Chapter 12: Antimicrobial Medications answer key

12.1 Infection Concepts

1. Client education includes:

• The importance of adhering to the prescribed medication regimen is vital to help prevent drug resistance.  The nurse should emphasize the need to complete the full course of medication, in the dosages and frequencies prescribed.
• Another solution used to prevent drug resistance in high-risk medications is called directly observed therapy (DOT).  DOT is the supervised administration of medications to clients. Clients are required to visit a health-care facility to receive their medications, or a health-care professional administers medications in the clients’ homes or other designated location. DOT has been implemented worldwide for the treatment of tuberculosis (TB), and research has been shown it to be effective in treating infections successfully and preventing additional drug resistance.

2. Antimicrobials are prescribed before lab results return for a few reasons. Prescribers will know that certain common pathogens can infect the urinary tract or respiratory system or the gut and will prescribe a broad-spectrum antibiotic initially. Second, some infections, if left untreated, can lead to more serious complications and even be life-threatening, not to mention the client is likely symptomatic and feeling poorly. To wait up to three days before labs return can put the client at risk.  Treating early with a broad-spectrum antibiotic is common practice, then once the labs return, the client may be switched to a different antimicrobial that is narrow spectrum.

3. Clients who are very young or older are more at risk with any meds, and certainly antimicrobials.  Infants and children are not able to take some antimicrobials due to negative effects. For example, tetracycline affects developing teeth and bones.  Sulfa antibiotics can displace bilirubin and precipitate kernicterus in the newborn.

For older adults, the normal aging process of a decline in renal function and liver function is important for the metabolism and excretion of meds. A lower dose may be prescribed due to this reason. Very often, a client’s kidney function will be assessed before meds are prescribed.

12.5 Penicillin

1. The administration of penicillin should be postponed for four hours because citrus juice can impede absorption of drugs like penicillin.  The remaining doses of penicillin for the day should be rescheduled based on the time the breakfast dose was actually administered. Additionally, the client should be educated about avoiding citrus juice while taking penicillin, and the dietary department should be notified to remove citrus juice from the meal choices.
2. a. Tazobactam is a beta-lactamase inhibitor. It will extend the antimicrobial action of piperacillin.

2.b. Take full dose of med, even if feeling better. Take the med on an empty stomach as it can interact with certain foods and meds. Avoid juices, cola, caffeine.  It is preferable to take with lots of water.  Also, take a probiotic such as yogurt.  Avoid NSAIDs and antacids. If you need to take these meds, take one hour before or 2 hours after Penicillin. Report any change in stool such as diarrhea and abdominal pain.

12.6 Cephalosporins

The changes in the client’s renal labs demonstrate decreased renal function.  The prescribing provider should be notified prior to administering additional doses of cefazolin because the medication or the dosage will likely need to be revised based on the client’s response.

12.7 Carbapenems

The nurse should check the progress notes in the electronic medical record to determine if anything is documented about John’s allergies and the decision to use imipenem. If nothing is documented, then the nurse should notify the prescribing provider of the client’s allergies to penicillin to confirm the appropriateness of this medication for John, document the provider’s response in the medical record, and provide this information in the end-of-shift handoff report.

12.8 Monobactams

Monobactams are narrow-spectrum antibacterial medications used primarily to treat gram-negative bacteria like Pseudomonas aeruginosa.  However, MRSA is a gram-positive bacteria, so aztreonam will not be effective in fighting this infection.  The nurse should notify the prescribing provider of the results of the new culture report before administering the azotreonam.

12.9 Sulfonamides

1. The nurse should review the other medications the client is taking.  Trimethoprim-Sulfamethoxazole has many significant drug interactions, including oral anti-diabetic medications.   This medication may increase hypoglycemic effects requiring closer monitoring of blood sugars.  Additionally, the client’s renal status should be verified before administration of trimethoprim-sulfamethoxazole because dose adjustment may be required.
2. The client has many questions to ensure they are comfortable taking the med at home. If they do not understand how to take the med safely, they may not finish the full course of the med or know when to report any issues. Explain to the client the full glass of water is to prevent crystals to form in the kidneys. We taking with lots of water, this will prevent this from occurring. If the client already has diarrhea, find out their bowel patterns. If they experience abdominal pain, and the amount of diarrhea increases, becomes bloody or has pus in it, they need to report to the prescriber.  This med can cause an increase in photosensitivity. They can certainly go outside, but try to avoid direct sunlight and wear sunscreen.

12.10 Fluoroquinolones

The nurse should immediately stop the medication and notify the provider regarding the new onset of tendon pain because this symptom indicates an adverse reaction of levofloxacin may be occurring.

12.11 Macrolides

The nurse should notify the provider of the client’s change in condition because it may indicate an adverse effect of liver damage is occurring. Anticipate liver panel that include AST, ALT, alk phosphate.  The client may be switched off this med, or a lower dose and closer monitoring may be done.

12.12 Aminoglycosides

The nurse should not administer the medication until the trough levels have been drawn.   The nurse should phone the lab and check on the status of the laboratory trough level.

12.13 Tetracyclines

1. The client is under the age of six and is at risk for the adverse effect of teeth discoloration.  The nurse should advocate for this client by notifying the prescribing provider of this concern and requesting an alternate medication. If this med was doxycycline, and the infection responds best to this med, then a short course of the antibiotic can be prescribed and shown to have no adverse effects.

2. a. Teaching points include to take the med on an empty stomach (1 hour before or 2 hours after a meal), avoid dairy products, antacids and iron supplements, take with a full glass of water. These points will improve absorption. Also, to wait 30 minutes before lying down after taking the med to avoid irritation.

2.b. Milk (calcium) binds with tetracycline and reduces its absorption. It forms insoluble complexes with calcium, resulting in decreased effectiveness.

2.c. Risk of photosensitivity: Tetracycline can cause exaggerated sunburn reactions → advise sunscreen and protective clothing.

2.d. Tetracycline decreases the effects of birth control pills. This occurs due to the antibiotics alter the gut flora, affecting estrogen reabsorption. Always use a back up method while on antibiotics.

12.14  Vancomycin

1. The nurse should not administer the vancomycin until after the trough level is drawn.  The nurse should call the lab to request prioritization of completing the trough level.
2. The nurse should monitor renal function due to risk of nephrotoxicity. The nurse should assess the client’s urine to see if cloudy or pink, decreased urine output and abdominal pain. If the creatinine level is low, hold the dose and notify the prescriber.

12.15 Anti-virals

Oseltamivir should be administered within the first 24-48 hours of the onset of influenza symptoms.  The client may have already passed the window for maximum therapeutic effectiveness of oseltamivir.  The provider should be notified regarding the onset of symptoms to clarify the prescription.

12.16 Anti-Fungals

If there are no signs of improvement from the prescribed medication therapy, the nurse should notify the provider. A stronger ointment may need to be prescribed. Before calling the prescriber, assess the area to determine if the area is getting larger, and document the appearance including redness, exudate, and pain. Ensure that the area is not being irritated by tight clothing and the area is cleaned and dried daily.

12.17 Anti-malarials

In order to prevent malaria, the CDC recommends clients should take antimalarial medications for a few days prior to entering the endemic area, once a day while there and then one week after leaving the endemic area.  The client needs to understand the importance of taking the med every day and perhaps setting an alarm to remember. If adverse effect occur, such as diarrhea or nausea, they are usually mild and can be minimized by taking the med with food or a dairy drink. Discuss other preventative measures such as wearing DEET and wearing light coloured clothing.

12.18 Antiprotozoals

Metronidazole is commonly used to treat C-diff.  The medication must be given by mouth for the GI infections. Recommend that the client takes the meds with food to avoid GI upset. They may get a metallic taste in their mouth which can be minimized with practicing good oral hygiene. If they start to feel better, continue to take the entire prescription. Avoid alcohol while on this med at it interacts with the med and can cause nausea and vomiting and even seizures.

12.19 Anthelmintic

The nurse should provide education regarding the use of the medication, as well as ways to prevent re-infection. Methods to prevent reinfection include using proper handwashing, washing all fruits and vegetables, and wearing shoes in the barn or where animals and their feces are present.

12.20  Antituberculars

The nurse should explain that directly observed therapy (DOT) means the administration of this medication will be supervised to ensure all doses are taken as prescribed to be sure the infection is treated properly and drug resistance does not develop. The client will be required to visit a health-care facility to receive their medications or a health-care professional will administer the medication in the client’s home or other designated location.