Antivirals + Cell Wall + Protien Synthesis & DNA + UTI, TB, Antifungal, & Malaria

Sulfamethoxazole/Trimethoprim (Bactrim)

(antibiotic) (Sulfonamide and Folate Synthesis Inhibitor)

MOA: Sulfonamides and trimethoprim are bacteriostatic medications that inhibit tetrahydrofolate syntheses that is needed to make DNA, RNA, & proteins.

Indications: Broad-spectrum against gram + and gram -

• Commonly used for UTI & P. Jiroveci, among others.

Sulfamethoxazole/Trimethoprim (Bactrim) Adverse Effects

Sulfonamide AE:

• Photosensitivity & Hypersensitivity reactions, including SJS/TENS

• Hemolytic anemia

• Kernicterus in newborns

• Renal damage from crystalline aggregates (crystalluria)

Trimethroprim AE:

• Megaloblastic anemia

• Hyperkalemia

Sulfamethoxazole/Trimethoprim (Bactrim) Nursing Considerations

• Monitor for rash and stop immediately if it is present.

• Cross allergies w/ other sulfa-containing meds.

• Monitor CBC and CMP and progression of infection s/s.

Nitrofurantoin (Macrobid)

(antibiotic) (Nitrofuran)

MOA: After conversion to reactive form, causes bacterial injury due to inhibition of protein, DNA, RNA, & protein synthesis, as well as energy metabolism.

Indications: Broad-spectrum against gram + and gram -.

• Currently only used for treatment and prophylaxis in acute lower UTIs.

Nitrofurantoin (Macrobid) Adverse Effects

• GI effects are most common, including, N/V/D.

• Pulmonary reactions, likely from hypersensitivity, leading to dyspnea, cough, and malaise.

• Various hematologic effects, including agranulocytosis, leukopenia, thrombocytopenia, and megaloblastic anemia.

Nitrofurantoin (Macrobid) Nursing Considerations

• Not indicated for upper UTI

• Encourage increased water intake and cranberry juice to avoid other potential nephrotoxic drugs. (proper hygiene)

Diagnosis of Tuberculosis

Step 1: Tuberculin skin test (Mantoux)

Step 2: If skin test results are positive, then chest x-ray

Step 3: If chest x-ray shows signs of TB, then culture of sputum or stomach secretions

Latent TB

May be Asymptomatic

Active TB

May present w/ productive cough >3 weeks, hemopytsis, chest pain w/ breathing/coughing, fatigue, fever, and chills.

TB medications typically cause problems in what organ?

Liver

Isoniazid (INH)

(antibiotic) (Primary Agent for Treatment and Prophylaxis of TB)

MOA: Inhibits synthesis mycolic acid, a component needed for mycobacterial cell walls.

• Bactericidal to actively dividing cell walls.

• Bacteriostatic to dormant bacteria.

Isoniazid (INH) Adverse Effects

• Hepatotoxicity/liver injury (RUQ tenderness, changes in urine, stool, and skin)→ multilobular necrosis

• Neuropathy & pyridoxine (B6) deficiency

• Optic neuritis and visual disturbances.

Isoniazid (INH) Nursing Considerations

• Do not take with antacids due to decreased absorption.

• Educate on and monitor for s/s hepatitis.

• Monitor liver enzymes

• Educate on s/s peripheral neuropathy; may be reversible w/ vitamin B6.

• Report visual changes immediately.

• Risk for non-adherence due to long term treatment duration.

Rifampin (Rifandin)

(antibiotic) (Rifamycin) (Primary Agent of Treatment and Prophylaxis of TB)

MOA: Inhibits DNA-dependent RNA polymerase to suppress RNA synthesis and protein synthesis.

Indications:

• Drug of choice (DOC) for TB in combination w/ at least one other agent due to resistance.

• Leprosy (once/month dosing)

• MAC (w/ ethambutol and macrolide)

Rifampin (Rifandin) Adverse Effects

• Hepatotoxicity

• Body fluid red-orange discoloration (urine, sweat, saliva, and tears)—harmless

• Hematologic disorders (blood issues)

• Effects r/t accelerated metabolism of oral contraceptives, warfarin, PI & NNRTI—(HIV patients at risk for TB)

Rifampin (Rifandin) Nursing Considerations

• Educate on and monitor for s/s hepatitis

• Monitor liver enzymes and CBC

• Education on fluid discoloration

• Child-bearing age female patients need additional birth control

Pyrazinamide

(antibiotic) (First-line agent used in combo therapy for TB) (Commonly affected joints in hyperuricemia are hallux, ankle, and knee)

MOA:

• Medication is metabolized to pyrazinoic acid to lower PH.

• Inhibits m. tuberculosis enzyme, fatty acid synthetase I

Indications:

• Part of multi-drug regimen for active TB

Pyrazinamide Adverse Effects

• Hepatotoxicity, particularly w/ concurrent TB agent use.

• Hyperuricemia → gouty arthritis (first digit in foot; accumulation of uric acid crystal)

Pyrazinamide Nursing Considerations

• Educate on and monitor for s/s hepatitis

• Monitor liver enzymes and serum uric acid levels

• Report any gout-like s/s; use an NSAID PRN.

Ethambutol (Myambutol)

(antibiotic) (First-line agent used in combo therpay for TB; Also used for MAC) (E for Eyes)

MOA: Promotes a bacteriostatic action by inhibiting arabinosyl transferase resulting in impaired mycobacterial cell wall synthesis.

Ethambutol (Myambutol) Adverse Effects

• GI tract disturbances

• Optic neuritis, resulting in blurred vision, constriction of visual field, and disturbance of color discrimination.

• Possible hepatotoxicity; higher risk w/ multi-drug TB regimen.

Ethambutol (Myambutol) Nursing Considerations

• Educate on and monitor for s/s hepatitis.

• Monitor liver enzymes.

• Take w/ food as needed to minimize GI upset.

• Monitor for acute visual changes. (CN II—ocular)

Amphotericin B (Abelect)

(antibiotic) (Polyene) (Amphoterrible!)

MOA: Binds to components of fungal cell membrane to increase permeability, w/ resultant leakage leading to reduced viability.

Indications:

• Broad-spectrum fungal coverage, and often DOC for most systemic mycoses.

Amphotericin B (Abelect) Adverse Effects

• Infusion reactions (fever, chills, urticaria, nausea, and headache)—these are expected reactions and not a reason to stop the infusion!

• Dysrhythmias

• Nephrotoxicity

Amphotericin B (Abelect) Nursing Considerations

Minimizes infusion reactions w/:

• Antipyretics → fever and headache

• Antihistamines → urticaria

• Antiemetics → nausea

• Corticosteroids → fever and chills

Monitor:

• V/S closely (i.e. every 15 minutes)

• Heart rhythm on telemetry

• CMP, I/O, and kidney function

Itraconazole (Sporanox)

(antibiotic) (PO and IV Azole)

MOA: Inhibits synthesis of ergosterol to cause increased membrane permeability and cellular component leakage.

Indications:

• Borad-spectrum fungal coverage of mycoses of esophageal, oropharyngeal, peritoneal, urinary tract, vaginal, and systemic candida;

Itraconazole (Sporanox) Adverse Effects

• GI most common (N/V/D)

• Cardiac suppression → decreased ventricular ejection fraction. (HF symptoms)

• Medication-associated liver injury.

Itraconazole (Sporanox) Nursing Considerations

• Assess medication use due to many possible drug interactions. (med recocilliation!)

• Administer w/ food to enhance medication absorption.

• Monitor s/s of liver injury and heart failure prior to and after medication administration.

Nystatin

(antibiotic) (PO and Topical Polyene) (more localized)

• MOA: binds to components of fungal cell membrane to increase permeability, w/ resultant leakage leading to reduced viability.

• Indications: Coverage similar to amphotericin B, but limited to use due to toxicity; currently used mostly for:

• Oropharyngeal candidiasis prophylaxis in patient w/ neutropenia.

• Treatment of oral and vaginal candidiasis.

Nystatin Adverse Effects

• GI (N/V/D) most common w/ PO.

• Rash and urticaria w/ topical.

Nystatin Nursing Considerations

• Monitor PO route carefully w/ pediatric patients as it can be given via lozenge/troche.

• Educate patient on proper administration w/ oral suspension. (swish and spit)

What do malaria symptoms mirror?

The flu

Chloroquine (Aralen)

(Mild Malaria)

MOA: (Target the plasmodium in an effort to potentially reduce it going into the RBCs)

• Prevents conversion of heme (RBCs) to nontoxic metabolites.

• Concentrates heme in parasitized erythrocytes to produce lethal effect.

Indications:

• DOC for mild to moderate acute attacks caused by P. vivax and P. falciparum and prophylaxis of infection in erythrocytes.

Chloroquine (Aralen) Adverse Effects

• Rare w/ prophylactic low dose

• GI effects → discomfort and N/V

• Visual disturbances

• Pruritus (itching)

Chloroquine (Aralen) Nursing Considerations

• Report condition for surveillance reporting.

• Monitor patients w/ hepatic disease closely.

• Minimize GI s/s by taking w/ meals.

• Not able to prevent primary infection of the liver.

Quinidine Gluconate

(antibiotic) (Parenteral Dextro Isomer of Quinine) (Bad Malaria)

MOA:

• Causes heme (RBCs) to accumulate within parasite.

• Concentrates heme in parasitized erythrocytes to produce lethal effect.

Indications:

• DOC for severe malarial infection

Quinidine Gluconate Adverse Effects

• Hypotension

• Acute Circulatory Failure

• Dysrhythmias

• Cardiotoxicity

Quinidine Gluconate Nursing Considerations

• Weight-based loading dose followed by slow IV administration over 24 hours.

• Co-administered w/ tetracycline or clindamycin → monitor for associated s/s.

• Monitor heart rhythm and BP frequently; slower administration if changes noted.

• Monitor electrolytes, particularly K and Mg.

Certain ________ _______ acts as the target site for the medication. This leads to the inability to grow _________ __________ with the lack of new amino acids.

ribosomal sububits, peptide chains

Doxycycline

(antibiotic) (Tetracycline)

MOA: Bacteriostatic antibiotic (abx) that binds to 30S ribosomal subunit to inhibit binding of transfer RNA to mRNA to inhibit protein synthesis.

Indications:

• Broad spectrum coverage against many gram + & - organisms.

Doxycycline Adverse Effects

• GI is most common, including cramps and N/V/D, along w/ alterations in normal flora & superinfections.

• Bone growth suppression and teeth discoloration in pediatric patients.

• Fatty liver infiltration and renal impairment exacerbation

• Photosensitivity

Doxycycline Nursing Considerations

• Decreased absorption if given with metal ions, including Ca, Fe, and Mg; administer on empty stomach if tolerated.

• Interactions w/ oral contraceptives (reduces effectiveness of birth control pills) and anticoagulants.

• Hepatic and renal monitoring.

• Avoid prolonged sunlight exposure and apply protective measures.

Erythromycin

(antibiotic) (Macrolide) (Third-Line Agent)

MOA: Bacteriostatic abx that binds to 50S ribosomal subunit to block addition of new amino acids growing in the peptide chain.

Indications:

• Most gram + and some gram – coverage.

Erythromycin Adverse Effects

• GI is the most common, including epigastric pain and N/V/D

• QT prolongation → sudden cardiac death (monitor w/ 12-lead/telemetry)

• Hepatotoxicity and ototoxicity

• Numerous medication interactions

Erythromycin Nursing Considerations

• Often first alternative to PCN sensitive bacterial infections if an allergy present.

• Administer via oral route on empty stomach to maximize absorption but can give w/ food if upset stomach persists.

• Avoid in patient w/ pre-existing QT prolongation; monitor heart rhythm on telemetry.

• Can increase half-lives of several medications, notably theophylline and warfarin.

Clindamycin (Cleocin)

(antibiotic) (Linecosamide)

MOA: Similar to macrolides; Bacteriostatic abx that binds to 50S ribosomal subunit to block addition of new amino acids to growing peptide chain.

Indications:

• Gram + and gram = anaerobes and most common gram + aerobes.

Clindamycin (Cleocin) Adverse Effects

(Clindamycin → c. diff) (even if you dont get c. diff, you still get diarrhea)

Severe to fatal c. diff colitis:

• Abdominal pain

• Fever

• Leukocytosis

Non-c. diff diarrhea

Clindamycin (Cleocin) Nursing Considerations

• Monitor and educate patient on monitoring stool and fluid status.

• > 5 loose stools per day concerning for clostridium difficile associated diarrhea and consider D/C clindamycin treatment.

• Vigorous fluid & electrolyte replacement w/ PO vancomycin treatment.

Linezolid (Zyvox)

(antibiotic) (Oxazolidinone)

MOA: Bacteriostatic abx that binds to 23S portion of 50S ribosomal subunit to block formation of initiation complex.

Indications:

• Very broad-spectrum coverage, including MDRO

Linezolid (Zyvox) Adverse Effects

Headache (HA), N/V/D

Myelosuppression (Bone marrow suppression)

• Anemia, leukopenia, and/or thrombocytopenia.

• Pancytopenia

*Is a weak inhibitor of MAO and can lead to interactions.

Linezolid (Zyvox) Nursing Considerations

• Monitor CBC (for the highs and the lows—opportunistic infections) and I/O, especially w/ existing myelosuppressive agents or on other myelosuppressive agents.

• Give w/ food to limit GI upset.

• Monitor for drug interaction w/ MAO (mono amine oxidase) (hypertensive crisis) and SSRI (serotonin syndrome). (so nervous system effects)

Gentamicin

(antibiotic) (Aminoglycoside)

MOA:

• Binds to 30S ribosomal subunit to inhibit protein syntheses, premature termination of protein synthesis, and production of abnormal proteins.

• Causes bactericidal activity effects that persists via post antibiotic effect.

Indications: gram + cocci and aerobic gram – bacilli

• Target organisms include E.coli, Klebsiella, & pseudomonas

• Primarily used for serious infections.

Gentamicin Adverse Effects

• Nephrotoxicity due to proximal renal tubule injury.

• Ototoxicity impairing both hearing and balance.

(kind of similar to vancomycin)

Gentamicin Nursing Considerations

• Assess serum peak (dosing—30 minutes after the completed infusion) and trough (nephro), urine output (UOP), & CMP (particularly w/ concurrent nephrotoxic agent use) to assist dosing adjustments and AE monitoring.

• Neuro-focused assessment, including hearing and balance, especially w/ concurrent ototoxic agent usage.

• Increase fluid intake unless contraindicated.

• Do not mix in same IV solution w/ PCN.

Ciprofloxacin (Cipro)

(antibiotic) (Fluoroquinolone)

MOA: Inhibits two enzymes needed for DNA replication and cell division.

Indications:

• Borad spectrum against most aerobic gram – and some gram +.

Ciprofloxacin (Cipro) Adverse Effects

• GI effects (N/V/D) and CDI

• Tendon rupture, particularly achilles (it affects the extracellular matrix and the collagen synthesis in the tendon) (pt. not able to plantar flex, swelling, and loss of function)

• Central Nervous System (CNS) effect

• Phototoxicity

Ciprofloxacin (Cipro) Nursing Considerations

• Educate on tendon injury (achilles) and report early signs.

• Utilize sunscreen and protective clothing.

• Separate administration from dairy products by at least six hours before or two hours after.

Metronidazole (Flagyl)

(antibiotic) (Nitromidazole) (Reasons used over vancomycin would be due to resistance, ototoxicity, and nephrotoxicity)

MOA: After activation into active forms. Interacts w/ bacterial DNA to cause strand breakage and loss of helical structure that results in inhibition of nucleic acid synthesis and cell death.

Indications:

• Anaerobic bacteria infections, particularly CDI; also covers peptostreptococcus, eubacterium, and Bacteroides

• Antiprotozoal coverage

Metronidazole (Flagyl) Adverse Effects

• Most common are GI effects, as well as headache, dry mouth, and fatigue.

• Many interactions that include ethanol, as well as toxicities of lithium, benzos, cyclosporine, CCB, mood stabilizers, and warfarin.

Metronidazole (Flagyl) Nursing Considerations

• Educate not to drink alcohol (ETOH) while on therapy; can cause disulfiram-like reactions.

• Monitor closely for drug interactions from altered metabolism.

• Give w/ food to minimize GI upset.

Daptomycin (Cubicin)

(antibiotic) (Cyclic Lipopeptide)

MOA:

• Causes efflux of intracellular potassium to depolarize the cell.

—>The loss of potassium from the cell causes a failure in maintaining the membrane potential, which is crucial for bacterial survival.

• Inhibit synthesis of DNA, RNA, and protein to cause cell death.

Indications:

• Gram + bacterial infections only; notably can cover MRSA and VRE.

Daptomycin (Cubicin) Adverse Effects

• GI effects common, including constipation, and N/V/D

• Myopathy, especially if already on statin. (rhabdomyolysis)

• Hypotension and hypertension

Daptomycin (Cubicin) Nursing Considerations

• Monitor for any new onset muscle pain or weakness and baseline CK.

• HMG-CoA reductase inhibitors (statins) may be stopped while on daptomycin.

• Monitor V/S closely, particularly for changes in blood pressure.

Parenteral route of administration entails…

Intravenous (IV): Directly into a vein.

Intramuscular (IM): Into a muscle.

Subcutaneous (SC): Under the skin.

Intradermal: Into the dermis layer of the skin.

Penicillin G (benzylpenicillin)

(antibiotic) (Parenteral Route Beta-Lactam)

MOA: Targets PCN-binding proteins (PBP) to weaken the bacterial cell wall through inhibition of transpeptidases and disinhibition of autolysins.

• Transpeptiadse is an enzyme that plays a role in building bacterial cell walls. Penicillin G inhibits that.

• Autolysins are enzymes produced by bacteria that help break down and remodel their own cell walls. When bacteria is exposed to Penicillin G, autolysins continue to break the existing cell wall w/o any new material to replace it.

——>Under typical conditions, bacteria regulates autolysin activity to ensure that their cell wall is only broken down at a controlled rate to allow growth and division.

Indications:

• Most used for infections caused by most gram + bacteria (e.g., strep, enterococcus, and staph)

Penicillin G (benzylpenicillin) Adverse Effects

• IM route-related pain, as well as peripheral nerve issues.

• Allergic reactions and possible cross allergy/cephalosporins.

Penicillin G (benzylpenicillin) Nursing Considerations

• Assess for history of allergic reaction s/s; if allergic to penicillin (PCN), possible allergy to cephalosporins.

• Monitor complete blood count (CBC), vital signs, and infection s/s.

Penicillin Allergies

Immediate: 2 to 30 minutes

Accelerated: 1 to 72 hours

Delayed: Days to Weeks

Penicillin Resistance

Beta lactam is the moelecular structure of the antibiotic itself. The bacteria is going to target that specific part and create beta-lactamase (enzyme).

Other PCNs are combined w/ a beta-lactamase inhibitor so we can continue to kill bacteria. (MRSA, VRE)

Sepsis/Septic Shock

Lack of O2 —> Anaerobic metabolism —> Lactate level

According to sepsis guidlines, when should antimicrobial therapy begin?

1 hour (it should given after cultures have been taken)

Piperacillin/tazobactam (Zosyn)

(antimicrobial) (Combination Parenteral Beta-Lactam and Beta-Lactamase Inhibitor)

MOA: Penicillin actions plus inhibition of bacterial beta-lactamase w/ tazobactam.

• Piperacillin is an antibiotic that stop bacteria from building strong cell walls. W/O these walls, bacteria burst and die.

• Tazobactam is a beta-lactamase inhibitor that blocks bacteria that destroy piperacillin.

Indications:

• Extended spectrum (penicillin susceptible organisms plus gram—and anaerobic coverage, including pseudomonas, Enterobacter, Klebsiella)

Piperacillin/tazobactam (Zosyn) Adverse Effects

• Low toxicity

• Allergic reactions

Piperacillin/tazobactam (Zosyn) Nursing Cosniderations

• Assess for history of allergic reaction s/s; if allergic to penicillin (PCN), possible allergy also to cephalosporins

• Monitor complete blood count (CBC), vital signs (v/s), and infection s/s.

• Parenteral route only, monitor IV infusion site and compatibility w/ other antibiotic therapy w/ aminoglycosides. (DIFFERENCE BETWEEN PENICILLIN G IS THAT IT CAN BE USED W/ AMINOGLYCOSIDES SUCH AS GENTAMICIN!!)

We don’t mix penicillins and __________ in the same intravenous solution because it can result in a drug interaction.

aminoglycosides (e.g., gentamicin)

Cephalosporin Generations Differences

First Generation (e.g., cephalexin): Low Activity Against Gram-Negative Bacteria, Low Resistaince to Beta-Lacatamases, and Poor Distribution to Cerebrospinal Fluid.

Second Generation (e.g., cefoxitin): Higher Activity Against Gram-Negative Bacteria, Higher Resistance to Beta-Lactamases, and Poor Distrubution to Cerebrospinal Fluid.

Third Generation (e.g., cefoaxime): Higher Activity Against Gram-Negative Bacteria, Higher Resistance to Beta-Lactamases, and Good Distrubution to Cerebrospinal Fluid.

Fourth Generation (e.g., cefepime): Highest Activity Against Gram-Negative Bacteria, Highest Resistance to Beta-Lactamases, and Good Distrubution to Cerebrospinal Fluid. (broad spectrum coverage)

Fifth Generation (e.g., ceftaroline): High Activity Against Gram-Negative Bacteria, Highest Resistance to Beta-Lactamases, and Good Distrubution to Cerebrospinal Fluid. (broad spectrum coverage)

Cephalosporins

(antibiotic)

MOA: Like penicillins, cephalosporins bind to penicillin-binding proteins to disrupt cell wall synthesis and activate autolysins.

Indications: Indications for each generation will depend on type of coverage needed/type of bacteria involved.

• Cefazolin (Ancef)—surgical prophylaxis (prevention)

• Cefepime (Maxipime)—resistant organisms

• Cefazoline (Teflaro)—skin infections and HCAP

Cephalosporins Adverse Effects

• Allergic reactions

• Bleeding tendencies through interference w/ vitamin K metabolism. (Warfarin intensification—more anticoagulation)

• Disulfiram-like reactions w/ alcohol. (flushing, n/v, ha, etc.)

Cephalosporins Nursing Considerations

Due to similarity of action w/ PCN, nursing consideration will be the same w/ cephalosporins.

Due to structural similarities, patient w/ a PCN allergy may have a __________ allergy as well. If allergy present, particularly if it is severe, ________ medication should be used.

cephalosporin, neither

Imipenem/cilastatin (Primaxin)

(antibiotic) (Carbapenem) (Metabolized by the kidneys!)

MOA: Bind specifically to Penicillin-Binding Protein (PBP) 1 & 2 to weaken cell wall and can resist beta-lactamases. (Serious infections!)

• Imipenem is a powerful antibiotic that stops bacteria from building their cell walls.

• Cilastatin protects imipenem from being broken down by enzymes in the kidneys, allowing it to stay active longer and work more effectively.

Indications:

• Very broad-spectrum w/ activity against most pathogens, including MDRO, for bone, joint, skin, and soft tissues infections (SSTI), urinary tract infections (UTI), intraabdominal, and pelvic infections.

Imipenem/cilastatin (Primaxin) Adverse Effects

• GI effects most common, including N/V/D

• Seizures, particularly w/ renal impairment (toxins are not wasted and the med is now in the blood, which circulates up to the brain)

• Superinfections

Imipenem/cilastatin (Primaxin) Nursing Considerations

• Co-administered w/ cilastatin to prevent rapid imipenem breakdown in the kidneys.

• Reserve use in patients w/ infections not covered by other antibiotics.

Vancomycin (Vancocin)

(antibiotic)

MOA: Inhibits cell synthesis by binding to molecules that serve as precursors for cell biosynthesis.

Indications:

• Include gram + positive coverage only for bone, joint, and bloodstream infections, particularly MRSA and clostridium difficile infection (CDI). (Oral route for c. diff and IV for MRSA)

Vancomycin (Vancocin) Adverse Effects

• Nephrotoxicity leading to renal failure

• Ototoxicity (med accumulates in the cochlea—hearing + balance)

• Red man syndrome (rashes, itching, flushing, tachycardia, and hypotension) w/ rapid infusion.

• Vancomycin-resistant enterococci (VRE)

Vancomycin (Vancocin) Nursing Considerations

• Usually administered IV (MRSA); oral administration for CDI.

• Monitor trough levels (30 minutes before new administration is due) appropriately.

• Monitor CMP for renal function.

• Monitor CN VIII (8-vestibulocochelar) function.

• Avoid concurrent use w/ other nephrotoxic medications (loop diuretics, ethacrynic acid, aminoglycoside antibiotics).

• Appropriate hygiene and cleaning w/ active CDI patients.

Nirmatrelvir & ritonavir (Paxlovid)

(COVID-19 treatment)

MOA: Nirmatrelvir acts as a protease inhibitor, w/ ritonavir increasing nirmatrelvir’s plasma concentrations via metabolism inhibition.

Indications:

• Oral therapy indicated for symptomatic, non-severe COVID-19 infection w/ risk factors for the development of severe COVID-19 infection.

Nirmatrelvir & ritonavir (Paxlovid) Adverse Effects

• Hypertension

• Diarrhea

• Impaired or altered sense of taste

• Myalgia (muscle pain)

• Rebound COVID-19 infection (retest the pt. for COVID-19)

Nirmatrelvir & ritonavir (Paxlovid) Nursing Considerations

• Patient education on medication regimen (twice daily x 5 days) and adherence.

• Numerous drug interactions; thoroughly assess medication usage during the patient interview. (medication reconciliation)

• Risk of HIV resistance if a patient has an uncontrolled undiagnosed infection.

Molnupiravir (Lageviro)

(COVID-19 treatment)

MOA: Once metabolized and phosphorylated, it is incorporated into viral RNA polymerase resulting in viral genome errors and replication inhibition.

Indications:

• Oral therapy indicated for symptomatic, non-severe COVID-19 infection w/ risk factors for development of severe COVID-19 infection.

Molnupiravir (Lageviro) Adverse Effects

• Erythema (redness), rash, urticaria.

• Hypersensitivity (skin issues), including anaphylaxis, angioedema.

Molnupiravir (Lageviro) Nursing Considerations

• Alternative outpatient option for those who cannot take Paxlovid. (such as if a patient has HTN, they will go w/ this med)

• Patient education on medication regimen (twice daily x 5 days) and adherence.

• Not commercially available; current use is under EUA from AmerisourceBergen

• Capsules can be administered w/ or w/o food; do not crush, open, or break.

Remdesevir (Veklury)

(IV SARS-CoV-2 Nucleotide Analog RNA Polymerase Inhibitor)

MOA: Inhibits RNA polymerase, which is necessary for viral replication, by acting as an ATP analog which results in delayed chain termination during replication.

Indications:

• Indicated for COVID-19 infection requiring hospitalization and supplemental oxygen in adults and pediatric patients aged 12 or older and weighing at least 40kg.

Remdesevir (Veklury) Adverse Effects

• **Potentially severe bradycardia

• Elevated liver enzymes (AST & ALT)

• Hypersensitivity reactions resulting in anaphylaxis, angioedema, rash, etc.

• Prolonged prothrombin time (PT) (may increase the risk for bleeding—the clotting is taking longer than normal)

Remdesevir (Veklury) Nursing Considerations

• Monitor CMP (Kidney function, Liver function, F&E balance, Glucose, Calcium) and RUQ (that’s where the liver is!) s/s

• Although unlikely, monitor renal function for impairment for duration of therapy.

• Discontinue infusion and provide appropriate intervention if hypersensitivity reactions occur.

BNT162b2 (Pfizer-BioNTech COVID-19 Vaccine)

Two-dose IM mRNA vaccine for prevention of symptomatic COVID-19 at or after day 7 following the second dose (95% efficacy)

BNT162b2 (Pfizer-BioNTech COVID-19 Vaccine) & mRNA-1273 (Moderna COVID-19 Vaccine) Adverse Effects

• Injection site soreness

• Fever, chills, fatigue, headache, and lymphadenopathy (swollen lymph nodes) within 24-48 hours.

• Anaphylaxis, very rarely; milder allergic reactions.

BNT162b2 (Pfizer-BioNTech COVID-19 Vaccine) Nursing Considerations

• Patient education, including duration of protection and time between doses (21 days)

• Careful preparation to maximize doses per vial and appropriate amount of diluent (1.8 mL of NS; 0.3 mL administered per dose)

• Once reconstituted, must be used within 6 hours.

• Intramuscular injection soreness can be treated w/ OTC analgesics.

• IM Locations: Deltoid, Vastus Lateralis, Dorsalgluteal

• Monitor patients for 15 minutes post-administration.

mRNA-1273 (Moderna COVID-19 Vaccine)

Two-dose IM mRNA vaccine for prevention of symptomatic COVID-19 at or after day 7 following the second dose (94.1% efficacy)

mRNA-1273 (Moderna COVID-19 Vaccine) Nursing Considerations

• Patient education, including duration of protection and time between doses (28 days)

• Careful preparation to maximize dose per vial.

• Once vial is punctured, must be used within 6 hours

• Intramuscular injection soreness can be treated with OTC analgesics.

• IM Locations: Deltoid, Vastus Lateralis, Dorsalgluteal

• Monitor patients for 15 minutes post-administration