邱偉嘉 1 蘇世斌 2 黃建元 2 前言 ( i m p e t i g o ) ( f u r u n c l e ) ( c a r b u n c l e ) ( s i m p l e abscess) (erysipelas) (cellulitis) (Staphylococcus) (Streptococci) 病因學 (S. aureus) ( -hemolytic Streptococci) 1 財團法人奇美醫院家庭醫學科 2 附設台南科學園區診所 : Methicillin-resistant Staphylococcus aureus, MRSA (aerobic Gram-positive cocci) (group A Streptococci) ( M e t h i c i l l i n - r e s i s t a n t Staphylococcus aureus, MRSA) MRSA 1961 MRSA Hospitalacquired MRSA, HA-MRSA MRSA MRSA Communityassociated MRSA, CA-MRSA CA- 144 家庭醫學與基層醫療第二十四卷第四期
MRSA ( ) CA-MRSA 流行病學 CA-MRSA 2008 3 1993-2005 (nonpurulent mastitis) (breast abscess) (felon) (onychia) (dental abscess) Bartholin's (pilonidal abscess) 1993 120 1.35 2005 340 2.98 1993-2001 CA-MRSA 10 2002 2005 2005 CA-MRSA 38 1995 2001 HA- MRSA 1 9 9 5 2 2 2 0 0 1 5 7 2005 94,360 MRSA 27 58 H A - M R S A i n f e c t i o n s w i t h c o m m u n i t y - onset 14 CA-MRSA 1993 Cephalosporins 65%, Macrolides 17%, Penicillins 15% 2005 Cephalosporins 49%, Trimethoprim-Sulfamethoxazole 19, C l i n d a m y c i n 16%, P e n i c i l l i n s 15%, Quinolones 7.2% 傳染途徑 MRSA (1) (2) MRSA MRSA (3) (4) 100 4-21 100 2-2 7 50 40 cotton-polyester blends 1-28 100 家庭醫學與基層醫療第二十四卷第四期 145
100 1-56 22-90 危險因子 MRSA MRSA MRSA MRSA MRSA MRSA MRSA Beta-lactam antibiotics MRSA M R S A MRSA ( ) (1) MRSA Cephalosporin, Fluoroquinolone MRSA MRSA 1 (odds ratios) 1.57 2-3 2.46 4 6.24 Fluoroquinolone 3.37 (2) 2000 2003 M R S A 3.3 CD4 count <50 cells/microl HIV RNA (>100,000 copies/ microl) (3) MRSA 5,287 15 MRSA MRSA (4) 15 50 MRSA 抗藥性之機轉 (Methicillin-susceptible S. aureus, MSSA) (ß-Lactamase) ( P e n i c i l l i n b i n d i n g p r o t e i n, PBP) PBP1, PBP2, PBP3 PBP4 PBPs PBPs MSSA PBPs 146 家庭醫學與基層醫療第二十四卷第四期
Mec MRSA M S S A MecA mec 2a (PBP 2a ) P B P 2 a 7 6 k D a PBPs PBP 2a PBP 2a PBPs m e c mecr1-meci beta-lactamase genes- blai, blari, blaz MecR1-mecI meca S. aureus 治療 MRSA Beta-lactam MRSA 5 MRSA Clindamycin, Trimethoprim Sulfamethoxazole, D o x y c y c l i n e o r Minocycline Linezolid MRSA 1-2 24-48 Clindamycin MRSA C l i n d a m y c i n 10-15 Clindamycin Trimethoprim -sulfamethoxazole Doxycycline or Minocycline MRSA Beta-lactam antibiotics Trimethoprim -sulfamethoxazole B e t a - l a c t a m a n t i b i o t i c s Trimethoprim -sulfamethoxazole MRSA Fluoroquinolones F l u o r o q u i n o l o n e s Rifampin 家庭醫學與基層醫療第二十四卷第四期 147
表一院內感染 MRSA 和社區感染 MRSA 危險因子之比較 院內感染 MRSA 近期及長期住院長期護理機構抗生素的使用外科手術放置中央靜脈導管接受氣切手術侵入性醫療裝置血液透析 社區感染 MRSA 接觸或照顧 MRSA 的病患高 MRSA 傳染的地區復發性皮膚病擁擠的居住環境 ( 軍隊 庇護所 ) 監獄運動員及球隊對 Beta-lactam antibiotics 反應很差的皮膚及軟組織感染症長期或經常性使用抗生素藥物濫用年齡小於兩歲的兒童男同性戀體毛修剪 Vancomycin L i n e z o l i d, D a p t o m y c i n, T i g e c y c l i n e Q u i n u p r i s t i n - dalfopristin Vancomycin Linezolid, Daptomycin 1-2 結論 HA-MRSA CA-MRSA 參考資料 1. Moran GJ, Krishnadasan A, Gorwitz RJ, et al: Methicillin-resistant S aureus infections among patients in the emergency department. N Engl J Med. 2006; 355:666-74. 2. Donald M, Marlow M, Swinburn E, Wu M: Emergency department managementof home intravenous antibiotic therapy for cellulitis. Emerg Med 2005; 22:715 7. 3. Hasty MB, Klasner A, Kness S, et al: Cutaneous community-associated methicillin-resistant Staphylococcus aureus among all skin and softtissue infections in two geographically distant pediatric emergency departments. Acad Emerg Med 2007; 14:35 40. 4. Koster JB, Kullberg BJ, Van der Meer JW, et al: Recurrent erysipelas despite antibiotic prophylaxis: an analysis from case studies. Neth J Med 2007; 65:89 94. 148 家庭醫學與基層醫療第二十四卷第四期