fungi Reproduce by budding Can be used for

Baking Alcoholic beverages

Moulds
Multicellular Characterized by long, branching filaments called hyphae

Mycotic Infections
Four general types

Cutaneous Subcutaneous Superficial, most Systemic*

*Can be life threatening *Usually occur in immunocompromised host

Mycotic Infections (contd)

Candida albicans

Due to antibiotic therapy, antineoplastics, or immunosuppressants (corticosteroids) May result in overgrowth and systemic infections Oral candidiasis or thrush Newborn infants and immunocompromised clients Yeast infection Pregnancy, diabetes mellitus, oral contraceptives

In the mouth

Vaginal candidiasis

Antifungal Agents
Systemic

amphotericin B, fluconazole, ketoconazole, itraconazole Examples: clotrimazole, miconazole, nystatin

Topical

Indications
Systemic and topical fungal infections Agent of choice for the treatment of many severe systemic fungal infections is amphotericin B Choice of agent depends on type and location of infection

Side Effects: Amphotericin B

Fever Shake and bake Headache Malaise Chills Hypotension Dysrhythmias Muscle and joint pain Nausea Lowered potassium levels

Anorexia

Main concerns:
Renal toxicity Neurotoxicity: seizures and paresthesias

Antifungal Agents: Side Effects (contd)

Fluconazole Nausea, vomiting, diarrhea, stomach pain Increased liver function studies
Griseofulvin Rash, urticaria, headache, nausea, vomiting, anorexia, others

Nursing Implications
Follow manufacturers directions carefully for reconstitution and administration Monitor VS of clients receiving IV infusions every 15 to 30 minutes During IV infusions, monitor I&O and urinalysis findings to identify adverse renal effects

Nursing Implications (contd)

Tissue extravasation of fluconazole at the IV site may lead to tissue necrosis monitor IV site carefully Oral forms of griseofulvin should be given with meals to decrease GI upset Monitor carefully for side/adverse effects

Nursing Implications (contd)

Monitor for therapeutic effects

Easing of the symptoms of infection Improved energy levels Normal vital signs, including temperature

Protozoal Infections
Parasitic protozoa: live in or on humans

Malaria Leishmaniasis Amoebiasis Giardiasis Trichomoniasis

Malaria
Caused by Plasmodium protozoa Four different Plasmodium species Cause: the bite of an infected adult female anopheline mosquito Can also be transmitted by infected individuals via blood transfusion, congenitally, or infected needles by individuals that abuse drugs

Malarial Parasite (Plasmodium)

Two interdependent life cycles

Sexual cycle: in the mosquito Asexual cycle: in the human Knowledge of the life cycles is essential in understanding antimalarial drug treatment Drugs are effective only during the asexual cycle

Antimalarial Agents

Attack the parasite during the asexual phase, when it is vulnerable

Erythrocytic phase drugs: chloroquine, hydroxychloroquine, quinine, mefloquine Primaquine: kills parasite in both phases

May be used together for synergistic or additive killing power

Antimalarial Agents (contd)

4-aminoquinolines for prevention and treatment atovaquone/proquanil chemoprophylaxis and first-line for uncomplicated multidrug resistant malaria quinine for treatment

Antimalarials: Drug Effects

Kill parasitic organisms Chloroquine and hydroxychloroquine also have anti-inflammatory effects

Antimalarials: Indications

Used to kill Plasmodium organisms, the parasites that cause malaria The drugs have varying effectiveness on the different malaria organisms Some agents are used for prophylaxis against malaria Chloroquine is also used for rheumatoid arthritis and lupus

Antimalarials: Side Effects

Many side effects for the various agents Primarily gastrointestinal: nausea, vomiting, diarrhea, anorexia, and abdominal pain

Antiprotozoals
atovaquone metronidazole pentamidine paromomycin

Protozoal Infections
Amoebiasis Giardiasis Pneumocystosis Toxoplasmosis Trichomoniasis

Protozoal Infections (contd)

Transmission

Person to person Ingestion of contaminated water or food Direct contact with the parasite Insect bite (mosquito or tick)

Protozoal Infections (contd)

Clients with compromised immune systems are at risk for acquiring these infections
Taking immunosuppressive drugs after a transplant Leukemia AIDS

Protozoal infections are often fatal in these cases

Table 41-3 Types of protozoal infections

Antiprotozoals: Mechanism of Action and Indications (contd)

metronidazole Disruption of DNA synthesis as well as nucleic acid synthesis Bactericidal, amoebicidal, trichomonacidal Used for treatment of trichomoniasis, amoebiasis, giardiasis, anaerobic infections, and antibiotic-associated pseudomembranous colitis

Antiprotozoals: Side Effects

atovaquone

Nausea, vomiting, diarrhea, anorexia, many others Metallic taste, nausea, vomiting, diarrhea, abdominal cramps, many others

metronidazole

Anthelmintics
Drugs used to treat parasitic worm infections: helminthic infections Unlike protozoa, helminths are large and have complex cellular structures Drug treatment is specific

Anthelmintics (contd)
mebendazole niclosamide praziquantel

Anthelmintics (contd)

It is IMPORTANT to identify the causative worm Done by finding the parasite ova or larvae in feces, urine, blood, sputum, or tissue
Cestodes (tapeworms) Nematodes (roundworms) Trematodes (flukes) Platyhelminthes (flatworm)

Table 41-8 Helminthic infections

Anthelmintics: Side Effects

praziquantel

Nausea, vomiting, diarrhea, dizziness, headache Diarrhea, abdominal pain, myelosuppression

mebendazole

Antimalarial, Antiprotozoal, Anthelmintic Agents: Nursing Implications

Before beginning therapy, perform a thorough health history and medication history, and assess for allergies Check baseline VS Check for conditions that may contraindicate use, and for potential drug interactions

Antimalarial, Antiprotozoal, Anthelmintic Agents: Nursing Implications (contd)

Some agents may cause the urine to have an asparagus-like odour, or cause an unusual skin odour, or a metallic taste; be sure to warn the client ahead of time Administer all agents as ordered and for the prescribed length of time Most agents should be taken with food to reduce GI upset; atovaquone should be taken with food, often fatty food, to increase plasma drug levels

Antimalarial Agents: Nursing Implications

Assess for presence of malarial symptoms When used for prophylaxis, these agents should be started 2 weeks before potential exposure to malaria, and for 8 weeks after leaving the area Medications are taken weekly, with 8 ounces of water

Antimalarial Agents: Nursing Implications (contd)

Instruct client to notify physician immediately if ringing in the ears, hearing decrease, visual difficulties, nausea, vomiting, profuse diarrhea, or abdominal pain occurs Alert clients to the possible recurrence of the symptoms of malaria so that they will know to seek immediate treatment

Antimalarial, Antiprotozoal, Anthelmintic Agents: Nursing Implications

Monitor for side effects

Ensure that clients know the side effects that should be reported Monitor for therapeutic effects and adverse effects with long-term therapy