Antibacterials

Nursing considerations for patients taking antibacterial medications. 

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Stacey Hobbick: 0:39

Hey and welcome to nursery with Dr. Hobbick. Today, I'm thinking about anti infective and thinking about medications that we take to help us when a pathogen is causing trouble. There's a couple of different types of anti infective, they're not all antibacterials. So first we're going to talk about those antibacterial medications. These are medications that either are bacterial Seidel, or bacterial static. Bacterial Seidel means exactly what it sounds like. It's a bacteria killer. Bacterial static means that the medication inhibits bacterial growth. If we have a medication that is killing bacteria, or inhibiting their growth, I think the biggest misconception is that you're going to start to feel better as soon as you start to take the antibiotic. In truth or in reality, it's going to take a couple of days before you start to feel better, because we can stop the bacteria. But you still have damage all that damage that caused your symptoms that has to be cleared up things that we need to know about antibacterials it's important for us to know when it's okay, and when it's not okay for us to administer these medications. It's not okay to administer these medications to someone who is allergic to them, it's not okay to administer to someone who is hypersensitive. So it's important to know that penicillins and cephalosporins can have a little bit of cross sensitivity. The research shows that there's about 10% of people who are allergic to penicillin are also allergic to cephalosporins. If a patient is hypersensitive, in other words, allergic to an antibiotic, like anaphylaxis, then we usually see that reaction within 15 or 30 minutes, it can happen up to two hours later, but usually it's within that first 15 or 30 minutes, then it is important for a nurse to monitor a patient very closely who is receiving a class or subclass of medication that they have never had before. antibacterials come in broad spectrum and narrow spectrum. Broad Spectrum typically works against a couple of different types of bacteria. The types are gram negative and gram positive and narrow spectrum, typically you're working only against one organism. Broad spectrum antibiotics and narrow spectrum antibiotics are not one better than the other, it's really more finding out which one is the most appropriate, or which one, this particular pathogen is going to be sensitive to. In other words, which one of these is going to kill this sucker, right? That's the important thing to know, we find out which one is good for this bacteria by performing a test called a culture insensitivity. This culture is going to culture the bacteria. In other words, they're going to put it in a petri dish and grow it. But they are also going to do a sensitivity test. And that means they're going to take impregnated disks and put them in that petri dish and see which substance that was impregnated into the disk will stop that bacteria from growing near that disk. Now, I know that sounds really simple, but this is going to take a couple of days, because we're talking about a micro organism, waiting for it to grow enough that we can tell whether or not this impregnated disk, whatever substances on that one is going to work against it is going to take a couple of days, it can take many days, seven days even for them to be able to get these results back. That brings me to another important point for nursing students. When you receive orders to start an antibiotic and get a culture, you should always get the culture first when possible. So if you get an order to culture, a wound, and then start an antibiotic, you want to get your wound culture before you start your medication. Let's get into the nitty gritty of these antibacterials. Something that's important to know is that protein binding doesn't have a major influence on most antibacterial drugs, and that it's not going to reach that steady state for a couple of half lives. So after the fourth or fifth Half Life or even seventh, are we going to be able to maintain a steady state of medication? It's also important to think about resistance. Bacteria develop resistance to antibiotics. How does that happen? Well, some bacteria are naturally resistant or inherently resistant, Pseudomonas is inherently resistant to penicillin. That's just how it is. There's also a thing called acquired resistance. Acquired resistance means that this bacteria has previously been exposed to this antibacterial medication, and has learned how to not be affected by it. That happens because antibiotics are given for infections that are not bacterial infections. Most of the time, a cold or even a sore throat is not caused by a bacteria. It's also caused by not finishing the full course of the antibiotics or skipping doses not taking them correctly forgetting doses, let's be frank, the more times you have to remember to take a medication and the more days in a row you have to take it, the more likely you are to skip miss, or just plain forget to take them. Unfortunately, this has become a big problem nowadays. And I don't know about you, but I have no desire to go back to the days when we did not have antibiotics. This is one of the important things for nurses to educate their patients on. When you take an antibiotic, you should take it as directed. And you should take the full course even if you feel better after three days and you have seven days worth of antibiotic, you need to take them all. Otherwise, that's how you get Merci, y'all. We might also see cross sensitivity where a bacteria becomes resistant to one medication. And because those this medication and another one have very similar actions, it's cross resistant to the other medication as well. This is something we might think about with penicillins and cephalosporins. Just like we might think about that cross sensitivity with those two medications. Antibacterial medications have three big things that you need to think about when you're administering them. The three big adverse reactions are going to be an allergy or hypersensitivity reaction. This can be anything from a mild rash to hives and itching to anaphylactic shock. Again, that typically happens within the first 15 to 20 minutes. So that's when you want to keep a close eye on your patient. Super infection is the next thing we think about. This is a secondary infection when the antibacterial that you take is wiping out your normal flora and disrupting the normal balance of normal flora. And so we have an organism that can cause an infection, this is often going to be a Proteus as Pseudomonas staphylococcus. Sometimes Candida likes to jump in there and cause infection like thrush or a yeast infection. So that's what a super infection is. The other one that we see is C. diff. Clostridium difficile, you'll see a lot of your antibiotics will have a side effect of C D A. D, Clostridium difficile associated diarrhea. The last of the three big side effects to think about in general with antibacterials is organ toxicity. Most of the time we're talking about liver and kidneys. Sometimes this can be ears, sometimes it can be eyes, mostly with the antibacterials its liver, kidneys, and ears. I think almost everyone knows that penicillins are the first category of antibacterials that were widely available beginning in like 1945. In World War two penicillins are not even broad spectrum penicillins broadly effective against all kinds of bacteria, like they once thought they were penicillin G when given intramuscularly can be painful, so it's good to mix an anaesthetic with it. If it's possible, you'll need to check your drug guide. Unfortunately, some bacteria have beta lactamase, which can pretty quickly inactivate penicillins There are some things that we can do for that, we might have some beta lactamase inhibitors mixed with our penicillin, amoxicillin clavulanic acid is an example of a beta lactamase inhibitor and we combine that with amoxicillin in the form of a medication with a brand name of augmentin is amoxicillin and clavulanic acid that's given by mouth and the clavulanic acid inhibits the beta lactamase that would break down the antibiotic, which means that the antibiotic amoxicillin has an extended antimicrobial effect. It's more effective because it's not being broken down piperacillin tazobactam is the same sort of combination of beta lactamase inhibitor and antibacterial This one is given intravenously. This is something that we get very commonly in the hospital. If you see the jokes about it on tick tock or someplace, it's because it just seems like it takes forever to reconstitute the medication comes in a vial and it's in a powder form which makes it last longer on the shelf and we reconstitute it with the piggyback bag, the little 100 milliliter bag of normal saline. It just seems like it takes forever for it to dissolve. So you'll see funny jokes on tick tock about that sometimes many of your antibacterials can cause GI distress, which is anorexia, vomiting, nausea, diarrhea, these can be alleviated somewhat by advising our patients to take their antibacterials with food, it's also going to be important for you to let your patients know if they're using oral contraceptives. penicillins can decrease the effectiveness so if they're using them as an oral contraceptive, they probably should choose some other additional form of contraception. One of the antibacterial subclasses is macrolides. These medications are Clarithromycin erythromycin and azithromycin, which is that Z Pak you may be familiar with. These are actually not really secreted in the urine, and so we don't have to worry about our patients renal sufficiency as much. vancomycin is a very commonly administered medication or antibacterial. It's from the subclass glyco peptides. This is the treatment of choice most of the time for Mersa, which is methicillin resistant Staphylococcus aureus, things that are important to know about vancomycin is that it can cause nephrotoxicity and ototoxicity. It can also cause problems with balance because of damage to the vestibular branch of cranial nerve eight Redman syndrome. It's also called red neck syndrome, characterized by red blotching on the upper torso and face neck arms back. This is a reaction that is usually caused by administering the vancomycin too quickly to litho myosin has some unique effects in that it can cause visual disturbance and can actually cause an exacerbation of myasthenia gravis tetracycline shouldn't be given to children younger than eight because it can cause discoloration of their permanent teeth and it can cause photosensitivity. And when you think of photo sensitivity, this doesn't mean oh my gosh, the sun's so bright today. This means you're going to burn super fast and easy and it could be a severe burn just from going out in the sun. You want to make sure you educate your patient to use protective clothing. Avoid sun exposure, using sunblock and of course wearing sunglasses. Milk, iron containing medications and antacids can interfere with your tetracycline absorption. We also have the fluoroquinolones which are Ciprofloxacin and level FlexiSign. moxifloxacin levofloxacin especially can cause tendon rupture tendinitis, peripheral neuropathy, and an exacerbation of myasthenia gravis level FlexiSign can also increase the effects of oral hypoglycemics are medications that are taken by type two diabetics to lower their blood sugar. So you should keep an eye on your patient's blood sugars to make sure they don't go too low. Some of the most important things to keep in mind when you're thinking about administering antibacterial medications. Is your patient allergic? Is your patient potentially going to experience cross sensitivity? Does your patient seem to be demonstrating resolution of signs and symptoms of their infection making sure that we understand some of the very common side effects we can see. So we're monitoring our patients, B un and creatinine for their kidney function alts T for their liver functions, monitoring their complete blood counts because for example, sulfonamides can cause hemolytic anemias and low white blood cells we want to make sure that we know the specific side effects like level FlexiSign can cause tendon rupture. vancomycin can cause Redmon syndrome anaphylaxis is going to happen within 15 to 20 minutes and that patient is going to need epinephrine when bronchodilators into histamines because of that allergic reaction. Knowing that antibacterial medications are very commonly going to cause GI distress switches, anorexia, nausea, vomiting, diarrhea. I've heard a lot of providers educate their patients to take probiotics or eat yogurt when they're taking an antibacterial to try to help restore that normal flora. While they're taking it. Of course, you'll want to know those very specific side effects. And we want to make sure that we know about peak and trough levels, some of these medications have a very narrow therapeutic index, meaning there's not much room between minimum effective concentration and toxic concentration. So we need to monitor these medications by monitoring their blood levels, they're going to monitor the peak, which is the highest concentration of medication in the blood, usually when you're administering it, and the trough, which is the lowest concentration in the blood, which is typically right before you administer the medication. Again, typically, if you need to get a peak level, you're going to draw that 45 to 60 minutes after administration. If you need to trough level, you're going to draw that blood minutes before you start the next dose of medication. I really like the way that my current facility handles these trough levels, especially you draw the trough and the medication is do I in the past, I've worked in facilities where we draw the trough, send it to the lab boy for the lab to process it, wait for the pharmacy to take a look at it. And then tell us whether or not to hang the medicine. Now we draw the level and go ahead and hang the medicine and the pharmacy will adjust the dose for the following dose. That way the patient doesn't have any delay in medication that they continue to receive their medication. Now I still watch for those trough levels to come back. And should they ever be high knock on wood they never have been, should they ever be high, then I would hold the medication and I would communicate with the pharmacy to see what I should what I should do next or how we should proceed. Finally, making sure that you're educating your patients to take their full course of antibiotics and how important that is in preventing resistance and making sure that they get better, even if they feel better. Making sure that your patient understands not to keep antibiotics or take antibiotics that were prescribed for another condition because not all antibacterials work for all organisms. And hand washing is still the number one way to prevent infection transmission, at least in the hospital, probably everywhere else. So wash your hands for 20 seconds, two rounds of Happy Birthday, Twinkle, twinkle little star, whatever you want to sing ABCs is fine. And that's all I got for you for today. I hope you enjoyed this trip through antibacterials. Tune in next week for a two for one. I'm going to cover antifungals antivirals and we're going to talk about diabetes. I hope you have a great week this week. Tune in let me know hit me up on social media. there's anything you'd like me to cover, and I'll see you next time on nursing with Dr. Hobbick.