What is the difference between an antiseptic and disinfectant?
Antiseptics are bacteriostatic (inhibits microorganisms) and are applied to living tissue, such as skin.
Disinfectants are bactericidal (Kills microrganisms) and are applied to nonliving objects
What is a nosocomial infection?
An HAI, an infection that a patient acquires during the course of receiving treatment for another condition. It is not present or incubating in the patient upon admission to the hospital, occurs 48 hours or after admission.
What is the most common HAI?
MRSA (methicillin resistant staphylococcus aureus)
-One of the top ten leading causes of death in the united states
What allergies would be associated with iodine based agents?
Ask the patient if they are allergic to iodine or seafood such as shellfish
When applying antiseptics what do you look for?
- assess for allergies
- has the patient had it use d before, had a reaction? if so, what reaction?
- allergies
Treat antiseptics just like a medication
When to use clean or sterile gloves?
Skin intact? clean gloves
Skin not intact? Sterile gloves
What is the hallmark symptom of infection?
Fever
Number of range for WBC
5,000-10,000 is normal
> 11000 is infection
Different types of drainages and what are they
...
Empiric therapy
Treatment of an infection before specific culture information has been reported or obtained
- would use a broad spectrum antibiotic
Definitive Therapy
antibiotic therapy tailored to treat organism identified with cultures,
Ex: baby comes into ER and has symptoms of meningitis and cultures are taken, instead of waiting for 3 days for the cultures we give empiric therapy and then when the cultures are rec
Prophylactic therapy
Giving antibiotics to prevent infection when there is a high possibility of getting contaminated
- antibiotics before surgery before making incision to prevent infection when there is a high potential for contamination (Ex: cholostomy or abdominal)
Sub therapeutic response
Signs and symptoms of infection do not improve
- when you may have bacteria that is resistant to the antibiotic that you are taking
- important that patient goes back into the doctor and gets a new antibiotic
Superinfection
Occurs when antibiotics reduce or completely eliminate the normal bacteria flora
other bacteria or fungi take over and cause infection
- Vaginal yeast infection, antibiotic associated diarrhea (watery)
What happens in superinfection?
The inflammatory response in the bowel Is happening, causing absorptive surface not to work properly, so it cannot absorb water back into the body system, most of the reabsorption of water happens in large intestine, so the big symptom of C. Diff is water
superinfection (Type 2)
When a patient has a second infection that closely follows the first
- need to tell patients to come back in if they don't feel better after 3 days they need to go back and get antibiotics for second infection
What is your next question when the patient says they are allergic to something?
What kind of reaction did you have?
Symptoms of Anaphylaxis
- Itching
- flushing
- hives and rash
- wheezing and bronchiospasms
- welling of tongue/throat
- anxiety
- hypotension
- fast
What are the actions of antibiotics?
bacteriocidal (kill bacteria)
and bacteriostatic (inhibit)
Antibiotic Assessment
People with renal insufficiency, drug allergies, renal liver and cardiac function, drug interactions, immune status
What should you ALWAYS do before you administer antibiotics
Obtain cultures
Administering antibiotics
- administer with fluids
- administer all medication, in full ,and around the clock to maintain blood levels
- do not omit a dose
- do not double up on a dose
what if the patient doesn't take the medication at the time it was scheduled?
Give the medication as soon as you can, and postpone the next treatment, and every treatment after that. Work with the pharmacist to reset the times and then do the correct time from that point forward
Do not administer oral antibiotics with:
antacids, calcium supplements, iron products, laxatives containing magnesium, or antilipemic drugs
What are the 3 types of hypersensitivity reactions?
Can occur:
- up to 30 minutes after administration (immediate)
- 1-72 hours after (accelerated reaction)
- >72 hours (delayed response)
Most common adverse effects of antibiotics?
- nausea, vomiting, and diarrhea
How do antibiotics effect oral contraceptives?
Effectiveness of oral contraceptive decreases, back up methods of contraception are encouraged
Food and beverage effects on antibiotics?
No alcohol, acidic fruit juices, or dairy products
What foods help prevent superinfections?
yogurt, butter, milk, new yogurts or probiotics
Sulfonamides
- bacteriostatic
What are sulfonamides most commonly used for?
- Urinary tract infections
- effective against both gram-positive and gram-negative bacteria
What do sulfonamides commonly cause?
- Allergic Reactions
Sulfonamides: adverse effects
- Photosensitivity- severe sunburn
- exfoliative dermatitis
-stevens-Johnson syndrome
- epidermal necrolysis
- horrible rash, skin sloughs off
- Hemolytic (red blood cells are destroyed)
- Aplastic anemia (bone marrow cant make enough red blood cells)
- A
Sulfonamides + diabetic treatment =
hypoglycemia effect
Assessment before giving sulfanomide?
Drug allergies to sufanomides? how did you tolerate it?
- assess skin
- assess RBC count
- Assess renal function
How many mL would you take a sulfonamide with?
2000 - 3000 mL of fluid in 24 hour period to try and prevent drug related crystalluria
4 major subclasses of Beta- Lactam Antibiotics
- Penicillins
- Cephalosporins
- carbapenems
- monobactams
All inhibit the synthesis of the bacterial cell wall
What is the thing that sets beta- lactam antibiotics apart?
Kill by time dependent killing, not concentration killing, the concentration must be above the minimum to kill the amount of bacteria over a certain amount of time.
- Amount of time the drug is above the minimum level over a period of time
Characteristics of Penicillins
- Bactericidal
- Beta-lactamases destroy penicillins, they inactivate penicillin molecule by opening the penicillin ring
Combination drugs used with Peniciilin
1. Clavulanic Acid
2. Tazobactam
3. Sulbactam
These chemicals inhibit the beta-lactamase enzymes to prevent the enzyme from breaking down the penicillin molecule
Ampicillin + sulbactam
Unasyn
Combination drug for penicillin
Amoxicillin + Clavulanic acid =
Augmentin
Combination drug for penicillin
Ticarcillin + clavulanic acid =
Timentin
Pepercallin + Tazobactam =
Zosyn
Mechanism of action for penicillin
- penicillin enter through cell wall
- result : bacteria cells die from lysis (rupture) caused by drug induced disruption of cell wall structure
Penicillin contraindication
Only contraindication is known allergy
Penicillin : adverse effects
- urticaria - skin rash that looks like hives
- Pruritis - itching
- Angioedema - swelling beneath the skin
Penicillin and warfarin interaction?
Enhanced anticoagulation effect, enhaces potential for bleeding
What allergies are more at risk for allergy to penicillin?
- asthma, sensitivity to multiple allergens, aspirin allergy, sensitivity to cephalosporins
What do you take penicillin with?
Always take with water
- do not take with juices, as acidic fluids, such as orange juice, nullify the drugs antibacterial action
Whats the order of doing things when there is an anaphylactic reaction to penicillin?
1. stop the infusion if the route is IV
2. epinephrine and other emergency drugs should be given as ordered
3. supportive treatment (oxygen)
Stop whats causing the problem FIRST, then continued with ABC's
Do you monitor patients given penicillin?
Yes, patient needs to be monitored for at least 30 minutes after injection for immediate reaction
Cephalosporins: Mechanism of Action
- Bactericidal action
- Broad spectrum
- Each generation are similar chemically and kill similar spectra of bacteria
- injectable drugs produce higher serum concentrations (used to treat more serious infection)
- Good for gram-positive coverage, not good
Ceftriaxone (Rocephin)
- administered for meningitis, requires 30 minute monitoring after
Cephalosporins: Contraindications
- If they have had a very potent reaction to penicillin
Cephalosporins: Interactions
Ethanol
- Acute drug alcohol intolerance after drinking alcohol within 72 hours of taking the cephalosporins
- Stomach cramps, NV, diaphoresis, pruritus, headache, hypotension
Carbapenems: characteristics
- VERY broad spectrum antibacterial action (broadest of any antibiotic to date)
- Reserved for complicated body cavity and connective tissue infections
- Given parenterally
- risk for people with allergies to penicillin
What is impenem/cilastatin (primaxin) used for?
A carbapenem used for treatment of bone, joint, skin and soft-tissue infections; many other uses
Implementing Carbapenems
Must be infused over 60 minutes, monitor for seizure activity
Macrolides: Mechanism of action
- Prevent protein synthesis within bacterial cells
-bacteriostatic
-may be bacteriocidal in higher concentrations
What are some common uses for macrolides?
Strep infections, mild to moderate URI and LRI, syphillis, lyme disease, Gonorrhea, Chlamydia, mycoplasma
What drug would be given to a patient who has strep throat and who has an allergy to penicillin?
Macrolides
- alternative drug for allergies to beta-lactam drugs
Tetracycline: Contraindications
- Allergy
- DO NOT give to women who are pregnant, nursing women, or children under the age of 8 years old
*Causes abnormal tooth enamel in both fetuses and children, also possible abnormal fetal development
Adverse effects of Tetracyclines?
- Strong affinity for calcium
- Discoloration of permanent teeth
Erythromycin is in what group?
Macrolides
What are the two photosensitivity drugs?
sulfonamides and tetracyclines
What should you not take with Tetracycline?
- avoid taking with milk or dairy products
- don't take with calcium, magnesium and iron
*important to eat yogurt in terms of supra infections, but not with administration of drug because of the binding with calcium
Aminoglycosides: mechanism of action
- Very potent with serious toxicities
- mostly kill gram negative bacteria
- concentration dependent ( Serum levels need to be 8 times higher than the minimum inhibitory concentration)
- dose is adjusted to renal function ( To prevent toxicity)
What is the major toxicity risk of aminoglycosides?
Nephrotoxicity and ototoxicity
What is the peak level?
Highest drug levels
Trough level?
Lowest drug levels, routinely monitored for adequate renal clearance to avoid toxicity. Its hard to anticipate when the peak level will happen, when giving the medication you measure when the blood is at the lowest concentration, so that is right before y
When do you measure the trough level?
When the medication is due
Ex: Drug needs to be administered at 9am, measure trough then and wait for the results
what is the overall accepted serum level for trough level in aminoglycosides?
Serum level < 1 mcg/mL
What does the serum level above 2 indicate?
Trough level at or above 2 mcg/mL is associated with nephrotoxicity and ototoxicity
What is nephrotoxicity?
Reduced renal function, which would be increased serum creatinine, reduced creatinine clearance.
What is Ototoxicity?
- permanent hearing loss and balance problems
How do aminoglycocides and beta-lactams or vancomycin work together?
The Beta-lactam destroys the cell wall of cells, aminoglycosides then are able to bind with the ribosomes and prevent protein synthesis of the bacteria, which destroys the bacteria
What is the only aminoglycoside given orally?
neomyacin is the only aminoglycoside given orally
How are aminoglycosides given?
Given parenterally, because it is absorbed through the GI tract
Pregnancy and aminoglycosides
causes fetus to be deaf
Quinolones
- Ciprofloxin
- levoflocacin
- Norfloxacin
- moxifloxacin
Indications of Quinolones
- complicated UTI
- respiratiry infections
- bone and joint infections
- GI infections
- Skin infections
- Sexually transmitted diseases
- Anthrax
Contraindications for Quinolones
Not recommended for adolescent children
- Cartilage development may be affected, shown to be affected in laboratory animals
- Commonly used in children with cystic fibrosis
What is the black box warning for quinolones?
Increased risk for tendonitis and tendon rupture with use of drugs
- More common in elderly, renal failure, and concurrent glucocorticoid therapy
Vancomycin (Vancocin)
...
Flagyl
Acute alcohol intolerance
no alcohol 24 hours before drug or 36 hours after last does
What is the treatment of choice for MRSA?
Vancomycin
Contraindications with vancomycin?
Allergy, Hypersensitivity, preexisting renal dysfunciton, and preexisting hearing loss use with caution
What are key assesment to vancomycin?
renal status, hearing status, skin color, and IV site
- Vancomycin kills the IV site, may have to change sites to get the dose in. Can cause reactions in skin
What is the normal trough level for Vancomycin?
- 15-20 mcg/mL
monitor trough levels closely
What is the best nursing action when the Vancomycin trough level is 30 mcg/mL
- draw the trough level before you give the next dose, right before the scheduled dose, and wait for the results of the trough
- When you see its level is 30: hold the medication and contact the health care provider
-When you see the trough is 17? give th
What is the implementation of Vancomycin?
Should be infused over one hour
What can rapid infusion of Vancomycin cause?
Red man syndrome or hypotension
- not harmful, flushing/itching of the head, neck, face and upper trunk
How do you know the difference between red man syndrome and anaphylactic shock snydrome?
- Different symptoms
With red man syndrome you have to slow down the administration of the drug, with shock you completely stop the medication
If a patient receiving vancomycin complains of itching on their head and neck, what is the best nursing action?
Slow down rate of infusion
can also obtain order for Benadryl or antihistamine