[ 醫學筆記 ] 抗生素使用 Antibiotics part.2 FQ, anti- MRSA, others by kphsien Published 二月 10, 2017 3 Comments http://charliekuo.com/?p=3163 1/8
2017/11/14 [醫學筆記] 抗生素使用 Antibiotics part.2 FQ, anti-mrsa, others 郭查理 Enterococcus裡還有分faecalis跟faecium 因為排版塞不下了 請再查一下熱病 之前Tigecycline標錯atypical pathogen 應該是susceptible(2017/02改) 需要圖檔或ai檔請留下信箱 原本的綠色不是這種螢光綠啊 為什麼顏色會跑掉嗚嗚 http://charliekuo.com/?p=3163 2/8
= Quinolone = GPC GNB PsA Anae Atyp Ciprofloxacin + ++ + Levofloxacin + + + + Moxifloxacin ++ + + + PsA : Ciprofloxacin > Levofloxacin (anti-psa 裡唯一可口服!) S.pneumoniae: Ciprofloxacin < Levofloxacin < Moxifloxacin FQ 類容易產生抗藥性且有 TB masking 的風險, 在 TB 盛行區並不適合作為治療 CAP 的首選 不過因為他抗菌譜廣又一天一針, 真是急診的好朋友無誤 又或者有時病人對 β-lactam 又過敏沒什麼藥好用只能選 FQ 總之用 FQ 不是不行, 但使用前要謹慎評估病人是否有 TB 的風險 ( 發燒? 久咳? 乾咳? 體重掉? 夜間盜汗? 胸痛? immune stauts? contact history? CXR 有無 TB 好發位置病灶?), 記得留個 AFS Ciprofloxacin (IV, Ciproxin ) GPC GNB : PsA better Mycobacterium => PNA, IAI, Soft tissue/bone, UTI, prostatitis, STD, Mycobac. 400mg IV Q8-12H QTc prolongation (Baseline EKG!), BM suppression, Pregnancy or age < 16, Tendon rupture, MG Chelation (Ca++, Mg++) : to avoid, 1 hr before meal or 2 hrs after meal Levofloxacin (IV, Cravit ) http://charliekuo.com/?p=3163 3/8
GPC GNB : PsA Mycobacterium => PNA, IAI, Soft tissue/bone, UTI, prostatitis, STD, Mycobac 250-750mg IV/PO QD QTc prolongation (Baseline EKG!), BM suppression, Pregnancy or age < 16, Tendon rupture, MG Chelation (Ca++, Mg++) : to avoid, 1 hr before meal or 2 hrs after meal Moxifloxacin (IV, Avelox ) Respiratory FQ GPC GNB : PsA Anaerobes Mycobacterium => PNA, IAI, Soft tissue/bone, UTI, prostatitis, STD, Mycobac 400mg IV/PO QD QTc prolongation (Baseline EKG!), BM suppression, Pregnancy or age < 16, Tendon rupture, MG Chelation (Ca++, Mg++) : to avoid, 1 hr before meal or 2 hrs after meal = Anti-MRSA = http://charliekuo.com/?p=3163 4/8
Vancomycin (IV, ) GPC: MRSA Loading dose 25-30 mg/kg -> 15-20 mg/kg Q12H Peak : 30-40 mcg/ml Trough : 5-15 mcg/ml, 15-20 mcg/ml for sever infection Ototoxicity, Nephrotoxicity, Redman syndrome, drug fever Teicoplanin (IV, Targocid ) GPC: MRSA Loading 12 mg/kg X 3doses -> 12 mg/kg QD (400mg Q12H X 3 doses -> 400mg QD ) BM suppression, drug fever, skin rash, less nephrotoxicity Teicoplanin is more potent against Streptococcus spp. Teicoplanin is more potent against Enterococcus spp. Esp. for VanB phenotype VRE Teicoplanin has slower bactericidal activity against Gram-positive pathogens than vancomycin Teicoplanin is less potent against coagulase negative Staphylococci, esp. S. epidermidis, S. haemolyticus, S. hominis, S. warneri, and S. xylosus. Daptomycin (IV, Cubicin ) GPC: MRSA => Better in soft tissue, not for PNA bacteremia 6-10 mg/kg/day QD http://charliekuo.com/?p=3163 5/8
skin/soft tissue 4mg/kg/day QD myopathy (f/u CK), BM suppression, eosinophilic PNA Tigecycline (IV, Tygacil ) GP : MRSA, VRE, PRSP GN : ESBL, PDRAB, PsA ( 所以會看到 tigecycline + ceftazidime 這種組合 ), proteus => PNA IAI, Soft tissue ; But poor serum concentration!! not for bacteremia!! 打不到 :Pseudomonas aeruginosa Proteus spp. Providencia spp. Morganella morganii Burkholderia cepaci 100mg STAT -> 50mg Q12H GI (N/V/D), photosensitivity, pseudotumor cerebri, pancreatitis pregnancy, age<18 Linezolid (IV,PO, Zyvox ) GPC: MRSA, VRSA, VRE, PRSP Norcardiosis, Listeriosis, Mycobacterial infection Bacteriastatic to Staph, Enterococcus ( 嚴重感染不建議用 Linezolid) 600mg IV/PO Q12H BM suppression (Thrombocytopenia! most often >2wk), N/V, GI MAOI ( 避免併用 MAOI,SSRI, TCA, bronchodilator, dopamine, meperidine, 減少奶酪蛋肉類攝取 ) Lactic acidosis, Rhabdomyolysis = Others = http://charliekuo.com/?p=3163 6/8
Amikacin (IV, Acemycin ), Gentamycin, = Aminoglycoside = GP : with beta-lactam GN : synergestic effect Myco (Streptomycin) Conventional => For IE, enterococcus Once daily : effect not inferior (Post antibiotic effect, neutorphil-dependent), less resistance, less toxicity GM 3-5mg/kg/day AM 10-15 mg/kg/day Poor in acidicity or anaerobic enviro. (PNA,BTI,CNS 不適用 ) 不能使用 once daily dosing 的場合 : Impaired renal function (ex. CCr < 60, hemodialysis, peritoneal dialysis) Altered volume of distribution (ex. ascites, severe burn) Neutropenia Combination with beta-lactam for GPC infection Ototoxicity, Nephrotoxicity (check trough level), NM blockade Narrow therapeutic range, cumulative toxicity (>7 days) Trimethoprim/sulfamethoxazole (TMP/SMX) (IV Sevatrim, PO Baktar ) http://charliekuo.com/?p=3163 7/8
GP: Norcardia GN: S. maltophilia, B. cenocepacia PJP 8-10 mg/kg/day in 2-4 doses PJP: therapeutic 15-20 mg/kg/day in 3-4 doses ( 不過學長姐是都抓 12 mg/kg) HyperK, GI, Psychosis, Sweet s syndrome, BM suppression, SJS, Hepatitis Clindamycin (IV, Clincin ; PO, Lindacin ) GPC Anaerobes => for PCN allergy ( 想換 MSSA 口服但病人又對 beta-lactam 過敏時可用 ) 0.6-2.7 g/day IV in 2-4 doses 150~450 mg PO Q6H CDAD, allergy, GI, drug fever Metronidazole (IV; PO, Flagyl ) Anaerobes => CDAD, IAI 7.5mg/kg/day IV Q6H 500 mg PO QID N/V, disulfiram reaction, Doxycycline (PO, Doxymycin ) 100mg PO Q12H Deposition in teeth, Hepatotoxicity in Pregnancy, Breast feeding, Age < 8 Erythromycin, Azithromycin (PO, Zithromax ), Clarithromycin (PO, Colirocin ) 500mg QD for 3 days clarithromycin 有 anti-inflammatory 的效果, 之前看過老師在 COPD 的病人會選用 QT prolongation, Cyt-P450 inhibition ( 抑制藥物代謝, 藥物在體內濃度升高 ), GI ( 有時 http://charliekuo.com/?p=3163 8/8