Anitbiotics

Question 1

SCIP: Surgical Care Improvement Project

Answer 1

anesthesia providers can make impact on prevention through timely and appropriate use of abx, maintenance of normothermia, proper syringe/med administration practices

Question 2

SCIP Measures

Answer 2

• Inf-1: prophylactic antibiotic received within one hour prior to surgical incision
• Inf-2: prphylactic antibiotic selection for surgical patients
• Inf-3- prophylactic antibiotics discontinued within 24 hours after surgery end time
• Inf-4: cardiac surgery patients with controlled 6a postop BG (<200)
• Inf-6: surgery patients with appropriate hair removal
• Inf-9: urinary catheter removed on POD 1 or 2
• Inf-10: surgery patients with preoperative temperature management
• Card-2: surgery patients on BB therapy prior to arrival who received BB during periop period
• VTE 1: surgery patients with recommended venous thromboembolism prophylaxis ordered
• VTE 2: surgery patients who received appropriate venous thromboembolism prophylaxis within 24h proper to surgery to 24h after surgery

Question 3

adverse outcomes associated with hypothermia

Answer 3

increased blood loss
increased transfusion requirements
prolonged PACU stay
postop pain
impaired immune function (neutrophil)

Question 4

SBE prophylaxis standard medications

Answer 4

amoxicillin 2g PO

IV ampicillin 2g

Question 5

SBE prophylaxis standard medications: PCN allergy

Answer 5

clindamycin 600mg IV

cefazolin 1g IV

Question 6

examples of bactericidal abx

Answer 6

PCN's and cephalosporins
isonazid
metronidazole
polymyxins
rifampin
vancomycin
aminoglycosides
bacitracin
quinolones

Question 7

examples of bacteriostatic abx

Answer 7

chloramphenicol
clindamycin
macrolides
sulfonamides
tetracyclines
trimethoprim

Question 8

PCN structure

Answer 8

diciclic nucleus that consists of thiazolidine ring connected to B lactam ring

Question 9

PCN MOA, excretion, adverse reactions

Answer 9

MOA: bactericidal, interferes with synthesis of peptidoglycan which is an essential component to cell walls of susceptible bacteria
Excretion: rapid, renal. 50% plasma concentration decrease in 1h.
adverse rx: hypersensitivity, rash, hemolytic anemia, maculopapular rash, anaphylaxis

Question 10

PCN organisms targeted

Answer 10

pneumococcal
meningococcal
streptococcal
actinomycosis

Question 11

probenecid

Answer 11

administration of probenecid will reduce renal excretion of PCN and prolong action

Question 12

2nd gen PCN organism targets

Answer 12

pneumococcal
meningococcal
streptococcal
actinomycosis
wider range of activity: gram negative bacilli, H influenza, e coli

Question 13

2nd gen PCN examples (2)

Answer 13

amoxicillin, ampicillin

Question 14

IgE mediated anaphylaxis to B lactam abx alternatives

Answer 14

Clindamycin, Vancomycin

Question 15

Cefazolin MOA, class, excretion, allergy

Answer 15

MOA, class: bactericidal antimicrobial that inhibit bacterial cell wall synthesis and have low toxicity

excretion: renal
allergy: cross reactivity with other cephalosporins, allergy incidence 1-10%

Question 16

all cephalosporins do these 2 things:

Answer 16

penetrate joints and cross placenta

Question 17

1st gen, 2nd gen, 3rd gen cephalosporin examples

Answer 17

1st: cefazolin
2nd: cefoxitin
3rd: cefotaxime
(as you go up in generation, it becomes more effective against gram (-) bacteria)

Question 18

macrolide examples (2)

Answer 18

erythromycin, azithromycin

Question 19

macrolide structure

Answer 19

compounds characterized by macrolytic lactone ring containing 14-16 atoms with deoxy sugar attached

Question 20

macrolide target organisms

Answer 20

gram (+) bacilli, pneumococci, streptococci, staphylococci, mycoplasma, chlamydia

Question 21

erythromycin MOA, metabolism, excretion, SE

Answer 21

MOA: bacteriostatic or bactericidal. inhibits bacterial protein synthesis
metabolism: by CYP450 system and thus increases serum concentration of theophylline, warfarin, cyclosporine, methylprednisone, digoxin
excretion: bile
SE: GI intolerance, severe N/V, gastric emptying, cholestasic hepatitis, QT effects (prolongs cardiac depolarization, torsades), thrombophlebitis

Question 22

Clindamycin MOA, class, SE

Answer 22

class: linomycins
MOA: bacteriostatic. similar to emycin in antimicrobial activity. more active with anaerobes.
SE: skin rash, prolonged pre and post junctional effects at NMJ in absence of NDMR (not antagonized with anti cholinesterase or calcium). pseudomembranous colitis- severe diarrhea should indicate d/c of therapy

Question 23

Clindamycin surgical use, dosing

Answer 23

surgical use: female GU surgeries
dosing: only 10% of administered dose excreted unchanged in urine, rest is inactive. decrease dose with severe liver disease

Question 24

Vancomycin Glycopeptide Derivative MOA, excretion, elimination t1/2, procedural use, SE

Answer 24

MOA: bactericidal, impairs cell wall synthesis
excretion: 90% unchanged in urine. glomerular filtration
elimination t1/2: 6h. can be prolonged up to 9 days with renal failure patients
procedural use: cardiac/ortho procedures using prosthetic devices, CSF and shunt related infections
SE: rapid infusion can cause profound hypotension, red man syndrome (histamine release), ototoxicity, nephrotoxicity

Question 25

vancomycin dosage

Answer 25

10-15mg/kg over 60 minutes | 1g mixed in 250ml

Question 26

vancomycin target organisms

Answer 26

gram (+) bacteria, severe staph infections, streptococcal, enterococcal endocarditis, MRSA. (administered with amino glycoside for endocarditis)

Question 27

indications for vancomycin

Answer 27

MRSA, endocarditis due to strep viridans or enterococci, patients allergic to B lactam

Question 28

vancomycin SE concomitant drugs to administer

Answer 28

diphenhydramine 1mg/kg and cimetidine 4mg/kg 1 hour before induction to limit histamine related effects

Question 29

aminoglycoside examples (5)

Answer 29

streptomycin, kanamycin (limited uses, frequent occurrence of vestibular damage) gentamicin (broader spectrum, toxic level >9mcg/ml amikacin: derivative of kanamycin, tx for infections cause by gentamicin or tobramycin resistant gram (-) bacilli neomycin: tx for skin, eye, mucous membrane info. adjunct therapy for hepatic coma, administered to decrease bacteria in intestine before GI surgery. most nephrotoxic

Question 30

ahminoglycosides MOA, excretion, elimination t1/2, SE

Answer 30

MOA: bactericidal excretion: renal through glomerular filtration elimination: 2-3h t1/2 that increases 20-40 fold with renal failure SE: limited by toxicity. ototoxicity, nephrotoxicity, skeletal muscle weakness, potentiation of NDMR blockade, muscle weakness (inhibit pre junctional release of Ach and decreases post synaptic sensitivity to neurotransmitter)

Question 31

aminoglycoside target organisms

Answer 31

effective for aerobic gram (-) and (+) effective for mycobacterium TB generally rx as combination therapy with beta lactam for gram (-)

Question 32

ahminoglycosides and potentiation of muscle relaxants

Answer 32

reversible with calcium gluconate or neostigmine but likely not a sustained reverse

Question 33

Fluroquinolones (2)

Answer 33

ciprofloxacin, moxiflocacin

Question 34

Ciprofloxacin treats

Answer 34

respiratory infections, TB, and anthrax. useful in tx of variety of systemic infections including bone, soft tissue, respiratory tract

Question 35

Moxifloxacin tx, SE

Answer 35

suitable for long acting tx of acute sinusitis, bronchitis, complicated abdominal infections SE: QT prolongation, peripheral neuropathy, psychosis, SJS

Question 36

Fluroquinolones MOA, absorption, excretion, elimination t1/2, SE

Answer 36

MOA: broad spectrum, bactericidal absorption: GI absorption rapid and penetration to body fluids/tissues is excellent excretion: renal, through glomerular filtration and renal tubular secretion. decrease dose in renal dysfunction elimination t1/2: 3-8h. can inhibit CYP450 enzymes SE: mild GI disturbances, N/V, CNS dizziness, insomnia, tendon or achilles rupture, muscle weakness in patients with MG

Question 37

Sulfonamide examples (2)

Answer 37

sulfamethoxazole, trimethoprim

Question 38

Sulfonamide MOA, metabolism, SE

Answer 38

MOA: bacteriostatic. antimicrobial activity due to ability of these drugs to prevent normal use of PABA by bacteria to synthesize folic acid. inhibit microbial synthesis of folate production metabolism: portion of drug is acetylated in liver and other is renal excretion. renal disease dose reduced SE: skin rash to anaphylaxis, photosensitivity, allergic nephritis, drug fever, hepatotoxicity, acute hemolytic anemia, thrombocytopenia, increase effect of PO anticoagulant

Question 39

sulfonamide clinical uses

Answer 39

UTI's, IBD, burns

Question 40

metronidazole MOA, absorption, SE

Answer 40

MOA: bactericidal, anaerobic gram (-) bacilli clostridium absorption: well absorbed orally and widely distributed in tissue including CNS SE: dry mouth, metallic taste, nausea, avoid ETOH

Question 41

metronidazole target organisms and uses/recommendations

Answer 41

``` anaerobic gram (-) bacilli clostridium useful for: CNS infx, abdominal and pelvic sepsis, pseudomembranous colitis (cdiff), endocarditis recommended for preop prophylaxis for colorectal surgery ```

Question 42

antimycobacterial agents (1st line) (4)

Answer 42

isoniazid- bacteriostatic-cidal if bacteria are dividing (hepato renal toxicity) rifampin-bactericidal. hepatic enzyme induction, hepato renal toxicity, theombocytopenia, anemia ethambutol-bacteriostatic, optic neuritis pyrazinamide-bacteriostatic, liver toxicity

Question 43

how are antimycobacterial agents used:

Answer 43

in combination therapy (3 or 4 agents) for 2 months, followed by a minimum of 4 months therapy with 2 agents

Question 44

amphotericin B MOA, class, use, excretion, SE

Answer 44

MOA: anti fungal use: for yeasts and fungi excretion: slow renal excretion. renal fx is impaired in 8-% of patients treated with this drug. most recover after drug is stopped but some resulting permanent decrease in GFR may remain SE: fever, chills, dyspnea, hypotension can occur during infusion, impaired hepatic function, hypokalemia, allergic reactions, seizure, anemia, thrombocytopenia

Question 45

interferons definition, MOA, tx, SE

Answer 45

definition: term used to designate glycoproteins produced in response to viral infections MOA: bind to receptors on host cell membranes and induce production of enzymes that inhibit viral replication- degradation of viral mRNA -enhance tumorcidal activities of macrophages tx: hep B and C SE: flu like sx, hematologic toxicity, depression, irritability, decreased mental concentration, development of auto immune conditions, rashes, alopecia, changes in CV/thyroid, hepatic function

Question 46

acyclovir

Answer 46

used to tx herpes, may cause renal damage if infused rapidly, thrombophlebitis, patients may complain of HA's during IV infusion

Question 47

when patients are on ARV's, CRNA's should note

Answer 47

existence of adverse effects (liver toxicity, peripheral neuropathy, nephro toxicity, neuromuscular weakness,) interactions with other medications (PPI's, cimetidine, NDMR, opioids, benzos)