By C. Rozhov. Simpson College, Redding California.
Te value rose to about 150 mg/ dL at one hour and fell back to normal by one-and-a-half hours generic modafinil 200mg line. At one hour buy generic modafinil 100 mg on-line, she showed a positive test for sugar in the urine, which stayed positive for another hour and then became negative. Usually, glucose spills into the urine when the blood glucose is greater than 180mg/dL. She thus had renal glycosuria, a benign condition, not diabetes mellitus. Biased by the strong family history of diabetes mellitus, the physician had made an erroneous diagnosis of diabetes based solely on the positive urine sugar. How she had tolerated the insulin for two years without more obvi- ous brain damage is still a puzzle. Te false diagnosis of diabetes in Sweet Ting had triggered several unfortunate behaviors in her family. First, her grandmother, still grieving the death of her daughter and now worried about her granddaughter, made a firm resolve to see to it that her grand- daughter took better care of herself. To make sure Sweet Ting followed the diabetic diet and took her insulin, the grandmother had insisted on taking the girl to the local city hospital clinic to see all the amputated diabetic patients who sat around the waiting room in wheelchairs. She told Sweet Ting that she would end up like the people she saw if she did not follow the diet and take the insulin. Te second and even more serious consequence of the diagno- sis was the nearly complete social withdrawal that her brothers and 58 Symptoms of Unknown Origin sisters forced on Sweet Ting after their mother died in her sleep. Now they were afraid to sleep in the same room with their sister, for fear she too would die in her sleep. Te girl stayed awake late into the nights wondering if she would die and when it might happen.
Thus buy modafinil 100mg, they may be useful in meningeal infections caused by Once absorbed purchase modafinil 200mg, cephalosporins are widely distributed into common pathogens, including H. Many cephalosporins do not reach drugs are active against Pseudomonas organisms, drug-resis- therapeutic levels in CSF; exceptions are cefuroxime, a second- tant strains may emerge when a cephalosporin is used alone for generation drug, and the third-generation agents. Most Overall, cephalosporins gain gram-negative activity and cephalosporins are excreted through the kidneys. Exceptions lose gram-positive activity as they move from the first to 518 SECTION 6 DRUGS USED TO TREAT INFECTIONS the third generation. The second- and third-generation drugs CARBAPENEMS are more active against gram-negative organisms because they are more resistant to the beta-lactamase enzymes Carbapenems are broad-spectrum, bactericidal, beta-lactam (cephalosporinases) produced by some bacteria to inacti- antimicrobials. Imipenem/cilastatin (Primaxin) is given parenterally and Fourth-Generation Cephalosporins distributed in most body fluids. Imipenem is rapidly broken down by an enzyme (dehydropeptidase) in renal tubules and Fourth-generation cephalosporins have a greater spectrum of therefore reaches only low concentrations in urine. Cilastatin antimicrobial activity and greater stability against breakdown was synthesized to inhibit the enzyme and reduce potential by beta-lactamase enzymes compared with third-generation renal toxicity of the antibacterial agent. Cefepime is the first fourth-generation cephalosporin indicate the amount of imipenem; the solution contains an to be developed. It is active against both gram-positive and equivalent amount of cilastatin. With gram-positive organisms, it The drug is effective in infections caused by a wide range is active against streptococci and staphylococci (except for of bacteria, including penicillinase-producing staphylococci, methicillin-resistant staphylococci). Its main in- similar to that of ceftazidime and its activity against Entero- dication for use is treatment of infections caused by organisms bacteriaceae is greater than that of third-generation ceph- resistant to other drugs. Moreover, cefepime retains activity against strains of other beta-lactam antibiotics, including the risk of cross- of Enterobacteriaceae and P. Seizures are more likely in clients with a seizure disorder or Indications for Use when recommended doses are exceeded; however, they have occurred in other clients as well.
These in- used to treat anemia if the client has a low plasma level clude conventional and lipid formulations of amphotericin B order modafinil 100mg without a prescription, of erythropoietin order modafinil 100 mg. As in other pop- ulations receiving these drugs, children should receive the lowest effective dosage and be monitored closely for adverse Effects of Antifungals on Other Drugs effects. The safety and efficacy of caspofungin in children have not been established. Amphotericin B increases effects of cyclosporine (nephro- toxicity), digoxin (risk of hypokalemia and resultant cardiac dysrhythmias), nephrotoxic drugs (eg, aminoglycoside anti- Use in Older Adults biotics), skeletal muscle relaxants (amphotericin B-induced hypokalemia may enhance muscle relaxation), and thiazide Specific guidelines for the use of antifungal drugs have not and loop diuretics (risk of hypokalemia). Azoles inhibit the metabolism of many drugs (by inhibit- Virtually all adults receiving IV amphotericin B experi- ing cytochrome P450 drug-metabolizing enzymes in the liver ence adverse effects. With the impaired renal and cardio- and small intestine, especially 3A4 enzymes) and therefore in- vascular functions that usually accompany aging, older adults crease their effects and risks of toxicity. These drugs include are especially vulnerable to serious adverse effects. They benzodiazepines (alprazolam, midazolam, triazolam), cal- must be monitored closely to reduce the incidence and sever- cium channel blockers (felodipine, nifedipine), cyclosporine, ity of nephrotoxicity, hypokalemia, and other adverse drug phenytoin, statin cholesterol-lowering drugs (lovastatin, sim- reactions. Lipid formulations are less nephrotoxic than the vastatin), sulfonylureas, tacrolimus, theophylline, warfarin, conventional deoxycholate formulation and may be preferred vincristine, and zidovudine. Azole drugs should probably be stopped if CHAPTER 40 ANTIFUNGAL DRUGS 609 hypertension, edema, or hypokalemia occur. Plasma drug levels should be monitored and conazole has been associated with heart failure, a common dosage should be adjusted to maintain blood levels below condition in older adults. Terbinafine clearance is reduced by 50% in clients with significant renal impairment (CrCl of 50 mL/ minute or less). Use in Clients With Cancer Clients with cancer are at high risk for development of seri- Use in Hepatic Impairment ous, systemic fungal infections. In clients receiving cytotoxic anticancer drugs, antifungal therapy is often used to prevent Although the main concern with amphotericin B is nephro- or treat infections caused by Candida and Aspergillus organ- toxicity, it is recommended that liver function tests be moni- isms. For prophylaxis, topical, oral, or IV agents are given be- tored during use. Caspofungin dosage must be reduced with fore and during periods of drug-induced neutropenia, often to moderate hepatic impairment; the drug has not been studied prevent recurrence of infection that occurred during previous in clients with severe hepatic impairment.
Culture and susceptibility studies are needed before Tetracyclines should not be used in children younger than tetracycline therapy is started because many strains of 8 years of age because of their effects on teeth and bones generic modafinil 100mg overnight delivery. In organisms are either resistant or vary greatly in drug sus- teeth purchase modafinil 200 mg without prescription, the drugs interfere with enamel development and may ceptibility. Cross-sensitivity and cross-resistance are cause a permanent yellow, gray, or brown discoloration. The oral route of administration is usually effective and tissue and may interfere with bone growth. Intravenous (IV) therapy is used when oral Systemic sulfonamides are contraindicated during late administration is contraindicated or for initial treat- pregnancy, lactation, and in children younger than 2 months. Tetracyclines decompose with age, exposure to light, tal transfer, in breast milk, or by direct administration, the and extreme heat and humidity. Because the break- drug displaces bilirubin from binding sites on albumin. As a down products may be toxic, it is important to store result, bilirubin may accumulate in the bloodstream (hyper- bilirubinemia) and central nervous system (kernicterus) and these drugs correctly. Few data are available regarding the effects of long-term or recurrent use of sulfamethoxazole in chil- Sulfonamides and Urinary Antiseptics dren younger than 6 years of age with chronic renal disease. With systemically absorbed sulfonamides, an initial prim (Bactrim, Septra), although trimethoprim has not been loading dose may be given to produce therapeutic blood established as safe and effective in children younger than 12 years of age. Some clinicians recommend that asymptomatic bacteriuria be treated in children younger than 5 years of age to decrease How Can You Avoid This Medication Error? Trimethoprim-sulfamethoxazole (Bactrim) DS bid is ordered for a client after urologic surgery. He takes no medications and reports an allergy to eggs, nuts, sulfa, and morphine. The unit dose provided Use in Older Adults from the pharmacy is a tablet containing 160 mg of trimethoprim and 800 mg of sulfamethoxazole. A major concern with the use of tetracyclines and sulfon- amides in older adults is renal impairment, which commonly 544 SECTION 6 DRUGS USED TO TREAT INFECTIONS CLIENT TEACHING GUIDELINES Oral Tetracyclines General Considerations Self-Administration ✔ Because tetracyclines inhibit rather than kill bacteria, ✔ Take most tetracyclines on an empty stomach, at least they must be taken correctly to achieve desired effects. Doxycycline and ✔ These drugs increase sensitivity to sunlight and risks minocycline may be taken with food (except dairy prod- of sunburn.
