Vancomycin

• Glycopeptide (Broad category)
• Ther. Class.- anti-infectives
• IV: Treatment of potentially life-threatening infections when less toxic anti-infectives are contraindicated.
• IV: Part of endocarditis prophylaxis in high-risk patients who are allergic to penicillin.
• Used against MRSA
• Therepeutic: 
• Bactericidal action against susceptible organisms. 
• Active against gram-positive pathogens.
• Poorly absorbed from the GI tract 
• Some penetration (20–30%) of CSF; crosses placenta.
• Oral doses excreted primarily in the feces
• IV eliminated almost entirely by the kidneys.
• Contraindicated in:
• Hypersensitivity
• Use Cautiously in:
• Renal impairment (LFT)
• Hearing impairment (Ototoxicitiy)
• Intestinal obstruction or inflammation (↑ systemic absorption when given orally)
• Adverse Rxns/Side effects:
• EENT: ototoxicity
• CV: hypotension
• GI: nausea, vomiting
• GU: nephrotoxicity (BUN/Creatinine)
• Derm: rashes
• Hemat: eosinophilia, leukopenia
• Local: phlebitis
• MS: back and neck pain
• Misc: HYPERSENSITIVITY REACTIONS INCLUDING ANAPHYLAXIS, chills, fever, "red man" syndrome (with rapid infusion), superinfection
• Ineffective for enterococci particularly vancomycin-resistant enterococci (VRE) - can cause staphylococcal endocarditis.

Doxycycline

• Ther. Class.- anti-infectives
• Pharm. Class.- tetracyclines
• Indications:
• Treatment of various infections caused by unusual organisms, including:
• Chlamydia,
• Rickettsia,
• Treatment of inhalational anthrax (postexposure) and cutaneous anthrax.
• Treatment of gonorrhea and syphilis in penicillin-allergic patients.
• Prevention of exacerbations of chronic bronchitis.
• Treatment of acne.
• Treatment of inflammatory lesions associated with rosacea (Oracea only).
• Malaria prophylaxis.
• Inhibits bacterial protein synthesis
• Bacteriostatic action against susceptible bacteria
• Well absorbed from the GI tract
•  crosses placenta and enters breast milk
• 20–40% excreted unchanged in urine
• Contraindicated in:
• Hypersensitivity
• Some products contain alcohol or bisulfites and should be avoided in patients with known hypersensitivity or intolerance.
• Use Cautiously in:
• Cachectic or debilitated patients
• Renal disease
• Hepatic impairment
• OB: Pregnancy–risk of permanent staining of teeth in infant if used during last half of pregnancy,
• Lactation: Pedi: Lactation or children <8 yr–permanent staining of teeth.
• Adverse rxns/side effects:
• GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, esophagitis, hepatotoxicity, pancreatitis
• Derm: ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, photosensitivity, rash
• Hemat: blood dyscrasias
• Local: phlebitis at IV site
• Misc: hypersensitivity reactions, superinfection,Nephrotoxicity.
• Interactions:
• Antacids, calcium, iron, and magnesium form insoluble compounds (chelates) and ↓ absorption of tetracyclines; this effect is least with doxycycline.
• Decreases effects of oral contraception
• Calcium in foods or dairy products ↓ absorption by forming insoluble compounds (chelates); this effect is minimal with doxycycline.
• When used with aminoglycosides, risk for kidney damage.
• With penicillin, penicillin effect is decreased and there is an increased risk of resistance to penicillin. 
• Implementations: 
• May cause yellow-brown discoloration and softening of teeth and bones if administered prenatally or during early childhood. Not recommended for children under 8 yr of age or during pregnancy or lactation, unless used for the treatment of anthrax.
• The Oracea product is only indicated for rosacea, not for infections.
• Avoid administration of calcium, antacids, magnesium-containing medications, sodium bicarbonate, or iron supplements within 1–3 hr of oraldoxycycline.

Erythromycin

• Ther. Class.- anti-infectives
• Pharm. Class.- macrolides
• Indications:
• Treat infections in the respiratory tract, sinuses. GI tract, skin and soft tissue, and diptheria, impetigo contagiosa and STDs.
• Useful when penicillin is the most appropriate drug but cannot be used because of hypersensitivity, including:
• Streptococcal infections,
• Treatment of syphilis or gonorrhea.
• Also treated for acne
• Drug of choice for mycoplasmal pneumonia and Legionnaire's disease.
• Suppresses protein synthesis
• Bacteriostatic action against susceptible bacteria. (Gram positive and gram negative)
• Crosses placenta; enters breast milk.
• Contraindicated in:
• Known alcohol intolerance (most topicals)
• Use Cautiously in:
• Liver/renal disease
• Adverse rxns/side effects
• CNS: seizures (rare)
• EENT: ototoxicity
• CV: TORSADE DE POINTES, VENTRICULAR ARRHYTHMIAS, QT interval prolongation
• GI: PSEUDOMEMBRANOUS COLITIS, nausea, vomiting, abdominal pain, cramping, diarrhea, hepatitis, infantile hypertrophic pyloric stenosis, pancreatitis(rare)
• GU: interstitial nephritis
• Derm: rash
• Local: phlebitis at IV site
• Misc: allergic reactions, superinfection
• Interactions:
• May ↑ colchicine levels and the risk for toxicity; use lower starting and maximum dose of colchicine.
• May ↑ theophylline levels and the risk for toxicity; ↓ theophylline dose.
• May ↑ warfarin levels and the risk for bleeding.
• Don't take on empty stomach. (crackers full 8oz glass of water)
• Can cause hepatotoxicity in high doses.
• Implementation:
• 1 hr before or 2 hr after meals; may be taken with food if GI irritation occurs.

Acyclovir

Ther. Class.
antivirals

Pharm. Class.
purine analogues

 Indications

• PO: Recurrent genital herpes infections. Localized cutaneous herpes zoster infections (shingles) and chickenpox (varicella).
• IV: Severe initial episodes of genital herpes in nonimmunosuppressed patients. Mucosal or cutaneous herpes simplex infections or herpes zoster infections (shingles) in immunosuppressed patients. Herpes simplex encephalitis.
• Topical: Cream–Recurrent herpes labialis (cold sores). Ointment–Treatment of limited non–life-threatening herpes simplex infections in immunocompromised patients (systemic treatment is preferred).

Action[image]

Interferes with viral DNA synthesis.

Therapeutic Effect(s):

Inhibition of viral replication and reduced time for healing of lesions.

• poor absorption (15–30%)
• Crosses placenta; enters breast milk.

Use Cautiously in:

• Pre-existing serious neurologic, hepatic, pulmonary, or fluid and electrolyte abnormalities
• Renal impairment (dose alteration recommended if CCr <50 mL/min)
• Geri: Due to age related ↓ in renal function
• Obese patients (dose should be based on ideal body weight)
• Patients with hypoxia

Adverse Reactions/Side Effects[image]

CNS: SEIZURES, dizziness, headache

GI: diarrhea, nausea, vomiting

GU: RENAL FAILURE

Derm: STEVENS-JOHNSON SYNDROME

Hemat: THROMBOTIC THROMBOCYTOPENIC PURPURA/HEMOLYTIC UREMIC SYNDROME (HIGH DOSES IN IMMUNOSUPPRESSED PATIENTS)

Local: pain, phlebitis

Implementation

• Start acyclovir treatment as soon as possible after herpes simplex symptoms appear and within 24 hr of a herpes zoster outbreak.
• PO: Acyclovir may be administered with food or on an empty stomach, with a full glass of water.
• Can be given IV slowly
• Wathch kidney function
• Encourage increased fluid intake 2400mls (2 1/2 L) of fluids
• Watch for CNS side effects
• May change menses in women

Amoxicillin

• Ther. Class.- anti-infectives; antiulcer agents
• Pharm. Class.- aminopenicillins
• Indications:
• Skin and skin structure infections,
• Otitis media,
• Sinusitis,
• Respiratory infections,
• Genitourinary infections.
• Endocarditis prophylaxis.
• Postexposure inhalational anthrax prophylaxis.
• Binds to bacterial cell wall, causing cell death.
• Therapeutic Effect(s): Bactericidal action; spectrum is broader than penicillins. Not as broadly effective as originally thought.
• Well absorbed
•  Crosses placenta; enters breast milk in small amounts.
• Contraindication:
• Hypersensitivity to penicillins (cross-sensitivity exists to cephalosporins and other beta-lactams);
• Use Cautiously in:
• Severe renal insufficiency
• Adverse rxns/ side effects
• CNS: SEIZURES (HIGH DOSES)
• GI: PSEUDOMEMBRANOUS COLITIS, diarrhea, nausea, vomiting, ↑ liver enzymes
• Derm: rash, urticaria
• Hemat: blood dyscrasias
• Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS, SERUM SICKNESS, superinfection
• Implementation: May be given without regard to meals or with meals to decrease GI side effects.
• Not penicillinase resistant- ineffective against S.aureus

Amantadine

Ther. Class.
antiparkinson agents
antivirals

Indications[image]

• Symptomatic initial and adjunct treatment of Parkinson's disease.
• Prophylaxis and treatment of influenza A viral infections.

Action[image]

• Potentiates the action of dopamine in the CNS.
• Prevents penetration of influenza A virus into host cell.

Therapeutic Effect(s):

• Relief of Parkinson's symptoms.
• Prevention and decreased symptoms of influenza A viral infection.

Oseltamivir

• Ther. Class.
• antivirals
• Pharm. Class.
• neuramidase inhibitors
• Treatment of uncomplicated acute illness due to influenza infection in adults and children ≥1 yr who have had symptoms for ≤2 days.
• Prevention of influenza in patients ≥1 yr.
• Inhibits the enzyme neuraminidase, which may alter virus particle aggregation and release.
• Therapeutic Effect(s):
• Reduced duration or prevention of flu-related symptoms.
• Rapidly absorbed from the GI tract and converted by the liver to the active form, oseltamivir carboxylate.
• Advers rxns/side effects:
• CNS: SEIZURES, abnormal behavior, agitation, confusion, delirium, hallucinations, insomnia, nightmares, vertigo
• Resp: bronchitis
• GI: nausea, vomiting
• Interaction:
• May ↓ the therapeutic effect of influenza virus vaccine avoid use 2 days prior to and 2 weeks after vaccine administration.
• Treatment with oseltamivir should be started as soon as possible from the first sign of flu symptoms within 2 days of exposure.
• Consider available information on influenza drug susceptibility patterns and treatment effects before using oseltamivir for prophylaxis.
• PO: May be administered with food or milk to minimize GI irritation.
• Should not be substituted for flu shot.

Zanamivir

Ther. Class.
antivirals

Pharm. Class.
neuramidase inhibitors

Indications[image]

• Treatment of uncomplicated acute illness caused by influenza virus in patients ≥7 yr who have been symptomatic ≤2 days.
• Prevention of influenza in patients ≥5 yr.

Action[image]

Inhibits the enzyme neuramidase, which may alter virus particle aggregation and release.

Therapeutic Effect(s):

Reduced duration or prevention of flu-related symptoms.

Use Cautiously in:

• Chronic obstructive pulmonary disease or asthma (↑ risk of decreased lung function and/or bronchospasm)

Adverse Reactions/Side Effects[image]

CNS: SEIZURES

Implementation

• Do not substitute for flu shot, flu shots should be encouraged
• Must be given w/in 48 hrs of symptoms
• early diagnosis is important

Isoniazid (INH)

• Ther. Class.- antituberculars
• Indications:
• First-line therapy of active tuberculosis, in combination with other agents.
• Prevention of tuberculosis in patients exposed to active disease (alone).
• Inhibits mycobacterial cell wall synthesis and interferes with metabolism.
• Therapeutic Effect(s):
• Bacteriostatic or bactericidal action against susceptible mycobacteria.
• Well absorbed; Crosses the placenta; enters breast milk in concentrations equal to plasma.
• Contraindicated in:
• Hypersensitivity
• Acute liver disease
• Previous hepatitis from isoniazid.
• Use Cautiously in:
• History of liver damage or chronic alcohol ingestion
• Severe renal impairment (dosage reduction may be necessary)
• Malnourished patients, patients with diabetes, or chronic alcoholics (↑ risk of neuropathy)
• Adverse rxns/side effects:
• CNS: psychosis, seizures
• EENT: visual disturbances
• GI: DRUG-INDUCED HEPATITIS, nausea, vomiting
• Derm: rashes
• Endo: gynecomastia
• Hemat: blood dyscrasias
• Neuro: peripheral neuropathy
• Misc: fever
• Interaction:
• Aluminum-containing antacids may decrease absorption.
• Concurrent administration of pyridoxine may prevent neuropathy.
• Severe reactions may occur with ingestion of foods containing high concentrations of tyramine (see food sources for specific nutrients).
• implementation
• PO: May be administered with food or antacids if GI irritation occurs, although antacids containing aluminum should not be taken within 1 hr of administration.
• IM: Medication may cause discomfort at injection site. Massage site after administration and rotate injection sites.
  • Solution may form crystals at low temperatures; crystals will redissolve upon warming to room temperature.

Pyridoxine (vitamin B6)

Ther. Class.
vitamins

Pharm. Class.
water soluble vitamins

Indications

• Treatment and prevention of neuropathy, which may develop from isoniazid
• Management of isoniazid overdose >10 g.

Action[image]

• Required for amino acid, carbohydrate, and lipid metabolism.
• Used in the transport of amino acids, formation of neurotransmitters, and synthesis of heme.

Therapeutic Effect(s):

• Prevention of pyridoxine deficiency.

Absorption: Well absorbed from the GI tract.

Distribution: Crosses the placenta and enters breast milk.

Adverse Reactions/Side Effects[image]

Adverse reactions listed are seen with excessive doses only

Neuro: sensory neuropathy, paresthesia

Interactions

• isoniazid (INH) blocks pyridoxine (vit b6)

Ketoconazole

• Ther. Class.- antifungals 
• Treatment of:
• Candidiasis (disseminated and mucocutaneous),
• Coccidioidomycosis
• cryptococcoiosis
• histoplansmosis
• paracoccidioidomycosis
• Action
• Disrupts fungal cell membrane.
• Interferes with fungal metabolism.
• Also inhibits the production of adrenal steroids.
• Therapeutic Effect(s):
• Fungistatic or fungicidal action against susceptible organisms, depending on organism and site of infection.
• Active against many pathogenic fungi
•  Absorption from the GI tract is pH dependent; increasing pH decreases absorption. Crosses the placenta; enters breast milk. highly protein bound
• Contraindicated in:
• Hypersensitivity
• Use Cautiously in:
• History of liver disease
• Alcoholism
• Adverse rxns/side effect:
• CNS: dizziness, drowsiness
• EENT: photophobia
• GI: DRUG-INDUCED HEPATITIS, nausea, vomiting, abdominal pain, constipation, diarrhea, flatulence
• GU: ↓ male libido, menstrual irregularities, oligospermia
• Derm: rashes
• Endo: gynecomastia
• Interactions:
• May alter the effectiveness of hormonal contraceptives (alternative method of contraception recommended).
• Drugs that ↑ gastric pH, including antacids, histamine H₂ antagonists, didanosine (chewable tablets, because of buffer), and gastric acid–pump inhibitors ↓ absorption (wait 2 hr before administration of ketoconazole).
• Sucralfate and isoniazid also ↓ bioavailability.
• Rifampin or isoniazid may ↓ levels and effectiveness.
• Implementation- Administer with meals or snacks to minimize nausea and vomiting.

Amphotericin B

Ther. Class.
antifungals

Indications[image]

• IV: Treatment of progressive, potentially fatal fungal infections.

Action[image]

• Binds to fungal cell membrane, allowing leakage of cellular contents.
• Toxicity (especially acute infusion reactions and nephrotoxicity) is less with lipid formulations.
• Active against many pathogenic fungi

Distribution: Poor penetration into CSF

Use Cautiously in:

• Renal impairment or electrolyte abnormalities
• Patients receiving concurrent leukocyte transfusions (↑ risk of pulmonary toxicity)

Adverse Reactions/Side Effects

CNS: anxiety, confusion, headache, insomnia

Resp: dyspnea, hypoxia

CV: hypotension, tachycardia

GI: diarrhea, hyperbilirubinemia, ↑ liver enzymes, nausea, vomiting, abdominal pain

GU: nephrotoxicity, hematuria

F and E: hyperglycemia, hypocalcemia, hypokalemia, hypomagnesemia

Hemat: anemia, thrombophlebitis

Derm: pruritis, rashes, paresthesias

MS: arthralgia, myalgia

Misc: HYPERSENSITIVITY REACTIONS, chills, fever, flushing

Interactions[image]

Drug-Drug

• Concurrent use with corticosteroids ↑ risk of hypokalemia.

Implementation

• is highly toxic: nephrotoxicity and elctrolyte imbalance, monitor patient closely; BUN/Creatinine
• Treat side effects with antiemetics and antipyretics (not dangerous)
• Peak: 1 to 2 hr after IV infusion, 20 hr duration

Fluconazole (Diflucan)

• Ther. Class.- antifungals (systemic)
• Indictions: 
• PO: IV: Fungal infections caused by susceptible organisms, including:
• Oropharyngeal or esophageal candidiasis ,
• Serious systemic candidal infections,
• Urinary tract infections,
• Peritonitis,
• Cryptococcal meningitis.
• Prevention of candidiasis in patients who have undergone bone marrow transplantation.
• PO: Single-dose oral treatment of vaginal candidiasis.
• Unlabeled Use(s):
• Prevention of recurrent vaginal yeast infections.
• Inhibits synthesis of fungal sterols, a necessary component of the cell membrane.
• Therapeutic Effect(s):
• Fungistatic action against susceptible organisms.
• May be fungicidal in higher concentrations.
• Well absorbed after oral administration.  good penetration into CSF, saliva, sputum, vaginal fluid, skin, eye, and peritoneum. Excreted in breast milk.
• Contraindicated in:
• Hypersensitivity to fluconazole or other azole antifungals;
• Use Cautiously in:
• Renal impairment (dose ↓ required if CCr <50 mL/min);
• Underlying liver disease
• Adverse rxns/side effects
• Incidence of adverse reactions is increased in HIV patients
• CNS: headache, dizziness, seizures
• GI: HEPATOTOXICITY, abdominal discomfort, diarrhea, nausea, vomiting
• Derm: EXFOLIATIVE SKIN DISORDERS INCLUDING STEVENS-JOHNSON SYNDROME
• Endo: hypokalemia, hypertriglyceridemia
• Misc: allergic reactions,including ANAPHYLAXIS
• Interactions: Rifampin, rifabutin, and isoniazid ↓ levels.

Mebendazole

• This medication is no longer available in the United States. Information provided here is for reference purposes only.
• Ther. Class.- anthelmintics
• Treatment of:
• Whipworm (trichuriasis),
• Pinworm (enterobiasis),
• Roundworm (ascariasis),
• Hookworm (uncinariasis) infections,
• Inhibits the uptake of glucose and other nutrients by susceptible helminths.
• Therapeutic Effect(s):
• Death of parasites, eggs, and hydatid cysts (vermicidal and ovacidal).
• Minimally (2–10%) absorbed after oral administration. distribution To liver, fat muscle, plasma, and hepatic cysts.
• Contraindicated in:
• Hypersensitivity.
• Use Cautiously in:
• Impaired liver function
• Crohn's ileitis
• Ulcerative colitis
• Adverse rxns/side effects:
• Most side effects and adverse reactions are seen with high-dose therapy only
• CNS: SEIZURES (RARE), dizziness, headache
• EENT: tinnitus
• GI: abdominal pain, diarrhea, increased liver enzymes (high dose, long-term therapy), nausea, vomiting
• Derm: rash, urticaria, alopecia
• Hemat: agranulocytosis, reversible myelosuppression (leukopenia, thrombocytopenia)
• Neuro: numbness
• Misc: fever
• Indications: Absorption may be increased by fatty foods.
• No special diets, fasting, laxatives, or enemas are required before administration of mebendazole.
• Pinworm: All members of the household should be treated concurrently, with treatment repeated in 2–3 wk.
• Hookworm and Whipworm: Patient may be required to take an iron supplement daily during treatment and for 6 mo after treatment if anemia occurs.

Quinine

Ther. Class.
antimalarials

Indications

Chloroquine-resistant falciparum malaria (alone or with pyrimethamine and a sulfonamide or with a tetracycline; has also been used with clindamycin and mefloquine depending on origin of illness).

Action[image]

• Increases the refractory period of skeletal muscle, increases the distribution of calcium within muscle fibers, decreases the excitability of motor end-plate regions, resulting in decreased response to repetitive nerve stimulation and acetylcholine.

Therapeutic Effect(s):

Death of P. falciparum.

Pharmacokinetics[image]

Absorption: Rapidly and almost completely (80%) absorbed following oral administration.

Distribution: does not enter CSF well. Crosses the placenta and enters breast milk.

Contraindication/Precautions

• QTc prolongation or conditions predisposing to QTc prolongation including hypokalemia and bradycardia
• Concurrent use of Class IA or Class III antiarrhythmics, mefloquine, pimozide, or macrolide anti-infectives (↑ risk of arrhythmias)
• Lactation: Discontinue drug or breastfeeding

Use Cautiously in:

• History of arrhythmias, especially QTc prolongation
• Atrial fibrillation/flutter (may cause paradoxical ↑ in ventricular response)
• Hypoglycemia

Adverse Reactions/Side Effects[image]

CV: ARRHYTHMIAS

GI: abdominal cramps/pain, diarrhea, nausea, vomiting, hepatotoxicity

Derm: rash

Endo: hypoglycemia (↑ in pregnancy)

Hemat: bleeding, blood dyscrasias, thrombotic thrombocytopenic pupura, thrombocytopenia

Misc: cinchonism, HYPERSENSITIVITY REACTIONS INCLUDING FEVER AND ANAPHYLAXIS, HEMOLYTIC UREMIC SYNDROME, STEVENS-JOHNSON SYNDROME

Toxicity Overdose:

Plasma quinine levels of >10 mcg/mL may cause tinnitus and impaired hearing.

• Signs of toxicity or cinchonism include tinnitus, headache, nausea, and slightly disturbed vision; usually disappear rapidly upon discontinuing quinine.

Implementation

• PO: Administer with or after meals to minimize GI distress. Aluminum-containing antacids will decrease and delay absorption; avoid concurrent use.