K9 q F Antibiotics part.1 cØ β-lactamVRE Daptomycin, Linezolid, Tigecycline MDRAB Carbapenem,...
Transcript of K9 q F Antibiotics part.1 cØ β-lactamVRE Daptomycin, Linezolid, Tigecycline MDRAB Carbapenem,...
2017/11/14 [醫學筆記] 抗生素使用 Antibiotics part.1 概論+β-lactam – 郭查理
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[醫學筆記] 抗生素使用 Antibiotics part.1 概論+β-lactam
by kphsienPublished 二月 10, 2017
97 Comments
一樣是整理成一張標籤貼紙圖表,若有需要圖檔或ai檔請留下信箱。歡迎取用。
Enterococcus裡還有分faecalis跟faecium,因為排版塞不下了,請再查一下熱病。
2017/11/14 [醫學筆記] 抗生素使用 Antibiotics part.1 概論+β-lactam – 郭查理
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之前Tigecycline標錯atypical pathogen,應該是susceptible(2017/02改)
抗生素使用的5D如下
Diagnosis Drug Dosage Duration De-escalation
要先判斷有沒有感染!當然臨床上可能燒個半天有沒有感染分攏分袂清,或是突如其來個血壓掉無法排除敗血性休克,這時先壓上個
Antibiotic也是合情合理。只是記得要隨時評估揪竟現在有沒有感染(有很多評估的方法例如 Vitals, S/Sx, WBC, DC, CRP?, PLT,Ferritin, Glucose, Procalcitonin,treatment response, image change….),如果有microbiological evidence請及早降階調整抗生素,如果
根本不是感染請考慮停掉抗生素吧(打到天荒地老又跑來個drug fever攪和一下…)。
至於到底要選哪種抗生素,我自己是用SPAM(這單字完全暴露年齡,遙想e-mail剛問世的年代)的順序去記,先決定抗菌譜,再來選
擇穿透力和組織濃度較好的,評估病人肝腎狀況和副作用,最後考慮成本 :
Spectrum → Penetration → Adverse effect → Money= Spectrum =
這裡先列出一些特別要考慮的菌種和常見的抗藥性菌株,同時附上相對應的治療選擇。詳細每個抗生素的抗菌譜和副作用請繼續往
下。
最愛問的我想就是Anti-pseudomonal。
Amp-C β-lactamase GNB Tazocin, Ceftazidime, Cefepime, Cefpirome, Cipro, Levo, Tienam, Meropenem,Aztreonam
ESBL 4th Cepha, Carbapenems, TG, fosfomycin
MRSA Vancomycin, Teicoplanin Daptomyxin, Linezolid, Tigecycline,
PsA Tazocin, Ceftazidime, Cefepime, Meropenem, Imipenem, Doripenem,Ciprofloxacin, Levofloxacin,Aztreonam, AG
VRE Daptomycin, Linezolid, Tigecycline
MDRAB Carbapenem, Unasyn, Brosym, Colistin
PRSP Ceftriaxone, Vancomycin, Teicoplanin, Tigecycline
Anaerobes Metronidazole, Unasyn, Tazocin
= Penetration/Tissue concentration =
過BBB: PCN, Ampicillin, Oxacillin, 3rd-4th Cephalosporin, Moxifloxacin, Vancomycin, Chloramphenicol, Rifampin, Imipenem,Meropenem
Prostatitis/Epididymo-orchitis: Ceftriaxone, Doxycycline, FQ, TMP-SMX
Endophthalmitis: 3rd Cepha, Vancomycin
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一定愛用 -cidal : immunocompromised, meningitis, IE, osteomyelitis, abscess, neutropenic fever, bacteremia, septic shock
= adverse effect =
$ Money $
renal hepatic
= Penicillin =
=Natural penicillin=
PCN-G, PCN-V
Spectrum GPC (Actinomyce), GNB (spirochetes!), Anaerobes (Actinomycosis) IE, Neurosyphilis
Dosage 2-4MU IV Q4H
AE Allergy, Anaphylaxis, BM suppression
Benzathine PCN
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Spectrum GPC, GNB (spirochetes!), Anaerobes (Actinomycosis) Primary and secondary syphilis
Dosage 2.4 MU IM QW
AE Allergy, drug fever, myelosuppression, CDAD
= Penicillinase-resistant PCN =
Oxacillin (IV) / Ducloxacillin (PO) / Cloxacillin (PO)
Spectrum GPC, MSSA 首選!(比Vanco,Cefa更好!)
Dosage 1-2g IV Q4-6H PO 吸收差 (50%) => 改Cephalexin (90%)
AE Allergy, drug fever, myelosuppression, CDAD, Hepatitis,
= Aminopenicillin =
加上β-lactamase inhibitor後可cover HMN
Ampicillin / Ampicillin + Sulbactam (Unasyn )
Spectrum
GPC: Listeriosis (過BBB), Enterococcus,
GNB: PEcK, H. influ, Shigella, Salmonella , A.baumannii (sulbactam, even for PDRAB)
Anaerobes
** Amp-C β-lactamase GNBs : Enterobacter, Citrobacter, S. marcenscens, M. morganii, PsA,P vulgaris **
Dosage
1g IV Q6-8H 3g IV Q6H for AB
Renal adjustment
AE
Allergy, drug fever, myelosuppression, CDAD
maculopapular rash in pts. with viral illness, infectious mononucleosis, and lymphocyticleukemia.
Amoxicillin / Amoxicillin + Clavulanate (Augmentin®)
Spectrum GPC, GNB, anaerobes => URTI, H.P
Dosage Amoxicillin 250mg~1gm PO TID
Augmentin 875/125mg PO BID
AE Allergy, drug fever, myelosuppression, CDAD
= Antipseudomonal PCN=
Piperacillin-tazobactam (Tazocin®)
Spectrum– GPC
– GNB : + PsA (Anti-PsA 遜於 Cefepime ) and Amp-C β-lactamase GNB – Anaerobes
Dosage
– 3gm~4gm IV Q6H (For PsA 4.5g Q6H IVD, combine AG for FN)
®
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– Prolonged infusion for ICU patients, immunocompromised pts, and MIC ≥ 8
AE – Allergy, drug fever, myelosuppression, CDAD – Na 2.79mEq/gm of PIP : Tazocin高鹽含量!用在dysnatremia或是fluid overload的病人要注意。
關於副作用中過敏反應還有兩個問題是臨床上常碰到的 = To PCN test or not to PCN test ???? =
其實就目前的文獻證據來看,PCN test並無實證證明能預測anaphylaxis(也就是我們最擔心的狀況),而另一方面則甚至有PCN造成
anaphylaxis的案例。 “若未有盤尼西林過敏反應病史,建議不需要做皮膚測試,但是在給藥中及給藥
後的過程中應注意是否發生過敏反應,並準備完善的急救措施。”
盤尼西林過敏反應與盤尼西林皮膚測試之 回顧與實務建議 http://www.tma.tw/se_dis/01files/7795-
%E5%AE%89%E5%85%A8%E5%93%81%E8%B3%AA%E8%A8%8E%E8%AB%96%E6%9C%83%E7%B3%BB%E5%88%971.PDF恩,不過…法官大大會怎麼解讀呢?護理師問你要不要做PCN test,你會不會做呢?
=Cross-allerginicity ?? =
如果病人已知有PCN allergic reaction,可以給其他β-lactam類的抗生素嗎?? 臨床常見的實務做法是若病人之前是anaphylaxis,那還是別用結構類似的β-lactam類藥物,不過如果之前只是皮疹等輕微反應,還是
可以用其他β-lactam類藥物,但建議密切監控過敏反應。真的不行就只好換其他種類的藥物,如Aztreonam(誒不過好像很多地方沒這
個藥了)或者FQ。
= Cephalosporin =
從一代到三代的抗菌力對GPC越來越差,對GNB則越來越好。四代則是對GPC和GNB都有效。
3rd以上過BBB (Brosym較弱)
3rd中ceftriaxone不能用來對抗PsA, ceftazidime不能用於GPC。
cephamycin有NMTT side chain可對抗anaerobes,但會有出血風險。
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Cephalosporin的罩門:Enterococcus, Listeria, Anaerobes (Cephamycin除外)
= 1st generation =
Cefazolin (IV), Cephradine (IV, U-save®), Cephalexin (PO, Ulex®)
SpectrumGPC: MSSA + PSSP
GNB: PEcK => UTI, Soft tissue infection, Surgery phrophylaxis
Dosage 1~1.5gm IV Q8H
500mg PO Q6H
AE Allergy, drug fever, myelosuppression, CDAD
= 2nd generation =
Cefuroxime (IV, Zinacef®, Furoxime®; PO Zinnat®), Cefaclor
Spectrum GPC: 比一代弱 GNB: PEcK + HMN=> CAP (COPD w/ AE),Dosage
Dosage
750mg-1.5gm IV Q6-8H 500mg PO Q8-12H
AE Allergy, drug fever, myelosuppression, CDAD
Cefmetazole (IV,Cetazone®), Cefoxitin(IV,Cexitin®)
Spectrum
GPC GNB: PEcK + HMN
Anaerobes (不過對Bacteroides效果不佳,應改用Metronidazole) * 對ESBL雖有in vitro susceptibility,不過in vivo效果如何目前無定論。(熱病:Do not use as
there are no clinical data for efficacy)=> IAI
Dosage 1-2g IV Q6-12H
No PO form
AE hypoprothrombinemia (老人,低白蛋白,肝腎功能差) disulfiram-like reaction (No alcohol drinking!)
Allergy, drug fever, myelosuppression, CDAD
= 3rd generation =
Ceftriaxone (IV, Rocephin®), Cefotaxime(IV, Claforan®), Cefixime(Cefspan®), Ceftibuten (PO, Seftem®)
SpectrumGPC
GNB : Neiserria, PsA => CAP, meningitis, BTI
Dosage
Ceftriaxone: 1-2g/day IV in 1-2 doses, meningitis: 2g IV Q12H Cefotaxime: 2gm IV Q8H
AE Pseudocholelithiasis, kernicterus Allergy, drug fever, myelosuppression, CDAD
Ceftazidime (IV, Fortum®, Tatumcef®)
Spectrum GPC: MSSA↓, PSSP ≅ 1st Cepha
GNB: PsA => health-care associated, hospital acquired infection for PsA coverage
2017/11/14 [醫學筆記] 抗生素使用 Antibiotics part.1 概論+β-lactam – 郭查理
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Dosage
1-2g IV Q8-12H
如果是針對PsA empirical coverage,一開始就應該先用full dose
AE Allergy, drug fever, myelosuppression, CDAD
Flomoxef (IV, Flumarin®) ≅ ceftriaxone + metronidazole ???
Spectrum
GPC GNB : ESBL?, PsA
Anaerobe => LRTI, UTI, Mixed infection
Dosage 1-2g/day IV in 2 doses ~ 4g/day in 2~4 dosesAE
AE side chain NMTT->HTT:較少NMTT副作用 Allergy, drug fever, myelosuppression, CDAD
Cefoperazone-sulbactam (IV, Brosym®)
Spectrum
GPC GNB : PsA, AB
Anae => BTI, PID
Dosage500mg-2g IV Q12H
AEhypoprothrombinemia
disulfiram-like reaction (No alcohol drinking!) Allergy, drug fever, myelosuppression, CDAD
= 4th generation =
Cefepime (Maxipime®), Cefpirome
Spectrum
GPC : Cefpirome > Cefepime GNB : Amp-C btalactamase GNB ; Cefpirome < Cefepime
Anae => Febrile neutropenia
Dosage Cefepime: 2g IV Q8-12H
Prolonged infusion: MIC≥4, Immunocompromised, crititcal pts
AE Allergy, drug fever, myelosuppression, CDAD
= Carbapenem =
2017/11/14 [醫學筆記] 抗生素使用 Antibiotics part.1 概論+β-lactam – 郭查理
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Penem類雖然神通廣大,不過有四隻殺不了:MRSA, E. faecium, S. maltophilia, B. cepacia.
GPC Imipenem > Doripenem ≅ Meropenem
PsA Doripenem > Meropenem > Imipenem
AB Doripenem ≅ Imipenem > Meropenem
Ertapenem (Invanz®)
Spectrum
GPC GNB : PsA, AB
Anaerobes => IAI, ESBL, Amp-C β-lactamase
Dosage 1g IV QD
AE Seizure Allergy, drug fever, myelosuppression, CDAD
Imipenem-Cilastatin (IV, Tienam®)
SpectrumGPC
GNB : PsA, AB Anaerobes
Dosage
500mg-1g IV Q6-8H Max 50mg/kg/day (Renal dose相當複雜直接對表…) Continuous infusion: MIC≥2, immunocompromised, critical
AE Seizure 風險在penem中較高, Cilastin降低imipenem腎毒性, Allergy, drug fever, myelosuppression, CDAD
Meropenem (Mepem®)
SpectrumGPC
GNB : PsA, AB Anae
Dosage 1g IV Q8H
Meningitis 2g IV Q8H
AE Seizure Allergy, drug fever, myelosuppression, CDAD
Doripenem (IV, Finibax®)
Spectrum GPC GNB : PsA, AB