Antibacterials

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Nursing considerations for patients taking antibacterial medications. 

Episode Transcript

Stacey Hobbick (00:00):
Hey and welcome to nursery with Dr. Hobbick.

(00:02):
Today, I'm thinking about antiinfective and thinking about
medications that we take to helpus when a pathogen is causing
trouble. There's a couple ofdifferent types of anti
infective, they're not allantibacterials. So first we're
going to talk about thoseantibacterial medications. These

(00:25):
are medications that either arebacterial Seidel, or bacterial
static. Bacterial Seidel meansexactly what it sounds like.
It's a bacteria killer.
Bacterial static means that themedication inhibits bacterial
growth. If we have a medicationthat is killing bacteria, or

(00:46):
inhibiting their growth, I thinkthe biggest misconception is
that you're going to start tofeel better as soon as you start
to take the antibiotic. In truthor in reality, it's going to
take a couple of days before youstart to feel better, because we
can stop the bacteria. But youstill have damage all that

(01:06):
damage that caused your symptomsthat has to be cleared up things
that we need to know aboutantibacterials 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 administerthese medications to someone who
is allergic to them, it's notokay to administer to someone

(01:28):
who is hypersensitive. So it'simportant to know that
penicillins and cephalosporinscan have a little bit of cross
sensitivity. The research showsthat there's about 10% of people
who are allergic to penicillinare also allergic to
cephalosporins. If a patient ishypersensitive, in other words,

(01:49):
allergic to an antibiotic, likeanaphylaxis, then we usually see
that reaction within 15 or 30minutes, it can happen up to two
hours later, but usually it'swithin that first 15 or 30
minutes, then it is importantfor a nurse to monitor a patient
very closely who is receiving aclass or subclass of medication

(02:11):
that they have never had before.
antibacterials come in broadspectrum and narrow spectrum.
Broad Spectrum typically worksagainst a couple of different
types of bacteria. The types aregram negative and gram positive
and narrow spectrum, typicallyyou're working only against one
organism. Broad spectrumantibiotics and narrow spectrum

(02:35):
antibiotics are not one betterthan the other, it's really more
finding out which one is themost appropriate, or which one,
this particular pathogen isgoing to be sensitive to. In
other words, which one of theseis going to kill this sucker,
right? That's the importantthing to know, we find out which

(02:57):
one is good for this bacteria byperforming a test called a
culture insensitivity. Thisculture is going to culture the
bacteria. In other words,they're going to put it in a
petri dish and grow it. But theyare also going to do a
sensitivity test. And that meansthey're going to take

(03:17):
impregnated disks and put themin that petri dish and see which
substance that was impregnatedinto the disk will stop that
bacteria from growing near thatdisk. Now, I know that sounds
really simple, but this is goingto take a couple of days,
because we're talking about amicro organism, waiting for it

(03:37):
to grow enough that we can tellwhether or not this impregnated
disk, whatever substances onthat one is going to work
against it is going to take acouple of days, it can take many
days, seven days even for themto be able to get these results
back. That brings me to anotherimportant point for nursing

(03:58):
students. When you receiveorders to start an antibiotic
and get a culture, you shouldalways get the culture first
when possible. So if you get anorder to culture, a wound, and
then start an antibiotic, youwant to get your wound culture

(04:18):
before you start yourmedication. Let's get into the
nitty gritty of theseantibacterials. Something that's
important to know is thatprotein binding doesn't have a
major influence on mostantibacterial drugs, and that
it's not going to reach thatsteady state for a couple of
half lives. So after the fourthor fifth Half Life or even

(04:41):
seventh, are we going to be ableto maintain a steady state of
medication? It's also importantto think about resistance.
Bacteria develop resistance toantibiotics. How does that
happen? Well, some bacteria arenaturally resistant or
inherently resistant,Pseudomonas is inherently

(05:02):
resistant to penicillin. That'sjust how it is. There's also a
thing called acquiredresistance. Acquired resistance
means that this bacteria haspreviously been exposed to this
antibacterial medication, andhas learned how to not be
affected by it. That happensbecause antibiotics are given

(05:24):
for infections that are notbacterial infections. Most of
the time, a cold or even a sorethroat is not caused by a
bacteria. It's also caused bynot finishing the full course of
the antibiotics or skippingdoses not taking them correctly
forgetting doses, let's befrank, the more times you have

(05:46):
to remember to take a medicationand the more days in a row you
have to take it, the more likelyyou are to skip miss, or just
plain forget to take them.
Unfortunately, this has become abig problem nowadays. And I
don't know about you, but I haveno desire to go back to the days

(06:07):
when we did not haveantibiotics. This is one of the
important things for nurses toeducate their patients on. When
you take an antibiotic, youshould take it as directed. And
you should take the full courseeven if you feel better after
three days and you have sevendays worth of antibiotic, you
need to take them all.
Otherwise, that's how you getMerci, y'all. We might also see

(06:28):
cross sensitivity where abacteria becomes resistant to
one medication. And becausethose this medication and
another one have very similaractions, it's cross resistant to
the other medication as well.
This is something we might thinkabout with penicillins and

(06:49):
cephalosporins. Just like wemight think about that cross
sensitivity with those twomedications. Antibacterial
medications have three bigthings that you need to think
about when you're administeringthem. The three big adverse
reactions are going to be anallergy or hypersensitivity
reaction. This can be anythingfrom a mild rash to hives and

(07:12):
itching to anaphylactic shock.
Again, that typically happenswithin the first 15 to 20
minutes. So that's when you wantto keep a close eye on your
patient. Super infection is thenext thing we think about. This
is a secondary infection whenthe antibacterial that you take
is wiping out your normal floraand disrupting the normal

(07:32):
balance of normal flora. And sowe have an organism that can
cause an infection, this isoften going to be a Proteus as
Pseudomonas staphylococcus.
Sometimes Candida likes to jumpin there and cause infection
like thrush or a yeastinfection. So that's what a

(07:53):
super infection is. The otherone that we see is C. diff.
Clostridium difficile, you'llsee a lot of your antibiotics
will have a side effect of C DA. D, Clostridium difficile
associated diarrhea. The last ofthe three big side effects to
think about in general withantibacterials is organ
toxicity. Most of the time we'retalking about liver and kidneys.

(08:17):
Sometimes this can be ears,sometimes it can be eyes, mostly
with the antibacterials itsliver, kidneys, and ears. I
think almost everyone knows thatpenicillins are the first
category of antibacterials thatwere widely available beginning
in like 1945. In World War twopenicillins are not even broad

(08:42):
spectrum penicillins broadlyeffective against all kinds of
bacteria, like they once thoughtthey were penicillin G when
given intramuscularly can bepainful, so it's good to mix an
anaesthetic with it. If it'spossible, you'll need to check
your drug guide. Unfortunately,some bacteria have beta

(09:04):
lactamase, which can prettyquickly inactivate penicillins
There are some things that wecan do for that, we might have
some beta lactamase inhibitorsmixed with our penicillin,
amoxicillin clavulanic acid isan example of a beta lactamase

(09:24):
inhibitor and we combine thatwith amoxicillin in the form of
a medication with a brand nameof augmentin is amoxicillin and
clavulanic acid that's given bymouth and the clavulanic acid
inhibits the beta lactamase thatwould break down the antibiotic,
which means that the antibioticamoxicillin has an extended

(09:47):
antimicrobial effect. It's moreeffective because it's not being
broken down piperacillintazobactam is the same sort of
combination of beta lactamaseinhibitor and antibacterial This
one is given intravenously. Thisis something that we get very
commonly in the hospital. If yousee the jokes about it on tick

(10:08):
tock or someplace, it's becauseit just seems like it takes
forever to reconstitute themedication comes in a vial and
it's in a powder form whichmakes it last longer on the
shelf and we reconstitute itwith the piggyback bag, the
little 100 milliliter bag ofnormal saline. It just seems
like it takes forever for it todissolve. So you'll see funny

(10:31):
jokes on tick tock about thatsometimes many of your
antibacterials can cause GIdistress, which is anorexia,
vomiting, nausea, diarrhea,these can be alleviated somewhat
by advising our patients to taketheir antibacterials with food,
it's also going to be importantfor you to let your patients

(10:51):
know if they're using oralcontraceptives. penicillins can
decrease the effectiveness so ifthey're using them as an oral
contraceptive, they probablyshould choose some other
additional form ofcontraception. One of the
antibacterial subclasses ismacrolides. These medications

(11:12):
are Clarithromycin erythromycinand azithromycin, which is that
Z Pak you may be familiar with.
These are actually not reallysecreted in the urine, and so we
don't have to worry about ourpatients renal sufficiency as
much. vancomycin is a verycommonly administered medication
or antibacterial. It's from thesubclass glyco peptides. This is

(11:36):
the treatment of choice most ofthe time for Mersa, which is
methicillin resistantStaphylococcus aureus, things
that are important to know aboutvancomycin is that it can cause
nephrotoxicity and ototoxicity.
It can also cause problems withbalance because of damage to the

(11:59):
vestibular branch of cranialnerve eight Redman syndrome.
It's also called red necksyndrome, characterized by red
blotching on the upper torso andface neck arms back. This is a
reaction that is usually causedby administering the vancomycin

(12:20):
too quickly to litho myosin hassome unique effects in that it
can cause visual disturbance andcan actually cause an
exacerbation of myastheniagravis tetracycline shouldn't be
given to children younger thaneight because it can cause
discoloration of their permanentteeth and it can cause

(12:41):
photosensitivity. And when youthink of photo sensitivity, this
doesn't mean oh my gosh, thesun's so bright today. This
means you're going to burn superfast and easy and it could be a
severe burn just from going outin the sun. You want to make
sure you educate your patient touse protective clothing. Avoid
sun exposure, using sunblock andof course wearing sunglasses.

(13:04):
Milk, iron containingmedications and antacids can
interfere with your tetracyclineabsorption. We also have the
fluoroquinolones which areCiprofloxacin and level
FlexiSign. moxifloxacinlevofloxacin especially can
cause tendon rupture tendinitis,peripheral neuropathy, and an

(13:28):
exacerbation of myastheniagravis level FlexiSign can also
increase the effects of oralhypoglycemics are medications
that are taken by type twodiabetics to lower their blood
sugar. So you should keep an eyeon your patient's blood sugars
to make sure they don't go toolow. Some of the most important

(13:48):
things to keep in mind whenyou're thinking about
administering antibacterialmedications. Is your patient
allergic? Is your patientpotentially going to experience
cross sensitivity? Does yourpatient seem to be demonstrating
resolution of signs and symptomsof their infection making sure
that we understand some of thevery common side effects we can

(14:10):
see. So we're monitoring ourpatients, B un and creatinine
for their kidney function alts Tfor their liver functions,
monitoring their complete bloodcounts because for example,
sulfonamides can cause hemolyticanemias and low white blood
cells we want to make sure thatwe know the specific side

(14:33):
effects like level FlexiSign cancause tendon rupture. vancomycin
can cause Redmon syndromeanaphylaxis is going to happen
within 15 to 20 minutes and thatpatient is going to need
epinephrine when bronchodilatorsinto histamines because of that
allergic reaction. Knowing thatantibacterial medications are

(14:57):
very commonly going to cause GIdistress switches, anorexia,
nausea, vomiting, diarrhea. I'veheard a lot of providers educate
their patients to takeprobiotics or eat yogurt when
they're taking an antibacterialto try to help restore that
normal flora. While they'retaking it. Of course, you'll
want to know those very specificside effects. And we want to

(15:21):
make sure that we know aboutpeak and trough levels, some of
these medications have a verynarrow therapeutic index,
meaning there's not much roombetween minimum effective
concentration and toxicconcentration. So we need to
monitor these medications bymonitoring their blood levels,
they're going to monitor thepeak, which is the highest

(15:43):
concentration of medication inthe blood, usually when you're
administering it, and thetrough, which is the lowest
concentration in the blood,which is typically right before
you administer the medication.
Again, typically, if you need toget a peak level, you're going
to draw that 45 to 60 minutesafter administration. If you
need to trough level, you'regoing to draw that blood minutes

(16:06):
before you start the next doseof medication. I really like the
way that my current facilityhandles these trough levels,
especially you draw the troughand the medication is do I in
the past, I've worked infacilities where we draw the
trough, send it to the lab boyfor the lab to process it, wait
for the pharmacy to take a lookat it. And then tell us whether

(16:28):
or not to hang the medicine. Nowwe draw the level and go ahead
and hang the medicine and thepharmacy will adjust the dose
for the following dose. That waythe patient doesn't have any
delay in medication that theycontinue to receive their
medication. Now I still watchfor those trough levels to come
back. And should they ever behigh knock on wood they never

(16:51):
have been, should they ever behigh, then I would hold the
medication and I wouldcommunicate with the pharmacy to
see what I should what I shoulddo next or how we should
proceed. Finally, making surethat you're educating your
patients to take their fullcourse of antibiotics and how
important that is in preventingresistance and making sure that
they get better, even if theyfeel better. Making sure that

(17:13):
your patient understands not tokeep antibiotics or take
antibiotics that were prescribedfor another condition because
not all antibacterials work forall organisms. And hand washing
is still the number one way toprevent infection transmission,
at least in the hospital,probably everywhere else. So

(17:33):
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 gotfor you for today. I hope you
enjoyed this trip throughantibacterials. Tune in next
week for a two for one. I'mgoing to cover antifungals
antivirals and we're going totalk about diabetes. I hope you

(17:56):
have a great week this week.
Tune in let me know hit me up onsocial media. there's anything
you'd like me to cover, and I'llsee you next time on nursing
with Dr. Hobbick.