Anti-bacterial drugs used in the integumentary system target skin infections by inhibiting bacterial growth or destroying pathogens, commonly applied topically to treat conditions like impetigo, cellulitis, and minor wounds with agents such as bacitracin, mupirocin, and neomycin.
Name of the Anti-Bacterial drugs
- Gentamicin sulfate
- Neomycin sulfate
- Polymyxin B
- Silver sulfadiazine
| Gentamicin sulfate |
| Availability: Cream: 0.1% Injection: 10 mg/ml (pediatric), 40 mg/ ml (adult) I.V. infusion (premixed in normal saline solution): 40 mg, 60 mg, 70 mg, 80 mg, 90 mg, 100 mg, 120 mg Ointment: 0.1% Ointment (ophthalmic): 0.3% (base) Solution (ophthalmic): 0.3% (base) |
| Indication & dosage Serious infections caused by Pseudomonas aeruginosa, Escherichia coli, and Proteus, Klebsiella, Serratia, Enterobacter, Citrobacter, or Staphylococcus species Adults: 3 mg/kg/day in three divided doses I.M. or I.V. infusion q 8 hours. For life-threatening infections, up to 5 mg/kg/day in three to four divided doses; reduce to 3 mg/kg/day as indicated. Children: 2 to 2.5 mg/kg q 8 hours I.M. or I.V. infusion Infants older than 1 week: 2.5 mg/kg q 8 hours I.M. or I.V. infusion Neonates younger than 1-week, preterm infants: 2.5 mg/kg q 12 hours I.M. or I.V. infusion. In preterm infants of less than 32 weeks’ gestational age, 2.5 mg/kg q 18 hours or 3 mg/kg q 24 hours also may produce satisfactory peak and trough blood levels. |
| Endocarditis prophylaxis before surgery Adults: 1.5 mg/kg I.M. or I.V. 30 minutes before surgery, to a maximum of 80 mg. As prescribed, give with ampicillin or vancomycin. Children: 2 mg/kg I.M. or I.V. 30 minutes before surgery, to a maximum of 80 mg |
| External ocular infections caused by susceptible organisms Adults and children: One to two drops of ophthalmic solution in eye q 4 hours. For serious infections, up to two drops q hour, or ophthalmic ointment applied to lower conjunctival sac two to three times daily |
| Treatment and prevention of superficial burns caused by susceptible bacteria Adults and children older than age 1: Gently rub small a amount of drug topically on affected area three or four times daily. |
| Mechanism of Action : Binds to negatively charged sites on the outer cell membrane of bacteria, thereby disrupting the membrane’s integrity. Gentamicin also binds to bacterial ribosomal subunits and inhibits protein synthesis. Both actions lead to cell death. |
Contraindications
Hypersensitivity to drug or other aminoglycosides
Administration:
- Before starting therapy, obtain specimens as needed for culture and sensitivity testing.
- For I.V. infusion, dilute with 50 to 200 ml of dextrose 5% in water (D5W) or normal saline solution, and administer over 30 minutes to 2 hours.
- After infusion, flush line with normal saline solution or D5W.
- Obtain peak drug blood level 30 minutes after 30-minute infusion; obtain trough level within 30 minutes of next scheduled dose.
- Give cephalosporin or parenteral penicillin 1 hour before or after gentamicin, as prescribed
- Know that for topical treatment of burns, gauze dressings may be applied
Metabolism & Elimination
Absorption: peak plasma time: IM (30-90min);iv (30 min after 30-min infusion)
Half-life :2-3 hr (NRF)
Renal clearance: Directly related to renal function
Excretion: Urine (70% recovered as unchanged drug in patient with NRF)
Precautions:
Neuromuscular disease, renal impairment, hearing impairment
- sulfite sensitivity (with parenteral use)
- obese patients
- elderly patients
- pregnant or breastfeeding patients
- infants, neonates, and premature infants.
Adverse reactions
CNS: dizziness, vertigo, tremors, numbness, depression, confusion, lethargy, headache, paraesthesia, neuromuscular blockade, seizures, neurotoxicity EENT: visual disturbances, dry eyes, nystagmus, photophobia, ototoxicity, hearing loss, tinnitus
GI: nausea, vomiting, stomatitis, increased salivation, splenomegaly, anorexia
GU: increased urinary casts, polyuria, dysuria, erectile dysfunction, azotaemia, nephrotoxicity
Hematologic: eosinophilia, leukemoid reaction, haemolytic anaemia, aplastic anaemia, neutropenia, agranulocytosis, leukopenia, thrombocytopenia, pancytopenia Hepatic: hepatomegaly, hepatotoxicity, hepatic necrosis
Musculoskeletal: joint pain, muscle twitching
Respiratory: apnea
Skin: exfoliative dermatitis, rash, pruritus, urticaria, purpura, alopecia
Other: weight loss, superinfection, pain and irritation at I.M. injection site
Patient monitoring
- Watch for signs and symptoms of hypersensitivity reactions.
- Know that drug blood level monitoring is especially important in therapy lasting more than 5 days, acute or chronic renal impairment, extracellular fluid volume changes, obesity, infants younger than 3 months, concomitant use of nephrotoxic drugs, patients requiring higher doses or dosage interval adjustments (such as those with cystic fibrosis, endocarditis, or critical illness), and patients with signs or symptoms of nephrotoxicity or ototoxicity.
- Assess fluid intake and output, urine specific gravity, and urinalysis for signs of nephrotoxicity.
- Monitor CBC, BUN, creatinine level, and creatinine clearance.
- Weigh patient regularly.
- Assess for signs and symptoms of ototoxicity (hearing loss, tinnitus, ataxia, and vertigo).
Patient teaching
- Teach patient to recognize and immediately report signs and symptoms of hypersensitivity reaction, infection, unusual tiredness, yellowing of skin or eyes, and muscle twitching.
- Advise patient to report signs and symptoms of ototoxicity (hearing loss, ringing in ears, vertigo).
- Instruct patient to drink plenty of fluids to ensure adequate urine output.
- Tell patient to monitor urine output and report significant changes.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
Nursing Considerations
- Before gentamicin therapy begins, expect to obtain a body fluid or tissue specimen for culture and sensitivity testing, as ordered, or check test results, if available.
- Drug is best absorbed when given by I.V. route. Blood level is unpredictable after I.M. administration.
- For I.V. use, dilute each dose with 50 to 200 ml normal saline solution or D5W to yield no more than 1 mg/ml. Administer slowly over 30 to 60 minutes.
- Don’t give gentamicin through same I.V. line as other drugs without first consulting pharmacist.
- Expect to adjust dosage based on peak and trough blood drug levels drawn after third maintenance dose, as prescribed.
- Don’t give gentamicin by subcutaneous route because it may be painful.
- When assisting with intrathecal injection, use only 2 mg/ml of preservative-free preparation. Drug may be injected directly or delivered by implanted reservoir.
- Don’t give drug to pregnant patient because it can cause hearing loss in fetus
| Neomycine sulfate |
| Availability: Ointment: 0.5% Oral solution: 125 mg/5 ml Tablets: 500 mg |
| Indication & dosage Preoperative intestinal antisepsis Adults: 1 g P.O. q hour for four doses, then 1 g q 4 hours for 24 hours or 1 g at 19 hours, 18 hours, and 9 hours before surgery |
| Hepatic encephalopathy Adults: 4 to 12 g/day P.O. in divided doses |
| Superficial bacterial infections Ø Adults: Apply ointment topically one to five times daily |
| Mechanism of Action : Is transported into bacterial cells, where it competes with messenger RNA to bind with a specific receptor protein on the 30S ribosomal subunit of DNA. This action causes abnormal, nonfunctioning proteins to form. A lack of functional proteins causes bacterial cell death |
| Contraindications Hypersensitivity to drug or other aminoglycosides Intestinal obstruction |
Administration:
Give preoperative dose before bowel surgery, after cathartic administration, as ordered.
Metabolism & Elimination
Half-life :3 hr
Peak plasma time: oral 1-4 hr; im 2 hr
Absorption: oral, percutaneous: poor (3%)
Metabolism: slightly hepatic
Excretion
Feces :97% of oral dose as unchanged drug
Urine :30-50% of absorbed drug as unchanged drug
Precautions:
renal impairment, neuromuscular diseases (such as myasthenia gravis), hearing impairment
- obese patients
- elderly patients
- pregnant or breastfeeding patients
- children under age 18 (safety not established)
Adverse reactions
CNS: neuromuscular blockade
EENT: ototoxicity (with prolonged, high-dose use)
GI: nausea, vomiting, diarrhoea, malabsorption syndrome
GU: nephrotoxicity (with prolonged, high-dose use)
Other: superinfection
Patient monitoring
- Assess for neuromuscular blockade, ototoxicity, and nephrotoxicity.
- Monitor kidney function tests.
Patient teaching
- Instruct patient to drink plenty of water.
- Tell patient to complete full course of therapy.
- Inform patient that drug may cause muscle weakness.
- Instruct patient to report hearing problems and change in urination pattern.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects neuromuscular status.
- Tell patient he’ll undergo frequent blood testing during therapy.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs mentioned above.
Nursing Considerations
- Be aware that 15 mg oral neostigmine bromide is equivalent to 0.5 mg parenteral neostigmine methylsulfate.
- If also giving atropine, be sure to administer it before neostigmine, as prescribed.
- When giving neostigmine I.V., make sure patient is well ventilated and airway remains patent until normal respiration is assured.
- If patient has myasthenia gravis, give drug night and day, as ordered, with larger portions of daily dose during periods of increased fatigue. If patient’s condition becomes refractory to neostigmine, expect to reduce dosage or discontinue drug, as prescribed, for a few days.
| Polymyxin B |
| Availability: IV: 15,000-25,000 units/kg/day divided q12hr; not to exceed 25,000 units/kg/day IM: 25,000-30,000 units/kg/day divided q4-6hr |
| Indication & dosage To treat infections resistant to less toxic drugs, such as bacteremia, septicemia, and UTI caused by susceptible organisms, including Enterobacter aerogenes, Escherichia coli, Haemophilus influenzae, and Klebsiella pneumoniae ØI.V. INFUSION Adults and children age 2 and over. 15,000 to 25,000 units/kg daily in divided doses every 12 hr or as a continuous infusion. Maximum: 2 million units daily. Infants and children under age 2. Up to 40,000 units/kg daily in divided doses every 12 hr or as a continuous infusion. ØI.M. INJECTION Adults and children age 2 and over. 25,000 to 30,000 units/kg daily in divided doses every 4 to 6 hr. Maximum: 2 million units daily. Infants and children under age 2. Up to 40,000 units/kg daily in divided doses every 4 to 6 hrs |
| To prevent bacteriuria and bacteremia in patients with an indwelling catheter BLADDER IRRIGATION Adults and children age 2 and over. Combination of 200,000 units (20 mg) polymyxin B sulfate and 57 mg neomycin sulfate added to 1,000 ml normal saline solution daily as a continuous bladder irrigation for up to 10 days |
| To treat meningitis caused by susceptible strains of Pseudomonas aeruginosa or H. influenzae INTRATHECAL INJECTION Adults and children age 2 and over. 50,000 units daily for 3 to 4 days, then 50,000 units every other day for at least 2 wk after CSF cultures are negative and glucose content is normal. Infants and children under age 2. 20,000 units daily for 3 to 4 days, then 25,000 units every other day for at least 2 wk after CSF cultures are negative and glucose content is normal. |
| Mechanism of Action : Binds to cell membrane phospholipids in gram-negative bacteria, increasing permeability of cell membrane. Polymyxin B also acts as a cationic detergent, altering osmotic barrier of membrane and causing essential intracellular metabolites to leak out. Both actions lead to cell death. |
Contraindications
Hypersensitivity to polymyxin B or its components
Administration:
Administer intrathecally or intraventricularly for treatment of meningitis or other CNS infections. Do not use IV or IM administration alone for treatment of meningitis or other CNS infections since distribution into CNS is expected to be low following these routes.
Metabolism & Elimination
Half –life elimination: 4.3-6 hr with normal renal function
Metabolism: N/A
Excretion: urine 60% (<1% as unchanged drug )
Precautions:
- Kidney disease
- Stomach ulcer or abdominal pain
Adverse Reactions
CNS: Ataxia, confusion, dizziness, drowsiness, fever, giddiness, headache, increased leukocyte and protein levels in CSF, neurotoxicity, paraesthesia (circumoral or peripheral), slurred speech
CV: Thrombophlebitis
EENT: Blurred vision, nystagmus
GU: Albuminuria, azotaemia, cylindruria, decreased urine output, haematuria, nephrotoxicity
HEME: Eosinophilia
RESP: Respiratory muscle paralysis
SKIN: Rash, urticaria
Other: Anaphylaxis, drug-induced fever, facial flushing, injection site pain, stiff neck (with intrathecal injection), superinfection
PATIENT TEACHING
- Encourage patient to maintain adequate fluid intake during polymyxin B therapy.
- Instruct patient to notify prescriber at once about diarrhea, mouth sores, or vaginitis, possible early signs of superinfection.
Nursing Considerations
- Be aware that patients receiving polymyxin B sulfate are hospitalized to allow appropriate supervision.
- Obtain blood, urine, or other samples for culture and sensitivity tests, as ordered, before giving drug. Expect to start drug before results are known. Keep in mind that baseline renal function tests should have been performed before administration. Check test results, if available, and notify prescriber of abnormalities.
- For I.M. injection, reconstitute sterile powder with 2 ml of sterile water for injection or sodium chloride for injection.
- Be aware that I.M. route isn’t usually recommended (especially for infants and children) because it can cause severe pain at injection site.
- For I.V. infusion, dissolve polymyxin B in 300 to 500 ml of D5W and infuse over 60 to 90 minutes.
- For intrathecal route, add 10 ml sodium chloride for injection to polymyxin B vial.
- Inspect for particles and discoloration before giving drug.
- During therapy, monitor renal function, including BUN and serum creatinine levels, especially in patients with a history of renal insufficiency.
| Silver sulfadiazine |
| Availability: Cream :1% Burn Wound Infections (2°/3°) 1% cream: Apply to thickness of 1/16 inch qDay-q12hr to burn |
| Indication & dosage Burn Wound Infections (2°/3°) 1% cream: Apply to thickness of 1/16 inch qDay-q12hr to burn |
| Mechanism of Action : Topical silver sulfadiazine kills certain types of bacteria by affecting their cell wall or membrane. |
| Contraindications •Sulfa allergy. •G6PD deficiency. •Hypersensitivity. •Suflanomides may increase possibility of kernicterus; therefore, do not use during near-term pregnancy, in premature infants, or in infants below age 2 months |
| Administration : Only topical formulations have approval for use by the United States Food and Drug Administration. Most formulations contain 1% silver sulfadiazine. Care is necessary to avoid the periocular region and mucosal surfaces when applying the medication, as research has shown that eye irritation and mucosal absorption can occur. Silver sulfadiazine application should be performed with sterile equipment and minimal trauma to the tissue |
| Metabolism & Elimination Absorption Peak plasma time :3-11 days Half life :10 hr Excreation : urine (50%) |
Precautions:
- If hepatic and renal functions become impaired and elimination of drug decreases, accumulation may occur and discontinuation of SILVADENE Cream 1% (silver sulfadiazine) should be weighed against the therapeutic benefit being achieved.
- In considering the use of topical proteolytic enzymes in conjunction with SILVADENE Cream 1%, the possibility should be noted that silver may inactivate such enzymes.
- SILVADENE Cream 1% (silver sulfadiazine) is for topical use only. Avoid contact of SILVADENE Cream 1% (silver sulfadiazine) with the eye.
Adverse Reactions/Side Effects
Derm: burning, itching, pain, rash, skin discoloration, skin necrosis.
Hemat: leukopenia
Indications
- Prophylaxis and treatment of infections
ofin severe burns - Treatment of infections in leg ulcers
Nursing Considerations
- Before applying this medicine, clean the affected areas. Remove dead or burned skin and other debris.
- Wear sterile gloves to apply this medicine. Apply a thin layer (about 1/16 inch) of silver sulfadiazine to the affected areas. Keep the affected areas covered with the medicine at all times.
- If this medicine is rubbed off the affected areas by moving around or if it is washed off during bathing, showering, or the use of a whirlpool bath, reapply the medicine.
- After this medicine has been applied, the treated areas may be covered with a dressing or left uncovered as desired.
REFERENCES
- Robert Kizior, Keith Hodgson, Saunders Nursing Drug handbook,1st edition 2024, Elsevier Publications. ISBN-9780443116070
- McGraw Hill- Drug Handbook, Seventh Edition, 2013, McGraw Hill Education Publications,9780071799430.
- April Hazard, Cynthia Sanoski, Davi’s Drug Guide for Nurses -Sixteenth Edition 2019, FA Davis Company Publications,9780803669451.
- Jones and Bartlet, Pharmacology for Nurses, Second Edition, 2020, Jones and Bartlet Learning Publications, ISBN 9781284141986.
- Nursebro.com, Search – Nursebro
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