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Antibacterial Drugs: Properties, Uses, Side Effects, and Nursing Considerations, Study notes of Nursing

Mindanao State University - Iligan Institute of Technology (MSUIIT)Nursing

An in-depth analysis of various antibacterial drugs, including their definitions, mechanisms of action, uses, side effects, and nursing considerations. It covers drugs such as azithromycin, clarithromycin, clindamycin, lincomycin, telavancin, telithromycin, tetracyclines, tigecycline, gentamicin sulfate, streptomycin sulfate, ciprofloxacin hcl, levofloxacin, norfloxacin, ofloxacin, and daptomycin. The document also includes information on drug interactions, cultural considerations, and nursing process assessment, diagnosis, and teaching.

Typology: Study notes

2023/2024

Uploaded on 02/19/2024

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C H A P T E R 30
Macrolides, Tetracyclines, Aminoglycosides,
and Fluoroquinolones
Topic Outline
1. Macrolides, Lincosamides,
Glycopeptides, and Ketolides
a. Macrolides
b. Nursing Process: Patient-
Centered Collaborative Care:
c. Antibacterials: Macrolides
d. Lincosamides
e. Glycopeptides
f. Ketolides
2. Tetracyclines
a. Nursing Process: Patient-
Centered Collaborative Care:
Antibacterials: Tetracyclines
3. Glycylcyclines
4. Aminoglycosides
a. Nursing Process: Patient-
Centered Collaborative Care:
b. Antibacterials: Aminoglycosides
5. Fluoroquinolones (Quinolones)
a. Nursing Process: Patient-
Centered Collaborative Care:
b. Antibacterials: Fluoroquinolones
6. Lipopeptides
7. Unclassified Antibacterial Drugs
Definition of Terms
• Bacteriostatic - inhibit bacterial growth
• Bactericidal - kill bacteria
• Pathogen – microorganism capable of
producing disease
• Hepatotoxicity - liver toxicity
• Photosensitivity - sunburn reaction
• Nephrotoxicity - kidney toxicity
• Superinfection - secondary infection
resulting from drug therapy
• Ototoxicity - hearing or balance
problems due to a medicine.
MACROLIDES, LINCOSAMIDES,
GLYCOPEPTIDES, AND KETOLIDES
Macrolides
• are primarily bacteriostatic; by binding
to the 50S subunit of the ribosome, they
inhibit bacterial protein synthesis.
• are used to treat mild to moderate
infections of the respiratory tract,
sinuses, gastrointestinal (GI) tract, skin
and soft tissue, and diphtheria,
impetigo contagiosa, and sexually
transmitted infections (STIs).
• can be administered orally or
intravenously (IV) but not
intramuscularly (IM).
Drugs: GENERIC (BRAND)
1. Azithromycin (Zithromax, AzaSite)
a. frequently prescribed for upper
and lower respiratory infections,
STIs, and uncomplicated skin
infections.
b. Excretion: In bile and small
amount in urine
c. PB: 51%
d. t1/2: 68 h
2. Clarithromycin (Biaxin)
a. for upper and lower respiratory
tract infections, skin and soft-
tissue infections
b. PB: 65%-75%
c. t1/2: 3-6 h
3. Erythromycin
a. the first macrolide
b. was derived from the funguslike
bacteria Streptomyces erythreus
and was first introduced in the
early 1950s.
c. drug of choice for the treatment
of mycoplasmal pneumonia and
Legionnaire’s disease.
d. For IV administration. Drug should
not be dissolved in solution that
contains preservative.
e. PB: 73%-81%
f. t1/2: PO: 1-2 h; IV: 3-5 h
4. Fidaxomicin (Dificid)
a. For treatment of Clostridium
difficile–associated diarrhea.
May cause GI bleeding, GI
obstruction, and elevated liver
enzyme
b. PB: unknown
c. T1/2: unknown
Pharmacokinetics
• Clarithromycin and erythromycin are
absorbed from the GI tract, mainly by
the duodenum.
• Azithromycin is incompletely absorbed
from the GI tract, and only 37% reaches
systemic circulation.
• Azithromycin and erythromycin are
available IV.
• Macrolides are excreted in bile, feces,
and urine.
Pharmacodynamics
• Macrolides suppress bacterial protein
synthesis.
• Oral preparations of erythromycin
o Onset: 1 hour
o Peak: 4 hours
o Duration of action: 6 hours
pf3
pf4
pf5
pf8
pf9
pfa

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C H A P T E R 30

Macrolides, Tetracyclines, Aminoglycosides, and Fluoroquinolones Topic Outline

  1. Macrolides, Lincosamides, Glycopeptides, and Ketolides a. Macrolides b. Nursing Process: Patient- Centered Collaborative Care: c. Antibacterials: Macrolides d. Lincosamides e. Glycopeptides f. Ketolides
  2. Tetracyclines a. Nursing Process: Patient- Centered Collaborative Care: Antibacterials: Tetracyclines
  3. Glycylcyclines
  4. Aminoglycosides a. Nursing Process: Patient- Centered Collaborative Care: b. Antibacterials: Aminoglycosides
  5. Fluoroquinolones (Quinolones) a. Nursing Process: Patient- Centered Collaborative Care: b. Antibacterials: Fluoroquinolones
  6. Lipopeptides
  7. Unclassified Antibacterial Drugs Definition of Terms
  • Bacteriostatic - inhibit bacterial growth
  • Bactericidal - kill bacteria
  • Pathogen – microorganism capable of producing disease
  • Hepatotoxicity - liver toxicity
  • Photosensitivity - sunburn reaction
  • Nephrotoxicity - kidney toxicity
  • Superinfection - secondary infection resulting from drug therapy
  • Ototoxicity - hearing or balance problems due to a medicine. MACROLIDES, LINCOSAMIDES, GLYCOPEPTIDES, AND KETOLIDES Macrolides
  • are primarily bacteriostatic; by binding to the 50S subunit of the ribosome, they inhibit bacterial protein synthesis.
  • are used to treat mild to moderate infections of the respiratory tract, sinuses, gastrointestinal (GI) tract, skin and soft tissue, and diphtheria, impetigo contagiosa, and sexually transmitted infections (STIs).
  • can be administered orally or intravenously (IV) but not intramuscularly (IM). Drugs: **GENERIC (BRAND)
  1. Azithromycin (Zithromax, AzaSite)** a. frequently prescribed for upper and lower respiratory infections, STIs, and uncomplicated skin infections. b. Excretion: In bile and small amount in urine c. PB: 51% d. t 1 /2: 68 h 2. Clarithromycin (Biaxin) a. for upper and lower respiratory tract infections, skin and soft- tissue infections b. PB: 65%-75% c. t 1 /2: 3-6 h 3. Erythromycin a. the first macrolide b. was derived from the funguslike bacteria Streptomyces erythreus and was first introduced in the early 1950s. c. drug of choice for the treatment of mycoplasmal pneumonia and Legionnaire’s disease. d. For IV administration. Drug should not be dissolved in solution that contains preservative. e. PB: 73%-81% f. t1/2: PO: 1-2 h; IV: 3-5 h 4. Fidaxomicin (Dificid) a. For treatment of Clostridium difficile–associated diarrhea. May cause GI bleeding, GI obstruction, and elevated liver enzyme b. PB: unknown c. T1/2: unknown Pharmacokinetics
  • Clarithromycin and erythromycin are absorbed from the GI tract, mainly by the duodenum.
  • Azithromycin is incompletely absorbed from the GI tract, and only 37% reaches systemic circulation.
  • Azithromycin and erythromycin are available IV.
  • Macrolides are excreted in bile, feces, and urine. Pharmacodynamics
  • Macrolides suppress bacterial protein synthesis.
  • Oral preparations of erythromycin o Onset: 1 hour o Peak: 4 hours o Duration of action: 6 hours
  • Clarithromycin (Biaxin) is administered twice a day, and Biaxin XL is administered once a day.
  • Azithromycin (Zithromax) has up to a 40- to 68-hour half-life. Side Effects and Adverse Reactions
  • Include GI disturbances such as nausea, vomiting, diarrhea, and abdominal cramping.
  • Conjunctivitis may develop as a side effect of azithromycin.
  • Allergic reactions to erythromycin are rare.
  • Hepatotoxicity can occur when erythromycin and azithromycin are taken in high doses with other hepatotoxic drugs, such as acetaminophen (high doses), phenothiazines, and sulfonamides.
  • Erythromycin should not be taken with clindamycin or lincomycin. Drug Interactions
  • Macrolides can increase serum levels of theophylline, carbamazepine, and warfarin.
  • Erythromycin should not be used with other macrolides. **Extended Macrolide Group
  1. Clarithromycin (Biaxin)** a. first extended macrolide group developed after the introduction of erythromycin b. is administered twice a day and the XL formulation is given once a day 2. Azithromycin (Zithromax) a. has a long half-life b. only prescribed once a day for 5 days Nursing Process Assessment
  • Assess vital signs and urine output. Report abnormal findings.
  • Check laboratory tests (liver enzyme values) to determine liver function. Order liver enzyme tests periodically for patients taking large doses of azithromycin fora continuous period.
  • Obtain a history of drugs patient currently takes. The peak level of azithromycin may be decreased by antacids. Nursing Diagnosis
  • Risk for infection related to invasion of bacteria through broken skin
  • Risk for impaired tissue integrity related to azithromycin side effects Planning
  • Patient’s infection will be controlled and later eliminated. Nursing Interventions
  • Obtain a sample from infected area and send to laboratory for culture and sensitivity (C&S) test before starting azithromycin therapy. Antibiotic can be initiated after obtaining culture sample.
  • Monitor vital signs, urine output, and laboratory values, especially liver enzymes: alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and bilirubin.
  • Monitor patient for liver damage resulting from prolonged use and high dosage of macrolides such as azithromycin. Signs of liver dysfunction include elevated liver enzyme levels and jaundice.
  • Administer oral azithromycin 1 hour before or 2 hours after meals. Give with a full glass of water, not fruit juice. Give the drug with food if GI upset occurs. Chewable tablets should be chewed, not swallowed whole.
  • Dilute in an appropriate amount of solution as indicated in the drug circular for IV azithromycin.
  • Administer antacids either 2 hours before or 2 hours after azithromycin. Patient Teaching General
  • Instruct patient to take full course of antibacterial agent as prescribed. Drug compliance is most important for all antibacterials (antibiotics). Side Effects
  • Encourage patient to report side effects, including adverse reactions (nausea, vomiting, diarrhea, abdominal cramps, itching).
  • Teach patient to report any evidence of superinfection such as stomatitis or vaginitis may occur.
  • Tell patient to report onset of loose stools or diarrhea. Pseudomembranous colitis should be ruled out.
  • Vancomycin may inhibit methotrexate excretion and increase methotrexate toxicity.
  • The absorption of oral vancomycin may be decreased when given with cholestyramine and colestipol. Ketolides
  • are structurally related to macrolides. Drugs: **GENERIC (BRAND)
  1. Telithromycin (Ketek)** a. are first drug in this class. b. used for adults 18 years of age and older to treat mild to moderate community-acquired pneumonia. c. PB: 60%-70% d. t 1/2: 10 h Pharmacokinetics
  • Telithromycin is given orally.
  • Telithromycin is excreted in the feces and urine.
  • 60% to 70% protein bound
  • Half-life: 10 hours Pharmacodynamics
  • Telithromycin inhibits protein synthesis in microorganisms by binding to the bacterial ribosomal RNA site of the 50S subunit.
  • Peak Action: 1 hour Side Effects and Adverse Reactions
  • Include visual disturbances (blurred vision and diplopia), headache, dizziness, altered taste, nausea, vomiting, diarrhea, and liver failure.
  • may also lead to an exacerbation of myasthenia gravis. Drug Interactions
  • Telithromycin levels are increased when taken concurrently with antilipidemic, itraconazole, ketoconazole, and benzodiazepines.
  • Blood levels of telithromycin are decreased when taken with rifampin, phenytoin, carbamazepine, or phenobarbital.
  • Telithromycin can increase levels of cisapride and pimozide.
  • Concurrent use of telithromycin with ergot alkaloid derivatives leads to ergot toxicity. Tetracyclines
  • isolated from Streptomyces aureofaciens in 1948, were the first broad-spectrum antibiotics effective against gram-positive and gram- negative bacteria and many other organisms.
  • act by inhibiting bacterial protein synthesis and have a bacteriostatic effect.
  • The tetracyclines are frequently prescribed for oral use, although they are also available for IM and IV use. 1. Short-Acting Tetracycline [tetracycline (Sumycin)] a. For infections caused by gram- positive and gram-negative microorganisms, respiratory and skin disorders, chlamydial infection, gonorrhea, syphilis, and rickettsial infections. b. PB: 65% c. t1/2 : 6-12 h 2. Intermediate-Acting Tetracycline [demeclocycline HCl (Declomycin)] a. For gram-positive and gram- negative bacteria. Severe photosensitivity may occur. b. PB: 65%-91% c. t1/2 : 10-15 h 3. Long-Acting Tetracyclines [minocycline HCl (Minocin)] a. For bacterial infections and acne. Should take with food. b. PB: 55%-88% c. t1/2 : 11-26 h Side Effects and Adverse Reactions
  • GI disturbances such as nausea, vomiting, and diarrhea are side effects of tetracyclines.
  • Photosensitivity (sunburn reaction) may occur in persons taking tetracyclines, especially demeclocycline (Declomycin).
  • Minocycline (Minocin) can cause damage to the vestibular part of the inner ear.
  • Outdated tetracyclines should always be discarded
  • Nephrotoxicity
  • Superinfection is another adverse reaction that might result. Drug Interactions
  • Antacids and iron-containing drugs can prevent absorption of tetracycline from the GI tract.
  • Lipid-soluble tetracyclines (doxycycline and minocycline) are actually better absorbed from the GI tract.
  • The activity of penicillins given with a tetracycline can be decreased.
  • Administering tetracycline with an aminoglycoside may increase the risk of nephrotoxicity. Glycylyclines
  • a synthetic analogue of the tetracyclines. Drugs: GENERIC (BRAND) : 1. Tigecycline (Tygacil) a. acts by blocking protein synthesis in bacterial cells. b. Indications for use are complicated skin infections and intraabdominal infections, including Staphylococcus aureus, Escherichia coli, Streptococcus pyogenes, Klebsiella pneumoniae, and Clostridium perfringens. c. PB: 71%-89% d. t1/2: 42 h Pharmacokinetics
  • Tigecycline is administered IV at an initial loading dose of 100 mg over 30 to 60 minutes, followed by 50 mg q12h.
  • Protein binding capacity: 71% - 89%
  • Half-life: 42 hours
  • The drug is eliminated from the body in bile, feces, and urine. Pharmacodynamics
  • Tigecycline binds to the 30S ribosomal subunit and causes cell death. Side Effects and Adverse Reactions
  • involve the GI tract and include nausea, vomiting, abdominal pain, and diarrhea.
  • Pseudomembranous colitis may occur but is rare.
  • Other side effects are photosensitivity, headache, dizziness, insomnia, hypertension, hypotension, anemia, leukocytosis, and thrombocythemia.
  • Hyperglycemia, hypokalemia, elevated BUN, and elevated liver enzymes may occur. Nursing Process Assessment
  • Assess vital signs and urine output. Report abnormal findings.
  • Check laboratory results, especially those that indicate renal and liver function (blood urea nitrogen, serum creatinine, aspartate aminotransferase, alanine aminotransferase, bilirubin).
  • Obtain a history of dietary intake and drugs patient currently takes. Dairy products, antacids, iron, calcium, and magnesium decrease drug absorption. Digoxin absorption is increased, which may lead to digitalis toxicity. Nursing Diagnosis
  • Risk for infection related to invasion of bacteria into respiratory tract
  • Noncompliance with drug regimen related to denial of illness
  • Risk for impaired skin integrity related to adverse effect of tetracycline (sunburn)
  • Imbalanced nutrition: less than body requirements, related to nausea and vomiting. Planning
  • Patient’s infection will be controlled and later eliminated. Nursing Interventions
  • Obtain a sample for culture from the infected area and send to laboratory for culture and sensitivity test. Antibiotic therapy can be started after the culture sample has been taken.
  • Administer tetracycline 1 hour before or 2 hours after meals for optimum absorption.
  • Monitor laboratory values for liver and kidney functions (in particular, liver enzymes, blood urea nitrogen, serum creatinine).
  • Record vital signs and urine output. Patient Teaching General
  • Tell patient to store tetracycline away from light and extreme heat. Tetracycline decomposes in light and heat, causing the drug to become toxic.
  • Advise patient to check expiration date on bottle of tetracycline; out-of-date tetracycline can be toxic.
  • Inform female patients who are contemplating pregnancy to avoid

should not be mixed together in the same container. Side Effects and Adverse Reactions

  • Serious adverse reactions to aminoglycosides include ototoxicity and nephrotoxicity.
  • Prolonged use of aminoglycosides could result in a superinfection. Nursing Process Assessment
  • Record vital signs and urine output. Compare these results with future vital signs and urine output. An adverse reaction to most aminoglycosides is nephrotoxicity.
  • Assess laboratory results to determine renal and liver functions, including blood urea nitrogen, serum creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and bilirubin. Serum electrolytes should also be checked. Aminoglycosides may decrease serum potassium and magnesium levels.
  • Obtain a medical history related to renal or hearing disorders. Large doses of aminoglycosides could cause nephrotoxicity or ototoxicity. Nursing Diagnosis
  • Risk for infection related to invasion of bacteria
  • Risk for impaired tissue integrity related to aminoglycoside side effect of rash
  • Imbalanced nutrition, less than body requirements, related to inability to ingest food
  • Risk for ineffective peripheral tissue perfusion: renal related to an aminoglycoside adverse effect of nephrotoxicity. Planning
  • Patient’s infection will be controlled and later eliminated. Nursing Interventions
  • Send sample from infected area to laboratory for culture to determine organism and antibiotic sensitivity before aminoglycoside is started.
  • Monitor intake and output. Urine output should be at least 600 mL/d. Immediately report if urine output is decreased. Urinalysis may be ordered daily. Check results for proteinuria, casts, blood cells, or appearance.
  • Check for hearing loss. Aminoglycosides can cause ototoxicity.
  • Evaluate laboratory results and compare with baseline values. Report abnormal results.
  • Monitor vital signs. Note if body temperature has decreased.
  • For IV use, dilute gentamicin in 50 to 200 mL of normal saline solution or 5% dextrose in water (D5W) solution and administer over 30 to 60 minutes.
  • Check that therapeutic drug monitoring has been ordered for peak and trough drug levels. Blood should be drawn 45 to 60 minutes after drug has been administered for peak levels and minutes before next drug dosing for trough levels. Gentamicin peak values should be 5 to 8 mcg/mL, and trough values should be 0.5 to 2 mcg/mL.
  • Monitor for signs and symptoms of superinfection: stomatitis (mouth ulcers), genital discharge (vaginitis), and anal or genital itching. Patient Teaching General
  • Unless fluids are restricted, encourage patient to increase fluid intake. Side Effects
  • Inform patient to report aminoglycoside side effects: nausea, vomiting, tremors, tinnitus, pruritus, and muscle cramps.
  • Direct patient to use sun block and protective clothing during sun exposure. Aminoglycosides can cause photosensitivity. Cultural Considerations
  • Do not give directions such as “Take one blue pill” at a specified time. Instead, provide the name and dosage of the medication in the language patient speaks and reads most easily. Evaluation
  • Evaluate the effectiveness of the aminoglycoside by determining whether or not the infection has ceased, and no side effects have occurred. Drug Interactions
  • When aminoglycosides are administered concurrently with penicillin, the desired effects of aminoglycosides are greatly decreased.
  • The risk of ototoxicity increases when ethacrynic acid and aminoglycoside are given. Fluoroquinolones
  • The mechanism of action of fluoroquinolones is to interfere with the enzyme DNA gyrase, which is needed to synthesize bacterial deoxyribonucleic acid (DNA). Drugs: **GENERIC (BRAND)
  1. Ciprofloxacin HCl (Cipro)** a. is approved for use for urinary tract infections; lower respiratory tract infections; and skin, soft- tissue, bone, and joint infections. b. PB: 20%-40% c. t1/2: 4 h 2. Levofloxacin (Levaquin) a. is used primarily to treat respiratory problems, such as community-acquired pneumonia, chronic bronchitis, acute sinusitis, urinary tract infections, and uncomplicated skin infections. b. PB: 24%-38% c. t1/2: 6-8 h 3. Moxifloxacin (Avelox) a. is available for once-a-day oral and parenteral dosing. b. is more active than levofloxacin against S. pneumoniae. c. PB: 30%-50% d. t1/2: 12 h 4. Norfloxacin (Noroxin) a. is indicated for urinary tract infections. b. PB: 10%-15% c. t 1 /2: 3-4 h 5. Ofloxacin (Floxin) a. for respiratory tract infections, UTIs, prostatitis, skin infections. b. Not to be taken with meals. c. PB: 32% d. t1/2: 4-8h Nursing Process Assessment
  • Record vital signs and intake and urine output. Compare these results with future vital signs and urine output. Fluid intake should be at least 2000 mL/d.
  • Assess laboratory results to determine renal function: blood urea nitrogen and serum creatinine.
  • Obtain a drug and diet history. Antacids and iron preparations decrease absorption of fluoroquinolones such as levofloxacin (Levaquin). Levofloxacin can increase the effects of theophylline and caffeine as well as the effects of oral hypoglycemics. When levofloxacin is taken with NSAIDs, CNS reactions including seizures may occur. Nursing Diagnosis
  • Risk for infection related to an invasion of bacteria
  • Risk for impaired tissue integrity related to a fluoroquinolone adverse effect of Stevens-Johnson syndrome
  • Noncompliance with drug regimen related to lack of understanding of importance of drug regimen. Planning
  • Patient’s infection will be controlled and later eliminated. Nursing Interventions
  • Obtain specimen from infected site and send to laboratory for culture and sensitivity before initiating antibacterial drug therapy.
  • Monitor intake and output. Urine output should be at least 750 mL/d. Patient should be well hydrated, and fluid intake should be >2000 mL/d to prevent crystalluria. Urine pH should be <6.7.
  • Record vital signs. Report abnormal findings.
  • Check laboratory results, especially blood urea nitrogen and serum creatinine. Elevated values may indicate renal dysfunction.
  • Administer levofloxacin 2 hours before or after antacids and iron products for absorption. Give with a full glass of water. If GI distress occurs, drug may be taken with food.
  • For IV levofloxacin, dilute antibiotic in an appropriate amount of solution as indicated in drug circular. Infuse over 60 minutes.
  • Check for signs and symptoms of superinfection: stomatitis (mouth ulcers), furry black tongue, anal or genital discharge and itching.
  • Monitor serum theophylline levels when taken concurrently. Levofloxacin can increase theophylline levels. Check for symptoms of central nervous system stimulation: nervousness, insomnia, anxiety, and tachycardia.
  • Monitor blood sugar. Levofloxacin can increase effects of oral hypoglycemics.

Unclassified Antibacterial Drugs Drugs: GENERIC (BRAND)

1. Chloramphenicol (Chloromycetin) a. was discovered in 1947 and has a bacteriostatic action by inhibiting bacterial protein synthesis. b. It is effective against gram- negative and gram-positive bacteria and many other microorganisms. 2. Quinupristin/dalfopristin (Synercid) a. effective for treating vancomycin-resistant Enterococcus faecium (VREF) bacteremia and skin infected by S. aureus and S. pyogenes. b. When administering the drug through a peripheral IV line, pain, edema, and phlebitis may occur. Reference:

Kee, J., Hayes, E., & McCuiston, L. (2015).

Pharmacology - A Patient-Centered

Nursing Process Approach (8e ed.).

evolve.elsevier.com. (Original work

published 1993)