Name of the Antimicrobials used as Antidiarrheal
- Norfloxacin
- Ciprofloxacin
- Ofloxacin
- Rifaximin
- Cotrimoxazole
- Tetracycline
- Erythromycin
- Metronidazole
1.Norfloxacin
| Norfloxacin |
| Availability Tablets: 400 mg |
| Indications and dosages ➣ Urinary tract infections (UTIs) caused by Escherichia coli, Klebsiella pneumoniae, or Proteus mirabilis Adults: 400 mg P.O. q 12 hours for 3 days ➣ UTIs caused by all organisms except E. coli, K. pneumoniae, and P. mirabilis Adults: 400 mg P.O. q 12 hours for 7 to 10 days. For complicated UTIs, may give for up to 21 days. ➣ Gonorrhea Adults: 800 mg P.O. as a single dose ➣ Prostatitis caused by E. coli Adults: 400 mg P.O. q 12 hours for 28 days |
Mechanism of Action
Inhibits the enzyme DNA gyrase, which unwinds and supercoils bacterial DNA before it replicates. By inhibiting this enzyme, norfloxacin interferes with bacterial cell replication and causes cell death.
Pharmacokinetics
- Well absorbed; food causes only minor alterations
- Bioavailability: 98%
- Protein Bound: 32%
- Half-Life: 4-5 hr
- Excretion: Urine (up to 80% unchanged; <5% metabolites); feces 4-8%
Administration
- Give with glass of water 1 hour before or 2 hours after a meal.
- Don’t give antacids within 2 hours of norfloxacin.
Contraindications
- Hypersensitivity to drug
- History of tendinitis or tendon rupture with fluoroquinolone use
Precautions :
- CNS diseases or disorders, renal impairment, cirrhosis, bradycardia, acute myocardial ischemia
- Known history of myasthenia gravis (avoid use)
- Elderly patients
- Pregnant or breastfeeding patients (safety not established except in postexposure inhalation or cutaneous anthrax).
- Children younger than age 18.
Adverse reactions
- CNS: dizziness, light-headedness, drowsiness, headache, asthenia, insomnia, agitation, confusion, acute psychoses, hallucinations, tremors, increased intracranial pressure, seizures
- CV: vasodilation, QT prolongation, arrhythmias
- GI: nausea, diarrhea, abdominal pain, pancreatitis, pseudomembranous colitis
- GU: interstitial cystitis, vaginitis
- Hematologic: leukopenia
- Hepatic: hepatitis Metabolic: hyperglycemia, hypoglycemia
- Musculoskeletal: tendinitis, tendon rupture
- Skin: rash, hyperhidrosis, photosensitivity, phototoxicity, Stevens-Johnson syndrome
- Other: altered taste, myasthenia gravis exacerbation, hypersensitivity reactions including anaphylaxis
Patient monitoring
- Monitor vital signs and cardiovascular status.
- Check fluid intake and output. Keep patient well-hydrated.
- Watch for signs and symptoms of tendinitis or tendon rupture.
- Assess patient’s response to therapy. Obtain specimens for repeat culture and sensitivity tests if he relapses or doesn’t improve.
- Monitor renal function
Patient teaching
- Tell patient to take on empty stomach with full glass of water, 1 hour before or 2 hours after a meal.
- If patient needs antacid for GI upset, instruct him not to take it within 2 hours of norfloxacin.
- Advise patient to stop taking drug and promptly report rash; severe GI problems; tendon pain, swelling, or inflammation; or weakness.
- Caution patient to avoid driving and other hazardous activities until he knows how drug affects concentration and alertness.
- Teach patient ways to counteract photosensitivity, such as by wearing sunglasses and avoiding excessive exposure to bright light
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.
Nursing Considerations
- Obtain urine specimen for culture and sensitivity tests before starting drug, if possible.
- Determine if patient has a history of CNS disorder because drug may lower seizure threshold. Notify prescriber before starting drug, and institute seizure precautions.
- Give drug on an empty stomach 2 hours before or after antacids, didanosine, sucralfate, or vitamins that contain iron or zinc.
- Keep emergency resuscitation equipment readily available, and watch for signs of hypersensitivity, such as angioedema, dyspnea, jaundice, rash, and urticaria. If you suspect anaphylaxis, prepare to give epinephrine, corticosteroids, and diphenhydramine, as prescribed.
- If patient has myasthenia gravis, assess her often for a change in respiratory status because drug may lead to life-threatening weakness of respiratory muscles.
- Notify prescriber if patient has symptoms of peripheral neuropathy (pain, burning, tingling, numbness, weakness, or altered sensations of light touch, pain, temperature, position sense, or vibration sense), which could be permanent. Expect to stop nofloxacin.
- Monitor patients prone to tendinitis, such as the elderly, athletes, and those taking corticosteroids, for complaints of tendon pain, inflammation, or rupture. If present, notify prescriber and expect to discontinue norfloxacin, place patient on bedrest with no exercise of affected limb, and obtain diagnostic tests to confirm rupture.
- Monitor patient for diarrhea, which may indicate pseudomembranous colitis caused by Clostridium difficile. If diarrhea occurs, notify prescriber and expect to withhold norfloxacin and treat with fluids, electrolytes, protein, and an antibiotic effective against C. difficile.
2.Ciprofloxacin
| Ciprofloxacin |
| Availability Injection: 200 mg/20 ml, 400 mg/40 ml, 200 mg/100 ml premixed in dextrose 5% in water (D5W), 400 mg/200 ml premixed in D5W, 1,200 mg/120-ml bulk package Ophthalmic ointment: 3.5-g tube Ophthalmic solution: 2.5-ml and 5-ml plastic dispensers Otic solution: 0.2% (0.5 mg in 0.25 ml) in single-use container Tablets: 250 mg, 500 mg, 750 mg |
| Indications and dosages ➣ Acute sinusitis Adults: 500 mg P.O. q 12 hours or 400 mg I.V. q 12 hours for 10 days ➣ Prostatitis Adults: 500 mg P.O. q 12 hours or 400 mg I.V. q 12 hours for 28 days ➣ Intra-abdominal infections Adults: 500 mg P.O. q 12 hours or 400 mg I.V. q 12 hours for 7 to 14 days ➣ Febrile neutropenic patients Adults: 400 mg I.V. q 8 hours for 7 to 14 days ➣ Gonorrhea Adults: 500 mg P.O. as a single dose ➣ Infectious diarrhea Adults: 500 mg P.O. q 12 hours for 5 to 7 days ➣ Inhalation anthrax (postexposure) Adults: 500 mg P.O. q 12 hours for 60 days or 400 mg I.V. q 12 hours for 60 days Children: 15 mg/kg P.O. q 12 hours for 60 days (not to exceed 500 mg/dose), or 10 mg/kg I.V. q 12 hours for 60 days, not to exceed 400 mg/dose Infections of lower respiratory tract, skin and skin structures, bones, and joints Adults: 500 to 750 mg P.O. q 12 hours or 400 mg I.V. q 8 hours for 7 to 14 days. Severe bone and joint infections may necessitate up to 6 weeks of therapy. ➣ Nosocomial pneumonia Adults: 400 mg I.V. q 8 hours for 10 to 14 days ➣ Typhoid fever Adults: 500 mg P.O. q 12 hours for 10 days ➣ Urinary tract infections Adults: 250 to 500 mg P.O. q 12 hours or 200 to 400 mg I.V. q 12 hours for 3 days in acute uncomplicated infection or for 7 to 14 days in acute complicated infection ➣ Complicated urinary tract infections or pyelonephritis Children ages 1 to 17: 6 to 10 mg/kg I.V. q 8 hours for 10 to 21 days (maximum, 400 mg/dose; not to be exceeded, even in patients weighing more than 51 kg [112 lb]). Or, 10 to 20 mg/kg P.O. q 12 hours for 10 to 21 days (maximum, 750 mg/dose; not to be exceeded, even in patients weighing more than 51 kg). ➣ Acute otitis externa Adults: Instill contents of one singleuse otic solution container (0.5 mg) into affected ear b.i.d. (approximately 12 hours apart) for 7 days ➣ Bacterial conjunctivitis caused by susceptible organisms Adults: 0.5″ ribbon of ophthalmic ointment applied to conjunctival sac t.i.d. on first 2 days, then 0.5″ ribbon b.i.d. for 5 days. Or one to two drops of ophthalmic solution applied to conjunctival sac q 2 hours while awake for 2 days, then one or two drops q 4 hours while awake for 5 days . ➣ Corneal ulcers caused by susceptible organisms Adults: Two drops of ophthalmic solution instilled into affected eye q 15 minutes for first 6 hours, then two drops into affected eye q 30 minutes for remainder of first day. On second day, two drops of ophthalmic solution hourly; on days 3 through 14, two drops q 4 hours. |
Mechanism of Action
Inhibits the enzyme DNA gyrase, which is responsible for the unwinding and supercoiling of bacterial DNA before it replicates. By inhibiting this enzyme, ciprofloxacin causes bacterial cells to die.
Pharmacokinetics
- Bioavailability (PO): ~50-85%
- Peak plasma time (PO): Immediate-release, 0.5-2 hr; extended-release, 1-2.5 hr
- Protein bound: 20-40%
- Metabolized in liver
- Half-life: 2-5 hr (children); 3-5 hr (adults)
- Excretion: Urine (30-50%), feces (15-43%)
Administration
- Administer oral drug with or without food but not with dairy products or calcium-fortified juices alone; however, drug may be taken with a meal that contains these products.
- Infuse I.V. dose over at least 1 hour, using pump to ensure 1-hour duration.
- Know that too-rapid I.V. infusion increases risk of anaphylaxis and other adverse reactions.
- Know that treatment with ophthalmic solution may be continued after 14 days if corneal re-epithelialization hasn’t occurred
Adverse reactions
- CNS: agitation, headache, restlessness, confusion, delirium, peripheral neuropathy, toxic psychosis
- CV: orthostatic hypotension, vasculitis
- EENT: nystagmus; with ophthalmic use—blurred vision; burning, stinging, irritation, itching, tearing, and redness of eyes; eyelid itching, swelling, or crusting; sensitivity to light
- GI: nausea, vomiting, diarrhea, constipation, abdominal pain or discomfort, dyspepsia, dysphagia, flatulence, pancreatitis, pseudomembranous colitis
- GU: albuminuria, candiduria, renal calculi
- Hematologic: methemoglobinemia, agranulocytosis, hemolytic anemia
- Hepatic: jaundice, hepatic necrosis
- Metabolic: hyperglycemia, hyperkalemia
- Musculoskeletal: myalgia, myoclonus, tendinitis, tendon rupture
- Skin: rash, exfoliative dermatitis, toxic epidermal necrolysis, erythema multiforme photosensitivity
- Other: injection-site reaction, altered taste, anosmia, exacerbation of myasthenia gravis, overgrowth of nonsusceptible organisms, hypersensitivity reactions including anaphylaxis and Stevens-Johnson syndrome
Patient monitoring
- In patients with renal insufficiency, assess creatinine level before giving first dose and at least once a week during prolonged therapy. Monitor drug blood level closely.
- Watch for signs and symptoms of serious adverse reactions, including GI problems, jaundice, tendon problems, and hypersensitivity reactions.
Patient teaching
- Tell patient to take drug with or without food at the same time each day.
- Advise patient not to take drug with dairy products or calcium-fortified juices alone or with caffeinated beverages.
- Advise patient to drink 8 oz of water every hour while awake to ensure adequate hydration.
- Instruct patient to stop taking drug and notify prescriber at first sign of burning, numbness, or tingling in hands or feet; yellow eyes or skin; unusual tiredness; persistent diarrhea; rash; or tendon pain, swelling, or inflammation.
- Advise patient to avoid excessive exposure to sun or ultraviolet light and to discontinue drug and notify prescriber if phototoxicity (burning, erythema, exudation, vesicles, blistering, edema) occurs.
- Advise patient taking hormonal contraceptives to use supplemental birth control method, such as condoms, because drug reduces contraceptive efficacy.
- Inform breastfeeding patient that drug is excreted in breast milk and can affect infant’s bone growth. Advise her to consult prescriber before using drug
- Teach patient how to use eye ointment or solution and tell patient not to touch eye dropper tip to any surface, to avoid contamination.
- Instruct patient how to use ear solution and to lie with affected ear upward for at least 1 minute after instilling solution.
- Caution patient with bacterial conjunctivitis not to wear contact lenses.
- 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
- Obtain culture and sensitivity test results, as ordered, before giving ciprofloxacin.
- Use drug cautiously in patients with CNS disorders and patients who may be more susceptible to drug’s effect on QT interval, such as those taking Class IA or III antiarrhythmics or those with uncorrected hypokalemia or a history of QT-interval prolongation.
- Dilute I.V. ciprofloxacin concentrate to 1 to 2 mg/ml using D5W or sodium chloride for injection. Don’t dilute solutions that come from manufacturer in D5W before I.V. infusion. Infuse slowly over 1 hour.
- Store reconstituted solution up to 14 days at room temperature or refrigerated.
- Don’t give oral suspension by feeding tube.
- Be aware that E.R. and immediate-release tablets aren’t interchangeable and that Proquin XR and Cipro XR aren’t interchangeable.
- Patient should be well hydrated during therapy to help prevent alkaline urine, which may lead to crystalluria and nephrotoxicity.
- Assess patient’s hepatic, renal, and hematologic functions periodically, as ordered, if he’s receiving prolonged therapy.
- Monitor patient closely for diarrhea, which may reflect pseudomembranous colitis. If it occurs, notify prescriber and expect to withhold drug and treat diarrhea.
- Assess patient for evidence of peripheral neuropathy. Notify prescriber and expect to stop drug if patient complains of burning, numbness, pain, tingling, or weakness in extremities or if physical examination reveals deficits in light touch, pain, temperature, position sense, vibratory sensation, or motor strength.
- Monitor patients (especially children, elderly patients, patients receiving corticosteroids, and patients who have renal failure or who have had a kidney, heart, or lung transplant) for evidence of tendon rupture, such as inflammation, pain, and swelling at the site. Be aware that tendon rupture may occur during or after ciprofloxacin therapy. Notify prescriber about suspected tendon rupture, and have patient rest and refrain from exercise until tendon rupture has been ruled out. If present, expect to provide supportive care as ordered.
- Assess patient routinely for signs of rash or other hypersensitivity reactions, even after patient has received multiple doses. Stop drug at first sign of rash, jaundice, or other sign of hypersensivitity, and notify prescriber immediately. Be prepared to provide supportive emergency care.
3.Ofloxacin
| Ofloxacin |
| Availability Ophthalmic solution: 3 mg/ml (0.3%) Otic solution: 0.3% Tablets: 200 mg, 300 mg, 400 mg |
| Indications and dosages ➣ Prostatitis caused by Escherichia coli Adults: 300 mg P.O. q 12 hours for 6 weeks ➣ Complicated urinary tract infections caused by E. coli, Klebsiella pneumoniae, or Proteus mirabilis Adults: 200 mg P.O. q 12 hours for 10 days ➣ Uncomplicated cystitis caused by E. coli or K. pneumoniae Adults: 200 mg P.O. q 12 hours for 3 days ➣ Acute uncomplicated urethral and cervical gonorrhea Adults: 400 mg P.O. as a single dose ➣ Nongonococcal cervicitis or urethritis caused by Chlamydia trachomatis; mixed infections of cervix or urethra caused by C. trachomatis or Neisseria gonorrhoeae Adults: 300 mg P.O. q 12 hours for 7 days ➣ Acute bacterial exacerbation of chronic bronchitis, community acquired pneumonia, and uncomplicated skin and skin-structure infections caused by susceptible organisms Adults: 400 mg P.O. q 12 hours for 10 days ➣ Acute pelvic inflammatory disease Adults: 400 mg P.O. q 12 hours for 10 to 14 days Bacterial conjunctivitis Adults and children ages 1 and older: One to two drops of ophthalmic solution in affected eye q 2 to 4 hours on days 1 and 2; then one to two drops q.i.d. on days 3 through 7 ➣ Corneal ulcers Adults: One to two drops of ophthalmic solution in affected eye q 30 minutes while awake on days 1 and 2, then one to two drops q hour while awake on days 3 to 7, then one to two drops q.i.d. while awake on days 7 to 9 ➣ Otitis externa Adults and children ages 13 and older: 10 drops of otic solution into affected ear daily for 7 days ➣ Chronic suppurative otitis media with perforated tympanic membrane Adults and children ages 12 and older: 10 drops of otic solution into affected ear b.i.d. for 14 days |
Mechanism of Action
Inhibits synthesis of the bacterial enzyme DNA gyrase by counteracting excessive supercoiling of DNA during replication or transcription. Inhibition of DNA gyrase causes rapid- and slow-growing bacterial cells to die
Pharmacokinetics
- Bioavailability: 98%
- Protein Bound: 32%
- Half-Life: 4-5 hr
- Excretion: Urine (up to 80% unchanged; <5% metabolites); feces 4-8%
Administration
Don’t give zinc- or iron-containing drugs within 2 hours of ofloxacin
Adverse reactions
- CNS: dizziness, drowsiness, headache, light-headedness, insomnia, acute psychoses, agitation, confusion, tremors, hallucinations, increased intracranial pressure, seizures
- CV: chest pain, vasodilation
- GI: nausea, diarrhea, constipation, abdominal pain, pseudomembranous colitis
- GU: interstitial cystitis, vaginitis
- Hematologic: eosinophilia, leukopenia
- Musculoskeletal: tendinitis, tendon rupture, joint pain, back pain
- Skin: rash, photosensitivity, phototoxicity, Stevens-Johnson syndrome
- Other: altered taste, superinfection, myasthenia gravis exacerbation
Patient monitoring
- Assess patient for signs and symptoms of superinfection.
- Inspect for rash. Check for signs and symptoms of hypersensitivity reaction.
- Watch for fever with diarrhea; diarrhea containing pus; or severe, persistent diarrhea; and tendinitis or tendon rupture.
- Evaluate neurologic status closely
Patient teaching
- Encourage patient to maintain fluid intake of at least 1,500 ml daily to prevent crystalluria.
- Inform patient being treated for gonorrhea that partners must be treated.
- Tell patient to immediately report fever and diarrhea, especially if stool contains blood, pus, mucus. Caution him not to treat diarrhea without consulting prescriber.
- Instruct patient to stop taking drug and immediately report rash or tendon pain or inflammation.
- Instruct patient not to take iron- or zinc-containing drugs or antacids within 2 hours of ofloxacin.
- Teach patient ways to counteract photosensitivity, such as by wearing sunglasses and avoiding excessive exposure to bright light.
- Teach patient how to use eye or ear drops. Caution him not to touch dropper tip to any surface (including eye or ear).
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, herbs, and behaviors mentioned above.
Nursing Considerations
- Because of increased risk of prolonged QT interval, ofloxacin shouldn’t be used if patient has had a prolonged QT interval, has an uncorrected electrolyte disorder, or takes a Class IA or III antiarrhythmic. Monitor elderly patients closely because risk of prolonged QT interval may be increased in this group.
- For I.V. infusion, dilute drug in normal saline solution or D5W to at least 4 mg/ ml, and infuse over 60 minutes to minimize the risk of hypotension. Discard unused portion.
- Monitor patient closely for hypersensitivity, which may occur as early as first dose. Reaction may include angioedema, bronchospasm, dyspnea, itching, rash, jaundice, shortness of breath, and urticaria. If these signs or symptoms appear, notify prescriber immediately and expect to discontinue drug.
- Notify prescriber if patient has symptoms of peripheral neuropathy (pain, burning, tingling, numbness, weakness, or altered sensations of light touch, pain, temperature, position sense, or vibration sense), which could be permanent; tendon rupture (pain and inflammation), which may occur more often in patients (especially elderly ones) taking corticosteroids and requires immediate rest; or a severe photosensitivity reaction. In each case, expect to stop ofloxacin. • Maintain adequate hydration to prevent development of highly concentrated urine and crystalluria.
- Expect an increased risk of toxicity in severe hepatic disease, including cirrhosis.
- Be aware that ofloxacin may stimulate the CNS and aggravate seizure disorders.
- If diarrhea develops, notify prescriber because it may indicate pseudomembranous colitis. Ofloxacin may need to be discontinued and additional therapy started.
- Be alert for secondary fungal infection.
4.Rifaximin
| Rifaximin |
| Availability Tablets: 200 mg, 550 mg |
| Indications and dosages ➣ Travelers’ diarrhea caused by noninvasive strains of Escherichia coli Adults and children age 12 and older: 200 mg P.O. three times daily for 3 days ➣ Reduction of risk of overt hepatic encephalopathy recurrence Adults: 550 mg P.O. b.i.d. |
Mechanism of Action
Binds to beta-subunit of bacterial DNA-dependent RNA polymerase, inhibiting bacterial RNA synthesis
Pharmacokinetics
- Bioavailability: <0.4%
- Peak plasma time: 1 hr
- Gut: 80-90%
- Metabolism: Induces CYP3A4 in hepatocytes in vitro
- Half-life: 2-5 hr
- Excretion: Feces (>90%)
Administration
Administer with or without food.
Don’t give to patients with diarrhea complicated by fever or blood in stool or to patients with suspected Campylobacter jejuni, Shigella, or Salmonella infection
Adverse reactions
- CNS: headache
- GI: nausea, vomiting, constipation, flatulence, abdominal pain, rectal tenesmus, defecation urgency, pseudomembranous colitis
- Other: pyrexia, overgrowth of susceptible organisms
Contraindications
Hypersensitivity to drug, its components, or rifamycin anti-infectives
Precautions:
- Elderly patients
- Pregnant or breastfeeding patients
- Children (safety and efficacy not established in those younger than age 12).
Patient monitoring
- Monitor for fever, blood in stools, and worsening of diarrhea.
- Monitor patient’s fluid and electrolyte status.
- Monitor for new infections; if needed, consider alternative therapy.
Patient teaching
- Tell patient drug can be taken with or without food.
- Advise patient to stop drug and notify prescriber if diarrhea symptoms worsen or last beyond 48 hours.
- As appropriate, review all other significant or life-threatening adverse reactions
5.Cotrimoxazole
| Cotrimoxazole |
| 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.
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
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.
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. 2Monitor 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.
- Teach patient to recognize and immediately report signs and symptoms of hypersensitivity, especially rash.
- Inform 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.
- Urge 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.
6.Tetracycline
| Tetracycline |
| Availability Capsules: 250 mg, 500 mg |
| Indications and dosages ➣ Mild to moderate infections caused by susceptible organisms Adults: 500 mg P.O. b.i.d. or 250 mg P.O. q.i.d. ➣ Severe infections caused by susceptible organisms Adults: 500 mg P.O. q.i.d. Children older than age 8: 25 to 50 mg/kg P.O. q.i.d. ➣ Syphilis in penicillin-allergic patients Adults: 500 mg P.O. q.i.d. for 14 days ➣ Late syphilis (except neurosyphilis) Adults: 500 mg P.O. q.i.d. for 28 days ➣ Leptospirosis when penicillin is contraindicated or ineffective Adults: 1 to 2 g P.O. daily in two to four divided doses for 5 to 7 days ➣ Yaws Adults: 1 to 2 g P.O. daily in two to four divided doses for 10 to 14 days ➣ Gonorrhea in penicillin-allergic patients Adults: Initially, 1.5 g P.O., followed by 500 mg P.O. q 6 hours for 4 days, up to a total of 9 g ➣ Uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis Adults: 500 mg P.O. q.i.d. for 7 days Rickettsial and mycoplasmal infections Adults: 1 to 2 g P.O. daily in two to four divided doses for 7 days ➣ Helicobacter pylori infection Adults: In patients with active duodenal ulcer, 500 mg P.O. q.i.d. at meals and bedtime for 14 days, given with other drugs (such as metronidazole, bismuth subsalicylate, amoxicillin, or omeprazole) ➣ Brucellosis Adults: 500 mg P.O. q.i.d. for 3 weeks, given with streptomycin I.M. b.i.d. during week 1 and streptomycin once daily during week 2 ➣ Granuloma inguinale; chancroid Adults: 1 to 2 g P.O. daily in two to four divided doses for 2 to 4 weeks ➣ Cholera Adults: 500 mg P.O. q 6 hours for 48 to 72 hours ➣ Plague when streptomycin is contraindicated or ineffective Adults: 2 to 4 g P.O. q.i.d. for 10 days Children older than age 8: 30 to 40 mg/kg P.O. q.i.d. for 10 to 14 days ➣ Tularemia as an alternative to streptomycin Adults: 1 to 2 g P.O. daily in two to four divided doses for 1 to 2 weeks ➣ Campylobacter infection Adults: 1 to 2 g P.O. daily in two to four divided doses for 10 days ➣ Relapsing fever caused by Borrelia recurrentis Adults: 1 to 2 g P.O. daily in two to four divided doses for 7 days or until patient is afebrile ➣ Adjunctive treatment of inflammatory acne Adults and adolescents: 500 mg to 1 g P.O. q.i.d. for 1 to 2 weeks, decreased gradually to 125 to 500 mg P.O. daily |
Mechanism of Action
Exerts a bacteriostatic effect against a wide variety of gram-positive and gram-negative organisms by passing through the bacterial lipid bilayer, where it binds reversibly to 30S ribosomal subunits. Bound tetracycline blocks the binding of aminoacyl transfer RNA to messenger RNA, thus inhibiting bacterial protein synthesis.
Pharmacokinetics
- Absorption: 75% (PO)
- Peak plasma time: 2-4 hr (PO)
- Protein bound: 65%
- Half-life: 8-11 hr (normal renal function); 57-108 hr (end-stage renal disease)
- Excretion: Urine (60% as unchanged drug); feces (as active form)
Administration
Give with 8 oz of water at least 1 hour before or 2 hours after a meal (especially if it includes milk or other dairy products), antacids, laxatives, or antidiarrheal drugs.
Adverse reactions
- CNS: paresthesia, benign intracranial hypertension
- CV: pericarditis
- EENT: abnormal conjunctival pigmentation, hoarseness, pharyngitis
- GI: nausea, vomiting, diarrhea, loose bulky stools, esophageal ulcers, epigastric distress, enterocolitis, oral and anogenital candidiasis, stomatitis, black hairy tongue, glossitis, anorexia, pancreatitis
- GU: dark yellow or brown urine, vaginal candidiasis, anogenital lesions
- Hematologic: eosinophilia, hemolytic anemia, neutropenia, thrombocytopenia, thrombocytopenia purpura
- Hepatic: fatty liver Musculoskeletal: retarded bone growth, polyarthralgia
- Respiratory: pulmonary infiltrates
- Skin: photosensitivity, maculopapular or erythematous rash, increased pigmentation, urticaria, onycholysis
- Other: permanent tooth discoloration (in children younger than age 8), tooth enamel defects, superinfection, hypersensitivity reactions including anaphylaxis, serum sickness–like reaction, exacerbation of systemic lupus erythematosus
Contraindications
Hypersensitivity to drug, other tetracyclines, bisulfites, or alcohol (in some products)
Precautions:
- Renal disease, hepatic impairment, nephrogenic diabetes insipidus
- Cachectic or debilitated patients
- Pregnant or breastfeeding patients (except in anthrax treatment)
- Children younger than age 8 (except in anthrax treatment)
Patient monitoring
- Monitor for signs and symptoms of superinfection and hypersensitivity reaction.
- With long-term use, monitor CBC, liver function tests, and (in prepubertal patients) bone growth.
- Assess neurologic status. Stay alert for benign intracranial hypertension (especially in children).
Patient teaching
- Tell patient to take oral form with 8 oz of water at least 1 hour before or 2 hours after eating a meal, consuming dairy products, or taking antacids, laxatives, or antidiarrheal drugs. Advise him to take last daily dose at least 1 hour before bedtime.
- Stress importance of completing entire course of therapy as ordered, even after symptoms improve.
- Caution patient not to use outdated tetracycline, because it may cause serious kidney disease.
- Teach patient to recognize and report signs and symptoms of yeast infection and other infections.
- With long-term therapy, tell patient he’ll undergo regular blood testing. Advise parents that prepubertal child should have periodic bone X-rays.
- Caution patient to avoid alcohol during therapy.
- Tell parents that tetracycline use during tooth development period (last half of pregnancy, infancy, and childhood to age 8) may cause permanent yellow, gray, or brownish tooth discoloration.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, foods, and behaviors mentioned above.
Nursing Considerations
- Avoid giving tetracycline to children under age 8 because drug may cause permanent brown or yellow tooth discoloration and enamel hypoplasia.
- Be aware that tooth discoloration and enamel hypoplasia may occur in breastfeeding infants, along with inhibition of linear skeletal growth, oral and vaginal candidiasis, and photosensitivity.
- To reduce the risk of esophageal irritation or ulceration, avoid bedtime dosing of tetracycline for patient with esophageal obstruction or compression.
- Assess for photosensitivity, which can develop within a few minutes or up to several hours after exposure to sunlight or other ultraviolet (UV) light. Effects may last for 1 to 2 days after discontinuation of drug.
- Be aware that citric acid in tetracycline preparations may accelerate drug deterioration and that using outdated drug may cause Fanconi’s syndrome, characterized by multiple defects in renal tubular function. Symptoms include acidosis, bicarbonate wasting, glycosuria, hypokalemia, osteomalacia, and phosphaturia.
7.Erythromycin
| Erythromycin |
| Availability Erythromycin base Capsules (delayed-release): 250 mg Ointment (ophthalmic): 0.5% Tablets: 250 mg, 500 mg Tablets (delayed-release, enteric-coated): 250 mg, 333 mg, 500 mg Tablets (particles in tablets): 333 mg, 500 mg erythromycin ethylsuccinate Oral suspension: 200 mg/5 ml, 400 mg/5 ml Powder for suspension: 100 mg/2.5 ml, 200 mg/5 ml, 400 mg/5 ml Tablets: 400 mg erythromycin lactobionate Powder for injection: 500 mg, 1 g erythromycin stearate Tablets (film-coated): 250 mg, 500 mg erythromycin (topical) Gel: 2% Ointment: 2% Solution: 2% Swabs: 2% |
| Indications and dosages ➣ Pelvic inflammatory disease Adults: 500 mg (base) I.V. q 6 hours for 3 days, then 250 mg (base, estolate, or stearate) or 400 mg (ethylsuccinate) q 6 hours for 7 days ➣ Syphilis Adults: 500 mg (base, estolate, or stearate) P.O. q.i.d. for 14 days ➣ Most upper and lower respiratory tract infections; otitis media; skin infections; Legionnaires’ disease Adults: 250 mg P.O. q 6 hours, or 333 mg P.O. q 8 hours, or 500 mg P.O. q 12 hours (base, estolate, or stearate); or 400 mg P.O. q 6 hours or 800 mg P.O. q 12 hours (ethylsuccinate); or 250 to 500 mg I.V. (up to 1 g) q 6 hours (gluceptate or lactobionate) Children: 30 to 50 mg/kg/day (base, estolate, ethylsuccinate, or lactobionate) I.V. or P.O., in divided doses q 6 hours when giving I.V. and q 6 to 8 hours when giving P.O. Maximum dosage is 2 g/day for base or estolate, 3.2 g/day for ethylsuccinate, and 4 g/ day for lactobionate. ➣ Intestinal amebiasis Adults: 250 mg (base, estolate, or stearate) or 400 mg (ethylsuccinate) P.O. q 6 hours for 10 to 14 days Children: 30 to 50 mg/kg/day (base, estolate, ethylsuccinate, or stearate) P.O. in divided doses over 10 to 14 days Prophylaxis of ophthalmia neonatorum caused by Neisseria gonorrhoeae or Chlamydia trachomatis Neonates: 0.5- to 1-cm ribbon of ointment into each lower conjunctival sac once ➣ Treatment of conjunctivitis of the newborn caused by susceptible organisms Neonates: 50 mg/kg/day (ethylsuccinate) P.O. in four divided doses for at least 14 days ➣ Pertussis Children: 40 to 50 mg/kg/day (estolate preferred) P.O. in four divided doses for 14 days ➣ Pneumonia of infancy Infants: 50 mg/kg/day (estolate or ethylsuccinate) P.O. in four divided doses for at least 3 weeks ➣ Acne Adults and children older than age 12: 2% ointment, gel, or solution applied topically b.i.d. |
Mechanism of Action
Binds with the 50S ribosomal subunit of the 70S ribosome in many types of aerobic, anaerobic, gram-positive, and gram-negative bacteria. This action inhibits RNA dependent protein synthesis in bacterial cells, causing them to die.
Pharmacokinetics
- Oral: variable but better with salt forms than with base form
- Peak Plasma Time: 4 hr (base)
- Protein Bound: 75-80%
- Half-Life: 1.4 hr
- Excretion: Primarily feces; urine (2-15% as unchanged drug)
Administration
- Be aware that ventricular arrhythmias and sudden death may occur if drug is given concurrently with potent CYP3A inhibitors (such as clarithromycin, diltiazem, nitroimidazole antifungal agents, protease inhibitors, verapamil, and troleandomycin).
- Give erythromycin ethylsuccinate and delayed-release products without regard to meals, but avoid giving with grapefruit juice.
- Give erythromycin base or stearate 1 hour before or 2 hours after meals for optimal absorption.
- Follow label directions to reconstitute drug for I.V. use. For intermittent infusion, infuse each 250 mg in at least 100 ml of normal saline solution over 20 to 60 minutes. Continuous infusion may be given over 6 to 24 hours as directed.
Adverse reactions
- CV: torsades de pointes, arrhythmias
- EENT: ototoxicity
- GI: nausea, vomiting, diarrhea, abdominal pain or cramps
- Hepatic: hepatic dysfunction, hepatitis
- Skin: rash
- Other: increased appetite, aggravation of weakness in myasthenia gravis, allergic reactions, superinfection, phlebitis at I.V. site
Contraindications
- Hypersensitivity to drug or tartrazine
- Concurrent use of astemizole, cisapride, pimozide, or terfenadine
- Hepatic impairment (with estolate)
- Pregnancy (with estolate)
Precautions:
- Myasthenia gravis
- Hepatic disease.
Patient monitoring
- Check temperature and watch for signs and symptoms of superinfection.
- Monitor liver function tests. Watch for signs and symptoms of hepatotoxicity.
- Assess patient’s hearing for signs of ototoxicity
Patient teaching
- Instruct patient to take with 8 oz of water 1 hour before or 2 hours after meals, and to avoid grapefruit juice.
- If drug causes GI upset, encourage patient to take it with food.
- Tell patient not to swallow chewable tablets whole and not to chew or crush enteric-coated tablets.
- Advise patient to immediately report irregular heart beats, unusual tiredness, yellowing of skin or eyes, or signs and symptoms of new infection.
- Tell patient he’ll undergo periodic blood tests to monitor liver function.
- As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs, tests, and foods mentioned above.
Nursing Considerations
- Use erythromycin cautiously in patients with impaired hepatic function because drug is metabolized by the liver.
- Use erythromycin cautiously in elderly patients, especially those with renal or hepatic dysfunction, because these patients are at increased risk of hearing loss and torsades de pointes. They’re also at increased risk of bleeding if taking an oral anticoagulant.
- Before giving first erythromycin dose, expect to obtain body fluid or tissue sample for culture and sensitivity testing.
- Reconstitute parenteral form before administration. Add at least 10 ml of preservative-free sterile water for injection to each 500-mg vial or at least 20 ml of diluent to each 1-g vial.
- For prolonged infusion, expect to infuse a buffered solution up to 24 hours after dilution.
- For intermittent infusion, dilute dose in 100 to 250 ml normal saline solution or D5W if needed; give slowly over 20 to 60 minutes.
- When giving I.V. erythromycin gluceptate, dilute the solution if needed to 1 g/L in normal saline solution or D5W injection for slow, continuous infusion. Diluted solution remains potent for 7 days if refrigerated.
- When giving I.V. erythromycin lactobionate, dilute the solution if needed to 1 to 5 mg/ml in normal saline solution, lactated Ringer’s solution, or other electrolyte solution for slow, continuous infusion. Diluted solution remains potent for 14 days if refrigerated and for 24 hours at room temperature.
- Be aware that infusions prepared in piggyback infusion bottles stay potent for 30 days if frozen, 24 hours if refrigerated, or 8 hours at room temperature. Don’t store infusions prepared in the ADDvantage system.
- Don’t use diluent with benzyl alcohol if parenteral erythromycin is for a neonate. It may cause a fatal toxic syndrome of CNS depression, hypotension, metabolic acidosis, renal failure, respiratory problems, and, possibly, seizures and intracranial hemorrhage.
- Periodically monitor liver function test results to detect hepatotoxicity, which is most common with erythromycin estolate. Signs typically appear within 2 weeks after continuous therapy starts and resolve when it stops.
- Assess hearing regularly, especially in elderly patients and those who receive 4 g or more daily or have hepatic or renal disease. Hearing impairment begins 36 hours to 8 days after treatment starts and usually begins to improve 1 to 14 days after it stops.
- During I.V. therapy, watch for evidence of fluid overload, such as acute dyspnea and crackles.
- Monitor infants for vomiting or irritability with feeding because infantile hypertrophic pyloric stenosis has been reported.
- Assess myasthenia gravis patients for weakness because drug may aggravate it. Keep in mind that myasthenic syndrome may arise in patients previously undiagnosed with myasthenia gravis.
- Watch closely for signs and symptoms of superinfection. If they occur, notify prescriber and expect to stop drug and provide appropriate therapy.
- Monitor patient for diarrhea during and for at least 2 months after erythromycin therapy; diarrhea may signal pseudomembranous colitis caused by Clostridium difficile. If diarrhea occurs, notify prescriber and expect to withhold drug and treat with fluids, electrolytes, protein, and an antibiotic effective against C. difficile.
- If patient receives an order for urine catecholamine analysis, notify prescriber because erythromycin interferes with fluorometric measurement of urine catecholamines
8.Metronidazole
| 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
- 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)
- 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.
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
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.
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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