CHEMOTHERAPY

› Chemotherapy is the use of antineoplastic

drugs to promote tumor cell destruction by
interfering with cellular function and
reproduction

› It includes the use of various chemotherapeutic

agents and hormones
 PRINCIPLES
OF
CHEMOTHERAPY
› The intent of chemotherapy is to destroy as
many tumor cells as possible with minimal
effect on healthy cells

› Cancer cells depend on the same mechanism

for cell division that are found in normal cells

› Damage to those mechanisms leads to cell

death.
› Chemotherapy is utilized in different clinical settings:
As induction chemotherapy for advanced disease
Primary treatment for patients who present with advanced
cancer for which no alternative treatment exists
As an adjunct to local methods of treatment
Adjuvant chemotherapy is the use of systemic treatment
after the primary tumor has been controlled by surgery
and/or radiation therapy
To palliate symptoms of metastatic disease and/or
prolong survival
THERAPEUTIC
STRATEGIES
 ADJUVANT THERAPY
› Given to patients who have no evidence of residual
disease but who are at high risk for relapse

› The justifications for adjuvant chemotherapy are the high

recurrence rate after surgery for apparently localized
tumors, the inability to identify cured patients at the time
of surgery, and the failure of therapy to cure these patients
after recurrence of disease.
 NEOADJUVANT THERAPY
› Preoperative chemotherapy

› Administered prior to surgery in an attempt to downstage

the primary tumor so that less invasive surgery can be
performed

› The goal of therapy is to decrease the amount of tissue

that needs to be removed as well as to attempt to
maximise cure potential .
 HIGH DOSE/INTENSIVE THERAPY
› Administration of high doses of
chemotherapy, usually in association with
growth factor support or before bone marrow
transplant/ stem cell rescue.
 DOSE INTENSIFICATION

› Has received increasing emphasis in recent years as

a strategy for overcoming resistance to
chemotherapy

› Malignant cells may be resistant to certain drugs

from the start of therapy (natural resistance) or
become resistant after therapy has begun (acquired
resistance)
 DOSE INTENSIFICATION
› It suggests that chemotherapy should be given in the
highest tolerated dose over the briefest interval, with the
growth factor support.

› This has been tested in breast cancer, and results show

that it is more effective than standard treatment schedules
and is equally tolerated.

› It continues to be tested with other malignancies with

unknown results.
 ROUTES OF ADMINISTRATION
› Oral – capsule, tablet or liquid

› I.V. – push (bolus) or infusion over a specified time period

› Intramuscular

› Intrathecal/intraventricular – given by injection via an ommaya

reservoir or by lumbar puncture

› Intra-arterial

› Intracavitay – such as peritoneal cavity

› Intravesical – into uterus or bladder

› Topical
 Details To Be Dealt: -
› Composition
› Action
› Dosage
› Route
› Indications
› Contraindications
› Drug Interactions
› Side Effects
› Adverse Effects
› Toxicity Role Of Nurse
PENICILLIN
 INTRODUCTION
› Sir Alexander Fleming discovered penicillin in 1928 from
Penicillium notatum.

› In 1941 penicillin was available for therapeutic use.

› Penicillins are one of the most important groups of

antibiotics.

› Penicillin is now obtained from the fungus Penicillium

chrysogenum for therapeutic use.
 CLASSIFICATION
1. Natural Penicillins

The natural penicillins are obtained from fungi P.notatm and

P.Chrysogenum. The most common of natural penicillins is
crystalline penicillin also known as Benzyl penicillin G. It is
administered in the form of injection. It has a very short duration
of action that lasts for 4 to 6 hours. The other examples is of
Procaine penicillin G. it has long duration of action for 12 to 24
hours so it can be administered once or twice a day.
› 2. Semisynthetic Penicillins
The natural penicillins are got destroyed by the acidic
secretions of stomach. They are less effective when given
orally.
The acidic secretions of stomach do not destroy the semi
synthetic penicillins.
The examples are of :
i. Phenoxy methyl penicillin
ii. Phenoxy ethyl penicillin
iii. Phenoxy propyl penicillin.
3. Synthetic Penicillins

The enzyme known as Penicillinase destroys the natural penicillins and

semi synthetic penicillins. The Penicillinase is elaborated by certain
bacteria and many strains of staphylococci. The Penicillinase inactivates
the action of penicillins and produce resistance to antibiotic. The synthetic
penicillins have been synthesized to make more effective. These are not
destroyed by the Penicillinase. Examples of Synthetic penicillins are

1. Methicillin sodium

2. Cloxacillin sodium

3. Oxacillin sodium

4. Nafcillin sodium
4. Broad spectrum penicillin

The broad – spectrum penicillins were synthesized as the synthetic

penicillins are effective only for gram positive microorganisms. They are
not effective for gram negative organisms. Therefore, broad spectrum
penicillins have been synthesized which are effective against gram
positive and gram negative microorganism.

Examples are:

1. Ampicillin

2. Hetacillin

3. Carbenicillin
 INDICATIONS OR USES OF PENICILLINS
› The penicillins are drug of choice for pneumonia caused
by streptococcus.
› STDs like syphilis and gonorrhoea.
› Diphtheria and Tetanus
› Meningococcal meningitis infections
 HARMFUL EFFECTS OF PENICILLINS

› Nephrotoxic

› Hypersensitivity

› Anaphylactic Shock

› Abcess
 Role Of Nurse/Nursing Responsibilities
› Nurses to assess haematuria, oliguria since penicillins are
nephrotoxic.
› Blood studies WBC, RBC, Hb, bleeding time, clotting time, liver
studies, SGOT, SGPT
› Bowel pattern during and before treatment.
› Skin eruption after administration of penicillin and one week after
discontinuing of penicillin therapy
› The nurse to notify the allergic reaction before starting of
treatment, reaction of each drugs administered.
› Oral penicillin to be administered empty stomach for best results.
Information and teaching to patient and his/her family memebers,
relatives must be given for the need of treatment therapy and to
complete course of treatment for cure.
 SPECIAL PRECAUTIONS

› Intradermal test or scratch test may be performed

first before administration of penicillin.
 BENZYL PENICILLIN G

› It is obtained by growing strains of penicillium

notatum in suitable culture media. It is also known as
crystalline penicillin G.

› It is available as sodium benzyl penicillin or Potassium

benzyl penicillin.
 MECHANISM OF ACTION

› The penicillin are bactericidal antibiotics. They kill the

bacteria by preventing their cell wall formation.

› Penicillin do not allow formation of cell wall and the

bacteria dies.

› These are helpful in preventing, multiplication of bacteria.

 USES
› It is used in the treatment of pneumonia, pharyngitis, otitis media,
meningitis, rat bite fever, osteomylitis.

DOSAGE:

0.5-5 million units IM or IV 6 Hourly

CONTRAINDICATION:

Avoid use of drug if there is history of itching, fever and sensitivity.

 AMPICILLIN

› It is a broad spectrum antibiotic.

› It is active against a number of gram negative microorganisms and

gram positive microorganisms.

› Ampicillin is stable in acidic medium.

› It is well absorbed when administered orally.

Ampicillin is white, crystalline, odourless powder with bitter taste.

It is soluble in water.
 MECHANISMS OF ACTION

› It interferes with cell wall replication of microorganisms. The cell

wall osmotically becomes unstable, swells and bursts. The
microorganisms dies.

USES:

It is used in various infections of respiratory system, genito urinary

infections skin & soft tissue and various other systemic infections.

DOSE: 250-500 mg, 6 of hourly or as required

ROUTE: It is administered by parental route IV or IM.

SIDE EFFECTS: Diarrhoea, gastro intestinal upset, skin
rash, nausea, vomiting, anxiety and depression

CONTRAINDICATION: Hypersensitivity to penicillin.

PRECAUTIONS:

To administer after sensitivity test.

 CEPHALOSPORINS

They are the antibiotics, which bind the bacterial enzyme,

which is necessary for the formation of bacterial cell wall.
The cell wall is not formed and the bacteria dies. The
cephalosporin are bactericidal.
 CLASIFICATION
› They can be classified as under: -
1. FIRST GENERATION CEPHALOSPORINS
The first generation injectales cephalosporin's are useful against
staphylococcal infections. The following drugs are included
under this classification:
i. Cephazolin sodium
ii. Cephradine
iii. Cephalridine
iv. cephalothin
2. Second Generation Cephalosporin's
The second generation injectables cephalosporin's act against the
staphylococcus and some of the gram negative organisms.

This group include:

i. Cefuroxime

ii. Cefamandole

iii. Cefoxitin
3. Third Generation Cephalosporins
These injectables cephalosporin's are effective against gram negative
organisms. They have no action against staphylococci. This group
includes the following drugs.

i. Cefotaxime

ii. Cefsoludin

iii. Cefdinir

iv. Ceftazidime

v. ceftrioxone
4. Fourth Generation Cephalosporins
The fourth generation cephalosporin's act as bactericidal. These
drugs act at plasma binding proteins by binding and disrupt the
bacterial cell wall, the bacteria are killed. They exert antimicrobial
effect to bacteria and have greater penetration in the bacterial cell
wall to kill bacteria. It includes:

i. Inj Cefpirome

ii. Cefepime
Oral Cephalosporin's
The oral cephalosporin's have same action as the injectables of first
generation cephalosporin's. The drugs included under this group :

i. Cefaclor

ii. Ceftibuten

iii. Cefadroxil
 CEFAZOLIN (CEFZOLIN SODIUM)
It is a broad spectrum bactericidal semi synthetic cephalosporin.

The injection of Cefazolin Sodium is administered IM or IV.

Indication: it is very effective in upper and lower respiratory tract

infections, lung abscess, post operative wounds, urinary tract
infections, otitis media, neonatal infections,

It is effective against gram positive and gram negative

microorganisms.
CONTRAINDICATION:

Patient with known allergy to cephalosporin group of medicine.

Infants under age of one month should not be administered

cephalosporin.

Person with impaired renal function should not b administered

cephalosporin.

If individual is having history of hypersensitivity to penicillin's, do

not administer cephalosporin.
MECHANISM OF ACTION: Cefazolin inhibits bacterial cell wall
synthesis by rendering cell wall osmotically unstable and causes the
germ cell death.

Dosage: 500mg to 1 gm IV or IM 6 to 8 hourly

Side effects: Gastro intestinal upsets, allergic reaction transient rise

of SGPT. Blood urea nitrogen, SGOT, convulsions.

Treatment of Anaphylaxis: Epinephrine (Injection Adrenaline )

Antihistamines, Resuscitation
 CEFADROXIL

It is a cephalosporin of first generation. It is used as broad spectrum antibiotic. It

is effective against gram negative as well as gram positive microorganisms.

MECHANISM OF ACTION: It acts on the cell wall of bacteria. The cell wall
renders osmotically unstable. The cell wall breaks leading to death of
microorganisms.

Indication: It is used in the respiratory tract infections. ENT infections, urinary

tract infections, gynaecological and obstetrics infections. It is effective when
penicillin is not suitable to the individual.

It is also used in dental infections, bones and soft tissues infections.

DOSAGE: Adult 1-2 gm daily BD

Contraindication: Hypersensitivity, pregnancy, lactation,

renal disease

Side Effects: Headache, weakness, fever, chills,

abdominal pains, nausea, vomiting, anorexia, diarrhoea
 CEPHALEXIN
› It is a first generation cephalosporin. It acts as bactericidal. It is
effective against gram negative and gram positive
microorganisms.

MECHANISMS OF ACTION: It inhibits bacterial cell wall

synthesis, it renders cell wall of germs unstable osmotically and
leads to death of microorganisms.

DOSE: 1 – 4 gm daily in equal divided doses 6 hourly.

INDICATION: It is effective in respiratory tract infections, ear nose
& throat infections, urinary tract infections, gynaecological and
obstetric infection. It is effective in skin soft tissue, bone and dental
infections.

CONTRAINDICATION: Hypersensitivity to cephalosporin.

Side Effects: Headache, fever, chills, dizziness, nausea, vomiting,

diarrhoea, anorexia, proteinuria, increase BUN, abdominal pain.

Drug Interaction: The drugs like furosemide, piretanide if

administered with cephalaxin may effect renal function adversely .
 CEFTRIAXONE

It is a third generation cephalosporin antibiotic.

It inhibits synthesis of bacterial cell wall which
makes the bacterial cell wall osmotically
unstable and leads to cell death.
DOSE: Adult 1 to 2 gms IV daily

INDICATIONS: Septicaemia, meningitis, urinary tract infections, postoperative

surgical infections, bone joint infections.

MECHANISMS OF ACTION: It makes or inhibits bacterial cell wall synthesis

and renders the bacteria cell wall osmotically unstable causing death of
microorganisms.

CONTRAINDICATIONS: Hypersensitivity to cephalosporin, use with caution

during pregnancy and lactation

SIDE EFFECTS: Headache, fever, chills, nausea, vomiting, anorexia,

nephrotoxicity, increased BUN.

DRUG INTERACTIONS: There is increased toxicity with aminoglycosides,

furosemide.
 Amino glycosides

› They are composed of amino sugars in glycoside linkage.

These antibiotics interfere with the synthesis of bacterial cell
proteins by binding ribosome, resulting inaccurate peptides
sequence is formed in protein chain, causing death of bacteria.
The amino glycosides antibiotics are used for the infections
caused by gram negative microorganisms.
Properties
› All the aminoglycosides are bactericidal drugs and are mpre active
in alkaline media.

› All the antibiotics are neophrotoxic and ototoxic.

› The salts of aminoglycosides are used as suphates such as

gentamycin sulphate, amikacin sulphate… and the suplhates are
soluble in water, the solution remains stable for months.

› The antibiotics hve narrow margin of safety on prolong use they

cause toxicity.
Use precautions
› These drug do not mix with any other drug in the same
syringe or infusion bottle.

› The muscle relaxant drugs should be used with caution

and with care to a patient who is administered
aminoglycoside drug.

› Do not use aminoglycoside drugs during pregnancy

because there is a risk of foetal ototoxicity.
GENTAMYCIN
It is a broad spectrum aminoglycoside antibiotic. It is an
antimicrobial substance produced by micromonospora purpurea. It
is a white cream coloured powder soluble in water. It is poorly
absorbed when administered orally. It is rapidly absorbed when
administered through injection route as IM or IV injection.

Mechanism of action: it interferes with protein synthesis in bacterial

cell by binding to the ribosomal sub unit cause misreading of
genetic code. The inaccurate peptide sequence form in protein
chain, cause death if bacteria.
Dose: 3 – 5 mg/kg body weight OM or IV daily in 3 divided doses 8
hourly
Indication: It is effective in septicaemia, meningitis caused by gram
negative bacilli, UTI, lung abscess
Contraindication: Severe renal function impairment, pregnancy and
neonates, hypersensitivity.
Side effects: Headache, rashes, joint pains, irreversible ototoxicity
Drug interactions: When combined with cephalosporin,
hydrocortisones, there may be increased of ototoxicity, kidney
failure.
Nursing Care:
calculation of dose is based on body weight, so actual body weight of
patient should be measured accurately before treatment.
Intake and output ratio, to report if there is change in urine output.
› Change in pulse rate, hypotension should be watched.

› To observe fever, malaise, itching

› Injection sites for swelling, redness, abscess be examined. Warm

compresses should be used at site.

AMIKACIN (AMIKACIN SULPHATE)
It is a semi synthetic aminoglycoside. It is effective gram negative
bacilli, including those which are resistant to gentamycin and other
aaminoglycosides. It is available as injections. It is administered as
intravenous or IM route.
Mechanism of action: It interferes with protein synthesis in gram cell
by binding to ribosomal sub unit. It cause the misreading of genetic
code.
Dose; 15 mg/kg body weight not to exceed 1.5gm/day in equal
divided doses every 8 to 12 hours. IM/IV
Indication: It is used in various infections like bacteraemias,
septicemia, respiratory tract infections, meningitis, CNS infections,
bones and joint infections, intraabdominal infections, burns, post
operative infections.
Contraindictaions: known hypersensitivity to aminoglycosides,
during pregnancy and lactation.
Side effects: Nephrotoxicity, skin rash, ototoxicity, tremors,
headache, nausea, vomiting.
Drug interaction: there is increased neurotoxicity, ototoxicity,
nephrotoxocity if other drug like cephalosporins, furosemide,
mannitol, vancomycin are administered with amikacin
sulphate.
 Macrolides And Broad Spectrum Antibiotics

Macrolides are antibiotics which in their structure contain a large

lactone ring. It includes the following drugs erythromycin,
azithromycin, roxithromycin, clindamycin, vancomycin.

The presence of a large lactone ring with sugar molecule gives name
macrolide.

Antibiotics are the drugs used either to kill the disease causing
microorganisms or to prevent their further growth.
ERYTHROMYCIN
It is a white or yellow crystals or powder, bitter in taste odourless. It is
less soluble in hot water.

It is soluble in water at 20ºC in 1000 parts of water.

It is obtained from fungi streptomyces erythreus. It acts on bacteria by

inhibiting protein synthesis by bacterial ribosomes. The disease causing
bacteria dies for lack of protein synthesis.

It is mainly used in the treatment of various infections of patients allergic

to penicillin and the infection is caused by penicillinase producing
staphylococci.
Mechanisms of action: It binds to 50s ribosomal subunit of bacteria
and depresses protein synthesis due to which bacteria dies.

Dose: 250 to 500 mg 6 hourly

Indications: Acne vulgaris, upper respiratory infections, acute

pneumonia

Contraindication:Rash, nausea, vomiting, heartburn, abdominal

pain, hearing loss

Drug interaction: There is increased action of oral anticoagulants

theophylline, methyl prednisolone.
NURSING CARE
› To assess skin eruption, itching

› Culture and sensitivity before treatment

› Bowel pattern before and during treatment

› Liver studies to be done

› Not to take with fruit juice

› Not to break crush or chew tablets

› To assess yellow colouration of eyes, skin

 AZITHROMYCIN
It is an azalide antibiotic ( a subclass of macrolides). It has the same
action of erythromycin against gram positive and gram negative
microorganisms. It has greater stability as gastric acid than
erythromycin. It acts by interfering with bacterial protein synthesis
by suppressing protein synthesis.

Mechanisms of action: It binds to 50s ribodomal subuniut of bacteria.

It suppress protein synthesis of greater spectrum of action in
comparison to the erythromycin drug. It has better toleration and
interaction.
Indication: Useful in upper and lower respiratory tract infections,
urogenital infections, tonsillitis, pharyngitis, skin and soft tissue
infections.
Contraindication: Hypersensitivity to macrolides/azithromycin, use
with caution during pregnancy and lactation.
Dose: 500mg on 1st day, folowed by 250mg daily OD, dose for next 4
days.
Side Effects: Nausea, vomiting, abdominal pain, diarrhea, headache,
vertigo, chest pain, nephritis.
Drug interactions: Absorption of azithromycin is reduced by food.
Antacids if administered with azithromycinreduce its absorptioj.
NURSING CARE:
› To assess allergies before and during treatment
› Culture and sensitivity before starting of grug therapy.
› Renal studies, urinalysis for protein, blood
› To assess therapeutic response, decrease signs of infection C & S
› Advise patient to take medicine azithromycin 1 hour before or two
with medicine.
SULFONAMIDES
› Sulfonamides are the derivatives of Para Amino Benzoic Acid(PABA).
› Sulfonamides are antibiotics which act as bacteriostatic. The sulfonamides have
more solubility in human plasma in comparison to water.
CLASSIFICATION
1. Rapidly absorbed and rapidly excreted sulfonamides
They are rapidly absorbed on administration and are quickly excreted in the urine.
The action of these sulfonamides remains for 4 to 6 hours. As the duration of
action is four to six hours, these are known as short acting sulfonamides. It
includes the following;
 Sulfamerazine
 Sulfadimidine
 Sulphadiazene
 sulfanilamide
2. Rapidly absorbed and slowly excreted sulfonamides
These sulfonamides are quickly absorbed in the body and are slowly
excreted in the urine. Their action lasts for 12 hours in the body. These
are also known as intermediate acting sulfonamides. This group includes:
Sulfamethoxazole
Sulphaphenazole
3. Rapidly absorbed sulfonamides and poorly excreted
These sulphonamides are also called as long acting sulfonamides and are
administered for local infection of gastrointestinal tract like diarrhea,
dysentery. These group includes drugs:
Sulfadimethoxine
Sulfamethoxy pyridiazine
Mechanism of action: Para amino benzoic acid is required for growth
and development of certain bacteria. These bacteria take para amino
benzoic acid from surrounding media and prepare folic acid. When
sulfonamides are administered, bacteria can not distinguish or
identify between para amino benzoic acid and para amino benzene
sulfonamides, because of their chemical resemblance. They take up
sulphonamide in place of para amino benzoic acid. They can not
convert it into folic acid. So for lack of folic acid, bacteria dies. The
sulfonamides act as bacteriostatic. This mechanism of action of
sulfonamides was suggested by woodfildes.
USEFUL ACTIVITIES OF SULFONAMIDES
› Composition
› Action
› Dosage
› Route
› Indications
› Contraindications
› Drug Interactions
› Side Effects
› Adverse Effects
› Toxicity Role Of Nurse