Antibiotic resistance

Introduction The British Pharmacological society defines Clinical pharmacology as the study of drugs in man and it is an integral part of pharmacology. It is an exciting medical speciality and scientific discipline focused on ensuring the safe, effective, and cost-effective use of medicines through clinical and regulatory practice, education, and research. This paper focuses and will discuss one group of Antibiotics – Penicillin therapy in treatment of infection in the elderly care and the impact on patients assessment and care.

It will also discuss how nurses can monitor and manage patients on antibiotic therapy, safe administration, side effects and drug interactions in elderly care settings that would help in creating the better understanding of contemporary nursing practice. Background The history of infections dates back to the 20th Century. Infections were treated primarily on medicinal folklore (Lindblad, 2008). The ancient Serbia, China and Greece, used mouldy bread which was pressed against wounds to prevent infection (MSU, 2011).

In Egypt, crusts of mouldy wheaten bread were applied on pustular scalp infections and “medicinal earth” was dispensed to cure infections. These remedies were believed to influence the spirits or the gods, believed to be responsible for illness and suffering. Currently, the cure is not believed has been influenced by spirit or gods but the curative properties which had active metabolites and chemicals present in these mixtures to cure or treat infections.

Laboratory research on antibiosis and micro-organisms led to the discovery of synthetic antibiotics. Even though Penicillin was discovered by Alexander Fleming in 1929, it was Dr Selman Waksmann who first used the term antibiotic; he and his collaborations described antibiotics as any substance produced by micro -organisms that prohibits or antagonist the growth of other micro-organisms under high dilution and it includes any substance that kills bacteria (Balwin, et al 1997) In modern and advanced medicine, most antibacterial are semi synthetic of various modified compounds. Antibiotics Four main types of antibiotics are identified.

They include Penicillin, Cephalosporins and Carbapenems, Aminoglycosides, and Sulphonamides and Quinolones. Penicillin is produced by fungus. Aminoglycosides is derived from living organisms, and Sulphnamides and Quinolones are produced by chemicals synthesis. For the purpose of this assignment, Penicillin antibiotic will be the focus. Penicillin antibiotic Penicillin, a Beta-lactam antibiotic drug is used to fights bacteria and in the treatment of bacterial infection of organisms usually gram positive, infections caused by multidrug-resistant Gram-positive bacteria.

Gram positive bacteria represents a major public health burden, not just in terms of morbidity and mortality but also in terms of increased expenditure on patient management and implementation of infection control measures (Woodford & Livermore, 2009). Antibacterial drugs are classified as gram positive or gram negative according to their targets (Lindblad, 2008). Those that target protein synthetic are bacteriostatic by inhibiting the reproduction and allowing the organism defence system to kill them. Example are macrolides, tetracycline and, the Aminoglycosides.

Penicillin antibiotics have a historical significance because it was the first drug that was effective against some serious infections such as Staphylococci, Tonsillitis and Syphilis. Penicillin which was discovered by chance by Fleming revolutionised medicine because it led to the discovery of life saving antibiotic. According to historical records, Fleming accidentally left a dish of staphylococcus bacteria uncovered for a few days and returned to find the dish dotted with bacteria growth, apart from one area where a patch of mould (Penicilin notatum) was growing.

The mould produced a substance which Fleming named penicillin. In 1945, the first antibiotic was finally isolated by Howard Florey and Earnst Chain. Now, life threatening infections can be controlled with antibiotics. According to Bennett and Chung (2001), Penicillin permanently changed infectious disease research and therapeutic medicine because it transformed the expectations of patients; the structures of drug companies contributed insights in microbiology, and captured the public imagination and scientific breakthroughs.

Types of Penicillin Four different types of Penicillin are classified based on their ability to kill types of bacterial and their effectiveness. The main classes are Natural Penicillins, Penicillinases-Resistant Prnicillins, Aminopenicillins and Extentended Spectrum Penicillins. The natural penicillins were the first agents in the penicillin family to be introduced for clinical use. The natural penicillins were base on the original penicillin-G structure and are effective against both gram-positive strains and gram negative bacteria (Miller, E. L. , (2010).

Examples of Natural Penicillins are Penicillin G, Procaine, Penicillin G, Penicillin V and Benzathine. The penicillinase-resistant penicillins are the second type of penicillin. It has a narrower spectrum of activity in contrast to the natural penicillins. Their antimicrobial effectiveness stems from their ability to target directly on penicillinase-producing strains of gram-positive cocci, such as Staphylococcal species. Penicillinases-Resistant drugs are also known as “anti-staphylococcal penicillins’. Examples of Penicillinase-Resistant Penicillins are Dicloxacillin, Methicillin, Nafcillin, Oxacillin and Cloxacillin.

The aminopenicillins were the third type and the first penicillins discovered to be active against gram-negative bacteria (such as E. coli). Aminopenicillins are acid-resistant therefore it is administered orally. Orally administered amoxicillin and ampicillin are used primarily to treat mild infections such as otitis media, sinusitis, bronchitis, urinary tract infections and bacterial diarrhoea. The examples of Aminopenicillins are Amoxicillin, Ampicillin and Bacampicillin. The Extended Spectrum Penicillins is the fourth type of Penicillins. These agents have similar spectrums of activity compared to the aminopenicillins.

However, it has an additional activity, which is against several gram negative organisms in the family Enterobacteriaceae and some strains of Pseudomonas aeruginosa. Similar to aminopenicillins, these agents are susceptible to inactivation by beta-lactamases and may be used alone or together with Aminoglyco Uses of Penicillin Penicillins are primarily used to treat various bacterial infections such as respiratory and intestinal infections. Doctors usually prescribe an antibiotic for patients with these infections, first to see if it works, and request a culture if the patient does not respond to the treatment.

The culture is determined by doctors taking a sample of the bacteria from the infected area and using a special medium to grow bacteria to determine the type of bacterial present in the infected area. Endocarditis and periodontal infections and patients with gonorrhoea can receive treatment with this Penicillin. Doctors use penicillin to perform surgeries to reduce the risk of sepsis and to prevent infection or stop disease from spreading. The use of pseudomonad Penicillin has also been successful in the treatment of neutropenia sepsis to boost the immune system and prevent infection for people undergoing treatment.

Penicillin can also be used to treat strep throat which cause by a bacterial infection in the throats and tonsils. Penicillin is widely used today even though some infections have become resistance to Penicillin. Administration and impact on patient The successful outcome of an antibiotic therapy depends on several factors; the location of the infection, the defence mechanism of the person, the pharmacodynamics and pharmacokinetics of the antibacterial properties, the frequency of concentration of the drug, and the mechanism of action (Cunha, 2006).

In addition to these factors antibiotic therapy must be administered according to the local, trust, and National Institute for Health and Clinical Excellence (NICE) policy guidelines. Such policies help to improve patient care and to avoid drug resistance. For example, NICE provide guideline 2008/043 on antibiotic prescribing for respiratory tract infections (RTI). The RTI guideline recommends the use of alternative prescription strategies for patients with RTIs in primary care and other face-to-face contact healthcare settings such as emergency departments and walk-in centres.

The strategies recommended include no antibiotic prescribing; delayed (or deferred) antibiotic prescribing; and immediate antibiotic prescribing. The purpose of the guideline was to show evidence that antibiotics have limited effectiveness in treating a large proportion of RTIs in adults and children and complications are likely to be rare if antibiotics are withheld (NICE, 2008). Before any antibiotic therapy, it is important for healthcare professional to ensure the choice of antibiotic is suitable for the patients and correct dosage is prescribed to ensure effective therapy.

The decision depends on the culture of the bacteria and the result of a sensitivity test of the antibiotic. The sensitive test of the antibiotic is performed to determine the antibiotic that will be most successful in treating a bacterial infection and detect common antimicrobial resistance mechanisms (Reller, et al. , 2009). In addition, the healthcare practitioner should administer the right dose and route of antibiotic to ensure therapeutic effect. As a result of increasing development of antimicrobial resistance, the medical community has a greater responsibility to limit the exposure of patients to antibiotics. Hedrick et al.

, (2006) concluded that shorter courses of antibiotics were associated with similar or fewer complications than prolonged therapy. Also the base duration on resolution of fever or leukocytosis appear to yield similar outcomes with less antibiotic use. Therefore, it is useful to use high doses at a short course of antibiotic therapy, to avoid resistance of bacteria. Long term of antibiotic may cause not only resistance but also deficiency of nutrients (English, & Dean, 2013). Viral and fungal infections will not respond to penicillin because penicillin works to kill bacteria, and viruses and fungal are not caused by bacteria.

Therefore, doctors need to ensure about the cause of the infections before prescribing an antidote of antibiotic for treatment of the infection. Most antibiotic therapy takes five to ten days and it is important for healthcare professionals to reinforce the full therapy to eradicate the infection (Hedrick, et al. , 2006). Penicillin can be administered orally, intravenously, intramuscular and as topical. Dosage depends on severerity of the infection, the weight of the person, route and any comorbidity.

Oral suspension, solution and tablet can be given every four to six hourly. Intravenous and intramuscular could be administered every four to six hours. However, Penicillin benzathine injection which is a long acting antibiotic used in treatment of Syphilis can be given as a single dose according to the weight of the patient intramuscularly. The most effective way of treating serious infection with Penicillin is by intravenous drip; because when taken orally it becomes inactive by gastric juice and renders it ineffective (Hedrick, et al. , 2006).

Moreover, some antibiotic when taken parenteral also becomes ineffective by rapid excretion in the urine. To ensure therapeutic range (effective result) is reached with the Penicillin therapy, regular blood test monitoring is essential to ensure the infection has not become resistance and to monitor the concentration of the drug level in blood plasma. Patients need to be educated about regular bloods test and monitoring of IV access route for signs of infection on Cannula site. Negative impact of Penicillin Like any other medicine, Penicillin has side effects which need to be monitored closely.

Side effect of Penicillin B-lactam effect varies such as diarrhoea which may leads to dehydration and electrolytes imbalance, to dizziness (Miller, 2002). It is the duty of the nurse to maintain a fluid balance chart in the case of diarrhoea so that patients do not become dehydrated and to encourage fluid intake. In addition, nausea and vomiting, hypersensitivity, super infection, fever, angioedema and colitis are all noted as some of the side effect of Penicillin (Forrest, 2001). Also, Penicillin has rare side effects, such as thrush, convulsion in epileptic patients, Nephritis, hepatitis and occasionally dizziness.

One of the complications of Penicillin drugs is that it can cause allergic reaction: from skin reaction to anaphylactic shock. In the elderly, the physiological functions of patients greatly changes with Penicillin therapy and usually renal and hepatic function become compromise (Salkind, et al, 2001). The effect of drugs on the body of older patients differs greatly in comparison to young adults. Old people’s ability to fight infection reduce and therefore they more susceptible to infection (Gardner, 1980). The profile of pharmacokinetic in the elderly changed and requires adjustment of dose to avoid toxicity.

In the hospital setting, there is always the probability of more than one medication being prescribed for a patient. Polypharmacy is the term use to describe the use of multiple medications (such as some antidepressants, muscle relaxants, antispasmodics, and antihistamines), and is a serious problem in the healthcare system (Bushardt, et al. , 2008). These medicines have strong anti cholinergic effects and, therefore, may cause confusion, blurred vision, dry mouth, light headedness, constipation, and difficulty with urination or loss of bladder control.

Interactions of antibiotic with other drugs could be severe or trivial (Baxter, 2003). Penicillin drugs; Amoxicillin and Ampicillin are known to interact with drugs such as Allopurinol with increased risk of non-allergic reaction. Penicillin is also noted to hinder the effectiveness of Oral Contraceptives thus increasing the chances of pregnancy (Weisberg, 1999). Moreover, drugs like Methotrexate when used alongside Penicillin decreases the excretion of it and therefore can cause serious complications. Knowledge Dissemination to Clinical Area.

Population of elderly is rapidly growing with high complications and state of chronic diseases. Nurses should have good knowledge of the use of medication for various diseases; risks related with multiple medication interactions, adverse effects, inappropriate dosing and drug interactions associated with antibiotics, and other medications to disseminate to patients. Knowledge about the right medication to administer is very important to avoid medication errors which can have adverse effect on patient, increase hospital stay, increase cost (Kripalani & Weiss, 2006) and NHS budget deficits.

Contemporary nurses are required to assess, plan, and evaluate the needs of patients on antibiotic therapy. Nurses should advice patient regarding the need to follow instructions on antibiotics use because it allows maintenance and attainment of the therapeutic range of drugs utilised (McCurry et al 2009). Nurses should also make patients aware that longer hospital stay induce other hospital acquired infections and disorders which can compromise the health of patient and inhibit patient from overcoming his or her existing disorder or complication (Shawler, 2008: pg. 528).

Recent research suggests that urinary tract infection and longer hospital stays are also directly associated with the failure of the nursing staff to monitor patient. The practice for monitoring and assessment of hospitalised patients on antibiotic therapy and proposing recommendations for patient education, care and changes on systems level can promote patient safety and quality care. Patient education can be implemented in any clinical setting. However, it is important to find the proper way to provide the education and evaluate the outcome of the knowledge given.

Asking patient to recall information is a way to not the comprehension of the knowledge disseminated. For the effective assessment and teaching of patient’s comprehension of knowledge, a practitioner must employ the mutual communication technique (Schwartzberg, et al 2007: pg. 98). During and after completing the session, the practitioner needs to ensure that the patient understood the given information. This method will shrink the gap between patient and clinician and increase the medical knowledge of patient. Self-management knowledge is particularly important in vital chronic disease patients as part of healthcare system (Austgard, 2006).

Knowledge of the appropriate medication, treatment, symptoms, and side effects must be disseminated to patients especially during discharge, assessment needs to be done to ensure the capability of patient to complete the therapy and any support should be in place before discharge. For instance referral to district nurses for continuation of care for vulnerable patients. How to deal with possible side effects are also some of the knowledge that healthcare professional need to communicate to patients before and after discharge (Yoo, 2003 pg: 444).

Educating elderly patients avoid can the negative consequences of polypharmacy by making them aware the risk of poly pharmacy(Galavis, & Wooten, 2005). Professional should also understand that the elderly may have several chronic disorders and each require more than one medication and therefore ask questions thoroughly before prescribing antibiotics to the elderly (Galavis, & Wooten, 2005). Guidelines on effective hand washing and appropriate use of protective equipment such as gloves should be maintained to prevent cross infection.

In addition it is the duty of the healthcare practitioner to assess any allergies the patient may have and counsel patients about treatment prescriptions before antibiotic therapy commences. Conclusion Antibiotic is the most commonly prescribed drug group in the UK. Safe antibiotic therapy requires that the cause of infection is identified before the drug is tailored to a patient. Untailored plan of antibiotic therapy may result in drug resistance and unnecessary side effects. It is also important that clinical side effects and drug interactions are closely monitored.

The cost of hospital stay and the time involved by staff in administering antibiotic would be wasted if proper plan was not put in place before antibiotic initiation. Antibiotics have adverse reactions and therefore extended use of antibiotic may make patient develop antibiotic resistant organisms. Proper assessment, education, monitoring by infection (Hedrick, et al. , 2006). healthcare professionals about pharmacokinetics, pharmacodynamics of drugs and polypharmacy can minimise contra indication of drugs and limit negative effect of Penicillin on the patients.

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