Timentin
ticarcillin disodium and clavulanate potassium
Pharmacologic class: Penicillin (extended-spectrum)
Therapeutic class: Anti-infective
Pregnancy risk category B
Action
Ticarcillin disodium inhibits bacterial cell-wall synthesis during replication; clavulanic acid extends ticarcillin's antibiotic spectrum by inactivating beta-lactamase enzymes (which otherwise would degrade ticarcillin).
Availability
Injection: 3 g ticarcillin and 100 mg clavulanic acid in 3.1-g vials
Indications and dosages
➣ Systemic and urinary tract infections caused by susceptible organisms
Adults weighing more than 60 kg (132 lb): 3.1 g (30:1 fixed-ratio combination of 3 g ticarcillin and 100 mg clavulanic acid) by I.V. infusion q 4 to 6 hours
Adults weighing less than 60 kg (132 lb): 200 to 300 mg/kg/day (based on ticarcillin content) by I.V. infusion in divided doses q 4 to 6 hours
➣ Gynecologic infections caused by susceptible organisms
Adults weighing more than 60 kg (132 lb): For moderate infections, 200 mg/kg/day (based on ticarcillin content) by I.V. infusion in divided doses q 6 hours. For severe infections, 300 mg/kg/day (based on ticarcillin content) by I.V. infusion in divided doses q 4 hours.
Adults weighing less than 60 kg (132 lb): 200 to 300 mg/kg/day by I.V. infusion q 4 to 6 hours
➣ Mild to moderate or severe infections in children caused by susceptible organisms
Children weighing more than 60 kg (132 lb): For mild to moderate infections, 3.1 g (30:1 fixed-ratio combination of 3 g ticarcillin and 100 mg clavulanic acid) by I.V. infusion q 6 hours. For severe infections, 3.1 g (30:1 fixed-ratio combination of 3 g ticarcillin and 100 mg clavulanic acid) by I.V. infusion q 4 hours.
Children ages 3 months to 16 years weighing less than 60 kg (132 lb): For mild to moderate infections, 200 mg/kg/day (based on ticarcillin content) by I.V. infusion in divided doses q 6 hours. For severe infections, 300 mg/kg/day (based on ticarcillin content) by I.V. infusion in divided doses q 4 hours.
Dosage adjustment
• Renal impairment
Contraindications
• Hypersensitivity to drug or other penicillins
Precautions
Use cautiously in:
• cystic fibrosis, renal or hepatic disease
• pregnant or breastfeeding patients.
Administration
• Ask patient about penicillin allergy before giving.
• Add 13 ml of sterile water or normal saline solution to vial; shake gently. Dilute further to 10 to 100 mg/ml of ticarcillin; infuse I.V. over 30 minutes.
• Give at least 1 hour before I.V. aminoglycosides (such as amikacin or gentamicin).
Adverse reactions
CNS: headache, giddiness, dizziness, lethargy, fatigue, hyperreflexia, neuromuscular excitability, asterixis, hallucinations, stupor, seizures
GI: nausea, vomiting, diarrhea, flatulence, pseudomembranous colitis
Hematologic: eosinophilia, transient neutropenia and leukopenia (with high doses)
Skin: urticaria, rash
Other: unpleasant taste; fever; overgrowth of nonsusceptible organisms; pain, vein irritation, erythema, phlebitis, and thrombophlebitis at I.V. site; hypersensitivity reactions including anaphylaxis
Interactions
Drug-drug. Aminoglycosides: physical incompatibility, causing aminoglycoside inactivation when mixed in same I.V. solution
Aminoglycosides, tetracyclines: additive activity against some bacteria
Lithium: altered lithium elimination
Probenecid: increased ticarcillin blood level
Drug-diagnostic tests. Alanine aminotransferase, alkaline phosphatase, aspartate aminotransferase, eosinophils, lactate dehydrogenase, sodium: increased levels
Bleeding time: prolonged
Granulocytes, hemoglobin, platelets, white blood cells: decreased levels
Liver function tests: transient increases
Urine glucose, urine protein: false-positive results
Patient monitoring
• Monitor liver function tests and CBC with white cell differential.
• Watch closely for signs and symptoms of superinfection and severe allergic reactions.
• Assess neurologic status, and stay alert for seizures.
Patient teaching
Advise patient to report skin reactions and severe diarrhea right away.
Tell patient drug may increase risk of other infections. Advise him to promptly report signs and symptoms of new infection.
• Instruct patient to limit sodium intake (drug contains sodium).
• As appropriate, review all other significant and life-threatening adverse reactions and interactions, especially those related to the drugs and tests mentioned above.
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.