Penicillins

1. Penicillins • Penicillin G (IM) • Penicillin V (PO) • Amoxicillin • Amoxicillin-clavulanate • Nafcillin • Oxacillin • Ticarcillin • Piperacillin

2. Expected pharmacological action • Destroy bacteria by weakening the bacterial cell wall • Therapeutic uses: • Treat infections due to gram-positive cocci such as streptococcus pneumoniae (pneumonia and meningitis) and streptococcus pyogenes (pharyngitis) • treat meningitis due to gram-negative cocci such as Neisseria meningitidis • Kills spirochetes, such as treponema pallidum (syphilis) • Provide prophylaxis against bacterial endocarditis in at-risk patients prior to dental and other procedures

3. Complications • Allergies, anaphylaxis • Kidney impairment • Hyperkalemia, hypernatremia, dysrhythmias • Contraindications/precautions • History of severe allergic reaction to penicillins and cephalosporins is a contraindication • Use cautiously in older patients, young children, and acutely ill patients • Patients who are allergic to one penicillin should not be given ANY penicillin as they are at risk for cross-sensitivity • Also, patient who are allergic to PCN are also very likel;y to be allergic to cephalosporins; do not administer

4. Interactions • Penicillin in the same IV solution as aminoglycosides inactivates the aminoglycoside- do not mix • Probenecid delays the excretion of penicillin • Nursing administration: • Advise patients to take penicillin preparations with food; can cause nausea and vomiting • Report any symptoms of allergic response (dyspnea, skin rash, itching, hives) • Advise patient to complete entire course of therapy • Advise female patient to use an additional form of contraception • ALWAYS assess patient for allergies!!! www.PresentationPro.com

5. Cephalosporins • Cephalexin • Cefazolin- IM or IV use • Cefaclor • Ceftriaxone • Cefotaxime • Cefepime • Ceftaroline www.PresentationPro.com

6. Expected pharmacological action • Destroy bacterial cell wall, similar to penicillins • There are 5 generations, with each subsequent generation: • More likely to reach CSF • Less susceptible to destruction by beta-lactamase • More effective against gram-negative organisms and anaerobes • Therapeutic uses: • UTIs • Post-op infections • Pelvic infections • Meningitis www.PresentationPro.com

7. Complications • Allergy, hypersensitivity, anaphylaxis • Possible cross-sensitivity with penicillin • Bleeding tendencies from ceftriaxone • Thrombophlebitis with IV infusion • Renal insufficiency • Pain with IM injection • Antibiotic-associated pseudomembranous colitis (C diff) www.PresentationPro.com

8. Contraindications/precautions and interactions • Do not give to patients with suspected or known sensitivity or allergy to penicillin • Use with caution in patients with renal insufficiency or bleeding tendencies • Intolerance to alcohol (disulfuram reaction) occurs with simultaneous use of alcohol and cefazolin • Probenecid delays renal excretion • Instruct patient to finish entire course of therapy • Advise patient to take cephalosporins with food • Instruct patient to store oral solutions in a refrigerator www.PresentationPro.com

9. Carbapenems • Imipenem-cilastatin • Meropenem- both for IV use (IVPB) • Expected pharmacological action: destroy bacterial cell walls • Therapeutic uses: pneumonia, peritonitis, UTI due to gram-positive cocci, gram-negative cocci, and anaerobic bacteria • Complications: • Allergy, hypersensitivity-possible cross-sensitivity to penicillin and cephalosporins • GI distress • Superinfection www.PresentationPro.com

10. Contraindications/precautions and interactions • Pregnancy/breastfeeding • Use cautiously in patients who have renal insufficiency • Interactions: • Imipenem-cilastatin can reduce blood levels of valproic acid with possible breakthrough seizures • Nursing administration: • Advise patients to complete entire course of therapy, even if symptoms resolve www.PresentationPro.com

11. Tetracyclines • Tetracycline • Doxycycline • Minocycline • Demeocycline • Expected pharmacological action: broad-spectrum antibiotics that prevent microorganism growth by preventing protein synthesis (bacteriostatic) www.PresentationPro.com

12. Therapeutic uses • Acne vulgaris (topical and oral) • Periodontal disease (topically) • Rickettsial infections (Rocky Mountain spotted fever, typhus fever) • Chlamydia • Brucellosis • Pneumonia due to Mycoplasma • Lyme disease • Cholera • Anthrax • H. pylori www.PresentationPro.com

13. Adverse effects • GI discomfort • Yellow or brown tooth discoloration • Hepatotoxicity • Photosensitivity • Superinfection • Dizziness/lightheadedness with parenteral administration www.PresentationPro.com

14. Contraindications/precautions and interactions • Pregnancy/breastfeeding • Use cautiously in liver and kidney disease • Interactions: • Milk products, calcium and iron supplements, antacids cause reduced absorption • Tetracycline decreases the effects of oral contraceptives • Increase risk of digoxin toxicity • Nursing administration • Take on an empty stomach with plenty of water; can take with food of gastric upset occurs • Advise to complete entire course of therapy • Advise use of an additional contraceptive www.PresentationPro.com

15. Macrolides • Erythromycin • Azithromycin • Clarithromycin • Expected pharmacological action: slows the growth of microorganisms by inhibiting protein synthesis; is bactericidal at high doses • Therapeutic uses: can use in patient with penicillin allergy, Legionnaires disease, pertussis, acute diptheria, chlamydia, and strep www.PresentationPro.com

16. Adverse effects • GI discomfort • Prolonged QT intervals • Ototoxicity with high doses • Superinfection of the bowel • Thrombophlebitis with IV administration • Contraindication: liver disease and prolonged QT syndrome www.PresentationPro.com

17. Interactions and nursing administration • Erythromycin inhibits the metabolism of antihistamines, theophylline, carbamezapine, warfarin and digoxin which can lead to toxicity • Nursing administration: • Except for azithromycin, administer oral preparations on an empty stomach • Instruct patient to complete entire course of therapy • Carefully monitor the PT/INR of patients on warfarin • Monitor LFTs f patients on therapy longer than 2 weeks www.PresentationPro.com

18. Aminoglycosides • Gentamycin • Vancomycin • Tobramycin • Neomycin • Streptomycin • Paromycin • Expected pharmacological action: destroy microorganisms by disrupting protein synthesis www.PresentationPro.com

19. Therapeutic uses • Gram-negative bacilli such as E. cloi, Klebsiella, proteus, psudomonas • Paromycin can be used for intestinal infections ans tapeworm infestations • Oral neomycin suppresses the normal GI flora pre-op • Streptomycin can treat TB infections in conjunction with other Abs • Adverse effects: • Ototoxicity • Nephrotoxicity • Respiiratory depression • Hypersensitivity • Peripheral neuritis www.PresentationPro.com

20. Contraindications/precautions • Use cautiously in patients with hearing loss or renal insufficiency; these patients should receive low doses • Interactions: • Penicillin can possibly inactivate aminoglycosides • Concurrent use of other ototoxic meds such as loop diuretics increases the risk of hearing loss • Nursing administration: • Most aminoglycosides are given parenterally • Effectiveness is measured in peak and trough levels www.PresentationPro.com

21. Antimycobacterial (selective antituberculosis) • Pyrazinimide • Ethambutol • Rifapentine • Isoniazid • Expected pharmacological action: highly specific for mycobacteria; prevents synthesis of mycolic acid in the cell wall • Therapeutic uses: latent and active tuberculosis; meds are given once daily for 9 months www.PresentationPro.com

22. Complications, contraindications and precautions • Peripheral neuropathy • Hepatotoxicity • Patients with liver disease should not take isoniazid • Interactions: can lead to phenytoin toxicity; concurrent use of tyramine-containing foods, alcohol increases the risk for hepatotoxicity • Nursing administration: meds are usually taken PO or IM; direct observation can increase adherence in active illness; take on empty stomach but can take with food if gastric upset occurs; patient must complete course of therapy www.PresentationPro.com

23. Broad-spectrum antimycobacterial- rifampin • Expected pharmacological action: inhibits protein synthesis • Therapeutic uses: effective for gram-positive and gram-negative bacteria, part of combination therapy to treat tuberculosis • Complications: • Orange-brown discoloration of body fluids (urine, saliva, sweat and tears) • Hepatotoxicity • Mild GI discomfort • Pseeudomembranous colitis (C. diff) • Use cautiously in patients who have liver dysfunction www.PresentationPro.com

24. Interactions and nursing administration • Diminishes the effects of warfarin, oral contraceptives, and HIV meds • Concurrent use with isoniazid causes increased risk of hepatotoxicity • Administer orally or via IV • Give on empty stomach • Advise female client to use an additional form of contraception www.PresentationPro.com

25. Antiprotozoal- metronidazole • Expected pharmacological action: broad-spectrum antimicrobial with bactericidal activity against anaerobic microorganisms • Therapeutic uses: treatment of trichomoniasis, intestinal amebiasis, prophylactic use in pre-op patients at high risk for infection • Complications: • GI discomfort • Darkening of urine • Neurotoxicity and CNS effects • Superinfection www.PresentationPro.com

26. Antiprotozoal • Contraindicated in pregnancy and breastfeeding • Alcohol causes facial flushing, vomiting, dyspnea, and tachycardia • Affects action of warfarin, phenytoin, and lithium • Administer via IV or orally • Complete entire course of therapy • If treating trichomoniasis, treat sexual partner also www.PresentationPro.com

27. Antifungals • Amphotericin B • Ketoconazole • Nystatin • Miconazole • Clotrimazole • Fluconazole • Acts on fungal cell membranes to act as a fungicidal or fungistatic • Treat superficial (nails, skin and mucous membranes) and systemic fungal infections www.PresentationPro.com

28. Complications • Infusion reactions • Thrombophlebitis • Nephrotoxicity • Electrolyte imbalance • Bone marrow suppression • Hepatotoxicity • Gynecomastia • Irregular menstrual flow www.PresentationPro.com

29. Contraindications, precautions and interactions • Use cautiously in patients with renal impairment, anemia • Pregnancy/lactation • Aminoglycosides have an increased nephrotoxic risk • Digoxin, warfarin, sulfonylureas: increase levels of these meds • Amphotericin B is highly toxic and should be reserved for life-threatening infections www.PresentationPro.com

30. Nonopioid analgesics • Aspirin • Ibuprofen • Naproxen • Indomethacin • Diclofenac • Ketorolac • Meloxicam • Celecoxib www.PresentationPro.com

31. Expected pharmacological action • Use results in reduced inflammation, fever and pain • Therapeutic uses: • Inflammation suppression • Mild-moderate pain • Fever reduction • Dysmenorrhea • Aspirin: above uses, plus inhibition of platelet aggregation, protecting against stroke and MI www.PresentationPro.com

32. Complications • GI distress • Impaired kidney function • Celecoxib: increased risk of MI, stroke • Aspirin: Reye syndrome • CNS effects: confusion, drowsiness, nausea • Headache • Sweating, flushing • Tachycardia • Tachypnea • Aspirin toxicity www.PresentationPro.com

33. Contraindications/precautions • Pregnancy • Peptic ulcer disease • Bleeding disorders • Hypersensitivity • Advanced kidney disease • Celecoxib: do not use in cardiac disease www.PresentationPro.com

34. Interactions • Anticoagulants increase the risk of bleeding • Glucocorticoids increase the risk of gastric bleeding • Alcohol increases the risk of bleeding • Ibuprofen decreases the effects of low-dose aspirin • There are many interactions with other OTC meds • Advise patient to stop aspirin 1 week prior to surgery • Do not crush or chew enteric-coated tablets report gastric discomfort www.PresentationPro.com

35. Acetaminophen • Expected pharmacological action: slows the production of prostaglandins in the CNS • Analgesic and Antipyretic effects • Acute toxicity: results in liver damage • Administer the antidote, acetylcysteine • Contraindicated in those who have three or more alcoholic drinks per day-increases the risk of liver damage • Can lead to increased levels of warfarin • The FDA recommends only taking one form of acetaminophen at a time www.PresentationPro.com

36. Opioid agonists • Morphine- oral, sub-q, IM, IV, epidural, intrathecal • Fentanyl- IV, IM, transdermal • Meperidine- oral, IM, IV, sub-q • Codeine- oral, sub-q, IM, IV • Methadone- oral, sub-q, IM • Oxycodone- oral, rectal • Hydromorphone- oral, sub-q, IM, IV • Act on mu receptors in CNS to produce analgesia, respiratory depression, euphoria, and sedation; also decreased GI motility www.PresentationPro.com

37. Complications • Respiratory depression • Constipation • Orthostatic hypotension • Urinary retention • Cough suppression • Sedation • Biliary colic (gallbladder pain) • Nausea, vomiting • Coma, pinpoint pupils, respiratory depression (overdose) www.PresentationPro.com

38. Contraindications/precautions • Do not use in biliary surgery (morphine) • Do not use prenatally in premature delivery • Do not use meperidine in renal failure • Use with caution in the following patients: • Asthma • Pregnancy • Labor • Inflammatory bowel disease • Enlarged prostate • Hepatic or renal disease www.PresentationPro.com

39. Interactions • CNS depressants have additive CNS effects • Anticholinergic agents: increased effects • Antihypertensives can have additive hypotensive effects • Assess pain levels and vital signs frequently • Follow controlled-substance procedures • Have naloxone and resuscitation equipment available • For cancer patients, give on a fixed schedule • Advise about physical dependence • The first dose of a transdermal fentanyl patch will take several hours to take effect www.PresentationPro.com

40. Opioid agonists-antagonists • Butorphanol- IM, IV, intranasal • Nalbupine- IM, IV, sub-q • Buprenorphine- IV, sublingual, transdermal • Pentazocine- IV, IM, sub-q • Have same actions, complications, contraindications and interactions as opioid agonists with less sedative and addictive effects www.PresentationPro.com

41. Opioid antagonists • Naloxone- IV, IM, sub-q, intranasal • Naltrexone- oral, IM • Interfere with the action of opioids by competing for opioid receptors (mu receptors) • Used to reverse effects of opioids • Can cause tachycardia, tachypnea, cramping, hypertension, vomiting • Has rapid action • Two or more doses may be needed-has shorter half-life than most opioids www.PresentationPro.com