🦠Exam 2
The bugs and the immune system: antibiotics, antifungals, antivirals, then the immunomodulators and cancer drugs.
Modules 2–3 · 50 questions · 33 drugs · 35 concepts
Module 2: Anti-Infectives
What is the difference between a bactericidal & bacteriostatic antibiotic?⭐ HIGH YIELD
BACTERICIDAL antibiotics KILL the bacteria. BACTERIOSTATIC antibiotics only stop them from reproducing and leave the existing bacteria for the immune system to clear.
- That distinction only matters when the patient's immune system cannot finish the job. A healthy patient does fine with either.
- Bactericidal is REQUIRED for immunocompromised patients (neutropenia, chemotherapy, HIV, transplant) and for life-threatening infections such as acute bacterial endocarditis, meningitis, and sepsis.
- Bacteriostatic drugs can fail in those patients because there is no functioning immune system to kill what is left behind.
- Some drugs are bacteriostatic at low concentration and bactericidal at high concentration, which is why dose and level matter.
- Combining a bacteriostatic drug with a bactericidal drug can be antagonistic, because the cidal drug needs actively dividing bacteria to work.
| Bactericidal | Bacteriostatic |
|---|
| Kills the organism outright | Halts reproduction; existing bacteria survive |
| Required if the patient is immunocompromised | Adequate only if the immune system is intact |
| Required for endocarditis, meningitis, sepsis, osteomyelitis | Used for mild to moderate infections in healthy hosts |
| Mostly cell-wall and DNA attackers | Mostly protein-synthesis blockers (aminoglycosides are the exception) |
-CIDAL = homiCIDAL, it kills. -STATIC = it just holds them STATIONARY.
Give examples of bactericidal & bactericidal antibiotics.⭐ HIGH YIELD
BACTERICIDAL: penicillins, cephalosporins, carbapenems, aztreonam, vancomycin, aminoglycosides, fluoroquinolones, metronidazole, daptomycin, isoniazid, rifampin. BACTERIOSTATIC: tetracyclines, macrolides, sulfonamides, trimethoprim, clindamycin, linezolid, chloramphenicol, nitrofurantoin.
- Easy rule: if it wrecks the CELL WALL or DNA, it kills. If it blocks the RIBOSOME (protein synthesis), it usually only stalls.
- THE EXCEPTION EXAMS LOVE: aminoglycosides (gentamicin, tobramycin, amikacin) block protein synthesis but are BACTERICIDAL.
- Trimethoprim and sulfamethoxazole are each bacteriostatic alone, but TOGETHER as Bactrim they are bactericidal. That is the textbook's example of a synergistic combination.
- Vancomycin is bactericidal against most organisms but only bacteriostatic against enterococci.
- All beta-lactams (anything with a beta-lactam ring: penicillins, cephalosporins, carbapenems, monobactams) are bactericidal.
| Bactericidal | Bacteriostatic |
|---|
| Penicillins (penicillin G/V, amoxicillin, piperacillin-tazobactam) | Tetracyclines (tetracycline, doxycycline, minocycline) |
| Cephalosporins (cefazolin, ceftriaxone, cefepime) | Macrolides (azithromycin, erythromycin, clarithromycin) |
| Carbapenems (meropenem, imipenem) and aztreonam | Sulfonamides and trimethoprim (individually) |
| Vancomycin, daptomycin | Clindamycin, linezolid, chloramphenicol |
| Aminoglycosides and fluoroquinolones | Nitrofurantoin (at usual urinary doses) |
| Metronidazole, isoniazid, rifampin | Trimethoprim-sulfamethoxazole is CIDAL only when combined |
Wall and DNA drugs KILL. Ribosome drugs STALL. Aminoglycosides cheat and kill anyway.
Broad-Spectrum vs Narrow-Spectrum Antibiotics⭐ HIGH YIELD
BROAD-spectrum antibiotics cover a wide variety of organisms, both gram-positive AND gram-negative. NARROW-spectrum antibiotics target only a specific subset, either gram-positive or gram-negative.
- Broad-spectrum is started EMPIRICALLY while culture results are pending, then narrowed once the organism and sensitivities are known (de-escalation).
- Broad-spectrum is also used for polymicrobial infections, for surgical and procedural prophylaxis, and when a narrow agent has already failed.
- The price of broad-spectrum is damage to the patient's MICROBIOME, which causes SUPERINFECTION: C. difficile pseudomembranous colitis (can be fatal) and Candida yeast infections.
- Probiotics such as lactobacillus may be recommended to help restore normal flora.
- Nurse's role: watch culture results, make sure the provider sees them, and advocate for narrowing the antibiotic when the sensitivities come back.
| Broad-spectrum | Narrow-spectrum |
|---|
| Kills gram-positive AND gram-negative | Kills either gram-positive OR gram-negative only |
| Used empirically before cultures result, for mixed infections, and for prophylaxis | Used once the organism is identified by culture and sensitivity |
| Higher risk of superinfection (C. diff, thrush, yeast) and of breeding resistance | Less disruption of normal flora, less resistance pressure |
| Examples: piperacillin-tazobactam, carbapenems, fluoroquinolones, third/fourth-gen cephalosporins, tetracyclines | Examples: penicillin G, nafcillin, vancomycin (gram-positive); aztreonam (gram-negative) |
Broad = shotgun while you wait. Narrow = sniper once you know the target.
How can antimicrobial resistance be prevented?⭐ HIGH YIELD
Prevent resistance by (1) taking the FULL prescribed course even after symptoms resolve, (2) not prescribing antibiotics for viral illnesses like the common cold, and (3) using directly observed therapy (DOT) for long regimens such as tuberculosis.
- Stopping early is the classic patient behavior that breeds resistance: it fails to kill the target organisms and selects for resistant variants.
- Overprescribing is the classic provider behavior. Patients often DEMAND antibiotics for viral upper respiratory infections; teaching is the nursing intervention.
- Longer courses mean worse adherence. TB treatment lasts 6 to 12 months, which is exactly why multidrug-resistant TB emerged.
- Other strategies: culture BEFORE the first dose, narrow the spectrum once sensitivities return, antimicrobial stewardship programs, hand hygiene and infection control, no leftover or shared antibiotics, and vaccination.
- Scale of the problem per the CDC: at least 2 million antibiotic-resistant infections and 23,000 deaths per year in the US. MRSA and VRSA are the named resistant organisms.
Finish the bottle, skip it for viruses, and watch them swallow it.
What is prophylactic treatment? Give an example of an anti-infective drug being used for prophylaxis.
Prophylactic treatment is giving an anti-infective to PREVENT an infection rather than to treat one that already exists. Classic example: cefazolin IV within 60 minutes before a surgical incision.
- Other examples: isoniazid for latent TB, trimethoprim-sulfamethoxazole for Pneumocystis prophylaxis in HIV, oseltamivir after a known influenza exposure, amoxicillin before dental work in high-risk cardiac patients, rifampin or ciprofloxacin for close contacts of meningococcal disease, antimalarials before travel, and tenofovir-emtricitabine as HIV PrEP.
- Surgical prophylaxis timing is a testable detail: give it within 60 minutes before the incision so tissue levels are at peak when the skin is cut.
- Prophylaxis is usually SHORT (often stopped within 24 hours postop). Continuing it longer just breeds resistance without lowering infection rates.
- Prophylaxis is a legitimate reason to use a broad-spectrum antibiotic even when no organism has been identified.
- Do not confuse prophylactic (prevent) with empiric (treat a presumed infection before culture results) or definitive (treat a confirmed organism).
Prophylaxis = before the bug. Empiric = before the culture. Definitive = after the culture.
What are the common adverse effects associated with antibiotics as a group?⭐ HIGH YIELD
As a class, antibiotics cause GI upset (nausea, vomiting, diarrhea), allergic and hypersensitivity reactions up to anaphylaxis, and SUPERINFECTION, meaning C. difficile diarrhea and candidiasis (oral thrush, vaginal yeast).
- GI distress is the most common complaint and is the reason patients stop early. Teach that food may ease it, but check whether the specific drug requires an empty stomach.
- Superinfection: new diarrhea (especially foul, watery, 3 or more stools a day), white patches in the mouth, or vaginal itching and discharge during or after antibiotics. C. diff colitis can be fatal.
- Allergy ranges from a mild rash to urticaria, laryngeal edema, and anaphylaxis. Always check allergies before the first dose and keep epinephrine available.
- Organ toxicities to know: NEPHROTOXICITY and OTOTOXICITY (aminoglycosides, vancomycin), hepatotoxicity (isoniazid, rifampin), photosensitivity (tetracyclines, sulfonamides, fluoroquinolones, macrolides), and QT prolongation (macrolides, fluoroquinolones).
- Antibiotics also reduce the effectiveness of ORAL CONTRACEPTIVES (the textbook flags this with amoxicillin and tetracyclines), so teach a backup method.
Every antibiotic: gut upset, allergy, and a yeast or C. diff surprise.
What is culture and sensitivity?⭐ HIGH YIELD
A CULTURE grows a sample from blood, urine, sputum, or a wound to identify the organism. The SENSITIVITY tells you which antibiotics that specific organism will respond to (and which it is resistant to). Always collect the culture BEFORE the first antibiotic dose.
- Giving the antibiotic first invalidates the result and can delay effective treatment. This is the single most tested nursing point on this topic.
- Results take about 1 to 5 days, so treatment usually starts empirically with a broad-spectrum drug and is narrowed later.
- A gram stain is the fast screen: violet = gram-positive (Staphylococcus, Streptococcus), red/pink = gram-negative (E. coli, Neisseria). It guides an initial choice in minutes rather than days.
- The nurse is responsible for collecting an accurate specimen, monitoring the results, making sure the provider sees them, and questioning the order if the prescribed drug does not cover the organism.
- 'Resistant' on the report means that drug will NOT work no matter the dose.
Culture BEFORE the cure. Draw it, then hang it.
Which drugs are contraindicated for clients with a penicillin allergy?🚨 DANGER
The whole beta-lactam family is the concern: CEPHALOSPORINS are the classic cross-sensitivity, plus carbapenems. All other penicillins (amoxicillin, ampicillin, nafcillin, piperacillin-tazobactam) are absolutely contraindicated. AZTREONAM, a monobactam, is the beta-lactam that is safe.
- The nurse's job is to ask WHAT the reaction was. A childhood upset stomach is not an allergy; hives, swelling, wheezing, or anaphylaxis is.
- NUMBERS: the classically taught cross-reactivity figure is about 10%, but current evidence puts the real risk under 1 to 2%, and it is driven by shared R1 SIDE CHAINS, not by the beta-lactam ring itself. First-generation cephalosporins (cefazolin, cephalexin) carry the higher risk; third and fourth generation (ceftriaxone, cefepime) are very low. Answer 10% only if the handout says 10%.
- For a true anaphylactic penicillin allergy, common substitutes are vancomycin, clindamycin, a macrolide (azithromycin), a fluoroquinolone, or aztreonam, depending on the organism.
- Carbapenem cross-reactivity is under 1%, but they are still usually avoided after anaphylaxis.
- The textbook states the reverse as well: a patient allergic to cephalosporins may react to penicillin.
- If a reaction occurs, STOP the drug, and be ready with epinephrine and airway support for anaphylaxis.
| Avoid / use caution | Generally safe alternatives |
|---|
| All penicillins: penicillin G and V, amoxicillin, ampicillin, nafcillin, piperacillin-tazobactam | Aztreonam (monobactam) - the safe beta-lactam |
| Cephalosporins, especially 1st generation (cefazolin, cephalexin) | Vancomycin |
| Carbapenems (meropenem, imipenem, ertapenem) | Clindamycin, macrolides (azithromycin), fluoroquinolones, tetracyclines, TMP-SMX |
Same ring, same risk. Aztreonam is the beta-lactam that gets a pass.
Which drugs cause photosensitivity?⭐ HIGH YIELD
The four antibiotic classes your textbook names are TETRACYCLINES, SULFONAMIDES, FLUOROQUINOLONES, and MACROLIDES. Outside antibiotics, the big ones are amiodarone, thiazide and loop diuretics, phenothiazines (promethazine, chlorpromazine), retinoids, and St John's wort.
- Teaching for ALL of them: broad-spectrum sunscreen, hat and long sleeves, avoid peak sun (10 a.m. to 4 p.m.), and no tanning beds. The reaction looks like an exaggerated sunburn that appears fast.
- Doxycycline is the one you will actually see this with in practice, because it is prescribed so often for acne, Lyme disease, and respiratory infections.
- Amiodarone causes a distinctive slate-gray or blue-gray skin discoloration with sun exposure, on top of ordinary photosensitivity.
- Also on the list: TMP-SMX (a sulfonamide), sulfonylureas, NSAIDs (especially piroxicam), TCAs and some SSRIs, isotretinoin and tazarotene, voriconazole, hydrochlorothiazide, and furosemide.
- Photosensitivity is not an allergy. It does not mean stop the drug, but it does mean the patient must protect their skin for the whole course.
| Category | Drugs |
|---|
| Antibiotics (textbook's four) | Tetracyclines/doxycycline, sulfonamides/TMP-SMX, fluoroquinolones (levofloxacin, ciprofloxacin), macrolides (azithromycin) |
| Cardiac | AMIODARONE, thiazide diuretics (HCTZ), furosemide |
| Psych | Phenothiazines (promethazine, chlorpromazine), TCAs, some SSRIs, St John's wort |
| Skin | Retinoids (isotretinoin, tretinoin, tazarotene), benzoyl peroxide products |
| Other | Sulfonylureas, NSAIDs (piroxicam), voriconazole, hydroxychloroquine |
SAT-M burns: Sulfonamides, Amiodarone, Tetracyclines, Macrolides plus fluoroquinolones. Sunscreen for all of them.
Which drugs require peak and trough monitoring?🚨 DANGER
AMINOGLYCOSIDES (gentamicin, tobramycin, amikacin, streptomycin) require BOTH peak and trough. VANCOMYCIN requires a TROUGH. Both are monitored because they are nephrotoxic and ototoxic and have a narrow therapeutic index.
- TROUGH is drawn 30 minutes BEFORE the next dose (the lowest level; it tells you about toxicity and accumulation). PEAK is drawn AFTER the dose is finished, usually about 30 minutes after an IV infusion ends (the highest level; it tells you about efficacy).
- If the lab has not drawn the trough yet, HOLD the dose and contact the lab and provider. Do not give the drug and then draw a trough. That is the classic exam question in both the aminoglycoside and vancomycin chapters.
- Aminoglycoside toxicity triad: NEPHROTOXIC, OTOTOXIC (tinnitus, hearing loss, vertigo, often permanent), and NEUROTOXIC (numbness and tingling). Monitor BUN, creatinine, GFR, urine output, and hearing.
- Vancomycin: monitor troughs plus renal function. Infusing too fast causes vancomycin flushing syndrome (formerly 'red man syndrome'), a red rash and flushing of the face, neck, and upper body. Slow the infusion, do not confuse it with an allergy.
- Other narrow-therapeutic-index drugs monitored by level (usually trough only) are digoxin, lithium, phenytoin, theophylline, and warfarin by INR.
- Peak and trough monitoring matters most in older adults and in anyone with liver or kidney impairment, who accumulate drug.
| Drug | What is monitored | When to draw |
|---|
| Aminoglycosides: gentamicin, tobramycin, amikacin, streptomycin | Peak AND trough | Trough 30 min before the next dose; peak about 30 min after the infusion ends |
| Vancomycin | Trough (some facilities use AUC dosing) | Trough 30 min before the next dose, usually before the 4th dose |
| Digoxin, lithium, phenytoin, theophylline | Trough level | Just before the next dose (lithium 12 hours after the last dose) |
Trough before, peak after. No trough drawn = no dose given.
What are the causes and treatments of oral candidiasis (thrush)?⭐ HIGH YIELD
Oral candidiasis (thrush) is a Candida albicans overgrowth caused by anything that disrupts normal flora or immunity: BROAD-SPECTRUM ANTIBIOTICS and INHALED CORTICOSTEROIDS without rinsing are the top two. Treat with NYSTATIN swish and swallow, clotrimazole troches, or oral fluconazole for moderate to severe cases.
- Nystatin technique (tested): swish for 30 seconds or as long as tolerated, then swallow (or spit if ordered), and DO NOT eat or drink for 10 to 30 minutes afterward so the drug stays in contact with the tissue.
- Prevention with inhaled steroids: use a spacer and RINSE AND SPIT after every dose.
- Other causes: immunosuppression (HIV/AIDS, chemotherapy, transplant, corticosteroids), uncontrolled diabetes, dentures, xerostomia, infancy, and old age.
- Looks like: white curd-like plaques on the tongue, palate, and buccal mucosa that SCRAPE OFF and leave a red, raw, sometimes bleeding base. Patients report burning, altered taste, and pain with swallowing.
- Thrush in a healthy adult with no obvious cause is a red flag: screen for HIV and diabetes. Extension into the esophagus (odynophagia) is an AIDS-defining condition and needs systemic fluconazole.
White patches that wipe off = thrush. Swish, swallow, then nothing by mouth for 30 minutes.
Which antibiotics are contraindicated during pregnancy?🚨 DANGER
Avoid TETRACYCLINES (fetal teeth and bone), FLUOROQUINOLONES (cartilage damage), AMINOGLYCOSIDES (fetal ototoxicity), SULFONAMIDES/TMP-SMX (folate antagonism early, kernicterus near term), and chloramphenicol (gray baby syndrome). SAFE: penicillins, cephalosporins, azithromycin/erythromycin.
- Tetracyclines are the textbook's flat contraindication: they are contraindicated in pregnancy AND in children 8 years old and under because they permanently stain developing teeth and impair bone growth. Teach the patient to stop tetracycline immediately if she becomes pregnant.
- Fluoroquinolones are contraindicated in children except for complicated UTI, pyelonephritis, plague, and anthrax exposure, and are used only cautiously in pregnancy.
- Aminoglycosides: the textbook instructs female patients to notify the provider if pregnancy is planned or they are breastfeeding.
- Nitrofurantoin and TMP-SMX are avoided in the FIRST trimester and at TERM (after about 38 weeks) because of neural tube risk and newborn kernicterus, but are used in the second trimester when alternatives are limited.
- Metronidazole is traditionally avoided in the first trimester, though current data are largely reassuring.
- The safe list for pregnancy is basically beta-lactams plus macrolides: penicillins, amoxicillin, cephalosporins, azithromycin. Erythromycin ESTOLATE is the one macrolide form to avoid (maternal hepatotoxicity).
| Avoid in pregnancy | Why |
|---|
| Tetracyclines (doxycycline, tetracycline, minocycline) | Permanent tooth staining and impaired bone/skeletal development; also avoid under age 8 |
| Fluoroquinolones (ciprofloxacin, levofloxacin) | Cartilage and tendon damage in the developing fetus |
| Aminoglycosides (gentamicin, tobramycin, amikacin) | Fetal ototoxicity, including congenital deafness, and nephrotoxicity |
| Sulfonamides / TMP-SMX | Folate antagonism (neural tube defects) early; kernicterus in the newborn at term |
| Nitrofurantoin | Hemolytic anemia in the newborn; avoid at term (after ~38 weeks) |
| Chloramphenicol | Gray baby syndrome |
| SAFE: penicillins, cephalosporins, azithromycin, erythromycin (not estolate) | Long safety record; these are the go-to choices |
Pregnancy safe = beta-lactams and azithromycin. Everything ending in -cycline, -floxacin, or -micin is out.
What are the different pharmacological classes of HIV antiretrovirals? Give an example of a drug in each class.⭐ HIGH YIELD
Five classes: NRTIs (tenofovir), NNRTIs (efavirenz), PROTEASE INHIBITORS (darunavir or atazanavir), INTEGRASE INHIBITORS/INSTIs (dolutegravir), and ENTRY INHIBITORS (maraviroc, a CCR5 antagonist; enfuvirtide, a fusion inhibitor).
- Suffix clues do most of the work: -navir is a protease inhibitor, -tegravir is an integrase inhibitor, -virine is an NNRTI.
- Standard first-line regimen today is 2 NRTIs plus an INSTI, for example tenofovir + emtricitabine + dolutegravir, often as a single combination tablet.
- Class effects worth knowing: NRTIs cause LACTIC ACIDOSIS with hepatomegaly and steatosis (the textbook names this plus pancreatitis, and says to stop the drug immediately if pancreatitis occurs). Zidovudine causes bone marrow suppression. Abacavir requires HLA-B*5701 testing first.
- Protease inhibitors cause metabolic problems (hyperlipidemia, insulin resistance, fat redistribution) and enormous CYP450 interactions. Ritonavir and cobicistat are used deliberately as 'boosters' because they inhibit CYP3A4.
- Many antiretrovirals affect the KIDNEYS. Monitor urine output and renal labs, per the textbook.
- St John's wort and rifampin induce CYP3A4 and can make antiretrovirals fail completely.
| Class | Mechanism | Example |
|---|
| NRTI (nucleoside reverse transcriptase inhibitor) | Faulty building block terminates the viral DNA chain | tenofovir, emtricitabine, lamivudine, abacavir, zidovudine |
| NNRTI (non-nucleoside RTI) | Binds and disables reverse transcriptase directly | efavirenz, rilpivirine, doravirine, nevirapine |
| Protease inhibitor | Blocks protease so new virions never mature | darunavir, atazanavir, ritonavir (-navir) |
| Integrase inhibitor (INSTI) | Blocks integrase so viral DNA cannot splice into host DNA | dolutegravir, bictegravir, raltegravir (-tegravir) |
| Entry inhibitors | Block attachment, the CCR5 coreceptor, or fusion with the cell membrane | maraviroc (CCR5), enfuvirtide (fusion), fostemsavir (attachment) |
-navir NAVigates protease. -tegravir inTEGRates. -virine is the NNRTI.
Why are multiple antiretroviral drugs given simultaneously?⭐ HIGH YIELD
Because HIV mutates constantly. Attacking several DIFFERENT STAGES of the viral life cycle at once suppresses replication far more completely and makes it nearly impossible for the virus to develop resistance to all the drugs at the same time. This is combination antiretroviral therapy (ART).
- A single drug would be defeated within weeks by a single mutation. Three drugs from two or more classes require multiple simultaneous mutations, which is statistically very unlikely.
- Standard regimen is at least 3 active drugs from 2 or more classes, usually 2 NRTIs plus an integrase inhibitor.
- The goal is an UNDETECTABLE viral load, which both preserves the CD4 count and makes sexual transmission effectively zero (U=U, undetectable equals untransmittable).
- ADHERENCE is the whole ballgame. Missed doses let the virus replicate in the presence of partial drug levels, which is the exact condition that selects for resistance. The textbook stresses compliance teaching.
- Single-tablet combination products exist specifically to support adherence.
- Never stop or hold antiretrovirals without provider direction, even for a hospital admission or NPO status.
One drug, one mutation, game over. Three drugs at three steps and the virus can't keep up.
💉 penicillinBLACK BOX
Broad-spectrum antiinfective, Natural penicillin
What it is for
Respiratory infections, scarlet fever, erysipelas, otitis media, pneumonia, skin and soft-tissue infections, gonorrhea; effective for gram-positive cocci (Staphylococcus, Streptococcus pyogenes, S. viridans, S. faecalis, S. bovis, S …
How it works
Interferes with cell-wall replication of susceptible organisms; lysis is mediated by cell-wall autolytic enzymes, results in cell death
Watch for
CNS: Lethargy, hallucinations, anxiety, depression, twitching, coma, seizures, hyperreflexia GI: Nausea, vomiting, diarrhea, increased AST, ALT, abdominal pain, glossitis, colitis, CDAD GU: Oliguria, proteinuria, hematuria, vaginitis, moniliasis, glomerulonephritis …
Teaching
- To report sore throat, fever, fatigue; may indicate superinfection; CNS effects: depression, hallucinations, seizures
- To wear or carry emergency ID if allergic to penicillins
- CDAD: To report diarrhea with blood, pus, mucus to prevent dehydration
- To shake susp well before each dose; to store in refrigerator for up to 2 wk
🔗 Full card in the drug guide
💉 amoxicillin
Antiinfective, antiulcer, Aminopenicillin
What it is for
Treatment of skin, respiratory, GI, GU infections, otitis media, gonorrhea; for gram-positive cocci (Staphylococcus aureus, Streptococcus pyogenes, Streptococcus faecalis, Streptococcus pneumoniae), gram-negative cocci (Neisseria gonorrhoeae …
How it works
Interferes with cell wall replication of susceptible organisms; bactericidal: lysis mediated by bacterial cell wall autolysins
Watch for
CNS: Seizures, agitation, confusion, dizziness, insomnia GI: Nausea, vomiting, diarrhea, pseudomembranous colitis HEMA: Anemia, bone marrow depression, granulocytopenia, hemolytic anemia, eosinophilia, thrombocytopenia, agranulocytosis INTEG: Urticaria, rash SYST: Anaphylaxis, serum sickness …
Teaching
- That capsules may be opened, contents taken with fluids; that chewable form is available; to take as prescribed, not to double dose
- All aspects of product therapy: to complete entire course of medication to ensure organism death; that culture may be taken after completed course of medication
- To report sore throat, fever, fatigue, diarrhea (superinfection or agranulocytopenia), blood in stool, abdominal pain (pseudomembranous colitis)
- That product must be taken in equal intervals around the clock to maintain blood levels; to take without regard to food, that capsules may be opened, contents taken with …
🔗 Full card in the drug guide
💉 cephalexin
Antiinfective, Cephalosporin (first generation)
What it is for
cefadroxil: gram-negative bacilli: Escherichia coli, Proteus mirabilis, Klebsiella (UTI only); gram-positive organisms: Streptococcus pneumoniae, Streptococcus pyogenes, Staphylococcus aureus; upper, lower respiratory tract; urinary tract, skin infections …
How it works
Inhibits bacterial cell wall synthesis; renders cell wall osmotically unstable, leads to cell death; lysis mediated by cell wall autolytic enzymes
Watch for
CNS: Headache, dizziness, weakness, paresthesia, fever, chills, confusion, fatigue, hallucinations, seizures (with high doses) GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, Clostridium difficileassociated diarrhea (CDAD) GU: Vaginitis, pruritus, candidiasis HEMA: Thrombocytopenia …
Teaching
- To take all medication prescribed for length of time ordered; take missed dose as soon as remembered, unless close to next dose; do not double dose; use calibrated device …
- To report vaginal itching; loose, foulsmelling stools; furry tongue occurs; may indicate superinfection
- To report immediately rash, flulike symptoms, blisters, stop product
- Diarrhea with mucus, blood (may indicate CDAD)
🔗 Full card in the drug guide
💉 meropenem
Antiinfective—miscellaneous, Carbapenem
What it is for
Acinetobacter sp., Aeromonas hydrophila, Bacteroides distasonis, Bacteroides fragilis, Bacteroides ovatus, Bacteroides thetaiotaomicron, Bacteroides uniformis, Bacteroides ureolyticus, Bacteroides vulgatus, Campylobacter jejuni, Citrobacter diversus …
How it works
Bactericidal; interferes with cell-wall replication of susceptible organisms
Watch for
CNS: Seizures, dizziness, headache CV: Hypotension, tachycardia ENDO: Hypoglycemia GI: Diarrhea, nausea, vomiting, CDAD; thrush (child), hepatitis, glossitis, jaundice INTEG: Rash, urticaria, pruritus, pain at inj site, phlebitis, erythema at inj site, DRESS RESP: Apnea …
Teaching
- CDAD: to report severe diarrhea, diarrhea with pus; not to self treat
- To avoid driving or other hazardous activities until response is known, dizziness may occur
- To discuss all OTC, Rx, herbals, supplements with prescriber
- To report sore throat, bruising, bleeding, joint pain; may indicate blood dyscrasias (rare)
🔗 Full card in the drug guide
💉 aztreonam
Antibiotic—miscellaneous, Monobactam
What it is for
UTI; septicemia; skin, muscle, bone infection; lower respiratory tract, intraabdominal infections; other infections caused by gram-negative organisms
How it works
Bactericidal, inhibits cell wall synthesis
Watch for
CV: Hypotension, chest pain, thrombophlebitis CNS: Confusion, headache, insomnia, fever, seizures EENT: Nasal congestion, sore throat GI: Pseudomembranous colitis, diarrhea, abdominal pain, nausea, vomiting RESP: Cough dyspnea, bronchospasm HEMA: Anemia, thrombocytopenia, neutropenia …
Teaching
- That IM injection is painful
- To report continuing signs/symptoms of infection
- To use bronchodilator, then inhalation product
- To report if pregnancy is planned or suspected or if breastfeeding
🔗 Full card in the drug guide
💉 vancomycin
Antiinfective—miscellaneous, Tricyclic glycopeptide
What it is for
Actinomyces sp., Bacillus sp., Clostridium difficile, Clostridium sp., Enterococcus faecalis, Enterococcus faecium, Enterococcus sp., Lactobacillus sp., Listeria monocytogenes, Staphylococcus aureus (MRSA), Staphylococcus aureus (MSSA) …
How it works
Inhibits bacterial cell-wall synthesis, damages bacterial plasma membrane and increases osmotic pressure
Watch for
CNS: Headache CV: Hypotension, peripheral edema cardiac arrest, vascular collapse EENT: Ototoxicity, permanent deafness, tinnitus, nystagmus GI: Nausea, CDAD GU: Nephrotoxicity HEMA: Leukopenia, eosinophilia INTEG: Chills, fever, rash, thrombophlebitis at inj site (red man syndrome) …
Teaching
- About all aspects of product therapy; about the need to complete entire course of medication to ensure organism death (7-10 days); that culture may be taken after complet …
- To report sore throat, fever, fatigue; could indicate superinfection
- That product must be taken in equal intervals around the clock to maintain blood levels
- That labs will need to be regularly monitored with IV infusion
🔗 Full card in the drug guide
fosfomycin
Fosfomycin (Monurol) is a bactericidal antibiotic given as a SINGLE 3-gram oral dose for uncomplicated urinary tract infection (cystitis) in women. Its selling point is one-and-done dosing, which makes adherence a non-issue.
- Administration: dissolve the entire packet of granules in 3 to 4 ounces of COLD water, stir, and drink immediately. Do NOT use hot water and do NOT take the dry powder.
- May be taken with or without food. One dose is the entire course; teach the patient not to expect a bottle of pills.
- It concentrates in the urine, so it works for cystitis but is NOT adequate for pyelonephritis or any systemic infection.
- Common side effects: diarrhea, nausea, headache, vaginitis. Generally well tolerated.
- Useful because it retains activity against many multidrug-resistant organisms, including ESBL-producing E. coli and VRE.
- Metoclopramide reduces its absorption; separate them. Symptoms should improve in 2 to 3 days; if not, the patient needs reevaluation.
Fosfomycin: one packet, cold water, one dose, done.
💉 tetracycline
Antiinfective, Tetracycline antibiotic
What it is for
Syphilis, Chlamydia trachomatis, gonorrhea, lymphogranuloma venereum; uncommon gram-positive, gram-negative organisms; rickettsial infections Acinetobacter sp., Actinomyces sp., Bacillus anthracis, Bacteroides sp., Balantidium coli, Bartonella bacilliformis …
How it works
Inhibits protein synthesis and phosphorylation in microorganisms; bacteriostatic Needed for pyruvate metabolism, carbohydrate metabolism
Watch for
CNS: Fever, headache, paresthesia, ICP CV: Pericarditis EENT: Dysphagia, glossitis, decreased calcification, discoloration of deciduous teeth, oral candidiasis, oral ulcers GI: Nausea, abdominal pain, vomiting, diarrhea, anorexia, enterocolitis, hepatotoxicity, flatulence, abdominal cramps …
Teaching
- To avoid sun exposure; that sunscreen does not seem to decrease photosensitivity
- That all prescribed medication must be taken to prevent superinfection
- To avoid milk products, antacids or to separate by 2 hr; to take with full glass of water; to take 1 hr before bedtime to prevent esophageal ulceration
- That tooth discoloration may occur, especially in children; not to use in child <8 yr, may cause bone formation abnormalities
🔗 Full card in the drug guide
💉 erythromycin
Antiinfective, Macrolide
What it is for
Mild to moderate respiratory tract, skin, soft tissue infections caused by Bordetella pertussis, Borrelia burgdorferi, Chlamydia trachomatis; Corynebacterium diphtheriae, Haemophilus influenzae (when used with sulfonamides) …
How it works
Binds to 50S ribosomal subunits of susceptible bacteria and suppresses protein synthesis
Watch for
CNS: Seizures CV: Dysrhythmias, QT prolongation GI: Nausea, vomiting, diarrhea, hepatotoxicity, abdominal pain, stomatitis, heartburn, anorexia, CDAD, esophagitis GU: Vaginitis, moniliasis INTEG: Rash, urticaria, pruritus, thrombophlebitis, injection site reactions (IV site) SYST: Anaphylaxis
Teaching
- To notify nurse of diarrhea stools, dark urine, pale stools, jaundice of eyes or skin, severe abdominal pain
- To take at evenly spaced intervals; to complete dosage regimen; to take without food
- To avoid use with other products unless approved by prescriber
- TREATMENT OF HYPERSENSITIVITY:
🔗 Full card in the drug guide
💉 gentamicinBLACK BOX
Antiinfective, Aminoglycoside
What it is for
Severe systemic infections of CNS, respiratory, GI, urinary tract, bone, skin, soft tissues caused by susceptible strains of Pseudomonas aeruginosa, Proteus, Klebsiella, Serratia, Escherichia coli, Enterobacter, Citrobacter, Staphylococcus, Shigella …
How it works
Interferes with protein synthesis by binding to 30S ribosomal subunit, thus causing misreading of genetic code; inaccurate peptide sequence forms in protein chain, thereby causing bacterial death
Watch for
CNS: Confusion, depression, numbness, tremors, seizures, muscle twitching, neurotoxicity, dizziness, vertigo, encephalopathy, fever, headache, lethargy CV: Hypo/hypertension, palpitations, edema EENT: Ototoxicity, deafness, visual disturbances, tinnitus GI: Nausea, vomiting, anorexia …
Teaching
- To report headache, dizziness, symptoms of overgrowth of infection, renal impairment
🔗 Full card in the drug guide
💉 ciprofloxacinBLACK BOX
Antiinfective—broad spectrum, Fluoroquinolone
What it is for
Infection caused by susceptible Escherichia coli, Enterobacter cloacae, Proteus mirabilis, Klebsiella pneumoniae, Proteus vulgaris, Citrobacter freundii, Serratia marcescens, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis …
How it works
Interferes with conversion of intermediate DNA fragments into high-molecular-weight DNA in bacteria; DNA gyrase inhibitor
Watch for
CNS: Headache, dizziness, fatigue, insomnia, depression, restlessness, seizures, suicidal ideation, pseudotumor cerebri, confusion, hallucinations GI: Nausea, diarrhea, increased ALT/AST, flatulence, vomiting, abdominal pain, pancreatitis, hepatotoxicity, CDAD GU: Vaginitis INTEG: Rash, pruritus …
Teaching
- Not to take any products that contain magnesium, calcium (such as antacids), iron, aluminum with this product or 2 hr before, 6 hr after product; to drink fluids to preve …
🔗 Full card in the drug guide
💉 metronidazole (also an antiprotozoal agent)BLACK BOX
Antiinfective—miscellaneous, Nitroimidazole derivative
What it is for
Intestinal amebiasis, amebic abscess, trichomoniasis, refractory trichomoniasis, bacterial anaerobic infections, giardiasis, septicemia, endocarditis; bone, joint, lower respiratory tract infections; rosacea
How it works
Direct-acting amebicide/trichomonacide binds and disrupts DNA structure, thereby inhibiting bacterial nucleic acid synthesis
Watch for
CNS: Headache, dizziness, confusion, irritability, restlessness, ataxia, depression, fatigue, drowsiness, insomnia, paresthesia, peripheral neuropathy, seizures, incoordination, depression, encephalopathy, aseptic meningitis (IV) CV: Flattening of T waves EENT: Blurred vision, sore throat …
Teaching
- That urine may turn dark reddish brown; that product may cause metallic taste; that both are normal
- About proper hygiene after bowel movement; handwashing technique
- To notify provider about numbness or tingling of extremities
- To avoid hazardous activities because dizziness can occur
🔗 Full card in the drug guide
trimethoprim‑sulfamethoxazole🚨 DANGER
Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim, Septra) is a SULFONAMIDE combination antibiotic. Individually each drug is only bacteriostatic; combined they are BACTERICIDAL. That is the textbook's example of a synergistic interaction. Used for UTI, MRSA skin infections, and Pneumocystis pneumonia.
- PUSH FLUIDS. Sulfonamides cause CRYSTALLURIA that can produce kidney stones and renal impairment. Teach a full glass of water with each dose and generous intake all day.
- STOP AT THE FIRST RASH. Sulfonamides are a leading cause of STEVENS-JOHNSON SYNDROME. Teach the patient to report any rash, sore throat, fever, or mouth sores immediately.
- Causes PHOTOSENSITIVITY: sunscreen and protective clothing.
- HYPERKALEMIA is a real risk, especially combined with ACE inhibitors, ARBs, or spironolactone, and in renal impairment.
- Raises WARFARIN levels dramatically (protein binding plus CYP2C9 inhibition). Watch the INR closely. Also raises methotrexate toxicity and interacts with phenytoin.
- Other adverse effects: GI upset, bone marrow suppression (monitor platelets on prolonged therapy), and hemolysis in G6PD deficiency. Anticipate a dose reduction in renal impairment.
Two weak drugs that kill together. Water it down, and stop it at the first rash.
💉 nitrofurantoin
Urinary tract antiinfective, Synthetic nitrofuran derivative
What it is for
Urinary tract infections caused by Escherichia coli, Klebsiella, Pseudomonas, Proteus vulgaris, Proteus morganii, Serratia, Citrobacter, Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus, Salmonella, Shigella
How it works
Inhibits bacterial acetyl-CoA interference with carbohydrate metabolism
Watch for
CNS: Dizziness, headache, drowsiness, peripheral neuropathy, chills, confusion, vertigo, polyneuropathy (high dose) CV: Bundle chest pain GI: Nausea, vomiting, abdominal pain, diarrhea, cholestatic jaundice, loss of appetite, CDAD, hepatitis, pancreatitis HEMA: Anemia, agranulocytosis …
Teaching
- To notify prescriber of continued symptoms of UTI, fever, myalgias, arthralgias, numbness or tingling of extremities
- To take as prescribed even if better
- To take with food or milk; to avoid alcohol
- To protect susp from freezing; shake well before taking
🔗 Full card in the drug guide
💉 ciprofloxacinBLACK BOX
Antiinfective—broad spectrum, Fluoroquinolone
What it is for
Infection caused by susceptible Escherichia coli, Enterobacter cloacae, Proteus mirabilis, Klebsiella pneumoniae, Proteus vulgaris, Citrobacter freundii, Serratia marcescens, Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis …
How it works
Interferes with conversion of intermediate DNA fragments into high-molecular-weight DNA in bacteria; DNA gyrase inhibitor
Watch for
CNS: Headache, dizziness, fatigue, insomnia, depression, restlessness, seizures, suicidal ideation, pseudotumor cerebri, confusion, hallucinations GI: Nausea, diarrhea, increased ALT/AST, flatulence, vomiting, abdominal pain, pancreatitis, hepatotoxicity, CDAD GU: Vaginitis INTEG: Rash, pruritus …
Teaching
- Not to take any products that contain magnesium, calcium (such as antacids), iron, aluminum with this product or 2 hr before, 6 hr after product; to drink fluids to preve …
🔗 Full card in the drug guide
phenazopyridine⭐ HIGH YIELD
Phenazopyridine (Pyridium, Azo) is a urinary tract ANALGESIC dye, NOT an antibiotic. It numbs the bladder and urethra to relieve burning, urgency, and frequency while an actual antibiotic treats the infection.
- It turns urine BRIGHT ORANGE-RED. Warn the patient in advance, because it looks alarming and it permanently STAINS clothing, undergarments, and soft contact lenses. Remove contacts while taking it.
- It treats only the SYMPTOM. Teach explicitly that they must still take the full antibiotic course. Feeling better is not being cured.
- Limit use to 2 DAYS when taken with an antibiotic. Longer use masks whether the infection is actually resolving.
- Take with or after food to reduce GI upset.
- Contraindicated or used with caution in renal impairment. Can cause hemolytic anemia and METHEMOGLOBINEMIA, especially in G6PD deficiency; report yellowing of the skin or eyes, blue-tinged skin, or shortness of breath.
- It can also interfere with urine dipstick tests (glucose, ketones, urinalysis), so note it on the lab requisition.
Pyridium numbs, it does not cure. Orange urine, ruined underwear, 2 days max.
💉 clindamycinBLACK BOX
Antiinfective—miscellaneous, Lincomycin derivative
What it is for
Skin, skin structure, respiratory tract infections; septicemia; intra-abdominal infections; endocarditis prophylaxis; infections caused by staphylococci, streptococci, Rickettsia, Fusobacterium, Actinomyces, Peptococcus, Bacteroides, Pneumocystis jiroveci
How it works
Binds to 50S subunit of bacterial ribosomes, suppresses protein synthesis
Watch for
GI: Nausea, vomiting, abdominal pain, diarrhea, CDAD, anorexia CV: Dysrrthmias, hypotension INTEG: Rash, urticaria, pruritus, abscess at inj site SYST: Stevens-Johnson syndrome, exfoliative dermatitis MISC: Candidiasis
Teaching
- To take oral product with full glass of water; that antiperistaltic products may worsen diarrhea
- About all aspects of product therapy; to complete entire course of medication to ensure organism death (10-14 days); culture may be taken after medication course complete …
- To report sore throat, fever, fatigue; may indicate superinfection
- To take with food to reduce GI symptoms
🔗 Full card in the drug guide
💉 isoniazidBLACK BOX
Antitubercular, Isonicotinic acid hydrazide
What it is for
Treatment, prevention of TB
How it works
Bactericidal interference with lipid, nucleic acid biosynthesis
Watch for
CNS: Peripheral neuropathy, dizziness, memory impairment, seizures, psychosis EENT: Blurred vision, optic neuritis GI: Nausea, vomiting, fatal hepatitis HEMA: Agranulocytosis, hemolytic, aplastic anemia, thrombocytopenia, eosinophilia, methemoglobinemia Hypersensitivity: DRESS …
Teaching
- That compliance with dosage schedule, duration is necessary; not to skip or double dose
- That scheduled appointments must be kept or relapse may occur
- To avoid alcohol while taking product; may increase risk for hepatic injury
- If diabetic, to use blood glucose monitor to obtain correct result
🔗 Full card in the drug guide
💉 rifampin
Antitubercular, Rifamycin B derivative
What it is for
Pulmonary TB, meningococcal carriers (prevention) Unlabeled: Endocarditis, Haemophilus influenzae type B prophylaxis, Hansen’s disease, Mycobacterium avium complex (MAC), orthopedic device–related infection, pruritus, CNS infections
How it works
Inhibits DNA-dependent polymerase, decreases tubercle bacilli replication
Watch for
CNS: Headache, fatigue, anxiety, drowsiness, confusion EENT: Visual disturbances GI: Nausea, vomiting, anorexia, diarrhea, CDAD, heartburn, sore mouth and tongue, pancreatitis, increased LFTs GU: Hematuria, acute renal failure, hemoglobinuria HEMA: Hemolytic anemia, eosinophilia, thrombocytopenia …
Teaching
- That compliance with dosage schedule, duration necessary
- That scheduled appointments must be kept because relapse may occur
- To take on an empty stomach 1 hr before or 2 hr after food
- To avoid alcohol because hepatotoxicity may occur
🔗 Full card in the drug guide
💉 amphotericin BHIGH ALERT
Antifungal, Amphoteric polyene
What it is for
Indicated for the treatment of invasive fungal infections in patients who cannot tolerate or have failed conventional amphotericin B therapy; broad-spectrum activity against many fungal, yeast and mold pathogen infections, including Aspergillus, Zygomycetes …
How it works
Increases cell membrane permeability in susceptible fungi by binding sterols; alters cell membrane, thereby causing leakage of cell components, cell death
Watch for
CNS: Headache, fever, chills, confusion, anxiety, insomnia CV: Hypotension, cardiac arrest, chest pain, hypertension, tachycardia, edema GI: Nausea, vomiting, anorexia, diarrhea, cramps, bilirubinemia GU: Nephrotoxicity HEMA: Anemia, thrombocytopenia, agranulocytosis, leukopenia INTEG: Burning …
Teaching
- That long-term therapy may be needed to clear infection (2 wk-3 mo, depending on type of infection), frequent blood draws will be needed
- To notify prescriber of bleeding, bruising, or soft tissue swelling, neurologic, renal symptoms
- Pregnancy/breastfeeding: to advise prescriber if pregnancy is planned or suspected; not to breastfeed
- HIGH ALERT
🔗 Full card in the drug guide
ketoconazole & fluconazole⭐ HIGH YIELD
Both are AZOLE antifungals that block ergosterol synthesis and destabilize the fungal cell membrane. KETOCONAZOLE is an imidazole, now used mainly TOPICALLY for skin infections because oral use carries severe HEPATOTOXICITY and QT risk. FLUCONAZOLE is a triazole, better tolerated and the workhorse ORAL/IV agent for systemic yeast infections.
- The textbook's split: imidazoles (miconazole, ketoconazole, clotrimazole) treat fungal SKIN infections such as athlete's foot, jock itch, and ringworm. Triazoles (fluconazole) treat systemic yeast infections including oral thrush and cryptococcal meningitis, both common in AIDS, and triazoles are more selectively toxic with fewer side effects.
- Fluconazole penetrates CSF and urine well, which is why it is used for cryptococcal meningitis. A single 150 mg oral dose treats uncomplicated vaginal candidiasis.
- BOTH are potent CYP450 inhibitors, so both raise levels of warfarin, phenytoin, statins, and many other drugs. Fluconazole plus warfarin is a bleeding risk; azoles plus simvastatin risks rhabdomyolysis. Oral ketoconazole is contraindicated with drugs that prolong QT.
- Monitor LIVER FUNCTION with either one. Teach the patient to report unexplained bruising or bleeding, abdominal pain, dark urine, jaundice, fever, or rash.
- Oral ketoconazole absorption requires an ACIDIC stomach, so PPIs, H2 blockers, and antacids block it. Fluconazole absorption is unaffected by gastric pH.
- Both may cause fetal harm; fluconazole at high dose is teratogenic. Finish the full course even after symptoms clear.
| Ketoconazole | Fluconazole |
|---|
| Imidazole | Triazole |
| Mostly TOPICAL now (creams, shampoo) for tinea and seborrheic dermatitis | Oral or IV for systemic and mucosal candidiasis, cryptococcal meningitis |
| Oral form carries boxed-warning HEPATOTOXICITY and QT prolongation | Much better tolerated; still monitor LFTs |
| Needs an acidic stomach; blocked by antacids, H2 blockers, PPIs | Absorption not affected by gastric pH |
| Extremely strong CYP3A4 inhibitor | Strong CYP2C9/3A4 inhibitor; classic warfarin interaction |
Ketoconazole stayed on the skin because it wrecked the liver. Fluconazole got to stay systemic.
💉 nystatin
Antifungal, Amphoteric polyene
What it is for
Candida species causing oral, intestinal infections
How it works
Interferes with fungal DNA replication; binds sterols in fungal cell membrane, which increases permeability, leaking of cell nutrients
Watch for
GI: Nausea, vomiting, anorexia, diarrhea, cramps
Teaching
- That long-term therapy may be needed to clear infection; to complete entire course of medication
- To avoid commercial mouthwashes for mouth infection
- To shake susp before measuring each dose, to swish and swallow
- To notify prescriber of irritation; product may have to be discontinued
🔗 Full card in the drug guide
acyclovir & valacyclovir⭐ HIGH YIELD
Both are antiherpes antivirals that terminate the viral DNA chain during replication. VALACYCLOVIR is a PRODRUG of acyclovir with much better oral absorption, so it is dosed far less often. Used for genital herpes, cold sores, chickenpox, and shingles.
- Neither one CURES herpes. They shorten and reduce outbreaks, and lower doses can be taken long-term for suppression. Say this plainly to patients.
- START AS EARLY AS POSSIBLE after symptoms appear, ideally within 24 to 72 hours or at the first tingling/prodrome. Started late, they do very little.
- PUSH FLUIDS. Both are NEPHROTOXIC because the drug can crystallize in the renal tubules. IV acyclovir must be infused over at least ONE HOUR to prevent renal tubular damage, never IV push.
- Route rules from the textbook: acyclovir is PO, IV, or topical. Never give it IM or subcutaneously. Give with food if GI upset occurs.
- Both LOWER THE SEIZURE THRESHOLD and can cause neurotoxicity (confusion, tremor, hallucinations), especially in older adults and in renal impairment. Doses must be reduced for reduced kidney function.
- Teach: avoid sexual contact while lesions are present, herpes is still transmissible without visible lesions, and expect fatigue so plan rest.
| Acyclovir | Valacyclovir |
|---|
| Active drug | Prodrug converted to acyclovir in the body |
| Oral bioavailability only about 10 to 20% | About 55%, three to five times higher |
| Oral dosing up to 5 times a day | Once to three times a day - much better adherence |
| Available PO, IV, and topical; IV is the choice for severe or disseminated disease | Oral only |
| Cheaper | More expensive but far easier to take |
Valacyclovir is acyclovir that learned to be absorbed. Start early, drink water, never IV push.
💉 oseltamivir
Antiviral, Neuraminidase inhibitor
What it is for
Prevention and treatment of influenza type A or B Unlabeled: Avian flu (H5N1)
How it works
Inhibits influenza virus neuraminidase with possible alteration of virus particle aggregation and release
Watch for
CNS: Headache, dizziness, fatigue, insomnia, seizures, delirium, self-injury (children) GI: Nausea, vomiting INTEG: Toxic epidermal necrolysis, Stevens-Johnson syndrome, erythema multiforme RESP: Cough
Teaching
- About all aspects of product therapy
- To avoid hazardous activities if dizziness occurs
- To take as soon as symptoms appear; to take full course even if feeling better
- To take missed dose as soon as remembered if within 2 hr of next dose
🔗 Full card in the drug guide
💉 enfuvirtide
Antiretroviral, Fusion inhibitor
What it is for
Treatment of HIV-1 infection in combination with other antiretrovirals in those who are treatment experienced only Unlabeled: HIV prophylaxis after occupational exposure
How it works
Inhibitor of the fusion of HIV-1 with CD4+ cells
Watch for
CNS: Anxiety, peripheral neuropathy, taste disturbance, Guillain-Barré syndrome, insomnia, depression, fatigue, peripheral neuropathy GI: Nausea, abdominal pain, anorexia, constipation, pancreatitis, dry mouth, weight loss GU: Glomerulonephritis, renal failure HEMA: Thrombocytopenia …
Teaching
- That pneumonia may occur; to contact prescriber if cough, fever occur
- That hypersensitive reactions may occur; rash, pruritus; to stop product, contact prescriber
- That product is not a cure for HIV-1 infection but controls symptoms; HIV-1 can still be transmitted to others; that product is to be used in combination only with other …
- How to prepare and give using SUBCUT injection, watch for site reactions, rotate sites; if more information is needed, call 877-438-9366
🔗 Full card in the drug guide
💉 efavirenz
Antiretroviral, Nonnucleoside reverse transcriptase inhibitor (NNRTI)
What it is for
HIV-1 in combination with at least 2 other antivirals
How it works
Binds directly to reverse transcriptase and blocks RNA, DNA polymerase, thus causing a disruption of the enzyme’s site
Watch for
CNS: Fatigue, impaired cognition, insomnia, abnormal dreams, depression, headache, dizziness, anxiety, drowsiness, odd feeling, suicidal thoughts/behaviors GI: Diarrhea, abdominal pain, nausea, vomiting, hepatotoxicity GU: Hematuria, kidney stones HEMA: Neutropenia INTEG: Rash …
Teaching
- To take as prescribed; if dose is missed, to take as soon as remembered; not to double dose; to take with water, juice; to take on empty stomach at bedtime; to take at sa …
- To make sure health care provider knows all medications, supplements, OTC products taken
- To notify health care provider if severe rash occurs; that adverse reactions (rash, dizziness, abnormal dreams, insomnia) lessen after 1 mo, not to stop taking
- To avoid hazardous activities if dizziness, drowsiness occur
🔗 Full card in the drug guide
💉 tenofovirBLACK BOX
Antiretroviral, Nucleoside reverse transcriptase inhibitor (NRTI)
What it is for
HIV-1 infection with at least 2 other antiretrovirals, hepatitis B
How it works
Inhibits replication of HIV virus by competing with the natural substrate and then incorporating into cellular DNA by viral reverse transcriptase, thereby terminating cellular DNA chain
Watch for
CNS: Headache, asthenia GI: Nausea, vomiting, diarrhea, anorexia, flatulence, abdominal pain, pancreatitis GU: Renal failure, renal tubular acidosis/necrosis, Fanconi’s syndrome HEMA: Neutropenia, osteopenia INTEG: Rash, angiedema META: Lactic acidosis, hypokalemia …
Teaching
- To take without regard to food
- That GI complaints resolve after 3-4 wk of treatment
- Not to breastfeed while taking this product
- That product must be taken daily even if patient feels better
🔗 Full card in the drug guide
💉 lopinavir/ritonavir
Antiretroviral, Protease inhibitor
What it is for
HIV-1 in combination with or without other antiretrovirals
How it works
Inhibits human immunodeficiency virus (HIV-1) protease and prevents maturation of the infectious virus
Watch for
CNS: Paresthesia, headache, seizures, fever, dizziness, insomnia, asthenia, intracranial bleeding, encephalopathy CV: QT, PR interval prolongation, deep vein thrombosis EENT: Blurred vision, otitis media, tinnitus GI: Diarrhea, buccal mucosa ulceration, abdominal pain, nausea, taste perversion …
Teaching
- To take as prescribed; if dose is missed, to take as soon as remembered up to 1 hr before next dose; not to double dose
- That product is not a cure for HIV; that opportunistic infections can continue to be acquired
- That redistribution of body fat or accumulation of body fat may occur
- That others can continue to contract HIV from patient
🔗 Full card in the drug guide
Module 3: Immunomodulators & Antineoplastic Drugs
💉 Interferon alfa-2bHIGH ALERTBLACK BOX
Immunomodulator
What it is for
Chronic hepatitis C infections in adults with compensated liver disease; chronic hepatitis B in adults who are HBe AG positive, HBe AG negative; HCV patients coinfected with HIV …
How it works
Stimulates genes to modulate many biologic effects, including the inhibition of viral replication; inhibits ion cell proliferation, immunomodulation; stimulates effector proteins; decreases leukocyte, platelet counts
Watch for
CNS: Headache, insomnia, dizziness, anxiety, hostility, lability, nervousness, depression, fatigue, poor concentration, pyrexia, suicidal ideation, homicidal ideation, relapse of drug addiction, emotional lability, mania, psychosis CV: Ischemic CV events ENDO: Hypothyroidism …
Teaching
- Provide patient or family member with written, detailed information about product
- Use 2 forms of effective contraception throughout treatment and for 6 mo after treatment (men and women) (combination therapy with ribavirin)
- To avoid driving, other hazardous activity if dizziness, confusion, fatigue, somnolence occur
- To use puncture-resistant container for disposal of needles/syringes if using at home
🔗 Full card in the drug guide
Aldesleukin🚨 DANGER
Aldesleukin (Proleukin) is recombinant INTERLEUKIN-2, a biologic response modifier that revs up T cells and natural killer cells to attack tumor. It is given IV for metastatic RENAL CELL CARCINOMA and metastatic MELANOMA.
- BOXED WARNING - CAPILLARY LEAK SYNDROME. Fluid pours out of the vasculature into the tissues, causing profound hypotension, massive edema, weight gain, hypoperfusion, and organ failure. It starts almost immediately after the infusion begins.
- Because of that, it is administered only in a specialized inpatient setting with intensive care backup, by staff trained in cardiopulmonary resuscitation. Monitor blood pressure, weight, intake and output, and daily labs closely.
- Expect flu-like symptoms with every dose: high fever, rigors, chills, myalgias, fatigue, nausea, vomiting, diarrhea. Premedicate with acetaminophen; meperidine is often used for rigors.
- Contraindicated in abnormal cardiac or pulmonary function tests and in organ allografts. Withhold for moderate to severe lethargy or somnolence, because continuing can cause coma.
- Also causes impaired neutrophil function with increased risk of gram-positive sepsis, so central lines are watched carefully, and it can trigger or worsen autoimmune disease and thyroid dysfunction.
- This is an immunoSTIMULANT, the opposite of chemotherapy. Aldesleukin does not kill tumor cells directly; the patient's own immune system does.
Aldesleukin turns the immune system up to eleven, and the blood vessels start to leak.
💉 CyclosporineBLACK BOX
Immunosuppressant, antirheumatic (DMARD), Fungus-derived peptide
What it is for
Organ transplants (liver, kidney, heart) to prevent rejection (GVHD), rheumatoid arthritis, psoriasis
How it works
Produces immunosuppression by inhibiting T lymphocytes
Watch for
CNS: Tremors, headache, seizures, progressive multifocal leukoencephalopathy, confusion, migraine, paresthesia GI: Nausea, vomiting, diarrhea, oral candida, gum hyperplasia, hepatotoxicity, pancreatitis GU: Nephrotoxicity INTEG: Rash, acne, hirsutism META: Hyperkalemia, hypomagnesemia …
Teaching
- To report fever, chills, sore throat, fatigue since serious infections may occur; tremors, bleeding gums, increased B/P
- To take at same time of day, every day; not to skip doses or double dose; not to use with grapefruit juice or receive vaccines; that there are many drug interactions; not …
🔗 Full card in the drug guide
💉 AzathioprineBLACK BOX
Immunosuppressant, antirheumatic (disease modifying), Purine antimetabolite
What it is for
FDA-labeled: prevention of kidney transplant rejection and severe rheumatoid arthritis. Also widely used off-label in lupus, inflammatory bowel disease and other autoimmune disease — on an exam, answer with the labeled two.
How it works
Turns into a fake purine that gets built into DNA, which stops fast-dividing cells from copying themselves. Lymphocytes are the fastest dividers in an immune response, so the immune system is what gets damped down.
Watch for
HEMA: Bone marrow suppression — leukopenia, thrombocytopenia, anemia. GI: Nausea, vomiting, mouth ulcers, pancreatitis. HEPA: Hepatotoxicity. SYST: Serious infection; long-term lymphoma and skin cancer risk.
Teaching
- CBC and liver enzymes get checked regularly — this drug suppresses the marrow, and that is the main thing being watched for.
- Any fever, sore throat, cough or wound that will not heal is reported immediately. The immune system is deliberately turned down.
- Avoid crowds and anyone who is sick. No live vaccines.
- Sunscreen and covered skin, every day. Skin cancer risk is real and long-term.
🔗 Full card in the drug guide
Monoclonal Antibodies (What are some examples of monoclonal antibody drugs?)⭐ HIGH YIELD
Monoclonal antibodies are lab-made antibodies engineered to bind one specific target (a receptor, a cytokine, or a tumor antigen). Every generic name ends in -MAB. Examples: rituximab, trastuzumab, bevacizumab, infliximab, adalimumab, omalizumab, palivizumab, pembrolizumab.
- INFUSION REACTIONS are the universal nursing concern: fever, chills, rigors, urticaria, bronchospasm, hypotension, usually during the first infusion. Premedicate (acetaminophen, diphenhydramine, sometimes a corticosteroid), start slowly, stay with the patient, and keep emergency equipment ready.
- Anything that suppresses immune function raises infection risk: screen for latent TB and hepatitis B BEFORE starting TNF inhibitors or rituximab, and give NO LIVE VACCINES during therapy.
- Drug-specific toxicities you must know: TRASTUZUMAB is CARDIOTOXIC (get a baseline ejection fraction and monitor it). RITUXIMAB can reactivate hepatitis B and cause PML. BEVACIZUMAB causes hypertension, bleeding, impaired wound healing, and GI perforation. Checkpoint inhibitors (pembrolizumab, nivolumab) cause autoimmune 'itis' of any organ: colitis, pneumonitis, hepatitis, thyroiditis.
- Naming clue: -ximab is chimeric (mouse-human, higher reaction risk), -zumab is humanized, -umab is fully human. The syllable before -mab often names the target: -tu- tumor, -ci- circulatory, -li- immune.
- Most are given IV or subcutaneously; they are proteins and would be digested if swallowed. Handle per hazardous drug policy where applicable, do not shake vials, and check for the correct diluent and filter.
- Common uses: cancer (rituximab, trastuzumab, bevacizumab, cetuximab, pembrolizumab), autoimmune disease (infliximab, adalimumab, etanercept is a fusion protein not a mab), asthma (omalizumab), RSV prophylaxis in high-risk infants (palivizumab, nirsevimab), migraine prevention (erenumab), and cholesterol (evolocumab).
| Drug | Target / use | Key nursing point |
|---|
| rituximab | CD20 on B cells; lymphoma, RA | Hepatitis B reactivation; severe infusion reactions |
| trastuzumab | HER2; breast cancer | CARDIOTOXIC - baseline and serial ejection fraction |
| bevacizumab | VEGF; colon, lung, renal cancer | Hypertension, bleeding, poor wound healing, GI perforation |
| infliximab / adalimumab | TNF-alpha; RA, Crohn's, psoriasis | Screen for TB and hep B; serious infection risk; no live vaccines |
| omalizumab | IgE; severe allergic asthma | Anaphylaxis risk - observe after dosing, prescribe an epinephrine autoinjector |
| palivizumab | RSV F protein; prophylaxis in high-risk infants | PREVENTION only, monthly IM during RSV season; it does not treat active RSV |
| pembrolizumab / nivolumab | PD-1 checkpoint; many cancers | Immune-mediated colitis, pneumonitis, hepatitis, endocrinopathies |
If it ends in -MAB, it's a Monoclonal AntiBody: watch the infusion, watch for infection.
DTaP⭐ HIGH YIELD
DTaP protects against Diphtheria, Tetanus, and acellular Pertussis, and is the CHILDHOOD formulation given under age 7. It is INACTIVATED (toxoid plus acellular components), so it is NOT a live vaccine and is safe in immunocompromised children and pregnant household contacts.
- Schedule: FIVE doses at 2 months, 4 months, 6 months, 15 to 18 months, and 4 to 6 years. It is IM.
- Capital letters mean full-strength antigen. DTaP (big D, big P) is for children under 7. Tdap (little d, little p) is the reduced-antigen adolescent and adult version.
- DT (no pertussis) is substituted for a child under 7 who has a contraindication to the pertussis component.
- Expected reactions: injection-site redness, swelling and pain, low-grade fever, and fussiness. Teach acetaminophen and a cool compress. Do NOT give prophylactic antipyretics before the dose.
- Contraindications: anaphylaxis to a prior dose, and ENCEPHALOPATHY within 7 days of a previous pertussis-containing dose (then use DT). Precautions include a progressive neurologic disorder, and Guillain-Barre within 6 weeks of a prior tetanus toxoid.
- Pertussis (whooping cough) immunity wanes, which is why the Tdap booster at age 11 to 12 and in every pregnancy exists: to protect infants too young to be fully vaccinated.
BIG letters for LITTLE kids: DTaP under 7, five doses, and it is not live.
Tdap⭐ HIGH YIELD
Tdap is the reduced-antigen Tetanus, diphtheria, and acellular Pertussis booster for age 7 and older. INACTIVATED, not live. One dose at age 11 to 12, then a Td or Tdap booster every 10 years, and a dose during EVERY PREGNANCY at 27 to 36 weeks.
- THE PREGNANCY POINT IS THE MOST TESTED: give Tdap in EVERY pregnancy, in the third trimester (27 to 36 weeks, preferably early in that window), regardless of when she last had one. Maternal antibodies cross the placenta and protect the newborn before the infant's own DTaP series can.
- COCOONING: everyone who will be around a new baby (partner, grandparents, siblings 11 and over, childcare providers) should be up to date on Tdap, ideally at least 2 weeks before contact.
- Any adult who has never had a Tdap should get one dose in place of a Td booster, at any age.
- It is also given for wound management when the last tetanus-containing dose was more than 5 years ago for a dirty or contaminated wound (more than 10 years for a clean minor wound).
- It is inactivated, so it is safe in pregnancy and in immunocompromised patients. Give IM in the deltoid.
- Expected: sore arm, low-grade fever, headache, fatigue.
Tdap: little letters, big kids and adults. EVERY pregnancy, 27 to 36 weeks, every time.
Td booster⭐ HIGH YIELD
Td is the Tetanus and diphtheria toxoid booster, given EVERY 10 YEARS to adults. It is INACTIVATED. Tdap may be substituted for any Td dose, and one lifetime Tdap should be given if the person has never had one.
- Ten years is the routine interval. In WOUND MANAGEMENT the interval shortens: for a dirty or contaminated wound, boost if it has been more than 5 years since the last tetanus-containing dose; for a clean minor wound, more than 10 years.
- If the patient has fewer than 3 lifetime tetanus doses or an unknown history, give the vaccine AND, for a dirty wound, tetanus immune globulin (TIG) at a different site with a different syringe.
- TIG is passive immunity: it gives borrowed antibodies that work now but wear off. The vaccine is active immunity: it takes weeks but lasts years. Give both when the wound is high risk and the history is inadequate.
- Safe in pregnancy and in immunocompromised patients because it is inactivated, but in pregnancy Tdap is preferred so the fetus also gets pertussis protection.
- Give IM in the deltoid. Expect a sore arm; report severe swelling of the whole limb or a hypersensitivity reaction.
Every 10 years routine, every 5 years for a dirty wound.
Haemophilus influenzae (Hib)⭐ HIGH YIELD
Hib is the Haemophilus influenzae type b CONJUGATE vaccine. It is INACTIVATED (a polysaccharide linked to a protein carrier), not live. It prevents Hib meningitis, epiglottitis, and sepsis in infants, and it essentially eliminated those diseases in the US.
- Schedule: primary doses at 2 and 4 months (plus 6 months depending on the brand), then a booster at 12 to 15 months. PedvaxHIB is a 2-dose primary series; ActHIB and Hiberix are 3-dose.
- It is NOT the flu vaccine. Haemophilus influenzae is a BACTERIUM that was misnamed during a flu epidemic. This confusion is a classic exam distractor.
- Not routinely needed after age 5 in healthy children, because natural immunity develops. It IS given to older children and adults with asplenia or sickle cell disease, HIV, complement deficiency, or after a stem cell transplant.
- Conjugation to a protein carrier is what makes it work in infants under 2, whose immune systems respond poorly to plain polysaccharide vaccines. Same principle as the pneumococcal and meningococcal conjugate vaccines.
- Given IM. Expected reactions are mild: injection-site soreness and low-grade fever.
- Because it is inactivated, it is safe for immunocompromised children.
Hib is a BACTERIUM, not influenza. Conjugated so babies can respond, and not live.
Influenza⭐ HIGH YIELD
Influenza vaccine is given ANNUALLY to everyone 6 months and older, ideally by the end of October. The INJECTED forms (IIV, RIV) are INACTIVATED; the intranasal spray (LAIV, FluMist) is LIVE ATTENUATED.
- THE LIVE-VS-INACTIVATED QUESTION: the nasal spray is LIVE and is therefore avoided in pregnancy, in immunocompromised patients, in children under 2, in adults 50 and over, in asthma or wheezing, and in close contacts of severely immunocompromised people. When in doubt, give the SHOT.
- The shot is safe and RECOMMENDED in pregnancy at any trimester, and safe in immunocompromised patients. Maternal antibodies also protect the infant, who cannot be vaccinated until 6 months.
- Children 6 months through 8 years getting flu vaccine for the FIRST time need 2 doses at least 4 weeks apart. After that, one dose a year.
- It is reformulated every year because influenza mutates (antigenic drift), which is why annual dosing is required. Protection takes about 2 weeks to develop.
- Egg allergy is no longer a barrier: any licensed flu vaccine may be given regardless of egg allergy severity. Cell-based and recombinant options exist.
- The vaccine CANNOT give you the flu. Post-vaccine soreness, low-grade fever, and achiness are the immune response, not infection. This is the teaching point patients need most. The 2025-2026 federal schedule moved routine influenza vaccination toward shared clinical decision-making; the AAP and most nursing curricula still teach universal annual vaccination from 6 months. Answer the universal recommendation on your exam.
Shot = dead and safe for everyone. Nasal spray = LIVE, so not for pregnancy or immunosuppression.
Rotavirus🚨 DANGER
Rotavirus vaccine is a LIVE ATTENUATED ORAL vaccine that prevents severe infant diarrhea and dehydration. It is the only routine infant vaccine given by MOUTH, and the only live one before 12 months.
- Schedule: RotaTeq (RV5) is 3 doses at 2, 4, and 6 months; Rotarix (RV1) is 2 doses at 2 and 4 months.
- AGE LIMITS ARE STRICT: the FIRST dose must be given by 14 weeks 6 days, and the LAST dose by 8 months 0 days. If the window is missed, the series is not started or not completed.
- CONTRAINDICATED in a history of INTUSSUSCEPTION and in SCID (severe combined immunodeficiency). Precaution in other immunocompromising conditions and in acute moderate to severe gastroenteritis.
- Teach parents to watch for intussusception in the week after a dose: sudden inconsolable crying with knees drawn up, vomiting, a palpable abdominal mass, and currant-jelly (bloody, mucousy) stool. That is an emergency.
- It is live, so the virus is SHED IN STOOL for days. Teach meticulous hand hygiene at diaper changes, especially around immunocompromised household members.
- Do NOT repeat the dose if the infant spits it out or vomits. Breastfeeding does not need to be held.
The oral one is the live one. First dose by 14 weeks, last by 8 months, and never after intussusception.
Poliovirus⭐ HIGH YIELD
In the United States the polio vaccine is IPV (inactivated poliovirus vaccine), given by injection. It is NOT LIVE. The oral polio vaccine (OPV) IS live and is no longer used in the US because it could rarely cause vaccine-associated paralytic polio.
- Schedule: 4 doses at 2 months, 4 months, 6 to 18 months, and 4 to 6 years. Given IM or subcutaneously.
- Because IPV is inactivated, it is safe in pregnancy when indicated and safe in immunocompromised patients and their household contacts. That is the entire reason the US switched from OPV to IPV in 2000.
- OPV is still used in some countries because it is cheap, needs no needle, and produces gut immunity that interrupts transmission. Its downside is vaccine-derived poliovirus.
- Adults in the US are not routinely revaccinated. A one-time booster is offered to adults at increased risk: travelers to endemic areas, lab workers handling the virus, and health care workers with possible exposure.
- Expected reactions are minimal: injection-site soreness and redness.
- IPV contains trace neomycin, streptomycin, and polymyxin B; a history of anaphylaxis to those is a contraindication.
IPV = Injected, Protected, not alive. OPV = Oral, live, and retired in the US.
Varicella🚨 DANGER
Varicella (chickenpox) vaccine is LIVE ATTENUATED. Two doses: at 12 to 15 months and again at 4 to 6 years. Because it is live, it is CONTRAINDICATED in pregnancy and in severely immunocompromised patients.
- Avoid pregnancy for at least 4 weeks (1 month) after the dose. Nonimmune pregnant women are vaccinated AFTER delivery, not during pregnancy.
- Contraindicated in severe immunosuppression: active chemotherapy, hematologic or solid malignancy, transplant, congenital immunodeficiency, advanced HIV, and high-dose corticosteroids (prednisone 20 mg/day or more, or 2 mg/kg/day, for 14 days or more).
- HOUSEHOLD CONTACTS of an immunocompromised person CAN be vaccinated, and should be. This is a favorite distractor. If the vaccinee develops a rash, cover it and avoid contact until it crusts.
- If two live vaccines are not given the SAME DAY, separate them by at least 28 days. Varicella and MMR are usually given together at 12 to 15 months.
- Recent immune globulin or blood products blunt the response; wait the product-specific interval (often 3 to 11 months).
- Do NOT give salicylates (aspirin) for 6 weeks after varicella vaccination because of Reye syndrome risk. MMRV (ProQuad) combines it with MMR but carries a higher febrile seizure rate for the first dose in 12 to 23 month olds, so separate MMR and varicella injections are preferred for dose one.
Varicella is LIVE: not pregnant, not immunosuppressed, no aspirin for 6 weeks.
Pneumococcal⭐ HIGH YIELD
Pneumococcal vaccines protect against Streptococcus pneumoniae (pneumonia, meningitis, bacteremia, otitis media). Both types are INACTIVATED, not live. PCV (conjugate: PCV15, PCV20, PCV21) is the infant series and the adult starting point; PPSV23 (polysaccharide) is used to complete the series after PCV15 and for certain high-risk groups.
- CHILDREN: a 4-dose PCV series at 2, 4, 6, and 12 to 15 months.
- ADULTS: everyone 50 and older who has never had a conjugate vaccine gets one dose of PCV15, PCV20, or PCV21. (The age was lowered from 65 to 50 in late 2024.) Adults 19 to 49 with risk conditions are also vaccinated.
- THE SEQUENCE RULE: if PCV15 is used, give PPSV23 one year later (minimum 8 weeks if immunocompromised, asplenic, or with a CSF leak or cochlear implant). If PCV20 or PCV21 is used, NO PPSV23 is needed.
- High-risk conditions that trigger earlier vaccination: chronic heart, lung, liver, or kidney disease, diabetes, smoking, alcoholism, asplenia or sickle cell disease, HIV, malignancy, transplant, cochlear implant, and CSF leak.
- Conjugate vaccines work in infants because the polysaccharide is linked to a protein carrier; plain polysaccharide (PPSV23) does not work well under age 2.
- Both are inactivated, so both are safe in immunocompromised patients, who are exactly the people who need them most. May be given at the same visit as influenza vaccine, in different arms.
| PCV15 / PCV20 / PCV21 (conjugate) | PPSV23 (polysaccharide) |
|---|
| Polysaccharide linked to a protein carrier | Plain polysaccharide |
| Works in infants; routine at 2, 4, 6, 12-15 months | Does not work under age 2 |
| All adults 50+ who are conjugate-naive; risk-based at 19-49 | Only to complete the series after PCV15, or for specific high-risk groups |
| Produces immune memory and longer protection | No memory response; broader serotype coverage |
PCV first, always. PPSV23 only chases PCV15, never PCV20 or PCV21.
Hepatitis A
Hepatitis A vaccine is INACTIVATED (killed virus), not live. Routine childhood series is 2 doses: the first at 12 to 23 months, the second 6 to 18 months later. Hepatitis A is spread FECAL-ORAL, through contaminated food and water.
- Adults are vaccinated based on risk: international travelers to endemic areas, men who have sex with men, injection or non-injection drug users, people experiencing homelessness, people with chronic liver disease or clotting factor disorders, food handlers in some jurisdictions, and household contacts of an adoptee from an endemic country.
- Because it is inactivated, it is SAFE in pregnancy when indicated and safe in immunocompromised patients.
- POST-EXPOSURE PROPHYLAXIS: give hepatitis A vaccine within 2 weeks of exposure; add immune globulin for those over 40, immunocompromised, with chronic liver disease, or under 12 months.
- Do not confuse the two: hepatitis A is fecal-oral, acute only, and NEVER becomes chronic. Hepatitis B is bloodborne and sexually transmitted and CAN become chronic and cause cirrhosis and liver cancer.
- Twinrix combines hepatitis A and B for adults (3 doses).
- The 2025-2026 federal schedule moved routine childhood hepatitis A vaccination toward shared clinical decision-making; the AAP still recommends the routine 2-dose series at 12 to 23 months. Give the routine schedule as your exam answer.
Hep A = fecal-oral, Acute only, and the vaccine is killed. Two doses, six months apart.
💉 Hepatitis B
Immune globulin
What it is for
Prevention of hepatitis B virus in exposed patients, including passive immunity in neonates born to HBsAgpositive mother, prevention of hepatitis B recurrence after liver transplant in HBsAg-positive patients
🔗 Full card in the drug guide
Meningococcal⭐ HIGH YIELD
Meningococcal vaccines prevent Neisseria meningitidis meningitis and sepsis. Both types are INACTIVATED. MenACWY: one dose at 11 to 12 years with a BOOSTER at 16. MenB: ages 16 to 23, usually 16 to 18, by shared clinical decision-making.
- The age-16 booster is the point: protection needs to be at its peak during the high-risk years of late adolescence, college dorms, and military barracks.
- First-year college students living in residence halls who have not had a dose after their 16th birthday should be vaccinated. Same for military recruits and travelers to the African meningitis belt or Hajj pilgrims.
- High-risk conditions that require the vaccine at any age, plus boosters: ASPLENIA or sickle cell disease, complement deficiency, HIV, and use of eculizumab or ravulizumab (complement inhibitors, which carry a boxed warning for meningococcal disease).
- MenACWY and MenB are NOT interchangeable and do not substitute for each other. Serogroup B is not covered by ACWY. Pentavalent MenABCWY products now exist.
- Both are inactivated, so they are safe in pregnancy and immunosuppression.
- CLOSE CONTACTS of a meningococcal case need chemoprophylaxis, not just vaccine: rifampin, ciprofloxacin, or ceftriaxone, given as soon as possible. The 2025-2026 federal schedule shifted routine adolescent meningococcal vaccination toward shared clinical decision-making or high-risk groups; the AAP continues to recommend 11-12 with a booster at 16. Answer the classic schedule.
MenACWY at 11-12, BOOST at 16 for the dorm years. MenB is separate and does not cover for it.
Human papillomavirus⭐ HIGH YIELD
HPV vaccine (Gardasil 9) is a RECOMBINANT, INACTIVATED vaccine (virus-like particles, no viral DNA at all, so it cannot cause infection). Routine at age 11 to 12, may start at 9. It prevents cervical, anal, oropharyngeal, penile, vulvar, and vaginal cancers and genital warts.
- DOSE RULE: if the series is STARTED BEFORE the 15th birthday, 2 doses 6 to 12 months apart. If started at 15 or older, or if the person is immunocompromised, 3 doses at 0, 1 to 2, and 6 months.
- Routine catch-up through age 26 for everyone. Ages 27 to 45 is shared clinical decision-making, with less benefit because most people have already been exposed.
- It is PREVENTIVE only. It does not treat an existing HPV infection, existing warts, or existing cervical dysplasia, and it does NOT replace Pap screening.
- Give it BEFORE any sexual activity, which is the whole reason for vaccinating at 11 to 12. Frame it to parents as CANCER PREVENTION, not as a sex conversation.
- SYNCOPE is the notable adverse event, because adolescents faint. Have the patient seated or lying down and OBSERVE FOR 15 MINUTES after the injection.
- It is not live, so it is safe in immunocompromised patients. It is not recommended in pregnancy simply for lack of data; if a dose is given and pregnancy is discovered, no intervention is needed, just delay remaining doses. Note: the 2025-2026 federal schedule moved to a single-dose HPV recommendation. The 2-dose/3-dose rule above is what nursing curricula and NCLEX still test; use it unless your handout says otherwise.
Under 15 = 2 doses. 15 and up = 3 doses. Sit them down for 15 minutes so they don't hit the floor.
Herpes zoster⭐ HIGH YIELD
Shingrix (recombinant zoster vaccine, RZV) is the current herpes zoster vaccine and it is NOT LIVE. Two doses IM, 2 to 6 months apart, for adults 50 and older AND for immunocompromised adults 19 and older. The old live vaccine (Zostavax) was discontinued in the US in 2020.
- THIS IS THE MOST-TESTED VACCINE SWITCH: Shingrix is recombinant, so it CAN be given to immunocompromised patients. Zostavax was live and could not. If a question says the zoster vaccine is live, it is testing the old vaccine.
- Give it even if the patient has already had shingles, already had chickenpox, or previously received Zostavax. Prior disease does not exempt them.
- It is 90%+ effective and also prevents POSTHERPETIC NEURALGIA, the burning nerve pain that can last months to years after the rash.
- Warn patients about reactogenicity: Shingrix hurts. Expect a very sore arm, fatigue, myalgia, headache, fever, and chills for 1 to 3 days, especially after dose 2. Tell them in advance or they will not come back for the second dose.
- Shingles happens because latent varicella-zoster virus in the dorsal root ganglia reactivates when immunity wanes with age, illness, or immunosuppression.
- Do not confuse the vaccine with treatment. Active shingles is treated with acyclovir or valacyclovir started within 72 hours of rash onset, plus pain control.
Shingrix is NOT live, 2 doses, 50 and up (19+ if immunocompromised), and it will make their arm miserable.
Rhogam
💉 cyclophosphamideHIGH ALERT
Antineoplastic alkylating agent, Nitrogen mustard
What it is for
Hodgkin’s disease, lymphomas, leukemia; cancer of female reproductive tract, breast, multiple myeloma; neuroblastoma; retinoblastoma; Ewing’s sarcoma; nephrotic syndrome
How it works
Alkylates DNA; is responsible for cross-linking DNA strands; activity is not cell-cycle–phase specific
Watch for
CV: Cardiotoxicity (high doses), myocardial fibrosis, hypotension ENDO: SIADH, gonadal suppression GI: Nausea, vomiting, weight loss, anorexia GU: Hemorrhagic cystitis, hematuria HEMA: Thrombocytopenia, leukopenia …
Teaching
- To take adequate fluids (3 L/day, adults) to eliminate product
- That amenorrhea can occur and may last up to 1 yr after therapy but is reversible after stopping treatment
- To report any changes in breathing or coughing
- To avoid foods with citric acid, hot temperature, or rough texture; that skin, fingernails may become darker
🔗 Full card in the drug guide
💉 mesna (What is the indication for administration of this drug?)
Antidote, chemoprotective agent
What it is for
Prevention of ifosfamideinduced hemorrhagic cystitis
How it works
Binds to ifosfumide urotoxic metabolism
🔗 Full card in the drug guide
💉 methotrexateHIGH ALERTBLACK BOX
Antineoplastic-antimetabolite (vesicant), Folic acid antagonist
What it is for
Acute lymphocytic leukemia; in combination for breast, lung, head, neck carcinoma; lymphoma, sarcoma, gestational choriocarcinoma, hydatidiform mole, psoriasis, RA, mycosis fungoides, osteosarcoma Unlabeled: Active Crohn’s disease, SLE, psoriatic arthritis
How it works
Inhibits an enzyme that reduces folic acid, which is needed for nucleic acid synthesis in all cells; specific to S phase of cell cycle; immunosuppressive
Watch for
CNS: Dizziness, seizures, leukoencephalopathy, headache, confusion, encephalopathy, hemiparesis, malaise, fatigue, chills, fever; arachnoiditis (intrathecal) EENT: Blurred vision, optic neuropathy GI: Nausea, vomiting, anorexia, diarrhea, ulcerative stomatitis, hepatotoxicity, cramps, ulcer …
Teaching
- That hair may be lost during treatment; that wig or hairpiece may make patient feel better; that new hair may be different in color, texture (alopecia rare)
- To avoid foods with citric acid, hot temperature, or rough texture if stomatitis is present
- To report stomatitis and any bleeding, white spots, ulcerations in mouth to prescriber; to examine mouth daily; to report symptoms to nurse; to use good oral hygiene
- To drink 10-12 glasses of fluid/day
🔗 Full card in the drug guide
💉 leucovorin (What is the indication for administration of this drug?)
Vitamin, folic acid/methotrexate antagonist antidote, Tetrahydrofolic acid derivative
What it is for
Megaloblastic or macrocytic anemia caused by folic acid deficiency, overdose of folic acid antagonist, methotrexate/pyrimethamine/trimetrexate/trimethoprim toxicity, pneumocystosis, toxoplasmosis
🔗 Full card in the drug guide
💉 doxorubicinHIGH ALERTBLACK BOX
Antineoplastic, antibiotic, Anthracycline glycoside
What it is for
Wilms’ tumor; bladder, breast, lung, ovarian, stomach, thyroid cancer; Hodgkin’s/non-Hodgkin’s disease; acute lymphoblastic leukemia; myeloblastic leukemia; neuroblastomas; soft tissue/bone sarcomas
How it works
Inhibits DNA synthesis primarily; replication is decreased by binding to DNA, which causes strand splitting; active throughout entire cell cycle; a vesicant
Watch for
CV: Increased B/P, sinus tachycardia, PVCs, chest pain, bradycardia, extrasystoles, irreversible cardiomyopathy, acute left ventricular failure GI: Nausea, vomiting, anorexia, mucositis, hepatotoxicity GU: Impotence, sterility, amenorrhea, gynecomastia, hyperuricemia …
Teaching
- To add 2-3 L of fluids unless contraindicated prior to and for 24-48 hr after to decrease possible hemorrhagic cystitis
- To report any complaints, side effects to nurse or prescriber
- That hair may be lost during treatment; that wig or hairpiece might make patient feel better; that new hair might be different in color, texture
- That continuing follow-up and lab work will be needed
🔗 Full card in the drug guide
vincristine – adverse effects, vesicant🚨 DANGER
Vincristine is a vinca alkaloid antineoplastic that blocks mitosis. Two things define it: it is a potent VESICANT (extravasation causes severe tissue necrosis), and it is FATAL IF GIVEN INTRATHECALLY. It is for INTRAVENOUS USE ONLY.
- FATAL IF GIVEN BY THE INTRATHECAL ROUTE - this is a boxed warning and a National Patient Safety Goal. Dispense it in a minibag, never a syringe, and label it 'For IV use only - fatal if given intrathecally.' Never transport it with intrathecal medications.
- DOSE-LIMITING TOXICITY IS PERIPHERAL NEUROPATHY, not bone marrow suppression. Assess for numbness and tingling in fingers and toes, loss of deep tendon reflexes (the earliest sign), foot drop, weakness, jaw pain, and difficulty with buttons or stairs.
- AUTONOMIC neuropathy causes severe CONSTIPATION and paralytic ILEUS. Start a bowel regimen (stool softener plus stimulant laxative) prophylactically, and assess bowel sounds and last bowel movement.
- VESICANT: give through a patent, free-flowing IV with a blood return, preferably a central line. STOP the infusion immediately for pain, burning, swelling, or loss of blood return. Extravasation management is HYALURONIDASE plus WARM compresses (the opposite of the cold compresses used for anthracyclines).
- Vincristine causes relatively LITTLE myelosuppression, which distinguishes it from vinblastine (its cousin, which does suppress marrow). Alopecia and SIADH with hyponatremia also occur.
- Neuropathy may be irreversible if the drug is continued after symptoms appear. Report new sensory or motor changes before the next dose.
Vincristine: IV ONLY, fatal intrathecally. Vin-CRIS-tine hits the CRISS-crossing NERVES; vinBLASTine BLASTS the marrow.
💉 tamoxifenHIGH ALERTBLACK BOX
Antineoplastic, Antiestrogen hormone
What it is for
Advanced breast carcinoma not responsive to other therapy in estrogenreceptor–positive patients (usually postmenopausal), prevention of breast cancer, after breast surgery/radiation for ductal carcinoma in situ Unlabeled: Mastalgia in men …
How it works
Inhibits cell division by binding to cytoplasmic estrogen receptors; resembles normal cell complex but inhibits DNA synthesis and estrogen response of target tissue
Watch for
CNS: Hot flashes, headache, light-headedness, depression, mood changes, stroke CV: Chest pain, stroke, fluid retention, flushing EENT: Blurred vision (high doses) GI: Nausea, vomiting, altered taste GU: Vaginal bleeding, uterine malignancies, altered menses, amenorrhea HEMA: Thrombocytopenia …
Teaching
- About risk of stroke and PE: to seek medical attention immediately in case of blurred vision, headache, weakness on one side of the body (stroke signs); or chest pain, fa …
- To report any complaints, side effects to prescriber; that use may be 5 yr
- To increase fluids to 2 L/day unless contraindicated
- To wear sunscreen, protective clothing, sunglasses
🔗 Full card in the drug guide
Nothing matched that. Try a shorter word.
Where this came from. Drug cards are pulled from your own drug guide, which was fact-checked against FDA labeling. The concept answers were written for this guide from your course textbook,
Pharmacology (WTCS, 2e), so they should match your lectures. Check anything that contradicts what your instructor said — they write the exam.