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By: Kathryn Eroschenko, PharmD, Clinical Assistant Professor, Department of Pharmacy Practice, Idaho State University, Meridian; Clinical Pharmacist in Ambulatory Care, Saint Alphonsus Medical Group Clinic, Boise, Idaho

Chlorhexidine gluconate is slower in its action than alcohols purchase silvitra 120mg free shipping erectile dysfunction 43, but purchase silvitra once a day erectile dysfunction video, because of its persistence cheap silvitra online visa impotence 1, it has residual activity when used repeatedly purchase 40mg levitra super active mastercard, producing bactericidal action equivalent to alcohols lasix 100 mg without a prescription. It is most effective against gram-positive cocci and less active against gram-positive and gram- negative rods. However, anionic and nonionic agents in moisturizers, neutral soaps, and surfactants may neutralize its action. Chlorhexidine digluconate formulations of 4% concentration have slightly greater antibacterial activity than newer 2% formulations. The combination of chlorhexidine gluconate in 70% alcohol, available in some countries including the United States, is the preferred agent for skin antisepsis in many surgical and percutaneous procedures. The advantage of this combination over povidone-iodine may derive from its more rapid action after application, its retained activity after exposure to body fluids, and its persistent activity on the skin. Chlorhexidine must not be used during surgery on the middle ear because it causes sensorineural deafness. It is not commonly used because of serious hypersensitivity reactions that may occur and because of its staining of clothing and dressings. An iodophor solution must be diluted according to the manufacturer’s directions to obtain full activity. Iodophors are less irritating and less likely to produce skin hypersensitivity than tincture of iodine. Although iodophors have a somewhat broader spectrum of activity than chlorhexidine, including sporicidal action, they lack its persistent activity on skin. Chlorine Chlorine is a strong oxidizing agent and universal disinfectant that is commonly provided as a 5. Because chlorine is inactivated by blood, serum, feces, and protein-containing materials, surfaces should be cleaned before chlorine disinfectant is applied. Rapid evolution of irritating chlorine gas occurs when hypochlorite solutions are mixed with acid and urine. These adverse actions are diminished by forming derivatives in which a functional group replaces a hydrogen atom in the aromatic ring. The phenolic agents most commonly used are o-phenylphenol, o-benzyl-p-chlorophenol, and p-tertiary amylphenol. Skin absorption and skin irritation still occur with these derivatives, and appropriate care is necessary in their use. Detergents are often added to formulations to clean and remove organic material that may decrease the activity of a phenolic compound. They are bactericidal (including mycobacteria) and fungicidal and are capable of inactivating lipophilic viruses. Phenolic disinfectants are used for hard surface decontamination in hospitals and laboratories, eg, floors, beds, and counter or bench tops.

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Draw the elimination curve between the steady-state peak concentration and the extrapolated trough concentration cheap silvitra 120mg line impotence used in a sentence. The patient is receiv- ing a tobramycin dose of 165 mg given every 8 hours that produces a steady state peak equal to 5 μg/mL and a steady-state trough equal to 2 buy 120 mg silvitra with amex erectile dysfunction at age 35. Because the patient is at steady state 120mg silvitra otc coffee causes erectile dysfunction, consecutive trough concentrations will be identical buy 100 mg kamagra soft, so the trough concentration can be extrapolated to the next predose time buy levitra soft american express. The change in concentra- tion after a dose is given (ΔC) is a surrogate measure of the volume of distribution and will be used to compute the new dose for the patient. Therefore, 1 half-life expired during the 7-hour time period between the peak concentration and extrapolated trough concentration, and the estimated half-life is 7 hours. In the current example the patient is receiving a tobramycin dose equal to 165 mg every 8 hours which produced steady-state peak and trough concentrations of 5 μg/mL and 2. The change in serum concentration is proportional to the dose, and this information will be used to set a new dose for the patient. For the purposes of this example, the desired steady-state peak and trough concentrations will be approximately 6 μg/mL and ≤1 μg/mL, respectively. Using the desired concentrations, it will take 1 half-life for the peak concentration of 6 μg/mL to decrease to 3 μg/mL, 1 more half-life for the serum concentration to decrease to 1. Therefore, the dosage interval will need to be approximately 3 half-lives or 21 hours (7 hours × 3 half- lives = 21 hours) which would be rounded to 24 hours. It is known from measured serum con- centrations that administration of 165 mg changes serum concentrations by 2. Tobramycin 360 mg every 24 hours would be started 24 hours after the last dose of the previous dosage regimen. Sawchuk-Zaske Method The Sawchuk-Zaske method of adjusting aminoglycoside doses was among the first tech- niques available to change doses using serum concentrations. The standard Sawchuk-Zaske method conducts a small pharmacokinetic experiment using 3–4 aminoglycoside serum concentra- tions obtained during a dosage interval and does not require steady-state conditions. The mod- ified Sawchuk-Zaske methods assume that steady state has been achieved and require only a pair of steady-state concentrations obtained during a dosage interval. A trough aminoglycoside concentration is obtained before a dose, a peak amino- glycoside concentration is obtained after the dose is infused (immediately after a 1-hour infusion or 1/ hour after a 1/ -hour infusion), and 1–2 additional postdose serum amino- 2 2 glycoside concentrations are obtained (Figure 4-10). Ideally, the 1–2 postdose concentrations should be obtained at least 1 estimated half-life from each other to minimize the influence of assay error. The postdose serum concentrations are used to calculate the aminoglyco- side elimination rate constant and half-life (Figure 4-10). The half-life can be computed by graphing the postdose concentrations on semilogarithmic paper, drawing the best straight line through the data points, and determining the time needed for serum concen- trations to decline by one-half. The peak and trough concentrations are used to calculate the volume of distribution, and the postdose concentrations (Cmax, C3, C4) are used to compute half-life.

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