2017/11/14 [ [醫學筆記] 抗生素使用 Antibiotics part.1 概論 β-lactam 郭查理 醫學筆記] 抗生素使用 Antibiotics part.1 概論 β-lactam by kphsien Published 10, 2017 97 Comments 二月 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 http://charliekuo.com/?p=3114 1/8
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 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 : Penetration Adverse effect Money = = 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 ESBL MRSA PsA VRE MDRAB PRSP Anaerobes Tazocin, Ceftazidime, Cefepime, Cefpirome, Cipro, Levo, Tienam, Meropenem, Aztreonam 4th Cepha, Carbapenems, TG, fosfomycin Vancomycin, Teicoplanin Daptomyxin, Linezolid, Tigecycline, Tazocin, Ceftazidime, Cefepime, Meropenem, Imipenem, Doripenem, Ciprofloxacin, Levofloxacin,Aztreonam, AG Daptomycin, Linezolid, Tigecycline Carbapenem, Unasyn, Brosym, Colistin Ceftriaxone, Vancomycin, Teicoplanin, Tigecycline 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 http://charliekuo.com/?p=3114 2/8
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 (Actinomyce), GNB (spirochetes!), Anaerobes (Actinomycosis) IE, Neurosyphilis 2-4MU IV Q4H Allergy, Anaphylaxis, BM suppression Benzathine PCN http://charliekuo.com/?p=3114 3/8
, GNB (spirochetes!), Anaerobes (Actinomycosis) Primary and secondary syphilis 2.4 MU IM QW = Penicillinase-resistant PCN = Oxacillin (IV) / Ducloxacillin (PO) / Cloxacillin (PO), MSSA 首選!( 比 Vanco,Cefa 更好!) 1-2g IV Q4-6H PO 吸收差 (50%) => 改 Cephalexin (90%), Hepatitis, = Aminopenicillin = 加上 β-lactamase inhibitor 後可 cover HMN Ampicillin / Ampicillin + Sulbactam (Unasyn ) : 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 ** 1g IV Q6-8H 3g IV Q6H for AB Renal adjustment maculopapular rash in pts. with viral illness, infectious mononucleosis, and lymphocytic leukemia. Amoxicillin / Amoxicillin + Clavulanate (Augmentin ), GNB, anaerobes => URTI, H.P Amoxicillin 250mg~1gm PO TID Augmentin 875/125mg PO BID = Antipseudomonal PCN= Piperacillin-tazobactam (Tazocin ) GNB : + PsA (Anti-PsA 遜於 Cefepime ) and Amp-C β-lactamase GNB Anaerobes 3gm~4gm IV Q6H (For PsA 4.5g Q6H IVD, combine AG for FN) http://charliekuo.com/?p=3114 4/8
Prolonged infusion for ICU patients, immunocompromised pts, and MIC 8 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%%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 越來越差, 對 GNB 則越來越好 四代則是對 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 cephamycin 有 NMTT side chain 可對抗 anaerobes, 但會有出血風險 http://charliekuo.com/?p=3114 5/8
Cephalosporin 的罩門 :Enterococcus, Listeria, Anaerobes (Cephamycin 除外 ) = 1st generation = Cefazolin (IV), Cephradine (IV, U-save ), Cephalexin (PO, Ulex ) : MSSA + PSSP GNB: PEcK => UTI, Soft tissue infection, Surgery phrophylaxis 1~1.5gm IV Q8H 500mg PO Q6H = 2nd generation = Cefuroxime (IV, Zinacef, Furoxime ; PO Zinnat ), Cefaclor : 比一代弱 GNB: PEcK + HMN=> CAP (COPD w/ ), 750mg-1.5gm IV Q6-8H 500mg PO Q8-12H Cefmetazole (IV,Cetazone ), Cefoxitin(IV,Cexitin ) 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 1-2g IV Q6-12H No PO form hypoprothrombinemia ( 老人, 低白蛋白, 肝腎功能差 ) disulfiram-like reaction (No alcohol drinking!) = 3rd generation = Ceftriaxone (IV, Rocephin ), Cefotaxime(IV, Claforan ), Cefixime(Cefspan ), Ceftibuten (PO, Seftem ) GNB : Neiserria, PsA => CAP, meningitis, BTI Ceftriaxone: 1-2g/day IV in 1-2 doses, meningitis: 2g IV Q12H Cefotaxime: 2gm IV Q8H Pseudocholelithiasis, kernicterus Ceftazidime (IV, Fortum, Tatumcef ) : MSSA, PSSP 1st Cepha GNB: PsA => health-care associated, hospital acquired infection for PsA coverage http://charliekuo.com/?p=3114 6/8
1-2g IV Q8-12H 如果是針對 PsA empirical coverage, 一開始就應該先用 full dose Flomoxef (IV, Flumarin ) ceftriaxone + metronidazole??? GNB : ESBL?, PsA Anaerobe => LRTI, UTI, Mixed infection 1-2g/day IV in 2 doses ~ 4g/day in 2~4 doses side chain NMTT->HTT: 較少 NMTT 副作用 Cefoperazone-sulbactam (IV, Brosym ) Anae => BTI, PID 500mg-2g IV Q12H hypoprothrombinemia disulfiram-like reaction (No alcohol drinking!) = 4th generation = Cefepime (Maxipime ), Cefpirome : Cefpirome > Cefepime GNB : Amp-C btalactamase GNB ; Cefpirome < Cefepime Anae => Febrile neutropenia Cefepime: 2g IV Q8-12H Prolonged infusion: MIC 4, Immunocompromised, crititcal pts = Carbapenem = http://charliekuo.com/?p=3114 7/8
Penem 類雖然神通廣大, 不過有四隻殺不了 :MRSA, E. faecium, S. maltophilia, B. cepacia. PsA AB Imipenem > Doripenem Meropenem Doripenem > Meropenem > Imipenem Doripenem Imipenem > Meropenem Ertapenem (Invanz ) Anaerobes => IAI, ESBL, Amp-C β-lactamase 1g IV QD Seizure Imipenem-Cilastatin (IV, Tienam ) Anaerobes 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 Seizure 風險在 penem 中較高, Cilastin 降低 imipenem 腎毒性, Meropenem (Mepem ) Anae 1g IV Q8H Meningitis 2g IV Q8H Seizure Doripenem (IV, Finibax ) http://charliekuo.com/?p=3114 8/8