clavulanate
clavulanate
[klav´u-lah-nāt]amoxicillin/clavulanate
(a-mox-i-sill-in/klav-yoo-lan -ate) amoxicillinclavulanate,Augmentin
(trade name),Augmentin ES
(trade name),Augmentin XR
(trade name),Clavulin
(trade name)Classification
Therapeutic: anti infectivesPharmacologic: aminopenicillins beta lactamase inhibitors
Indications
- Skin and skin structure infections,
- Otitis media,
- Sinusitis,
- Respiratory tract infections,
- Genitourinary tract infections.
Action
Therapeutic effects
- Streptococci,
- Pneumococci,
- Enterococci,
- Haemophilus influenzae,
- Escherichia coli,
- Proteus mirabilis,
- Neisseria meningitidis,
- N. gonorrhoeae,
- Staphylococcus aureus,
- Klebsiella pneumoniae,
- Shigella,
- Salmonella,
- Moraxella catarrhalis.
Pharmacokinetics
Time/action profile (peak blood levels)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| PO | 30 min | 1–2 hr | 8–12 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- seizures (high doses) (life-threatening)
Gastrointestinal
- pseudomembranous colitis (life-threatening)
- diarrhea (most frequent)
- hepatic dysfunction
- nausea
- vomiting
Genitourinary
- vaginal candidiasis
Dermatologic
- rash (most frequent)
- urticaria
Hematologic
- blood dyscrasias
Miscellaneous
- allergic reactions including anaphylaxis and serum sickness (life-threatening)
- superinfection
Interactions
Drug-Drug interaction
Probenecid ↓ renal excretion and ↑ blood levels of amoxicillin—therapy may be combined for this purpose.May ↑ the effect of warfarin.Concurrent allopurinol therapy ↑ risk of rash.May ↓ the effectiveness of hormonal contraceptives.Clavulanate absorption is ↓ by a high fat meal.Route/Dosage
Most Infections (Dosing based on amoxicillin component)Renal Impairment
Oral (Adults) CCr 10–30 mL/min—250–500 mg q 12 hr (do not use 875 mg tablet); CCr <10 mL/min—250–500 mg q 24 hr.Availability (generic available)
Nursing implications
Nursing assessment
- Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
- Obtain a history before initiating therapy to determine previous use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.
- Observe for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Notify health care professional immediately if these occur.
- Obtain specimens for culture and sensitivity prior to therapy. First dose may be given before receiving results.
- Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy.
- Lab Test Considerations: May cause ↑ serum alkaline phosphatase, LDH, AST, and ALT concentrations. Elderly men and patients receiving prolonged treatment are at ↑ risk for hepatic dysfunction.
- May cause false-positive direct Coombs’ test result.
Potential Nursing Diagnoses
Risk for infection (Indications, Side Effects)Noncompliance (Patient/Family Teaching)
Implementation
- Oral: Administer around the clock. Administer at the start of a meal to enhance absorption and to decrease GI side effects. Do not administer with high fat meals; clavulanate absorption is decreased. XR tablet is scored and can be broken for ease of administration. Capsule contents may be emptied and swallowed with liquids. Chewable tablets should be crushed or chewed before swallowing with liquids. Shake oral suspension before administering. Refrigerated reconstituted suspension should be discarded after 10 days.
- Two 250-mg tablets are not bioequivalent to one 500-mg tablet; 250-mg tablets and 250-mg chewable tablets are also not interchangeable. Two 500-mg tablets are not interchangeable with one 1000-mg XR tablet; amounts of clavulanic acid and durations of action are different. Augmentin ES 600 (600 mg/5 mL) does not contain the same amount of clavulanic acid as any of the other Augmentin suspensions. Suspensions are not interchangeable.
- Pediatric: Do not administer 250-mg chewable tablets to children <40 kg due to clavulanate content. Children <3 mo should receive the 125-mg/5 mL oral solution.
Patient/Family Teaching
- Instruct patients to take medication around the clock and to finish the drug completely as directed, even if feeling better. Advise patients that sharing of this medication may be dangerous.
- Pediatric: Teach parents or caregivers to calculate and measure doses accurately. Reinforce importance of using measuring device supplied by pharmacy or with product, not household items.
- Advise patient to report the signs of superinfection (furry overgrowth on the tongue, vaginal itching or discharge, loose or foul-smelling stools) and allergy.
- Instruct patient to notify health care professional immediately if diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without consulting health care professionals.
- Instruct the patient to notify health care professional if symptoms do not improve or if nausea or diarrhea persists when drug is administered with food.
- Instruct female patients taking oral contraceptives to use an alternate or additional method of contraception during therapy and until next menstrual period; may decrease effectiveness of hormonal contraceptives.
Evaluation/Desired Outcomes
- Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection.
ticarcillin/clavulanate
(tye-kar-sil-in/klav-yoo-la-nate) ticarcillinclavulanate,Timentin
(trade name)Classification
Therapeutic: anti infectivesPharmacologic: extended spectrum penicillins
Indications
- Skin and skin structure infections,
- Bone and joint infections,
- Septicemia,
- Lower respiratory tract infections,
- Intra-abdominal, gynecologic, and urinary tract infections.
Action
Therapeutic effects
- Pseudomonas aeruginosa,
- Escherichia coli,
- Citrobacter,
- Enterobacter,
- Haemophilus influenzae,
- Klebsiella,
- Serratia marcescens.
Pharmacokinetics
Time/action profile (blood levels)
| ROUTE | ONSET | PEAK | DURATION |
|---|---|---|---|
| IV | rapid | end of infusion | 4–6 hr |
Contraindications/Precautions
Adverse Reactions/Side Effects
Central nervous system
- seizures (high doses) (life-threatening)
- confusion
- lethargy
Cardiovascular
- chf (life-threatening)
- arrhythmias
Gastrointestinal
- pseudomembranous colitis (life-threatening)
- diarrhea (most frequent)
- nausea
Genitourinary
- hematuria (children only)
- hemorrhagic cystitis
Dermatologic
- rash (most frequent)
- urticaria
Fluid and Electrolyte
- hypokalemia (most frequent)
- hypernatremia
Hematologic
- bleeding
- blood dyscrasias
- ↑ bleeding time
Local
- phlebitis (most frequent)
Metabolic
- metabolic alkalosis
Miscellaneous
- hypersensitivity reactions including anaphylaxis (life-threatening)
- superinfection
Interactions
Drug-Drug interaction
Probenecid ↓ renal excretion and ↑ blood levels.Route/Dosage
Ticarcillin/clavulanate contains 4.51 mEq sodium/g and 0.15 mEq potassium/g of ticarcillin/clavulanate. 3 g ticarcillin plus 100 mg clavulanate labeled as 3.1 g combined potency. Dosing is based on ticarcillin component.Renal Impairment
Intravenous (Adults) Give loading dose of 3 g ticarcillin × 1 dose, followed by maintenance dose based on CCr. CCr 30–60 mL/min—2 g ticarcillin q 4 hr; 10–30 mL/min—2 g ticarcillin q 8 hr; CCr <10 mL/min—2 g ticarcillin q 12 hr; CCr <10mL/min with hepatic dysfunction—2 g ticarcillin q 24 hr; Peritoneal dialysis—3 g ticarcillin q 12 hr; Hemodialysis—2 g ticarcillin q 12 hr supplemented with 3 g ticarcillin after each dialysis session.Availability
Nursing implications
Nursing assessment
- Assess patient for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
- Obtain a history before initiating therapy to determine use of and reactions to penicillins or cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response.
- Obtain specimens for culture and sensitivity before initiating therapy. First dose may be given before receiving results.
- Observe patient for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing). Discontinue drug and notify physician immediately if these problems occur. Keep epinephrine, an antihistamine, and resuscitation equipment close by in case of anaphylactic reaction.
- Monitor bowel function. Diarrhea, abdominal cramping, fever, and bloody stools should be reported to health care professional promptly as a sign of pseudomembranous colitis. May begin up to several weeks following cessation of therapy.
- Lab Test Considerations: Evaluate renal and hepatic function, CBC, serum potassium, and bleeding times prior to and routinely throughout therapy.
- May cause false-positive urine protein testing and increased BUN, creatinine, AST, ALT, serum bilirubin, alkaline phosphatase, LDH, and uric acid levels. May also cause ↑ bleeding time.
- May cause hypernatremia and hypokalemia with high doses.
Potential Nursing Diagnoses
Risk for infection (Indications, Side Effects)Implementation
Intravenous Administration
- Intravenous: Change IV sites every 48 hr to prevent phlebitis.
- Intermittent Infusion: Add 13 mL of sterile water for injection or 0.9% NaCl for injection to each 3.1-g vial, to provide a concentration of ticarcillin 200 mg/mL and clavulanic acid 6.7 mg/mL. Diluent: Further dilute in 0.9% NaCl, D5W, or LR. Reconstituted vials stable for 24 hr at room temperature or 72 hr if refrigerated. Infusion is stable for 24 hr at room temperature. If refrigerated, infusion is stable for 3 days (diluted in D5W) or 7 days (if diluted in 0.9% NaCl or LR). Concentration: 10–100 mg/mL.
- Rate: Infuse over 30 min.
- Y-Site Compatibility: alfentanyl, allopurinol, amifostine, amikacin, aminocaproic acid, aminophylline, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid, atropine, aztreonam, benztropine, bivalirudin, bleomycin, bumetanide, buprenorphine, butorphanol, calcium chloride, calcium gluconate, carboplastin, carmustine, cefazolin, cefepime, cefotaxime, cefotetan, cefoxitin, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, cisplatin, clindamycin, cyclophosphamide, cyclosporine, cytarabine, dactinomycin, daptomycin, dexamethasone sodium phosphate, dexmedetomidine, digoxin, diltiazem, diphenhydramine, docetaxel, dopamine, doxorubicin hydrochloride, doxorubicin liposome, doxycycline, enalaprilat, ephedrine, epinephrine, epoetin alfa, eptifibatide, esmolol, etoposide phosphate, famotidine, fenoldopam, fentanyl, filgrastim, fluconazole, fludarabine, fluorouracil, folic acid, furosemide, gemcitabine, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone sodium succinate, hydromorphone, ifosfamide, imipenem/cilastatin, indomethacin, insulin, irinotecan, isoproterenol, ketorolac, labetalol, levofloxacin, lidocaine, linezolid, lorazepam, magnesium sulfate, mannitil, mechlorethamine, melphalan, meperidine, methotrexate, methyldopate, methylprednisolone sodium succinate, metoclopramide, metoprolol, metronidazole, milrinone, morphine, multivitamins, nafcillin, nalbuphine, naloxone, nitroglycerin, nitroprusside, norepinephrine, octreotide, ondansetron, oxacillin, oxaliplatin, oxytocin, paclitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, pemetrexed, penicillin G, perphenazine, phenobarbital, phentolamine, phenylephrine, phytonadione, potassium acetate, potassium chloride, procainamide, prochlorperazine, propofol, propranolol, pyridoxime, ranitidine, remifentanil, rituximab, rocuronium, sargramostim, sodium acetate, sodium bicarbonate, streptokinase, succinylcholine, sufentanil, tacrolimus, teniposide, theophylline, thiamine, thiotepa, tigecycline, tirofiban, tobramycin, tolazoline, trastuzumab, trimetaphan, vasopressin, vecuronium, verapamil, vincristine, vinorelbine, voriconazole, zoledronic acid
- Y-Site Incompatibility: acyclovir, alemtuzumab, amphotericin B cholesteryl, azithromycin, caspofungin, chlorpromazine, dantrolene, diazepam, diazoxide, dobutamine, epirubicin, erythromycin, ganciclovir, haloperidol, hydroxyzine, idarubicin, mitoxantrone, mycophenolate, papaverine, pentamidine, pentazocine, phenytoin, promethazine, protamine, quinupristin/dalfopristin, tranexamic acid, trimethoprim/sulfamethoxazole.If aminoglycosides and penicillins must be administered concurrently, administer in separate sites at least 1 hr apart.
Patient/Family Teaching
- Advise patient to report signs of superinfection (black, furry overgrowth on the tongue; vaginal itching or discharge; loose or foul-smelling stools) and allergy.
- Caution patient to notify health care professional if fever and diarrhea occur, especially if stool contains blood, pus, or mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to several weeks after discontinuation of medication.
Evaluation/Desired Outcomes
- Resolution of the signs and symptoms of infection. Length of time for complete resolution depends on the organism and site of infection.