Name of the Antimicrobial Drugs which Interfere with intermediary Metabolism
- Sulfonamides
- Trimethoprim
- Pyrimethamine
- Para amino salicylic acid
- Metronidazole
1.Sulfonamides
| Sulfonamides |
| Availability Tablet ,500mg, Load, 2-4 g PO Maintenance 2-4 g/day divided 3-6x/day PO |
| Indications and Dosages To treat asymptomatic carriers of meningitis TABLETS Adults and adolescents. 1 g every 12 hr for 2 days. Children ages 1 to 12. 500 mg every 12 hr for 2 days. Children ages 2 to 12 months. 500 mg daily for 2 days. To prevent recurrent rheumatic fever TABLETS Adults and adolescents. 500 mg daily (for patients weighing less than 30 kg [66 lb]) to 1 g daily (for patients weighing 30 kg or more). To treat inclusive nocardiosis TABLETS Adults and adolescents. 4 to 8 g daily for at least 6 wk. As adjunct to treat toxoplasmosis in patients with AIDS TABLETS Adults and adolescents. 1 to 2 g every 6 hr, with 50 to 100 mg daily of pyrimethamine and 10 to 25 mg daily of leucovorin. Children age 2 months and over. 50 mg/kg b.i.d. for 12 mo, together with 2 mg/kg daily of pyrimethamine for 2 days, then 1 mg/kg/day of pyrimethamine for 2 to 6 mo, then 1 mg/kg daily of pyrimethamine 3 times/wk for remainder of 12 mo; in addition, 5 mg of leucovorin given 3 times/ wk for 12 mo. Maximum: 6 g daily. To treat toxoplasmosis in pregnant women after week 16 of gestation TABLETS Adults. 1 g every 6 hr, together with 25 mg daily of pyrimethamine and 5 to 15 mg daily of leucovorin. |
Mechanism of Action
Inhibits para-aminobenzoic acid, a bacterial enzyme responsible for synthesizing folic acid, which susceptible bacteria require for growth. By inactivating bacteria, sulfadiazine prevents or alleviates infection.
Pharmacokinetics
- Absorption: well absorbed
- Distribution: sulfadiazine is distributed into most body tissues; appears to cross cell membranes freely; at a plasma concentration of 100 mcg/mL
- Protein Bound: approximately 32-56%
- Elimination: largely in urine; urinary concentrations usually are 10-25 times those attained in serum
Contraindications
Breastfeeding; hypersensitivity to sulfadiazine, its components, or other chemically related drugs, such as sulfonamides; pregnancy at term
Adverse Reactions
- CNS: Dizziness, fatigue, fever, headache, lethargy, weakness
- EENT: Pharyngitis
- GI: Anorexia, diarrhea, dysphagia, nausea, vomiting
- GU: Crystalluria
- HEME: Agranulocytosis, aplastic anemia, hemolytic anemia, leukopenia, thrombocytopenia, unusual bleeding or bruising
- MS: Arthralgia, myalgia
- SKIN: Blisters, erythema, jaundice, pallor, photosensitivity, pruritus, rash
- Other: Drug-induced fever
Nursing Considerations
- Use sulfadiazine cautiously in patients with blood dyscrasias or megaloblastic anemia from folate deficiency because drug may cause blood dyscrasias; in those with G6PD deficiency because hemolysis may occur; in those with hepatic or renal impairment because of increased risk of toxicity; and in those with porphyria because drug may precipitate an acute attack.
- Obtain blood sample for CBC and body tissue or fluid specimen for culture and sensitivity tests, as ordered, before giving drug. Expect first dose to be given before results are available.
- Monitor fluid intake and output during therapy. Altered fluid balance may increase risk of crystalluria.
- Frequently monitor blood glucose level, and assess for signs and symptoms of hypoglycemia in patients who take an oral antidiabetic drug. Be prepared to respond if hypoglycemia develops.
Patient Teaching
- Instruct patient to take sulfadiazine exactly as prescribed and to complete the full course even if he feels better.
- Advise patient to take drug with a full glass of water and to drink plenty of fluids during therapy.
- Urge patient to notify prescriber if urine turns reddish brown; this may indicate crystalluria.
- Inform patient about possible dizziness, and urge him to avoid potentially hazardous activities until drug’s CNS effects are known.
- Advise patient to avoid prolonged exposure to sunlight and to wear sunscreen and protective clothing when outdoors.
- Urge patient who takes oral contraceptives to use an additional method of birth control during therapy.
- Advise patient who takes an oral antidiabetic drug to check his blood glucose level frequently because of the increased risk of hypoglycemia during therapy
2.Trimethoprim
| Availability Injection: 80 mg/ml sulfamethoxazole and 16 mg/ml trimethoprim Suspension: 200 mg sulfamethoxazole and 40 mg trimethoprim/5 ml Tablets: 400 mg sulfamethoxazole and 80 mg trimethoprim (single strength); 800 mg sulfamethoxazole and 160 mg trimethoprim (double strength) |
| Indications and dosages ➣ Urinary tract infections caused by susceptible organisms Adults: One double-strength tablet or two single-strength tablets or 20 ml suspension P.O. q 12 hours for 10 to 14 days Children ages 2 months and older: 40 mg/kg sulfamethoxazole and 8 mg/ kg trimethoprim P.O. q 12 hours for 10 days ➣ Severe urinary tract infections caused by susceptible organisms Adults and children ages 2 months and older: 8 to 10 mg/kg (based on trimethoprim component) I.V. q 6, 8, or 12 hours for up to 14 days ➣ Shigellosis caused by susceptible strains of Shigella flexneri or Shigella sonnei Adults: One double-strength tablet or two single-strength tablets or 20 ml suspension P.O. q 12 hours for 10 to 14 days. Alternatively, 8 to 10 mg/kg (based on trimethoprim component) I.V. q 6, 8, or 12 hours for 5 days. Children ages 2 months and older: 40 mg/kg (sulfamethoxazole) and 8 mg/ kg (trimethoprim) P.O. q 12 hours for 5 days. Alternatively, 8 to 10 mg/kg (based on trimethoprim component) I.V. q 6, 8, or 12 hours for up to 5 days. ➣ Acute exacerbation of chronic bronchitis caused by susceptible strains of Streptococcus pneumoniae or Haemophilus influenzae Adults: One double-strength tablet or two single-strength tablets or 20 ml suspension P.O. q 12 hours for 10 to 14 days ➣ Pneumocystis jiroveci pneumonia Adults and children older than 2 months: 75 to 100 mg/kg (sulfamethoxazole) and 15 to 20 mg/kg (trimethoprim) P.O. daily in equally divided doses q 6 hours for 14 to 21 days. Alternatively, 15 to 20 mg/kg (based on trimethoprim component) I.V. q 6 to 8 hours for up to 14 days. Prophylaxis of P. jiroveci pneumonia Adults: One double-strength tablet P.O. daily Children ages 2 months and older: 750 mg/m2 (sulfamethoxazole) and 150 mg/m2 (trimethoprim) P.O. b.i.d. in equally divided doses on 3 consecutive days each week. Total dosage should not exceed 1,600 mg sulfamethoxazole and 320 mg trimethoprim. Traveler’s diarrhea caused by susceptible strains of enterotoxigenic Escherichia coli Adults: One double-strength tablet or two single-strength tablets or 20 ml suspension q 12 hours for 5 days Acute otitis media caused by susceptible strains of S. pneumoniae or H. influenzae Children ages 2 months and older: 40 mg/kg sulfamethoxazole and 8 mg/kg trimethoprim P.O. q 12 hours for 10 days |
Mechanism of Action
Inhibits para-aminobenzoic acid, a bacterial enzyme responsible for synthesizing folic acid, which susceptible bacteria require for growth. By inactivating bacteria, sulfamethoxazole prevents or alleviates infection.
Pharmacokinetics
- Time to peak: 1-4 hours
- Protein bound: TMP (44%); SMX (70%)
- Metabolism: Hepatic
- Half-life: TMP (8-10 hr); SMX (10 hr)
- Excretion: Urine (as unchanged drug)
Administration
- Dilute each 5 ml of I.V. drug in 125 ml of dextrose 5% in water.
- Infuse I.V. over 60 to 90 minutes. Avoid rapid infusion.
- Don’t mix with other drugs or solutions. Don’t refrigerate. Use within 6 hours after dilution.
Contraindications
- Hypersensitivity to sulfonamides, trimethoprim, sulfonylureas, thiazides, or loop diuretics
- Porphyria
- Marked renal or hepatic impairment
- Megaloblastic anemia caused by folate deficiency
- Pregnancy at term or when premature birth is possible
- Infants younger than 2 months (except in P. jiroveci pneumonia prophylaxis)
Precautions:
- Urinary obstruction, renal or hepatic disease, bronchial asthma, G6PD deficiency, group A beta-hemolytic streptococcal infection, blood dyscrasias
- History of multiple allergies
- Elderly patients
- Pregnant (before term) or breastfeeding patients
- Children.
Adverse reactions
- CNS: headache, depression, hallucinations, insomnia, drowsiness, fatigue, apathy, anxiety, ataxia, vertigo, polyneuritis, peripheral neuropathy, seizures
- CV: allergic myocarditis or pericarditis
- EENT: periorbital edema, optic neuritis, transient myopia, tinnitus
- GI: nausea, vomiting, abdominal pain, stomatitis, glossitis, dry mouth, pancreatitis, anorexia, pseudomembranous colitis GU: hematuria, proteinuria, crystalluria, toxic nephrosis with oliguria and anuria, renal failure
- Hematologic: megaloblastic anemia, agranulocytosis, aplastic anemia, thrombocytopenia, leukopenia, hemolytic anemia
- Hepatic: jaundice, hepatitis, hepatocellular necrosis
- Respiratory: shortness of breath, pleuritis, allergic pneumonitis, pulmonary infiltrates, fibrosing alveolitis
- Skin: generalized skin eruption, urticaria, pruritus, alopecia, local irritation, exfoliative dermatitis, photosensitivity reaction, epidermal necrolysis, erythema multiforme, Stevens-Johnson syndrome
- Other: irritation at I.V. site, chills, drug fever, hypersensitivity reactions including anaphylaxis, serum sickness, lupus-like syndrome
Patient monitoring
- Monitor CBC with white cell differential. Watch for evidence of blood dyscrasias.
- Stay alert for erythema multiforme. Report early signs before condition can progress to Stevens-Johnson syndrome.
- Monitor patient for signs and symptoms of superinfection, including fever, tachycardia, and chills.
- Monitor liver function tests and assess for evidence of hepatitis.
- Check kidney function tests weekly. Evaluate patient’s fluid intake, urine output, and urine pH. Report hematuria, oliguria, or anuria right away.
- Monitor neurologic status. Report seizures, hallucinations, or depression.
Patient teaching
- Advise patient to take on regular schedule as prescribed, along with a full glass of water. Tell him to drink plenty of fluids to minimize crystal formation in urine.
- If suspension is prescribed, make sure patient has a specially marked measuring spoon or other device so he can measure doses accurately.
- Instruct patient to complete full course of treatment even if he starts to feel better. 2Teach patient to recognize and immediately report signs and symptoms of hypersensitivity, especially rash. 2Inform patient that drug can cause blood disorders, GI and liver problems, serious skin reactions, and other infections. Describe key warning signs and symptoms (easy bruising or bleeding, severe diarrhea, unusual tiredness, yellowing of skin or eyes, sore throat, rash, cough, mouth sores, fever). Tell him to report these right away. 2Urge patient to promptly report scant or bloody urine or inability to urinate.
- Tell patient to contact prescriber if he develops depression.
- Teach patient effective ways to counteract photosensitivity effect. Advise him that dong quai and St. John’s wort increase phototoxicity risk and should be avoided during therapy.
- Advise female patient to inform prescriber if she is pregnant. Tell her not to take drug near term.
- Caution female patient not to breastfeed, because she could pass drug effects to infant.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, herbs, and behaviors mentioned above.
Nursing Considerations
- Use sulfamethoxazole cautiously in patients with blood dyscrasias or megaloblastic anemia from folate deficiency because drug may cause blood dyscrasias; in those with G6PD deficiency because hemolysis may occur; in those with hepatic or renal impairment because of increased risk of toxicity; and in those with porphyria because drug may precipitate an acute attack
- Obtain blood sample for CBC and body tissue or fluid specimen for culture and sensitivity tests, as ordered, before giving drug. Expect first dose to be given before results are available
- Monitor fluid intake and output during therapy. Altered fluid balance may increase risk of crystalluria.
- Frequently monitor blood glucose level and assess for signs and symptoms of hypoglycemia in patients who take an oral antidiabetic drug. Be prepared to respond if hypogly-cemia develops.
3.Pyrimethamine
| Pyrimethamine |
| Availability Tablets: 25 mg |
| Indications and dosages ➣ To control plasmodia transmission and suppress susceptible strains Adults and children ages 10 and older: 25 mg P.O. daily for 2 days, given with a sulfonamide ➣ Toxoplasmosis Adults: Initially, 50 to 75 mg P.O. daily for 1 to 3 weeks, given with a sulfonamide. Depending on response and tolerance, reduce dosages of both drugs by 50% and continue therapy for 4 to 5 more weeks. Children: 1 mg/kg P.O. daily in two equally divided doses for 2 to 4 days, then reduced to 0.5 mg/kg/day for approximately 1 month. Alternatively, 2 mg/kg (up to 100 mg) P.O. daily in two equally divided doses for 3 days, then 1 mg/kg (up to 25 mg) in two equally divided doses for 4 weeks, given with sulfadiazine for 4 weeks. ➣ Prophylaxis of malaria caused by susceptible plasmodia strains Adults and children older than age 10: 25 mg P.O. weekly Children ages 4 to 10: 12.5 mg P.O. weekly Infants and children younger than age 4: 6.25 mg P.O. weekly |
Mechanism of Action
Inhibits reduction of dihydrofolic acid to tetrahydrofolic acid (folinic acid) by binding to and reversibly inhibiting dihydrofolate reductase
Pharmacokinetics
- Absorption: well absorbed
- Distribution: widely, mainly in blood cells, kidneys, lungs, liver, & spleen; crosses into CSF; crosses placenta; enters breast milk
- Protein Bound: 80-87%
- Metabolism: hepatic
- Half-life elimination: 80-95 hr
- Peak Plasma Time: 1.5-8 hr
- Excretion: urine (20-30% as unchanged drug)
Administration
- Administer with meals.
- When giving tablets to young children, crush them and administer as oral suspension in water, cherry syrup, or sweetened solution.
- Know that because of worldwide resistance to pyrimethamine, its use alone to prevent or treat acute malaria is no longer recommended.
- Be aware that fixed combination of pyrimethamine and sulfadoxine is available and has been used for uncomplicated mild to moderate malaria caused by chloroquineresistant Plasmodium falciparum and for presumptive self-treatment by travelers.
Contraindications
- Hypersensitivity to drug
- Megaloblastic anemia caused by folate deficiency
- Concurrent folate antagonist therapy
Precautions :
- Anemia, bone marrow depression, hepatic or renal impairment, G6PD deficiency
- History of seizures
- Patients more than 16 weeks pregnant
- Breastfeeding patients.
Adverse reactions
- CNS: headache, light-headedness, insomnia, malaise, depression, seizures
- CV: arrhythmias
- EENT: dry throat
- GI: nausea, vomiting, diarrhea, anorexia, atrophic glossitis
- GU: hematuria Hematologic: megaloblastic anemia, leukopenia, pancytopenia, thrombocytopenia
- Metabolic: hyperphenylalaninemia
- Respiratory: pulmonary eosinophilia
- Skin: pigmentation changes, dermatitis, erythema multiforme, toxic epidermal necrolysis, Stevens-Johnson syndrome Other: fever, anaphylaxis
Patient monitoring
- Monitor CBC. Watch for evidence of blood dyscrasias.
- Assess for signs and symptoms of folic acid deficiency.
- Closely monitor neurologic and cardiovascular status. Stay alert for seizures and arrhythmias. 2Watch for evidence of erythema multiforme, including sore throat, cough, mouth sores, rash, iritic lesions, and fever. Report early signs before condition can progress to StevensJohnson syndrome.
Patient teaching
- Advise patient to take with meals.
- Tell patient to discontinue drug and contact prescriber at first sign of rash.
- 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
4.Para amino salicylic acid
| Para amino salicylic acid |
| Indications and Dosages To treat tuberculosis as adjunct to isoniazid, streptomycin, or both and in patients with multidrug-resistant tuberculosis or when therapy with rifampin and isoniazid isn’t possible because of resistance or intolerance TABLETS Adults. 14 to 16 g daily in 2 or 3 divided doses. Children. 275 to 420 mg/kg daily in 3 or 4 divided doses |
Mechanism of Action
Inhibits incorporation of para-aminobenzoic acid into folic acid and prevents synthesis of folic acid, a compound needed for bacterial growth. Amino salicylate sodium is bacteriostatic against Mycobacterium tuberculosis, and it delays bacterial resistance to streptomycin and isoniazid.
Pharmacokinetics
- Peak Plasma Time: Initial time 2 hr (range 45 min to 24 hr); median time 6 hr (range 1.5-24 hr
- Protein Bound: 50-60%
- Metabolized by acetylation
- Excretion: Urine 80%, with 50% in acetylated form
Contraindications
Hypersensitivity to aminosalicylate sodium, severe renal disease
Adverse Reactions
- CNS: Encephalopathy, fever
- CV: Vasculitis
- ENDO: Goiter with or without myxedema
- GI: Abdominal pain, diarrhea, hepatitis, nausea, vomiting
- HEME: Agranulocytosis, hemolytic anemia, leukopenia, thrombocytopenia
- SKIN: Jaundice, various types of eruptions
- Other: Infectious mononucleosis-like syndrome, Loeffler’s syndrome (anorexia, breathlessness, fever, and weight loss)
Nursing Considerations
- Administer aminosalicylate with food to reduce GI upset.
Patient Teaching
- Teach patient to discard aminosalicylate that appears brown or purple.
- Instruct patient to take drug with food.
5.Metronidazole
| Availability Capsules: 375 mg Powder for injection: 5 mg/ml, 500-mg vials Premixed injection: 500 mg/100 ml Tablets: 250 mg, 500 mg Tablets (extended-release): 750 mg Topical cream, topical gel: 0.75% in 28.4-g tubes Topical lotion: 0.75% in 59-ml bottle Vaginal gel: 0.75% (37.5 mg/5-g applicator) in 70-g tubes |
| Indications and dosages ➣ Trichomoniasis Adults: 2 g P.O. as a single dose or in two 1-g doses given on same day. Alternatively, 500 mg P.O. b.i.d. for 7 days. ➣ Bacterial infections Adults: Initially, 15 mg/kg I.V., followed by 7.5 mg/kg I.V. q 6 hours, not to exceed 4 g/day for 7 to 10 days ➣ Amebiasis Adults: 750 mg P.O. q 8 hours for 5 to 10 days ➣ Amebic liver abscess Adults: 500 to 750 mg P.O. t.i.d. for 5 to 10 days. If drug can’t be given orally, administer 500 mg I.V. q 6 hours for 10 days. Children: 35 to 50 mg/kg/day P.O. in three divided doses for 10 days, to a maximum of 750 mg/dose ➣ Bacterial vaginosis Adults: In nonpregnant patients, 750 mg/day P.O. (extended-release) for 7 days or 5 g of 0.75% vaginal gel b.i.d. for 5 days. In pregnant patients, 250 mg P.O. t.i.d. for 7 days. ➣ Perioperative prophylaxis in colorectal surgery Adults: Initially, 15 mg/kg I.V. infusion over 30 to 60 minutes, completed 1 hour before surgery; if necessary, 7.5 mg/kg I.V. infusion over 30 to 60 minutes at 6 and 12 hours after initial dose ➣ Rosacea Adults: Rub a thin layer of topical lotion, gel, or cream onto entire affected area morning and evening. Improvement should occur within 3 weeks |
Mechanism of Action
Undergoes intracellular chemical reduction during anaerobic metabolism. After metronidazole is reduced, it damages DNA’s helical structure and breaks its strands, which inhibits bacterial nucleic acid synthesis and causes cell death.
Pharmacokinetics
Absorption
Peak plasma concentration
- IV (steady state): 25 mcg/mL
- Capsule: 20.4-21.4 mcg/mL (fasted)
- Oral solution and tablets: 6 mcg/mL (250-mg dose); 12 mcg/mL (500-mg dose); 40 mcg/mL (2,000-mg dose)
Trough levels
- IV: 18 mcg/mL
Peak plasma time
- Capsule: 1.4-1.6 hr (fasted)
- Tablet: 1-2 hr
- Oral solution: 0.25-6 hr
AUC: Capsule: 218-223 mcg⋅hr/mL (fasted); 99 mcg⋅hr/mL (fed)
Protein bound: <20%
Metabolism: Side-chain oxidation resulting in 2 metabolites (1-(ßhydroxyethyl)-2-hydroxymethyl-5-nitroimidazole and 2-methyl-5-nitroimidazole-1-ylacetic acid)
Glucuronide conjugation
Elimination
Clearance: 10 hr (PO)
Half-life
- Capsule or tablet: 8 hr
- Oral solution: 10 hr
Excretion
- PO or IV: 60-80% (urine); 6-15% (feces)
Administration
- Reconstitute powder for injection by adding 4.4 ml of sterile or bacteriostatic water for injection, 0.9% sodium chloride injection, or bacteriostatic sodium chloride injection to 500-mg vial. Further dilute resulting concentration (100 mg/ml) in 0.9% sodium chloride injection, 5% dextrose injection, or lactated Ringer’s injection solution to a concentration of 8 mg/ml or less. Infuse each I.V. dose over 1 hour.
- Be aware that for I.V. injection, drug need not be diluted or neutralized.
- Don’t use equipment containing aluminum to reconstitute or transfer reconstituted solution to diluent; solution may turn reddish-brown.
- Don’t interchange vaginal gel with topical gel, cream, or lotion.
Contraindications
- Hypersensitivity to drug, other nitroimidazole derivatives, or parabens (topical form only)
- First-trimester pregnancy in patients with trichomoniasis
Precautions:
- Severe hepatic impairment
- History of blood dyscrasias, seizures, or other neurologic problems
- Breastfeeding patients
- Children.
Adverse reactions
- CNS: dizziness, headache, ataxia, vertigo, incoordination, insomnia, fatigue
- EENT: rhinitis, sinusitis, pharyngitis
- GI: nausea, vomiting, diarrhea, abdominal pain, furry tongue, glossitis, dry mouth, anorexia
- GU: dysuria, dark urine, incontinence
- Hematologic: leukopenia
- Skin: rash, urticaria, burning, mild skin dryness, skin irritation, transient redness (with topical forms)
- Other: unpleasant or metallic taste, superinfection, phlebitis at I.V. site
Patient monitoring
- Monitor I.V. site. Avoid prolonged use of indwelling catheter.
- Evaluate hematologic studies, especially in patients with history of blood dyscrasias.
Patient teaching
- Advise patient to take drug with food if it causes GI upset. However, instruct him to take extended-release tablets 1 hour before or 2 hours after meals.
- Tell patient with trichomoniasis to refrain from sexual intercourse or to have male partner wear a condom to prevent reinfection. Explain that asymptomatic sex partners should be treated simultaneously.
- Advise patient to report fever, sore throat, bleeding, or bruising.
- Inform patient that drug may cause metallic taste and may discolor urine deep brownish-red.
- Tell patient using topical form to clean area thoroughly with mild cleanser before use and then wait 15 to 20 minutes before applying drug. Tell her she may apply cosmetics to skin after applying drug; with topical lotion, instruct her to let skin dry at least 5 minutes before applying cosmetics.
- Tell female patient to consult prescriber if she is pregnant or plans to become pregnant.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and behaviors mentioned above.
Nursing Considerations
- Give I.V. drug by slow infusion over 1 hour; don’t give by direct I.V. injection.
- Discontinue primary I.V. infusion during metronidazole infusion
- Monitor patient with severe liver disease because slowed metronidazole metabolism may cause drug to accumulate in body and increase the risk of adverse effects.
- If skin irritation occurs, apply topical metronidazole gel less frequently or discontinue it, as ordered.
- Monitor CBC and culture and sensitivity tests if therapy lasts longer than 10 days or if second course of treatment is needed.
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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