Anti-Infective Agents Cholinergics Surface Tension Reducing Agents Nicotine Replacement Therapy

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Anti-Infective AgentsCholinergicsSurface
Tension Reducing AgentsNicotine Replacement
Therapy

• Module G

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Topics for Discussion

• Anti-infective agents
• Antibacterial
• Antitubercular
• Antiviral
• Antifungal
• Antiprotozoal
• Parasympathomimetics (cholinergics)
• Surfactant Agents
• Nicotine Replacement Therapy

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Terminology

• Antibiotic Substance that kills microorganism
  growth.
• Pathogen Disease causing microorganism.
• Empiric Therapy that is started based upon on
  experience and precedent in the observation and
  treatment of disease.
• Normal flora Organisms found in various parts of
  the body living symbiotically.
• Aerobic Requires oxygen to survive.
• Anaerobic Does not require oxygen to survive.

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Terminology

• Gram Stain Laboratory test used to determine if
  an organism is gram-positive or gram-negative.
• C S Culture and sensitivity. Determines the
  organism present in the culture and the
  antibiotic to which it is sensitive (susceptible
  to).
• Bacteriostatic Inhibits replication of
  microorganisms and prevents growth. Does not
  kill bacteria.
• Bacteriocidal Kills the bacteria.
• Broad spectrum vs. Narrow spectrum

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Classes of Anti-infective Agents
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Classes of Antibiotics
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Antibiotics

• Beta Lactams
• penicillins
• cephalosporins (4 generations)
• Broader coverage with each generation.
• Aminoglycosides
• tobramycin
• Vancomycin
• MRSA
• Protein Synthesis Inhibitors
• macrolides
• tetracyclines
• Folate Inhibitors
• metronidazole

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tobramycin

• Antibiotic used to treat pneumonias associated
  with cystic fibrosis (p. 286).
• Pseudomonas aeruginosa
• Trade Name is Tobi
• Dosage
• 300 mg/5 mL unit dose vial
• Give one vial BID
• 28 days on, 28 days off
• Very viscous solution
• Administer a bronchodilator prior to giving Tobi.
• Bronchospasm common side-effect.

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Pari LC Plus Nebulizer

• Tobi needs to be delivered with Pari LC Plus
  nebulizer
• Flowrates should be set at 10 12 L/min

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colistimethate

• Brand Name Colymycin, Colistin
• Alterative to Tobi in drug-resistant strains of
  Pseudomonas.
• From a group of antibiotics known as polymyxins
  and is similar to polymyxin B.
• Supplied as a powder that needs to be
  reconstituted.
• Has been identified to produce bronchospasm in
  some patients.
• May require pre-treatment with a bronchodilator.
• Dose
• Children less than 2 years of age 1 MU twice
  daily.
• Children older than 2 years of age adults 2 MU
  twice daily

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Antibiotics and Pneumonias
Page 281
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Anti-Viral Agents

• A virus is an obligate parasite.
• Kill the organism, risk killing the host.
• RNA Viruses
• Influenza
• Polio
• HIV
• Rabies
• Encephalitis
• DNA
• Adenovirus Respiratory Disease
• Papilloma warts
• Herpes Simplex
• Epstein-Barr Mononucleosis

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Anti-Viral Agents

• Anti-Prototozoal Agents
• pentamidine
• Used to treat Pneumocystis carinii pneumonia
  (PCP) Organism may be a virus, may be a
  protozoa.
• Anti-viral Agents
• ribavirin
• Used to treat Respiratory Syncytial Virus

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ribavirin

• Trade Name Virazole
• Antiviral Drug given with SPAG nebulizer
• Used to treat Respiratory Syncytial Virus (RSV),
  influenza A and B and herpes simplex
• Bronchiolitis and pneumonia.
• RSV virus affects all children by age 3.
• Use of ribavirin has decreased dramatically over
  the past 5 years.

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Environmental Exposure

• In animal studies, ribavirin has been found to be
• Mutagenic
• Carcinogenic
• Teratogenic
• Embryocidal
• Pregnant women or women thinking of becoming
  pregnant should avoid exposure

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ribavirin

• American Academy of Pediatrics recommends
  ribavirin to ONLY be given for children with RSV
  and
• Congenital Heart Disease
• Bronchopulmonary Dysplasia
• Immunodeficient patients (cancers, AIDS,
  malnutrition)
• Infants requiring mechanical ventilation
• Premature infants or infants less than 6 weeks

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RESPIRATORY SYNCYTIAL VIRUS IMMUNE GLOBULIN
INTRAVENOUS RSV-IGIV (1996)

• Trade Name RespiGam
• Indications
• Indicated for the prevention of serious lower
  respiratory tract infection with RSV in children
  under 24 months of age.
• RSV-IGIV is a sterile liquid formulation of
  immunoglobulin G (IgG) containing antibody to RSV
  
• Administration is by IV

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RSV Virus

• Supportive Care
• Hydration
• Oxygen
• Bronchodilators
• Most Commonly seen in Winter Months
• November March
• Handwashing is the most effective way to
  interrupt the spread of RSV

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Anti-Fungal Infections

• Fungi include mushrooms, yeasts molds.
• Fungal infections occur in immunocompromised
  patients.
• Common examples include athlete's foot, ringworm.
• Histoplasmosis capsulatum, Aspergillosis,
  Blastomycosis, Candida albicans (oral thrush).
• Key agents
• amphotericin B
• nystatin
• IV administration. Given experimentally by
  aerosol.
• No approval from FDA

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NON-AEROSOLIZED ANTI-INFECTIVE DRUGS
ANTI-TUBERCULOSIS AGENTS

• The standard approach to treating tuberculosis
  (TB) today consists of multiple first line drugs
  for a period of either 6 or 9 months.
• First line drugs are
• Rifapentine
• Isoniazid
• Rifampin
• Ethambutol
• Pyrazinamide
• Streptomycin used to be a front-line drug, but
  has been replaced by Rifapentine.

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NON-AEROSOLIZED ANTI-INFECTIVE DRUGS
ANTI-TUBERCULOSIS AGENTS

• 9 Month approach
• Isoniazid and Rifampin are given for 9 months and
  in an initial 2 to 8 week period these two drugs
  are supplemented with one of the other first line
  drugs.
• 6 Month approach
• Four drugs are used for 2 months followed by 4
  months of Isoniazid and Rifampin.
• There is an association of TB and HIV infection.
• Along with the disturbing increase in the number
  of TB cases in conjunction with AIDS, there has
  been an emergence of drug resistant strains of
  TB. The cure rate is poor in this subset.

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lidocaine

• Trade Name Xylocaine
• Effect Anesthetic
• Indications
• Aerosolized prior to bronchoscopy
• Topically as nasal spray/jelly prior to
  intubations
• Anesthetize area prior to chest tube insertion,
  (thoracentesis)

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lidocaine

• Dosage for nebulization Use SVN
• 2 solution 20 mg/mL 3-7 mL total volume
• 4 solution 40 mg/mL 3-7 mL total volume
• Nasal Spray
• 2 solution
• Jelly for lubricating ET tubes
• 2

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Nicotine Replacement Therapy

• What
• Nicotine Replacement Therapy should be used as
  part of a comprehensive smoking cessation
  program.
• Why
• Smoking kills 440,000 Americans each year and
  debilitates ½ of all long-term smokers.
• Tobacco dependence is a powerful addiction.
• Tobacco relapses are high (5 attempts?).
• Who
• Fagerstrom Test for Nicotine Dependence.
• Figure 13-4, Page 256
• When
• Best time is when they are in the hospital.

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Nicotine Replacement Therapy

• Nicotine Transdermal System
• Habitrol
• Nicoderm
• Nicotrol
• ProStep
• Nicotine Gum
• Nicorette
• Nicotine Nasal Spray
• Nicotrol
• Other (Non-NRT)
• bupropion (Zyban, Wellbutrin)
• Vareniciline (Chantix)

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Nicotine Replacement Therapy

• Nicotine stimulates the cholinergic receptor site
• Nicotinic Receptor Sites
• Autonomic and Somatic Nervous System
• Involuntary and voluntary skeletal muscle systems
• Nicotine directly affects brain cells
• Increases alertness
• Euphoria
• Cognitive performance

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Other Agents

• bupropion (Zyban, Wellbutrin)
• Antidepressant usually used to treat major
  depressive disorders and season affective
  disorders.
• Also decreases urge to smoke mechanism is
  unclear.
• vareniciline (Chantix)
• Mechanism of action is to partially block the
  a4-b2 nicotinic receptor in the brain.
• Within 10 to 20 seconds of a single puff from a
  cigarette, nicotine attaches to this receptor.
• The receptor, in turn, triggers large increases
  in dopamine, which rewards the smoker with a
  pleasurable sensation.

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Nicotine Replacement Therapy

• Precautions/Instructions
• Replacement formulas DO contain nicotine.
• Side effects can occur if using replacement
  formulas with tobacco.
• Transference of nicotine dependency can occur.
• Replacement formulas should be gradually
  withdrawn and stopped within 3 months.
• HCW should avoid handling nicotine products.
• varenicline and bupropion Mood swings even after
  drug has been stopped some instances of suicide
  ideation have been associated with Chantix.
• Questionable whether Chantix had direct influence
  or not.

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methacholine

• Trade Name Provocholine
• Used in Pulmonary Function Lab
• Methacholine Challenge Test
• Bronchoprovocation Test
• Used to test for hypersensitive airways
• Parasympathomimetic
• Induces bronchospasm

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methacholine Challenge Test

• Used for patients with normal pulmonary functions
• Chronic cough
• Recurrent respiratory infections
• History of wheezing
• Have crash cart in the room
• Be prepared to administer a fast acting
  bronchodilator (metaproterenol)

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Surfactant Agents

• Ethyl Alcohol
• Used in the treatment of pulmonary edema
• Alcohol breaks the bubbles and decreases the
  surface tension of the exudate
• Lack of approved clinical use
• Efficacy is not well established
• Dosage 30 50 3-5 mL of a 40 solution by
  aerosol or direct instillation down ET tube

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Exogenous Surfactants

• Natural Surfactants
• Surfactants from natural sources with addition or
  removal of certain molecules
• Survanta, Calfactant, Poractant Alfa
• Artificial Surfactants
• Surfaxin (?)
• Synthetic Natural genetic engineering cloning
  gene of natural surfactant
• None present

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Beractant

• Trade Name Survanta (1991)
• Mixture of bovine (cow) lung extract to which
  DPPC (lecithin) has been added
• Watch ventilator settings after administration
• O2 can increase, over-ventilation, hypocarbia
• Administered down ET tube

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New Surfactants

• Calfactant (Infasurf)
• Bovine Extract
• Poractant Alfa (Curosurf)
• Porcine Extract