Name of the Antimicrobial Drugs that Inhibits cell wall synthesis
- Vancomycin
- Cycloserine
1.Vancomycin
| Vancomycin |
| Availability Capsules: 125 mg, 250 mg Powder for injection: 500-mg vial, 1-g vial, 5-g vial, 10 g-vial |
| Indications and dosages Severe, life-threatening infections caused by susceptible strains of methicillin-resistant staphylococci, Staphylococcus epidermidis, Streptococcus viridans or Streptococcus bovis (alone or combined with an aminoglycoside), or Enterococcus faecalis (combined with an aminoglycoside) Adults: 500 mg I.V. q 6 hours or 1 g I.V. q 12 hours Children: 10 mg/kg I.V. q 6 hours Infants and neonates: Initially, 15 mg/ kg I.V., followed by 10 mg/kg I.V. q 8 hours in infants 8 days to 1 month old, or 10 mg/kg I.V. q 12 hours in infants less than 8 days old Endocarditis prophylaxis in penicillin-allergic patients at moderate risk who are scheduled for dental and other invasive procedures Adults: 1 g I.V. slowly over 1 to 2 hours, with infusion completed 30 minutes before invasive procedure begins Children: 20 mg/kg I.V. over 1 to 2 hours, with infusion completed 30 minutes before invasive procedure begins Enterocolitis caused by Staphylococcus aureus Adults: 500 mg to 2 g P.O. daily in three or four divided doses for 7 to 10 days Children: 40 mg/kg P.O. daily in three or four divided doses for 7 to 10 days; total daily dose shouldn’t exceed 2 g. Clostridium difficile–associated diarrhea Adults: 125 mg P.O. q.i.d. for 10 days Children: 40 mg/kg P. O. in three or four divided doses for 7 to 10 days; total daily dose shouldn’t exceed 2 g. |
Mechanism of Action
Inhibits bacterial RNA and cell wall synthesis; alters permeability of bacterial membranes, causing cell wall lysis and cell death.
Pharmacokinetics
- Absorption: Poorly absorbed
- Metabolism: There is no apparent metabolism of the vancomycin
- Half-life: 4-6 hr (normal renal function); 7.5 days (anephric patients) Excretion: Urine (IV; 80-90% as unchanged drug); primarily feces (PO)
Administration
- Know that I.V. therapy is ineffective against enterocolitis and pseudomembranous diarrhea.
- For intermittent I.V. infusion, dilute by adding 10 or 20 ml of sterile water for injection to vial containing 500 mg or 1 g of drug, respectively, to yield a concentration of 50 mg/ml. Dilute further by adding at least 100 ml or 200 ml, respectively, of dextrose 5% in water or normal saline solution; infuse over at least 1 hour.
- Don’t give by I.M. route.
- Be aware that capsules aren’t systemically absorbed; therefore, oral therapy is ineffective in infections other than C. difficile–associated diarrhea and enterocolitis caused by S. aureus.
- Keep emergency equipment and epinephrine on hand in case of anaphylaxis.
Contraindications
Hypersensitivity to drug
Precautions :
- Renal impairment, preexisting hearing loss
- Concurrent use of anesthetics, immunosuppressants, or nephrotoxic or ototoxic drugs
- Elderly patients
- Pregnant or breastfeeding patients
- Neonates.
Adverse reactions
- CV: hypotension, cardiac arrest, vascular collapse
- EENT: permanent hearing loss, ototoxicity, tinnitus
- GI: nausea, vomiting, abdominal pain, pseudomembranous colitis
- GU: nephrotoxicity, severe uremia
- Hematologic: eosinophilia, leukopenia, neutropenia
- Metabolic: hypokalemia
- Respiratory: wheezing, dyspnea
- Skin: “red man” syndrome (nonallergic histamine reaction with rapid I.V. infusion), rash, urticaria, pruritus, necrosis Other: chills, fever, thrombophlebitis at injection site, anaphylaxis
Patient monitoring
- Monitor closely for signs and symptoms of hypersensitivity reactions, including anaphylaxis.
- Check drug blood level weekly. Therapeutic peak ranges from 30 to 40 g/L; therapeutic trough, 5 to 10 mg/L.
- Assess BUN and creatinine levels every 2 days, or daily in patients with unstable renal function.
- Monitor urine output daily. Weigh patient at least weekly.
- Assess hearing before and during therapy; stay alert for hearing loss.Patient may require baseline and weekly audiograms. Check I.V. site often for phlebitis.
- Watch for “red-man” syndrome, which can result from rapid infusion. Signs and symptoms include hypotension, pruritus, and maculopapular rash on face, neck, trunk, and limbs.
- Monitor CBC. Watch for signs and symptoms of blood dyscrasias.
- Closely monitor respiratory status. Stay alert for wheezing and dyspnea.
- Monitor vital signs and cardiovascular status, especially for vascular collapse and other signs of impending cardiac arrest
Patient teaching
- Tell patient he may take with or without food.
- Instruct patient to take oral drug exactly as prescribed for as long as prescribed, even if symptoms improve.
- Explain importance of prophylactic I.V. therapy to patients at risk for endocarditis who are scheduled for invasive procedures.
- Advise patient to promptly report rash, hearing loss, breathing problems, and signs and symptoms of “red-man” syndrome, nephrotoxicity, and blood dyscrasias.
- 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
- To reconstitute 500-mg vial of vancomycin for I.V. use, add 10 ml of sterile water for injection; further dilute with at least 100 ml of compatible I.V. solution. For 1-g vial of dry, sterile powder, add 20 ml of sterile water for injection; further dilute with at least 200 ml of compatible I.V. solution.
- Monitor blood vancomycin levels, as ordered; therapeutic levels are 10 to 15 mcg/ ml trough and 30 to 40 mcg/ml peak.
- Monitor serum vancomycin concentration in patients with renal impairment or colitis because significant increases in blood drug level have occurred in such patients taking multiple oral doses of vancomycin.
- If patient has an inflammatory intestinal disorder, assess him often for adverse reactions because vancomycin absorption may be increased in these conditions.
- Check CBC results and serum creatinine and BUN levels during therapy, especially if patient has renal impairment or takes an aminoglycoside.
- Observe I.V. infusion site for evidence of extravasation, including necrosis, pain, tenderness, and thrombophlebitis. If extravasation occurs, discontinue infusion immediately and notify prescriber.
- Assess hearing during therapy. Transient or permanent ototoxicity may occur if patient receives an excessive amount of drug, has an underlying hearing loss, or receives concurrent aminoglycosides.
- Monitor patient closely for diarrhea because it may indicate pseudomembranous colitis aused by Clostridium difficile, a risk with many antibiotics. If diarrhea occurs during therapy, notify prescriber and expect to withhold drug. If confirmed, treat with fluids, electrolytes, protein, and an antibiotic effective against C. difficile
2.Cycloserine
| Cycloserine |
| Availability Capsules: 25 mg, 100 mg Injection: 50 mg/ml Oral solution: 100 mg/ml Solution (ophthalmic): 0.05% (0.4 ml in 0.9 ml single-use vial) |
| Indications and dosages Psoriasis Adults: Neoral only—1.25 mg/kg P.O. b.i.d. for 4 weeks. Based on patient response, may increase by 0.5 mg/kg/day once q 2 weeks, to a maximum dosage of 4 mg/kg/day. Severe active rheumatoid arthritis Adults: Neoral only—1.25 mg/kg P.O. b.i.d. May adjust dosage by 0.5 to 0.75 mg/kg/day after 8 weeks and again after 12 weeks, to a maximum dosage of 4 mg/kg/day. If no response occurs after 16 weeks, discontinue therapy. Gengraf only—2.5 mg/kg P.O. daily given in two divided doses; after 8 weeks, may increase to a maximum dosage of 4 mg/kg/day To prevent organ rejection in kidney, liver, or heart transplantation Adults and children: Sandimmune only—Initially, 15 mg/kg P.O. 4 to 12 hours before transplantation, then daily for 1 to 2 weeks postoperatively. Reduce dosage by 5% weekly to a maintenance level of 5 to 10 mg/kg/day. Or 5 to 6 mg/kg I.V. as a continuous infusion 4 to 12 hours before transplantation. To increase tear production in patients whose tear production is presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca Adults: 1 drop in each eye b.i.d. given 12 hours apart |
Mechanism of Action
Causes immunosuppression by inhibiting the proliferation of T lymphocytes, the production and release of lymphokines, and the release of interleukin-2.
Pharmacokinetics
- Absorption: 70-90%
- Metabolism: Hepatic
- Half-life: 10 hr (normal renal function)
- Peak plasma serum: 4-8 hr
- Excretion: Urine (60 to 70%)
Administration
- For I.V. infusion, dilute as ordered with dextrose 5% in water or 0.9% normal saline solution. Administer over 2 to 6 hours.
- Mix Neoral solution with orange juice or apple juice to improve its taste.
- Dilute Sandimmune oral solution with milk, chocolate milk, or orange juice. Be aware that grapefruit and grapefruit juice affect drug metabolism.
- In postoperative patients, switch to P.O. dosage as tolerance allows.
- Be aware that Sandimmune and Neoral aren’t bioequivalent. Don’t use interchangeably.
- Before administering eyedrops, invert unit-dose vial a few times to obtain a uniform, white, opaque emulsion.
- Know that eyedrops can be used concomitantly with artificial tears, allowing a 15-minute interval between products.
Contraindications
- Hypersensitivity to drug and any ophthalmic components
- Rheumatoid arthritis, psoriasis in patients with abnormal renal function, uncontrolled hypertension, cancer (Gengraf, Neoral)
- Active ocular infections (ophthalmic use)
Precautions:
- Hepatic impairment, renal dysfunction, active infection, hypertension
- Herpes keratitis (ophthalmic use)
- Pregnant or breastfeeding patients
- Children younger than age 16 (safety and efficacy not established for ophthalmic use).
Adverse reactions
- CNS: tremor, headache, confusion, paresthesia, insomnia, anxiety, depression, lethargy, weakness
- CV: hypertension, chest pain, myocardial infarction
- EENT: visual disturbances, hearing loss, tinnitus, rhinitis; (with ophthalmic use) ocular burning, conjunctival hyperemia, discharge, epiphora, eye pain, foreign body sensation, itching, stinging, blurring
- GI: nausea, vomiting, diarrhea, constipation, abdominal discomfort, gastritis, peptic ulcer, mouth sores, difficulty swallowing, anorexia, upper GI bleeding, pancreatitis
- GU: gynecomastia, hematuria, nephrotoxicity, renal dysfunction, glomerular capillary thrombosis
- Hematologic: anemia, leukopenia, thrombocytopenia
- Metabolic: hyperglycemia, hypomagnesemia, hyperuricemia, hyperkalemia, metabolic acidosis
- Musculoskeletal: muscle and joint pain Respiratory: cough, dyspnea, Pneumocystis jiroveci pneumonia, bronchospasm
- Skin: acne, hirsutism, brittle fingernails, hair breakage, night sweats
- Other: gum hyperplasia, flulike symptoms, edema, fever, weight loss, hiccups, anaphylaxis
Patient monitoring
- Observe patient for first 30 to 60 minutes of infusion. Monitor frequently thereafter.
- Monitor cyclosporine blood level, electrolyte levels, and liver and kidney function test results.
- Assess for signs and symptoms of hyperkalemia in patients receiving concurrent potassium-sparing diuretic.
Patient teaching
- Advise patient to dilute Neoral oral solution with orange or apple juice (preferably at room temperature) to improve its flavor.
- Instruct patient to use glass container when taking oral solution. Tell him not to let solution stand before drinking, to stir solution well and then drink all at once, and to rinse glass with same liquid and then drink again to ensure that he takes entire dose.
- Tell patient taking Neoral to avoid high-fat meals, grapefruit, and grapefruit juice.
- Advise patient to dilute Sandimmune oral solution with milk, chocolate milk, or orange juice to improve its flavor.
- Instruct patient to invert vial a few times to obtain a uniform, white, opaque emulsion before using eyedrops and to discard vial immediately after use.
- Inform patient that eyedrops can be used with artificial tears but to allow 15-minute interval between products.
- Caution patient not to wear contact lenses because of decreased tear production; however, if contact lenses are used, advise patient to remove them before administering eyedrops and to reinsert 15 minutes after administration.
- Inform patient that he’s at increased risk for infection. Caution him to avoid crowds and exposure to illness.
- Instruct patient not to take potassium supplements, herbal products, or dietary supplements without consulting prescriber.
- Tell patient he’ll need to undergo repeated laboratory testing during therapy.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and herbs mentioned above
Nursing Considerations
- Monitor blood cycloserine level, as appropriate. Blood level should be maintained at 25 to 30 mcg/ml.
- Monitor mental status, mood, and affect for aggression or depression.
- Monitor CBC to detect blood dyscrasias.
- To prevent injury from falls, take safety precautions if adverse CNS reactions, such as dizziness or drowsiness, develop
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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