Name of the Carbapenem Drugs
- Doribax(Doripenem)
- Ertapenem (Invanz)
- Imipenem/cilastatin/Primaxin
- Meropenem/vaborbactam
- Merrem IV
- Sulopenem etzadroxil/probenecid (pending FDA approval)
1.Doribax (Doripenem)
| Doribax (Doripenem) |
| Availability Powder for reconstitution for infusion: 500 mg single-use vials |
| Indications and dosages Complicated intra-abdominal infections caused by Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Bacteroides caccae, Bacteroides fragilis, Bacteroides thetaiotaomicron, Bacteroides uniformis, Bacteroides vulgatus, Streptococcus intermedius, Streptococcus constellatus, and Peptostreptococcus micros; complicated urinary tract infections (UTIs), such as pyelonephritis caused by E. coli (including cases with concurrent bacteremia), K. pneumoniae, Proteus mirabilis, P. aeruginosa, and Acinetobacter baumannii Adults ages 18 and older: 500 mg q 8 hours by I.V. infusion over 1 hour; continue for 5 to 14 days for complicated intra-abdominal infections and 10 days for complicated UTIs, with possible extension to 14 days for patients with concurrent bacteremia |
Mechanism of Action
Inhibits cell wall synthesis in susceptible bacteria. Doripenem inactivates multiple penicillin-binding proteins essential in cell wall synthesis to cause cell death.
Administration
- Don’t use constituted suspension for direct injection; dilute further before giving by I.V. infusion.
- To prepare 500-mg dose, constitute vial with 10 ml sterile water for injection or normal saline solution for injection, and shake gently to form suspension; resulting concentration is 50 mg/ml. Withdraw suspension using syringe with 21G needle, and add it to infusion bag containing 100 ml normal saline solution or 5% dextrose; shake gently until clear. Final infusion solution concentration is 4.5 mg/ml.
- To prepare 250-mg dose, constitute vial with 10 ml sterile water for injection or normal saline solution for injection, and shake gently to form suspension. Resulting concentration is 50 mg/ml. Withdraw suspension using syringe with 21G needle and add it to infusion bag containing 100 ml normal saline solution for injection or 5% dextrose; shake gently until clear. Remove 55 ml of this solution from bag and discard. Infuse remaining solution, which contains 250 mg (4.5 mg/ml). To prepare infusions in Baxter Minibag Plus infusion bags, see infusion bag manufacturer’s instructions.
- Know that infusion solutions range from clear and colorless to clear and slightly yellow. Color variations within this range don’t affect product potency.
- Don’t mix with or physically add to solutions containing other drugs.
- Don’t administer by inhalation.
Contraindications
- Serious hypersensitivity to drug or other carbapenems
- History of anaphylactic reactions to beta-lactams
Precautions:
- renal impairment
- pregnant or breastfeeding patients
- children (safety and efficacy not established).
Adverse reactions
- CNS: headache
- CV: phlebitis
- GI: nausea, diarrhea, oral candidiasis, Clostridium difficile–associated diarrhea
- GU: vulvomycotic infection
- Hematologic: anemia
- Respiratory: pneumonitis (with inhalation use)
- Skin: rash, allergic or bullous dermatitis, erythema, macular and papular eruptions, urticaria, erythema multiforme
- Other: hypersensitivity reactions (including anaphylaxis)
Patient monitoring
- Closely monitor patient for diarrhea.
- If allergic reaction occurs, discontinue drug and intervene for serious anaphylactic reactions by giving epinephrine and taking other emergency measures as ordered and needed, including oxygen, I.V. fluids and antihistamines, corticosteroids, pressor amines, and airway management.
- Monitor renal function in patients with moderate to severe renal impairment.
Patient teaching
- Tell patient to immediately report rash, diarrhea, or difficulty breathing.
- 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
- Use cautiously in patients with a history of hypersensitivity to cephaloporins or penicillins because cross sensitivity may occur.
- Constitute vial with 10 ml sterile water for injection or normal saline solution and gently shake to form a suspension. Withdraw suspension using a syringe with a 21G needle and add it to an infusion bag containing 100 ml normal saline solution or 5% dextrose. Gently shake until clear. If administering reduced dosage of 250 mg, remove 55 ml of prepared solution from infusion bag and discard before infusion.
- Be aware that upon constitution, suspension in the vial must be diluted within 1 hour. Once drug is diluted in infusion solution, drug stored at room temperature must be used within 8 hours if mixed in normal saline solution and within 4 hours if mixed in 5% dextrose. If infusion solution is refrigerated, it must be used within 24 hours or discarded
- Monitor patient closely for evidence of hypersensitivity, especially if patient has multiple allergies, because serious and occasionally fatal hypersensitivity reactions have occurred in patients receiving beta-lactam antibiotics. If an allergic reaction occurs, discontinue drug immediately, notify prescriber, and expect to administer emergency treatment such as epinephrine, oxygen, I.V. fluids, I.V. antihistamines, corticosteroids, and pressor amines, as ordered, and provide airway management.
- Assess patient’s bowel pattern daily; severe diarrhea may be caused by Clostridium difficile. If suspected, expect to stop drug and provide treatment as prescribed.
2.Ertapenem (Invanz)
| Ertapenem (Invanz) |
| Availability Powder for infusion (lyophilized): 1 g/vial |
| Indications and dosages Community-acquired pneumonia; skin infections; complicated genitourinary (GU) infections; complicated intra-abdominal infections; acute pelvic infections Adults and children older than age 13: 1 g I.M. or I.V. daily. Length of treatment varies with type of infection: community-acquired pneumonia, 10 to 14 days; skin and skin structures, 7 to 14 days; GU, 10 to 14 days; intra-abdominal, 5 to 14 days; acute pelvic, 3 to 10 days. Children age 3 months to 12 years: 15 mg/kg twice daily (not to exceed 1 g/day). May be given by I.V. infusion for up to 14 days or I.M. injection for up to 7 days. Prophylaxis of surgical site infection in elective colorectal surgery Adults: 1 g I.V. as single dose given 1 hour before surgical incision |
Mechanism of Action
Inhibits bacterial cell wall synthesis by binding to specific penicillin-binding proteins inside the cell wall. Penicillin-binding proteins are responsible for various steps in bacterial cell wall synthesis. By binding to these proteins, ertapenem leads to bacterial cell wall lysis.
Pharmacokinetics
- Bioavailability: IM, 90%
- Peak plasma time: IM, 2.3 hr
- Protein bound (concentration dependent): 300 mcg/mL, 85%; <100 mcg/mL, 95%
- Vd: 3 months-12 years, 0.2 L/kg; 13-17 years, 0.16 L/kg; adults, 0.12 L/kg
- Metabolism: Hydrolysed to inactive metabolite
- Half-life: 3 months-12 years, 2.5 hr; >12 years, 4 hr
- Excretion: Urine (80% as unchanged drug and metabolite), feces (10%)
Administration
- Reconstitute for I.V. use by adding to vial 10 ml of sterile or bacteriostatic water or normal saline for injection. Don’t use diluents containing dextrose.
- Further dilute reconstituted drug in 50 ml of normal saline solution; infuse over 30 minutes. Don’t mix or infuse with other drugs.
- Reconstitute for I.M. use by adding 3.2 ml of 1% lidocaine to vial and shaking well.
- Inject I.M. dose deep into large muscle mass, such as gluteus maximus or lateral thigh.
Contraindications
- Hypersensitivity to drug, its components, other carbapenems, or beta-lactams
- I.M. injection in patients allergic to lidocaine or other amide local anesthetics
Precautions:
- seizure disorder
- pregnant or breastfeeding patients
- children (not recommended in infants younger than age 3 months).
Adverse reactions
- CNS: headache, dizziness, asthenia, fatigue, insomnia, altered mental status, anxiety,seizures
- CV: hypotension, hypertension, chest pain, phlebitis, thrombophlebitis, arrhythmias, heart failure
- EENT: pharyngitis
- GI: nausea, vomiting, diarrhea, constipation, abdominal pain, dyspepsia, gastroesophageal reflux disease, pseudomembranous colitis
- GU: vaginitis Hepatic: hepatotoxicity
- Respiratory: crackles, cough, dyspnea, wheezing, respiratory distress
- Skin: rash, erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrolysis
- Other: fever, pain, induration, and inflammation at I.V. site; edema; hypersensitivity reactions including anaphylaxis
Patient monitoring
- Monitor vital signs, ECG, and cardiovascular status closely. Stay alert for arrhythmias, edema, respiratory distress, and other signs and symptoms of heart failure.
- Assess neurologic status and watch for signs of impending seizure.
- Monitor bowel pattern and stay alert for signs and symptoms of pseudomembranous colitis.
- Inspect injection site for evidence of thrombophlebitis and induration.
- Watch for indications of erythema multiforme (sore throat, rash, cough, iris lesions, mouth sores, fever). Report early signs before condition progresses to Stevens-Johnson syndrome, and stay alert for other hypersensitivity reactions (including anaphylaxis)
Patient teaching
- Tell patient to notify nurse right away if drug causes pain or swelling at injection site.
- Inform patient that drug can be toxic to many organ systems. Tell him to promptly report significant adverse reactions.
- Tell female patient to inform prescriber of pregnancy or breastfeeding before taking drug.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs mentioned above.
Nursing Considerations
- Obtain sputum, urine, or other specimens for culture and sensitivity testing, as ordered, before giving ertapenem. Expect to start therapy before results are available.
- When preparing drug for I.V. use, reconstitute 1 g with 10 ml of sterile water for injection, 0.9% sodium chloride injection, or bacteriostatic water for injection. Don’t use solutions that contain dextrose. Shake well to dissolve. Immediately transfer reconstituted drug to 50 ml normal saline solution. Use within 6 hours if stored at room temperature, 24 hours if refrigerated at 5° C (41° F). Don’t freeze. Give I.V. infusion over 30 minutes.
- Inspect drug for particles and discoloration after reconstitution.
- For I.M. injection, reconstitute 1 g of drug with 3.2 ml of 1% lidocaine hydrochloride injection (without epinephrine). Shake thoroughly to form solution. Use within 1 hour after preparation. Withdraw contents of vial and inject deep into a large muscle mass such as the gluteal muscle
- Monitor patient closely for a life-threatening anaphylactic reaction. Patients with a history of hypersensitivity to penicillin, cephalosporins, other beta-lactams, or other allergens are at increased risk.
- Be aware that patients with a history of seizures, other CNS disorders that predispose them to seizures (such as brain lesions), or compromised renal function may be at increased risk for seizures. Administer anticonvulsant, as ordered.
- Monitor patient for diarrhea during and for at least 2 months after drug therapy; diarrhea may signal pseudomembranous colitis caused by Clostridium difficile. If diarrhea occurs, notify prescriber and expect to withhold ertapenem and treat with fluids, electrolytes, protein, and an antibiotic effective against C. difficile.
- Be aware that because ertapenem is excreted in breast milk, its use by nursing mothers is carefully evaluated.
3.Imipenem/cilastatin
| Imipenem/cilastatin |
| Availability Powder for I.M. injection: 500 mg imipenem/500 mg cilastatin, 750 mg imipenem/750 mg cilastatin Powder for I.V. injection: 250 mg imipenem/250 mg cilastatin, 500 mg imipenem/500 mg cilastatin |
| Indications and dosages Lower respiratory tract infections, urinary tract infections, abdominal infections, gynecologic infections, skin infections, bone and joint infections, endocarditis, and polymicrobial infections Adults: For mild infections, 250 to 500 mg I.V. q 6 hours; for moderate infections, 500 mg I.V. q 6 to 8 hours or 1 g I.V. q 8 hours; for serious infections, 500 mg I.V. q 6 hours to 1 g q 6 to 8 hours or 500 to 750 mg I.M. q 12 hours Children: 15 to 25 mg/kg I.V. q 6 hours or 10 to 15 mg/kg I.M. q 6 hours Infants ages 4 weeks to 3 months: 25 mg/kg I.V. q 6 hours Infants ages 1 to 4 weeks: 25 mg/kg I.V. q 8 hours Infants age 1 week and younger: 25 mg/kg I.V. q 12 hours |
Mechanism of Action
Acts against many gram-positive and gram-negative organisms by binding to bacterial cell wall, causing cell death. Addition of cilastatin prevents renal inactivation of imipenem, resulting in increased urinary concentration. Imipenem resists actions of many enzymes that degrade most other penicillins and penicillin-like drugs.
Pharmacokinetics
- Protein bound: Imipenem, 13-21%; cilastatin, 40%
- Imipenem is metabolized in the kidney by dehydropeptidase 1; activity is blocked by cilastatin
- Half-life (both drugs): 60 min; prolonged with renal impairment
- Excretion (both drugs): Urine (~70% as unchanged drug)
Administration
- For I.V. use, reconstitute each 250- or 500-mg vial with 10 ml of diluent; shake well.
- For piggyback infusion, add 250- or 500-mg I.V. dose to 100 ml of diluent; shake solution until clear and drug has dissolved completely.
- Infuse doses of 500 mg or less over 20 to 30 minutes; infuse doses of 750 to 1,000 mg over 40 to 60 minutes.
- Slow infusion rate if patient experiences nausea, vomiting, dizziness or sweating.
- For I.M. use, inject into large muscle
Contraindications
Hypersensitivity to drug, penicillins, or cephalosporins
Precautions:
- seizure disorders, renal impairment
- history of multiple hypersensitivity reactions
- elderly patients
- pregnant or breastfeeding patients.
Adverse reactions
- CNS: dizziness, drowsiness, seizures
- CV: hypotension
- GI: nausea, vomiting, diarrhea, pseudomembranous colitis
- Hematologic: eosinophilia
- Skin: rash, pruritus, diaphoresis, urticaria
- Other: phlebitis at I.V. site, fever, superinfection, allergic reactions including anaphylaxis
Patient monitoring
- Stay alert for seizures in patients with brain lesions, head trauma, or other CNS disorders and in those receiving more than 2 g daily.
- Monitor closely for severe diarrhea and hypersensitivity reaction.
- Assess tissue or fluid culture results obtained before and during therapy.
- Monitor for signs and symptoms of infection, such as fever and elevated white blood cell count. Also evaluate for bacterial and fungal superinfection.
- Monitor electrolyte levels, especially sodium.
Patient teaching
- Caution patient to report discomfort at I.V. site.
- Instruct patient to report rash, hives, difficulty breathing, and signs or symptoms of superinfection (such as diarrhea, mouth sores, and vaginal itching or discharge).
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
4.Meropenem/vaborbactam
| Meropenem/vaborbactam |
| Availability Powder for injection: 500-mg and 1-g vials |
| Indications and dosages ➣ Intra-abdominal infections Adults: 1 g I.V. q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Children weighing 50 kg (110 lb) or more: 1 g I.V. q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Children ages 3 months and older weighing less than 50 kg (110 lb): 20 mg/kg q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection ➣ Bacterial meningitis Children weighing 50 kg (110 lb) or more: 2 g I.V. q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection Children ages 3 month and older weighing less than 50 kg (110 lb): 40 mg/kg q 8 hours over 15 to 30 minutes by infusion or over 3 to 5 minutes as a bolus injection, to a maximum of 2 g q 8 hours ➣ Complicated skin and skinstructure infections Adults: 500 mg I.V. q 8 hours |
Mechanism of Action
Penetrates cell walls of most gramnegative and gram-positive bacteria, inactivating penicillin-binding proteins. This action inhibits bacterial cell wall synthesis and causes cell death
Pharmacokinetics
- Protein bound: 2% (meropenem); 33% (vaborbactam)
- Vd: 20.2 L (meropenem); 18.6L (vaborbactam)
- Meropenem: Minor pathway for elimination is hydrolysis of the beta-lactam ring (meropenem open lactam), which accounts for 22% of a dose eliminated via the urine
- Vaborbactam: Does not undergo metabolism
- Clearance: 15.1 L/hr (meropenem); 10.8 L/hr (vaborbactam)
- Half-life: 1.22 hr (meropenem); 1.68 hr (vaborbactam)
- Excretion, urine over 24-48 hr: 40-60% (meropenem); 75-95% (vaborbactam)
- Excretion, feces: ~2% (meropenem)
Administration
- For I.V. bolus, add 10 or 20 ml of sterile water to 500-mg or 1-g vial, respectively, to yield a concentration of 50 mg/ml. Shake until clear. Administer single dose over 3 to 5 minutes.
- For intermittent I.V. infusion, piggyback vials can be reconstituted with compatible I.V. solution (0.9% sodium chloride or 5% dextrose) to yield a concentration of 2.5 to 50 mg/ml. Or vials can be reconstituted as for direct I.V. injection and added to compatible I.V. solution for further dilution. To reconstitute and administer ADDVantage systems, follow manufacturer’s instructions. Infuse drug over 15 to 30 minutes.
- Use diluted solution immediately, if possible
Contraindications
Hypersensitivity to drug, its components, or other beta-lactams
Precautions:
- sulfite sensitivity, renal disease, seizure disorder
- pregnant or breastfeeding patients
- children.
Adverse reactions
- CNS: headache, insomnia, dizziness, drowsiness, weakness, seizures
- CV: hypotension, phlebitis, palpitations, heart failure, cardiac arrest, myocardial infarction
- GI: nausea, vomiting, diarrhea, constipation, tongue discoloration, oral candidiasis, glossitis, pseudomembranous colitis
- GU: vaginal candidiasis
- Hematologic: anemia, eosinophilia, leukopenia, bone marrow depression, thrombocytopenia, neutropenia Musculoskeletal: myoclonus
- Respiratory: chest discomfort, dyspnea, hyperventilation
- Skin: rash, urticaria, pruritus, erythema at injection site
- Other: altered taste, fever, pain, fungal infection, anaphylaxis
Patient monitoring
- Collect specimens for culture and sensitivity testing as needed. However, be aware that drug therapy may start pending results. 2Monitor patient for hypersensitivity reaction or anaphylaxis. If either occurs, stop infusion immediately and initiate emergency treatment.
- Monitor for CNS irritability and seizures.
- In prolonged therapy, evaluate hematopoietic, renal, and hepatic function and watch for overgrowth of nonsusceptible organisms.
- If diarrhea occurs, check for pseudomembranous colitis and obtain stool cultures.
- Obtain hearing tests in child being treated for bacterial meningitis.
Patient teaching
Advise patient to report such adverse reactions as CNS irritability, diarrhea, rash, shortness of breath, or pain at infusion site. 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
- Obtain body fluid and tissue samples, as ordered, for culture and sensitivity testing. Expect to review test results, if possible, before giving first dose of meropenem.
- For I.V. bolus, add 10 ml sterile water for injection to 500 mg/20-ml vial, or 20 ml diluent to 1 g/30-ml vial of drug. Shake to dissolve.
- Monitor patient closely for diarrhea, which may indicate pseudomembranous colitis caused by Clostridium difficile. If diarrhea occurs, notify prescriber and expect to withhold meropenem and treat with fluids, electrolytes, protein, and an antibiotic effective against C. difficile.
- Take seizure precautions according to facility policy, especially for patients with bacterial meningitis or CNS or renal disorders because of an increased risk of seizures with meropenem.
- Monitor patient with creatinine clearance of 10 to 26 ml/min/1.73 m2 for signs and symptoms of seizures, heart failure, renal failure, or shock
5.Merrem IV
| Merrem IV |
| Availability powder for injectable solution 500mg/vial ,1g/vial |
| Indications and dosages Complicated Skin/Skin Structure Infections 500 mg IV q8hr; not to exceed 2 g IV q8hr Complicated Intra-abdominal Infections 1 g IV q8hr; not to exceed 2 g IV q8hr |
Contraindications
Hypersensitivity to IV components, beta-lactams, or other drugs in this class
Mechanism of Action
Inhibits cell-wall synthesis by binding to penicillin-binding proteins; resistant to most beta-lactamases
Pharmacokinetics
- Peak tissue time: 1 hr after infusion
- Distribution: Penetrates well into most body fluids and tissues; CSF concentrations approximate those in plasma
- Protein bound: 2%
- Vd: Adults, 15-20 L; children, 0.3-0.4 L/kg
- Metabolized in liver to open beta-lactam form (inactive)
- Half-life: Normal renal function, 1-1.5 hr; CrCl >30-80 mL/min, 1.9-3.3 hr; CrCl >2-30 mL/min, 3.82-5.7 hr
- Excretion: Urine (~25% as inactive metabolites)
Administration
IV Incompatibilities
Additive: Amphotericin B, metronidazole, multivitamins
Y-site: Amphotericin B, diazepam, metronidazole
IV Administration
Administer IV infusion over 15-30 minutes; administer IV bolus over 3-5 minutes
Adverse Reactions/Side Effects
- CNS: SEIZURES, dizziness, headache.
- Resp: APNEA.
- GI: PSEUDOMEMBRANOUS COLITIS, constipation, diarrhea, glossitis (increased in children), nausea, thrush (increased in children), vomiting.
- Derm: moniliasis (children only), pruritus, rash.
- Local: inflammation at injection site, phlebitis.
- Misc: ALLERGIC REACTIONS, INCLUDING ANAPHYLAXIS.
Precautions
- Caution in infants with impaired renal or hepatic function.
- Caution in infants with history of seizures.
6.Sulopenem etzadroxil/probenecid
| Sulopenem etzadroxil/probenecid |
| Availability Tablet 500mg/500mg |
| Indications and dosages Urinary Tract Infection 1 tablet (sulopenem etzadroxil 500 mg/probenecid 500 mg) PO BID x 5 days with food |
Mechanism of Action
Sulopenem etzadroxil
Orally available ester prodrug form of sulopenem, a thiopenem with broad-spectrum antibacterial activity against most gram-positive and gram-negative bacteria
Bactericidal activity results from inhibition of cell wall synthesis and is mediated through sulopenem binding to penicillin binding proteins
Probenecid
Renal tubular inhibitor
Probenecid inhibits OAT3-mediated renal clearance of sulopenem, resulting in increased plasma concentrations of sulopenem
Pharmacokinetics
Sulopenem etzadroxil
- •Bioavailability: 40% (fasted); 64% (fed)
- •Peak plasma time: 1 hr (fasted); 2 hr (fed)
- Effect of high fat meal
- Peak plasma concentration: Increased by 45%
- AUC: Increased by 48%
- Protein bound: 11%
- Vd: 134 L (fasted); 92.09 L (fed)
Sulopenem etzadroxil is hydrolyzed by esterases to active sulopenem, then further metabolized by hydrolysis followed by dehydrogenation
- Half-life: 1.18 hr (fasted); 1.28 hr (fed)
- Clearance: 77.6 L/hr (fasted); 50.55 L/hr (fed)
- Excretion: Feces 44.3% (26.9% unchanged); urine 40.8% (3.1% unchanged)
Probenecid
- Peak plasma time: 3 hr (fasted); 2 hr (fed)
- Effect of high fat meal
- Peak plasma concentration: Decreased by 27%
- AUC: Decreased by 8%
- Vd: 8.81L (fasted); 11.94 L (fed)
- Half-life: 2.93 hr (fasted); 3.83 hr (fed)
- Clearance: 2.06 L/hr (fasted); 2.22 L/hr (fed)
Administration
Oral Administration
Administer with food
Contraindications
- A history of hypersensitivity to sulopenem etzadroxil/probenecid or other beta-lactam antibiotics
- Known blood dyscrasias
- Known uric acid kidney stones
- Coadministration with ketorolac
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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