UTI, TB, Malaria, and Antifungal Agents

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.