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Antibiotics - Carbapenems and Monobactams: Nursing Pharmacology

Notes

Notes

ANTIBIOTICS: CARBAPENEMS AND MONOBACTAMS
DRUG NAME
doripenem, ertapenem (INVanz), meropenem, meropenem-vaborbactam (Vabomere), imipenem–cilastatin  (Primaxin IV)
aztreonam
(Azactam, Cayston)
CLASS
Carbapenem; beta-lactam antibiotic
Monobactam; beta-lactam antibiotic
MECHANISM of ACTION
Bind to the PBPs of gram-negative bacteria and inhibit cell wall formation, eventually eliminating the bacteria
INDICATIONS
  • Gram-positive bacteria: methicillin-sensitive Staphylococcus aureus, Streptococcus pneumoniae, and group A beta-hemolytic streptococci

  • Gram-negative bacteria: Enterococcus faecalis, Klebsiella spp., Neisseria spp., Pseudomonas aeruginosa, Acinetobacter spp
  • Gram-negative bacteria: Pseudomonas aeruginosa
ROUTE(S) of ADMINISTRATION
  • All: IV
  • ertapenem: IM
  • INH
SIDE EFFECTS
  • Gastrointestinal distress, nausea, vomiting
  • Hypersensitivity reactions 
  • Central nervous system toxicity: headaches, confusion, seizures 
  • Clostridioides difficile infection 
  • Oral or vaginal candidiasis
  • Cough
  • Sore throat
  • Bronchospasm
CONTRAINDICATIONS & CAUTIONS
Contraindications:
  • Allergy to any beta-lactam antibiotic

Precautions:
  • Pregnancy
  • Breastfeeding
  • Severe renal disease

Drug interactions:
  • Reduce the serum levels of the antiepileptic medication - valproate
  • imipenem with ganciclovir and theophylline can also precipitate seizures
  • carbapenems with probenecid can lead to carbapenem toxicity
Contraindications:
  • Allergy to any beta-lactam antibiotic

Precautions:
  • Pregnancy
  • Breastfeeding

NURSING CONSIDERATIONS FOR ANTIBIOTICS: CARBAPENEMS AND MONOBACTAMS
ASSESSMENT AND MONITORINGAssessment and monitoring: imipenem-cilastatin
Assessment
  • Current symptoms: malaise, chills
  • Vital signs
  • Laboratory test results: renal and hepatic function tests, CBC, blood culture and sensitivity, urinalysis and urine culture
  • Diagnostic test results: chest X-ray
Monitoring
  • Side effects
    • Phlebitis
      • Restart therapy at a different site
    • Nausea and vomiting
      • Request an antiemetic
      • Provide comfort measures
    • Hypersensitivity reaction
      • Stop the infusion
      • Notify the healthcare provider
    • Clostridioides difficile 
      • Stop the infusion
      • Notify the healthcare provider
      • Collect stool sample to send to the lab for analysis
  • Evaluate for resolution of bacteremia
CLIENT EDUCATION
  • Purpose of medication: helps eliminate the bacteria in their blood
  • Report side effects
    • Pain or discomfort at the infusion site
    • Nausea
    • Throat tightness, difficulty breathing or swallowing, itchiness
Transcript

Content Reviewers:

Carbapenems and monobactams are beta-lactam antibiotics, which means that they have a characteristic beta-lactam ring in their structure. However, due to their widespread use, some bacteria have acquired resistance to many beta-lactams by developing enzymes called beta-lactamases, which latches on to the beta-lactam ring and degrades the antibiotic. For this reason, carbapenems and monobactams have a slight modification in their beta-lactam ring structure, which makes them less susceptible to beta-lactamases.

Now, carbapenems can be used to treat serious infections, such as complicated appendicitis, peritonitis, soft-tissue infections, bacterial meningitis, as well as gynecological infections, pyelonephritis, and bacteremia. Carbapenems have a wide range of action against gram-positive bacteria like methicillin-sensitive Staphylococcus aureus, Streptococcus pneumoniae, and group A beta-hemolytic streptococci; and gram-negative bacteria like Enterococcus faecalis, Pseudomonas aeruginosa, Klebsiella spp, Neisseria spp, and Acinetobacter spp.

On the other hand, monobactams are only useful in the treatment of gram-negative bacterial species, and are primarily used to treat clients with cystic fibrosis who have pulmonary Pseudomonas aeruginosa infections.

Starting with carbapenems, the most commonly used ones include doripenem, ertapenem, meropenem, as well as meropenem-vaborbactam, a combination of meropenem and vaborbactam, a beta-lactamase inhibitor, which further increases the spectrum of activity, and imipenem-cilastatin, a combination of carbapenem and the dipeptidase inhibitor cilastatin which prevents imipenem from being broken down, prolonging its antibacterial effect. Now, all of the carbapenems are administered intravenously, and ertapenem can also be given intramuscularly.

Moving on to monobactams, the only medication in this group is aztreonam, which is only given via inhalation. Once administered, carbapenems and monobactams work by binding to and inhibiting a bacterial enzyme called DD-transpeptidase, or penicillin-binding proteins, or PBPs for short, which bacteria need to build their cell walls. As a result, carbapenems and monobactams act by inhibiting bacterial cell wall synthesis, which ultimately kills the bacteria.

Common side effects of carbapenems and monobactams include gastrointestinal disturbances, like nausea, vomiting, and hypersensitivity reactions. These medications can also disrupt the normal bacterial flora, increasing the risk of superinfections like Clostridioides difficile infection, as well as oral and vaginal candidiasis.

Clients taking these medications may also experience central nervous system disturbances like headaches, confusion, and even seizures. Some clients may present with serious hypersensitivity reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, angioedema, and even anaphylaxis. Finally, when given via injection, these medications can cause injection site reactions like pain, redness, and even thrombophlebitis; while aztreonam administered via inhalation can cause cough, bronchospasm, and sore throat.

Now, carbapenems and monobactams are contraindicated in clients allergic to any beta-lactam antibiotic due to the risk of cross-reactivity between the different classes. Carbapenems and monobactams should be used with caution in clients with a history of seizures and during pregnancy and breastfeeding. Additional precautions should be taken in clients with renal disease.