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Antibiotics - Glycopeptides: Nursing Pharmacology

Notes

Notes

ANTIBIOTICS: GLYCOPEPTIDES
DRUG NAME
vancomycin (Vancocin); telavancin (Vibativ); dalbavancin (Dalvance); oritavancin (Orbactiv)
CLASS
Glycopeptides
MECHANISM OF ACTION
Interfere with peptidoglycan polymerization and cross-linking → inhibit bacterial cell wall synthesis → bacterial cell death
INDICATIONS
All:
  • Skin and skin structure infections caused by gram-positive bacteria

Only vancomycin:
  • Staphylococcal enterocolitis, Clostridioides difficile gastrointestinal infection, joint or bone infections, and other serious infections like pneumonia, bacteriemia, and septicemia
ROUTE(S) OF ADMIN
  • IV 
  • PO (only vancomycin)
SIDE EFFECTS
  • Headache, ototoxicity
  • Chills, fever
  • Prolonged QT interval, arrhythmias, peripheral edema
  • Nausea, vomiting, diarrhea, CDI
  • Back pain
  • Leukopenia, eosinophilia
  • Immune thrombocytopenia, neutropenia, flushing syndrome (vancomycin)
  • Nephrotoxicity (boxed warning for telavancin) 
  • Embryonic and fetal toxicity (boxed warning for vancomycin and telavancin)
CONTRAINDICATIONS & CAUTIONS
  • Pregnancy, breastfeeding 
  • Neonates, elderly clients
  • Hearing loss
  • Renal disease (boxed warning for telavancin) 

Drug interactions
  • Medications that prolong QT (e.g.,  quinidine, amiodarone)
  • Nephrotoxic and ototoxic medications (e.g., furosemide, aminoglycosides, colistin, cisplatin)
  • Dimenhydrinate: mask ototoxicity
  • Unfractionated heparin: contraindicated for 120 hours after administering oritavancin
NURSING CONSIDERATIONS for ANTIBIOTICS: GLYCOPEPTIDES
ASSESSMENT AND MONITORING
Assessment and monitoring: vancomycin
Assessment
  • Weight, vital signs, site of infection
  • Laboratory test results: CBC, renal function tests, wound culture and sensitivity tests; confirm a negative pregnancy test as appropriate
  • Check dose by calculating mg/kg
Intervention and monitoring
  • Patent peripheral IV 
  • Indwelling urinary catheter 
  • Monitor for side effects
    • Vancomycin flushing syndrome: flushing of the neck, face, and upper body
      • Slow infusion rate down; contact healthcare provider
    • Clostridioides difficile: abdominal pain, loose, watery or bloody stools
      • Contact healthcare provider
      • Stool sample to the lab for testing
    • Nephrotoxicity 
      • Monitor renal function, I & O, presence of hematuria or edema
    • Obtain serum trough levels per facility protocol 
  • Evaluate therapeutic response: infection resolution
CLIENT EDUCATION
  • Purpose of medication: eliminate the bacterial infection
  • Administered IV  slowly over one hour 
  • Periodic blood draw to measure trough
  • Report
    • Pain or discomfort at the infusion site
    • Ringing in the ears or dizziness
    • Flushing
    • Itching
Transcript

Glycopeptides are antibiotics primarily used to treat skin infections such as erysipelas, cellulitis, wound infections, and skin abscesses caused by gram-positive bacteria.

Additionally, some glycopeptides can be used to treat staphylococcal enterocolitis, gastrointestinal Clostridioides difficile infection, joint or bone infections, and other serious infections like pneumonia, endocarditis, bacteriemia, and septicemia.

Glycopeptides work well against Staphylococcus epidermidis, Staphylococcus agalactiae, Staphylococcus aureus, especially the methicillin-resistant type called MRSA, as well as Streptococcus pneumoniae, Streptococcus pyogenes, and vancomycin susceptible Enterococcus faecalis.

There are four medications in this group: vancomycin, telavancin, dalbavancin, and oritavancin. All glycopeptides are administered intravenously, while vancomycin can also be given orally.

Once administered, glycopeptides inhibit bacterial cell wall synthesis by interfering with peptidoglycan polymerization and cross-linking, ultimately causing bacterial cell death.

Common side effects of glycopeptides include ototoxicity, injection site reactions, and gastrointestinal disturbances like nausea, vomiting, and diarrhea.

In some cases, glycopeptides can disrupt the healthy intestinal flora and allow resistant bacteria to overgrow, which may result in superinfection, such as Clostridioides difficile infection or CDI for short. For treatment, CDI and staphylococcal enterocolitis are the only indications for oral vancomycin.

Some glycopeptides can also cause side effects like prolonged QT interval, arrhythmias, and peripheral edema. Clients taking glycopeptides can also develop anaphylactic reactions. Other serious side effects include nephrotoxicity, which is a boxed warning for telavancin!

Some clients taking glycopeptides may also develop hematologic side effects like leukopenia and eosinophilia; while vancomycin can also cause immune thrombocytopenia and neutropenia.

Also, if given too rapidly, vancomycin can cause a reaction called vancomycin flushing syndrome, previously known as red man syndrome, which presents as flushing, sweating, rash, urticaria, and hypotension. Finally, vancomycin and telavancin have a boxed warning for causing embryonic and fetal toxicity.

Glycopeptides should be used with caution during pregnancy and breastfeeding, as well as in neonates and elderly clients. Precaution should also be taken in clients with hearing loss; as well as in those with renal disease or who are receiving other nephrotoxic medications. In particular, telavancin comes with a boxed warning for use in clients with renal disease.

Regarding interactions, glycopeptides should not be used with any medication that is known to prolong the QT interval, such as quinidines or amiodarone, as this can cause arrhythmias. In addition, glycopeptides shouldn’t be combined with other nephrotoxic and ototoxic medications, such as furosemide, aminoglycosides, colistin, and cisplatin.

Sources
  1. "Focus on Nursing Pharmacology" LWW (2015)
  2. "Pharmacology" Elsevier Health Sciences (2014)
  3. "Mosby's 2021 Nursing Drug Reference" Mosby (2020)