Antibiotics 100420021406-phpapp01

Anti-Infective AgentsAnti-Infective Agents
Antibiotics:Antibiotics:
SulfonamidesSulfonamides
PenicillinsPenicillins
CephalosporinsCephalosporins
TetracyclinesTetracyclines
AminoglycosidesAminoglycosides
QuinolonesQuinolones
MacrolidesMacrolides

AntibioticsAntibiotics
• Medications used to treat bacterial infectionsMedications used to treat bacterial infections
• Ideally, before beginning antibiotic therapy,Ideally, before beginning antibiotic therapy,
the suspected areas of infection should bethe suspected areas of infection should be
cultured to identify the causative organismcultured to identify the causative organism
and potential antibiotic susceptibilities.and potential antibiotic susceptibilities.

• Empiric therapy: treatment of an infectionEmpiric therapy: treatment of an infection
before specific culture information has beenbefore specific culture information has been
reported or obtainedreported or obtained
• Prophylactic therapy: treatment withProphylactic therapy: treatment with
antibiotics to prevent an infection, as in intra-antibiotics to prevent an infection, as in intra-
abdominal surgeryabdominal surgery

• Bactericidal: kill bacteriaBactericidal: kill bacteria
• Bacteriostatic: inhibit growth of susceptibleBacteriostatic: inhibit growth of susceptible
bacteria, rather than killing them immediately;bacteria, rather than killing them immediately;
will eventually lead to bacterial deathwill eventually lead to bacterial death

Antibiotics: SulfonamidesAntibiotics: Sulfonamides
One of the first groups of antibioticsOne of the first groups of antibiotics
• sulfadiazinesulfadiazine
• sulfamethizolesulfamethizole
• sulfamethoxazolesulfamethoxazole
• sulfisoxazolesulfisoxazole

Sulfonamides: Mechanism of ActionSulfonamides: Mechanism of Action
• Bacteriostatic actionBacteriostatic action
• Prevent synthesis of folic acid required forPrevent synthesis of folic acid required for
synthesis of purines and nucleic acidsynthesis of purines and nucleic acid
• Does not affect human cells or certainDoes not affect human cells or certain
bacteria—they can use preformed folic acidbacteria—they can use preformed folic acid

Sulfonamides: sulfamethoxazoleSulfonamides: sulfamethoxazole
Therapeutic UsesTherapeutic Uses
Azo-GantanolAzo-Gantanol
• Combined with phenazopyridineCombined with phenazopyridine
(an analgesic-anesthetic that affects the mucosa(an analgesic-anesthetic that affects the mucosa
of the urinary tract).of the urinary tract).
• Used to treat urinary tract infections (UTIs) and toUsed to treat urinary tract infections (UTIs) and to
reduce the pain associated with UTIsreduce the pain associated with UTIs..
BactrimBactrim
• Combined with trimethoprim.Combined with trimethoprim.
• Used to treat UTIs, Pneumocystis carinii pneumonia,Used to treat UTIs, Pneumocystis carinii pneumonia,
ear infections, bronchitis, gonorrhea, etc.ear infections, bronchitis, gonorrhea, etc.

Sulfonamides: sulfisoxazoleSulfonamides: sulfisoxazole
Therapeutic UsesTherapeutic Uses
Azo-GantrisinAzo-Gantrisin
• Combined with phenazopyridineCombined with phenazopyridine
• Used for UTIsUsed for UTIs
PediazolePediazole
• Combined with erythromycinCombined with erythromycin
• Used to treat otitis mediaUsed to treat otitis media

Sulfonamides: Side EffectsSulfonamides: Side Effects
Body SystemBody System EffectEffect
BloodBlood Hemolytic and aplasticHemolytic and aplastic
anemia, thrombocytopeniaanemia, thrombocytopenia
IntegumentaryIntegumentary Photosensitivity, exfoliativePhotosensitivity, exfoliative
dermatitis, Stevens-Johnsondermatitis, Stevens-Johnson
syndrome, epidermalsyndrome, epidermal
necrolysisnecrolysis

Sulfonamides: Side EffectsSulfonamides: Side Effects
Body SystemBody System EffectEffect
GIGI Nausea, vomiting, diarrhea,Nausea, vomiting, diarrhea,
pancreatitispancreatitis
OtherOther Convulsions, crystalluria,Convulsions, crystalluria,
toxic nephrosis, headache,toxic nephrosis, headache,
peripheral neuritis, urticariaperipheral neuritis, urticaria

Antibiotics: PenicillinsAntibiotics: Penicillins
• Natural penicillinsNatural penicillins
• Penicillinase-resistant penicillinsPenicillinase-resistant penicillins
• AminopenicillinsAminopenicillins
• Extended-spectrum penicillinsExtended-spectrum penicillins

Natural penicillinsNatural penicillins
• penicillin G, penicillin V potassiumpenicillin G, penicillin V potassium
Penicillinase-resistant penicillinsPenicillinase-resistant penicillins
• cloxacillin, dicloxacillin, methicillin, nafcillin, oxacillincloxacillin, dicloxacillin, methicillin, nafcillin, oxacillin

AminopenicillinsAminopenicillins
• amoxicillin, ampicillin, bacampicillinamoxicillin, ampicillin, bacampicillin
Extended-spectrum penicillinsExtended-spectrum penicillins
• piperacillin, ticarcillin, carbenicillin, mezlocillinpiperacillin, ticarcillin, carbenicillin, mezlocillin

• First introduced in the 1940sFirst introduced in the 1940s
• Bactericidal: inhibit cell wall synthesisBactericidal: inhibit cell wall synthesis
• Kill a wide variety of bacteriaKill a wide variety of bacteria
• Also called “beta-lactams”Also called “beta-lactams”

• Bacteria produce enzymes capable ofBacteria produce enzymes capable of
destroying penicillins.destroying penicillins.
• These enzymes are known asThese enzymes are known as
beta-lactamases.beta-lactamases.
• As a result, the medication is not effective.As a result, the medication is not effective.

• Chemicals have been developed to inhibitChemicals have been developed to inhibit
these enzymes:these enzymes:
– clavulanic acidclavulanic acid
– tazobactamtazobactam
– sulbactamsulbactam
• These chemicals bind with beta-lactamaseThese chemicals bind with beta-lactamase
and prevent the enzyme from breaking downand prevent the enzyme from breaking down
the penicillinthe penicillin

• Penicillin-beta-lactamase inhibitorPenicillin-beta-lactamase inhibitor
combination drugs:combination drugs:
– ampicillin + sulbactam = Unasynampicillin + sulbactam = Unasyn
– amoxicillin + clavulanic acid = Augmentinamoxicillin + clavulanic acid = Augmentin
– ticarcillin + clavulanic acid = Timentinticarcillin + clavulanic acid = Timentin
– piperacillin + tazobactam = Zosynpiperacillin + tazobactam = Zosyn

Penicillins: Mechanism of ActionPenicillins: Mechanism of Action
• Penicillins enter the bacteria via the cell wall.Penicillins enter the bacteria via the cell wall.
• Inside the cell, they bind to penicillin-binding protein.Inside the cell, they bind to penicillin-binding protein.
• Once bound, normal cell wall synthesis is disrupted.Once bound, normal cell wall synthesis is disrupted.
• Result: bacteria cells die from cell lysis.Result: bacteria cells die from cell lysis.
• Penicillins do not kill other cells in the body.Penicillins do not kill other cells in the body.

Penicillins: Therapeutic UsesPenicillins: Therapeutic Uses
• Prevention and treatment of infectionsPrevention and treatment of infections
caused by susceptible bacteria, such as:caused by susceptible bacteria, such as:
– gram-positive bacteriagram-positive bacteria
– Streptococcus, Enterococcus, StaphylococcusStreptococcus, Enterococcus, Staphylococcus
speciesspecies

Penicillins: Adverse EffectsPenicillins: Adverse Effects
• Allergic reactions occur in 0.7% – 8% ofAllergic reactions occur in 0.7% – 8% of
treatmentstreatments
– urticaria, pruritus, angioedemaurticaria, pruritus, angioedema
• 10% of allergic reactions are life-threatening10% of allergic reactions are life-threatening
andand
• 10% of these are fatal10% of these are fatal

Penicillins: Side EffectsPenicillins: Side Effects
• Common side effects:Common side effects:
– nausea, vomiting, diarrhea, abdominal painnausea, vomiting, diarrhea, abdominal pain
• Other side effects are less commonOther side effects are less common

Antibiotics: CephalosporinsAntibiotics: Cephalosporins
• First GenerationFirst Generation
• Second GenerationSecond Generation
• Third GenerationThird Generation
• Fourth GenerationFourth Generation

Antibiotics: CephalosporinsAntibiotics: Cephalosporins
• Semisynthetic derivatives from a fungusSemisynthetic derivatives from a fungus
• Structurally and pharmacologically relatedStructurally and pharmacologically related
to penicillinsto penicillins
• Bactericidal actionBactericidal action
• Broad spectrumBroad spectrum
• Divided into groups according to theirDivided into groups according to their
antimicrobial activityantimicrobial activity

Cephalosporins: First GenerationCephalosporins: First Generation
• cefadroxilcefadroxil
• cephalexincephalexin
• cephradinecephradine
• cefazolincefazolin
• cephalothincephalothin
• cephapirincephapirin
– Good gram-positive coverageGood gram-positive coverage
– Poor gram-negative coveragePoor gram-negative coverage

Cephalosporins: First GenerationCephalosporins: First Generation
cefazolincefazolin cephalexincephalexin
(Ancef and Kefzol)(Ancef and Kefzol) (Keflex and Keftab)(Keflex and Keftab)
IV and POIV and PO POPO
used for surgical prophylaxis, URIs, otitis mediaused for surgical prophylaxis, URIs, otitis media

Cephalosporins: Second GenerationCephalosporins: Second Generation
• cefaclorcefaclor •• cefonicidcefonicid
• cefprozilcefprozil •• ceforanideceforanide
• cefamandolecefamandole •• cefmetazolecefmetazole
• cefoxitincefoxitin •• cefotetancefotetan
• cefuroximecefuroxime
– Good gram-positive coverageGood gram-positive coverage
– Better gram-negative coverage than first generationBetter gram-negative coverage than first generation

Cephalosporins: Second GenerationCephalosporins: Second Generation
CefoxitinCefoxitin cefuroximecefuroxime
(Mefoxin)(Mefoxin) (Kefurox and Ceftin)(Kefurox and Ceftin)
IV and IMIV and IM POPO
Used prophylactically forUsed prophylactically for Surgical prophylaxisSurgical prophylaxis
abdominal or colorectalabdominal or colorectal
surgeriessurgeries Does not killDoes not kill
Also kills anaerobesAlso kills anaerobes anaerobesanaerobes

Cephalosporins: Third GenerationCephalosporins: Third Generation
• cefiximecefixime •• ceftizoximeceftizoxime
• cefpodoxime proxetilcefpodoxime proxetil •• ceftriaxoneceftriaxone
• cefoperazonecefoperazone •• ceftazidimeceftazidime
• cefotaximecefotaxime •• moxalactammoxalactam
– Most potent group against gram-negativeMost potent group against gram-negative
– Less active against gram-positiveLess active against gram-positive

cefixime (Suprax)cefixime (Suprax)
• Only oral third-generation agentOnly oral third-generation agent
• Best of available oral cephalosporins againstBest of available oral cephalosporins against
gram-negativegram-negative
• Tablet and suspensionTablet and suspension
ceftriaxone (Rocephin)ceftriaxone (Rocephin)
• IV and IM, long half-life, once-a-day dosingIV and IM, long half-life, once-a-day dosing
• Easily passes meninges and diffused into CSFEasily passes meninges and diffused into CSF
to treat CNS infectionsto treat CNS infections

ceftazidime (Ceptaz, Fortaz, Tazidime, Tazicef)ceftazidime (Ceptaz, Fortaz, Tazidime, Tazicef)
• IV and IMIV and IM
• Excellent gram-negative coverageExcellent gram-negative coverage
• Used for difficult-to-treat organisms such asUsed for difficult-to-treat organisms such as
Pseudomonas spp.Pseudomonas spp.
• Eliminated renally instead of biliary routeEliminated renally instead of biliary route
• Excellent spectrum of coverageExcellent spectrum of coverage

Cephalosporins: Fourth GenerationCephalosporins: Fourth Generation
cefepime (Maxipime)cefepime (Maxipime)
• Newest cephalosporin agents.Newest cephalosporin agents.
• Broader spectrum of antibacterial activity thanBroader spectrum of antibacterial activity than
third generation, especially against gram-positivethird generation, especially against gram-positive
bacteria.bacteria.

Cephalosporins: Side EffectsCephalosporins: Side Effects
• similar to penicillinssimilar to penicillins

Antibiotics: TetracyclinesAntibiotics: Tetracyclines
• demeclocycline (Declomycin)demeclocycline (Declomycin)
• oxytetracyclineoxytetracycline
• tetracyclinetetracycline
• doxycycline (Doryx, Doxy-Caps, Vibramycin)doxycycline (Doryx, Doxy-Caps, Vibramycin)
• minocyclineminocycline

• Natural and semi-syntheticNatural and semi-synthetic
• Obtained from cultures of StreptomycesObtained from cultures of Streptomyces
• Bacteriostatic—inhibit bacterial growthBacteriostatic—inhibit bacterial growth
• Inhibit protein synthesisInhibit protein synthesis
• Stop many essential functions of the bacteriaStop many essential functions of the bacteria

• Bind to CaBind to Ca2+2+ and Mgand Mg2+2+ and Aland Al3+3+ ions toions to
form insoluble complexesform insoluble complexes
• Thus, dairy products, antacids, and ironThus, dairy products, antacids, and iron
salts reduce absorption of tetracyclinessalts reduce absorption of tetracyclines

Tetracyclines: Therapeutic UsesTetracyclines: Therapeutic Uses
• Wide spectrum:Wide spectrum:
– gram-negative, gram-positive, protozoa,gram-negative, gram-positive, protozoa,
Mycoplasma, Rickettsia, Chlamydia, syphilis,Mycoplasma, Rickettsia, Chlamydia, syphilis,
Lyme diseaseLyme disease
• Demeclocycline is also used to treat SIADH,Demeclocycline is also used to treat SIADH,
and pleural and pericardial effusionsand pleural and pericardial effusions

Tetracyclines: Side EffectsTetracyclines: Side Effects
Strong affinity for calciumStrong affinity for calcium
• Discoloration of permanent teeth and toothDiscoloration of permanent teeth and tooth
enamel in fetuses and childrenenamel in fetuses and children
• May retard fetal skeletal development if takenMay retard fetal skeletal development if taken
during pregnancyduring pregnancy

Alteration in intestinal flora may result in:Alteration in intestinal flora may result in:
• Superinfection (overgrowth of nonsusceptibleSuperinfection (overgrowth of nonsusceptible
organisms such as Candida)organisms such as Candida)
• DiarrheaDiarrhea
• Pseudomembranous colitisPseudomembranous colitis

May also cause:May also cause:
• Vaginal moniliasisVaginal moniliasis
• Gastric upsetGastric upset
• EnterocolitisEnterocolitis
• Maculopapular rashMaculopapular rash

Antibiotics: AminoglycosidesAntibiotics: Aminoglycosides
• gentamicin (Garamycin)gentamicin (Garamycin)
• kanamycinkanamycin
• neomycinneomycin
• streptomycinstreptomycin
• tobramycintobramycin
• amikacin (Amikin)amikacin (Amikin)
• netilmicinnetilmicin

• Natural and semi-syntheticNatural and semi-synthetic
• Produced from StreptomycesProduced from Streptomyces
• Poor oral absorption; no PO formsPoor oral absorption; no PO forms
• Very potent antibiotics with serious toxicitiesVery potent antibiotics with serious toxicities
• BactericidalBactericidal
• Kill mostly gram-negative; someKill mostly gram-negative; some
gram-positive alsogram-positive also

• Used to kill gram-negative bacteria such asUsed to kill gram-negative bacteria such as
Pseudomonas spp., E. coli, Proteus spp.,Pseudomonas spp., E. coli, Proteus spp.,
Klebsiella spp., Serratia spp.Klebsiella spp., Serratia spp.
• Often used in combination with otherOften used in combination with other
antibiotics for synergistic effect.antibiotics for synergistic effect.

• Three most common (systemic): gentamicin,Three most common (systemic): gentamicin,
tobramycin, amikacintobramycin, amikacin
• Cause serious toxicities:Cause serious toxicities:
– Nephrotoxicity (renal failure)Nephrotoxicity (renal failure)
– Ototoxicity (auditory impairment and vestibularOtotoxicity (auditory impairment and vestibular
[eighth cranial nerve])[eighth cranial nerve])
• Must monitor drug levels to prevent toxicitiesMust monitor drug levels to prevent toxicities

Aminoglycosides: Side EffectsAminoglycosides: Side Effects
Ototoxicity and nephrotoxicity areOtotoxicity and nephrotoxicity are
the most significantthe most significant
• HeadacheHeadache
• ParesthesiaParesthesia
• Neuromuscular blockadeNeuromuscular blockade
• DizzinessDizziness
• VertigoVertigo
• Skin rashSkin rash
• FeverFever
• SuperinfectionsSuperinfections

Antibiotics: QuinolonesAntibiotics: Quinolones
• ciprofloxacin (Cipro)ciprofloxacin (Cipro)
• enoxacin (Penetrex)enoxacin (Penetrex)
• lomefloxacin (Maxaquin)lomefloxacin (Maxaquin)
• norfloxacin (Noroxin)norfloxacin (Noroxin)
• ofloxacin (Floxin)ofloxacin (Floxin)

• Excellent oral absorptionExcellent oral absorption
• Absorption reduced by antacidsAbsorption reduced by antacids
• First oral antibiotics effective againstFirst oral antibiotics effective against
gram-negative bacteriagram-negative bacteria

Quinolones: Mechanism of ActionQuinolones: Mechanism of Action
• BactericidalBactericidal
• Effective against gram-negative organismsEffective against gram-negative organisms
and some gram-positive organismsand some gram-positive organisms
• Alter DNA of bacteria, causing deathAlter DNA of bacteria, causing death
• Do not affect human DNADo not affect human DNA

Quinolones: Therapeutic UsesQuinolones: Therapeutic Uses
• Lower respiratory tract infectionsLower respiratory tract infections
• Bone and joint infectionsBone and joint infections
• Infectious diarrheaInfectious diarrhea
• Urinary tract infectionsUrinary tract infections
• Skin infectionsSkin infections
• Sexually transmitted diseasesSexually transmitted diseases

Quinolones: Side EffectsQuinolones: Side Effects
Body SystemBody System EffectsEffects
CNSCNS headache, dizziness, fatigue,headache, dizziness, fatigue,
depression, restlessnessdepression, restlessness
GIGI nausea, vomiting, diarrhea,nausea, vomiting, diarrhea,
constipation, thrush,constipation, thrush,
increased liver functionincreased liver function studiesstudies

Quinolones: Side EffectsQuinolones: Side Effects
Body SystemBody System EffectsEffects
IntegumentaryIntegumentary rash, pruritus, urticaria,rash, pruritus, urticaria,
flushing, photosensitivityflushing, photosensitivity
(with lomefloxacin)(with lomefloxacin)
OtherOther fever, chills, blurred vision,fever, chills, blurred vision,
tinnitustinnitus

Antibiotics: MacrolidesAntibiotics: Macrolides
• erythromycinerythromycin
• azithromycin (Zithromax)azithromycin (Zithromax)
• clarithromycin (Biaxin)clarithromycin (Biaxin)
• dirithromycindirithromycin
• troleandomycintroleandomycin
– bactericidal actionbactericidal action

Macrolides: Therapeutic UsesMacrolides: Therapeutic Uses
Strep infectionsStrep infections
• Streptococcus pyogenesStreptococcus pyogenes
(group A beta-hemolytic streptococci)(group A beta-hemolytic streptococci)
Mild to moderate URIMild to moderate URI
• Haemophilus influenzaeHaemophilus influenzae
Spirochetal infectionsSpirochetal infections
• Syphilis and Lyme diseaseSyphilis and Lyme disease
Gonorrhea, Chlamydia, MycoplasmaGonorrhea, Chlamydia, Mycoplasma

Macrolides: Side EffectsMacrolides: Side Effects
GI effects, primarily with erythromycin:GI effects, primarily with erythromycin:
• nausea, vomiting, diarrhea, hepatotoxicity,nausea, vomiting, diarrhea, hepatotoxicity,
flatulence, jaundice, anorexiaflatulence, jaundice, anorexia
• Newer agents, azithromycin and clarithromycin:Newer agents, azithromycin and clarithromycin:
fewer side effects, longer duration of action,fewer side effects, longer duration of action,
better efficacy, better tissue penetrationbetter efficacy, better tissue penetration

Antibiotics: Nursing ImplicationsAntibiotics: Nursing Implications
• Before beginning therapy, assess drug allergies;Before beginning therapy, assess drug allergies;
hepatic, liver, and cardiac function; and other labhepatic, liver, and cardiac function; and other lab
studies.studies.
• Be sure to obtain thorough patient health history,Be sure to obtain thorough patient health history,
including immune status.including immune status.
• Assess for conditions that may be contraindicationsAssess for conditions that may be contraindications
to antibiotic use, or that may indicate cautious use.to antibiotic use, or that may indicate cautious use.
• Assess for potential drug interactions.Assess for potential drug interactions.

• It is ESSENTIAL to obtain cultures fromIt is ESSENTIAL to obtain cultures from
appropriate sites BEFORE beginningappropriate sites BEFORE beginning
antibiotic therapy.antibiotic therapy.

• Patients should be instructed to take antibioticsPatients should be instructed to take antibiotics
exactly as prescribed and for the length of timeexactly as prescribed and for the length of time
prescribed; they should not stop taking theprescribed; they should not stop taking the
medication early when they feel better.medication early when they feel better.
• Assess for signs and symptoms of superinfection:Assess for signs and symptoms of superinfection:
fever, perineal itching, cough, lethargy, or anyfever, perineal itching, cough, lethargy, or any
unusual discharge.unusual discharge.

• For safety reasons, check the name of theFor safety reasons, check the name of the
medication carefully since there are manymedication carefully since there are many
agents that sound alike or have similaragents that sound alike or have similar
spellings.spellings.

• Each class of antibiotics has specific sideEach class of antibiotics has specific side
effects and drug interactions that must beeffects and drug interactions that must be
carefully assessed and monitored.carefully assessed and monitored.
• The most common side effects of antibioticsThe most common side effects of antibiotics
are nausea, vomiting, and diarrhea.are nausea, vomiting, and diarrhea.
• All oral antibiotics are absorbed better ifAll oral antibiotics are absorbed better if
taken with at least 6 to 8 ounces of water.taken with at least 6 to 8 ounces of water.

SulfonamidesSulfonamides
• Should be taken with at least 2400 mL of fluidShould be taken with at least 2400 mL of fluid
per day, unless contraindicated.per day, unless contraindicated.
• Due to photosensitivity, avoid sunlight andDue to photosensitivity, avoid sunlight and
tanning beds.tanning beds.
• These agents reduce the effectiveness ofThese agents reduce the effectiveness of
oral contraceptives.oral contraceptives.

PenicillinsPenicillins
• Any patient taking a penicillin should be carefullyAny patient taking a penicillin should be carefully
monitored for an allergic reaction for at least 30monitored for an allergic reaction for at least 30
minutes after its administration.minutes after its administration.
• The effectiveness of oral penicillins is decreasedThe effectiveness of oral penicillins is decreased
when taken with caffeine, citrus fruit, cola beverages,when taken with caffeine, citrus fruit, cola beverages,
fruit juices, or tomato juice.fruit juices, or tomato juice.

CephalosporinsCephalosporins
• Orally administered forms should be given with foodOrally administered forms should be given with food
to decrease GI upset, even though this will delayto decrease GI upset, even though this will delay
absorption.absorption.
• Some of these agents may cause an Antabuse-likeSome of these agents may cause an Antabuse-like
reaction when taken with alcohol.reaction when taken with alcohol.

TetracyclinesTetracyclines
• Milk products, iron preparations, antacids, and otherMilk products, iron preparations, antacids, and other
dairy products should be avoided because of thedairy products should be avoided because of the
chelation and drug-binding that occurs.chelation and drug-binding that occurs.
• All medications should be taken with 6 to 8 ouncesAll medications should be taken with 6 to 8 ounces
of fluid, preferably water.of fluid, preferably water.
• Due to photosensitivity, avoid sunlight andDue to photosensitivity, avoid sunlight and
tanning beds.tanning beds.

• Monitor peak and trough blood levels of theseMonitor peak and trough blood levels of these
agents to prevent nephrotoxicity and ototoxicity.agents to prevent nephrotoxicity and ototoxicity.
• Symptoms of ototoxicity include dizziness, tinnitus,Symptoms of ototoxicity include dizziness, tinnitus,
and hearing loss.and hearing loss.
• Symptoms of nephrotoxicity include urinary casts,Symptoms of nephrotoxicity include urinary casts,
proteinuria, and increased BUN and serumproteinuria, and increased BUN and serum
creatinine levels.creatinine levels.

• Should be taken with at least 3 L of fluid per day,Should be taken with at least 3 L of fluid per day,
unless otherwise specifiedunless otherwise specified

MacrolidesMacrolides
• These agents are highly protein-bound and willThese agents are highly protein-bound and will
cause severe interactions with other protein-boundcause severe interactions with other protein-bound
drugs.drugs.
• The absorption of oral erythromycin is enhancedThe absorption of oral erythromycin is enhanced
when taken on an empty stomach, but becausewhen taken on an empty stomach, but because
of the high incidence of GI upset, many agentsof the high incidence of GI upset, many agents
are taken after a meal or snack.are taken after a meal or snack.

Monitor for therapeutic effects:Monitor for therapeutic effects:
• Disappearance of fever, lethargy, drainage,Disappearance of fever, lethargy, drainage,
and rednessand redness

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