細菌培養結果culture result (B/C)
= 汙染常見細菌Contamination
---Coagulase-negative staphylococci (CoNS)
---Micrococcus
---GPB: bacillus, Corynebacterium diphtheriae
---Viridans streptococci
= 常見移生菌Colonization (附著於醫材、植入物上)
---插管使用呼吸器的病人,容易在痰液培養(sputum culture)中發現
---U/C: Foley (應重新更換再留檢體培養)
---B/C: CVC (應重新更換再留檢體培養)
---Pus/C: 引流管外端(penrose)
= 感染致病菌Infection (無論有無感染臨床表現)
---下列細菌血液、尿液、痰液中都不應該出現
---S. aureus
---Group A, B, or D streptococcus
---GNB
---Candida
---Anaerobes
皮膚上的常見細菌(skin resident flora)
= Staphylococcus epidermidis, S. hominis, propionibacteria corynebacteria , dermobacteria, and micrococci, Pityrosporum (Malassezia) spp.
= Normal human skin is colonized by bacteria
--- more than 1 × 106 colony forming units (CFU)/cm2 on the scalp
--- 5 × 105 CFUs/cm 2 in the axilla
--- 4 × 104 CFU/cm2 on the abdomen
--- 1 × 104 CFU/cm2 on the forearm
抗生素
= 殺菌性抗生素
--- β lactam, Glycopeptides, Fosfomycin
--- Daptomycin, polymyxins
--- Aminoglycosides
--- Quinolone, metronidazole, rifampin,
--- Baktar (TMP SMX)
= 抑菌性抗生素
--- Macrolides, tetracycline, glycylcyline, clindamycin, linezolid, fusidic acid
--- TMP, SMX
= 選擇建議
---大部分效果相似,除了bacterial meningitis、bacterial endocarditis、neturopenia特別建議選用殺菌型=抗生素作用方式
---MIC = 最低抑菌濃度
---T = 高於最低抑菌濃度的時間
---Cmax = 藥物最高血漿濃度
---AUC = 曲線下面積,代表暴露程度
---Time dependent
**** β lactams, carbapenems, linezolid, erythromycin, clarithromycin, lincosamides
**** T的時間越長越好
**** T > MIC應大於40~50%的治療時間
****給藥間隔約為半衰期4倍
---Concentration dependent
**** aminoglycosides, metronidazole, quinolones daptomycin, colistin
**** Cmax/MIC的比值越高越好
**** Cmax/MIC建議能有10倍以上
---Area dependent
**** glycopeptides, quinolones, azithromycin, aminoglycosides, tetracyclines, tigecycline, colistin, linezolid
**** AUC/MIC比值越高越好
****建議AUC/MIC可以能有400倍以上
抗生素的後效應(post-antibiotic effect, PAE)
=是指細菌在接觸抗生素後雖然抗生素血清濃度降至最低抑菌濃度以下或已消失後,對微生物的抑製作用依然維持一段時間的效應
=它可被看作為病原體接觸抗生素後復甦所需要的時間
=一般來說
--- β lactam對GNB無PAE,所以務必使T > MIC有40~50%以上
--- Carbapenem對GNB有PAE
--- Aminoglycoside對GNB有PAE,所以一般頻次為QD使用
--- Colistin對GNB無PAE,所以頻次建議bid ~ tid
抗生素給予方式
= 抗生素藥物的吸收與給藥途徑有關
---口服腸胃道吸收達到最高血清濃度需4~6小時(吸收易受食物影響)
---肌肉皮下注射需1~4小時
---靜脈注射需20~60分鐘
= 一般來說口服藥物會因為先經過腸胃和肝臟,而使進入血液中或感染病灶的量較低
= 但以下的抗生素口服時,最高血中濃度的影響較小(PO約等於IV)
--- Fluoroquniolone, Amoxicillin/augmentin, Linezolid, Doxycycline, Minocycline, Baktar, Metronidazole, Fluconazole, Voriconazole
= 建議空腹、飯前1hr或飯後2hr再使用的抗生素
---(大部分抗生素為此類)penicillin, cephalosporins, fluoroquinolone ,tetracycline
= 建議與食物並用
--- augmentin, clarithromycin,cefuroxime, intraconazole, posaconazole
抗生素和血腦障壁(blood-brain barrier, BBB)
= 有無發炎皆可過BBB (therapeutic levels in CSF with or without inflammation)
---Trimethoprim, Chloramphenicol , Metronidazole, Rifampin, INAH
= 有發炎可過BBB (therapeutic levels in CSF with inflammation of meninges)
---Penicillins (Penicillin G, oxacillin, Ampicillin, Ticarcillin, Nafcillin, Piperacillin), Cephalosporins (Cefuroxime (2nd, marginal), Cefotaxime (3rd), Ceftriaxone (3rd), Ceftizoxime (3rd), Ceftazidime (3rd), Cefepime (4th)), Carbapenems (Imipenem (但會seizure,所以很少用), Meropenem), Fluoroquinolones (Ofloxacin, Ciprofloxacin, Moxifloxacin), Vancomycin, Tetracycline (mycoplasma encephalitis)
= 有無發炎皆不過BBB (nontherapeutic levels in CSF with or without inflammation)
---Aminoglycosides (Amikacin, Gentamicin), 1st generation Cephalosporin, Teicoplanin, Clindamycin, Macrolide (Azithromycin, Erythromycin, Clarithromycin), Carbapenem (Doripenem, Ertapenem), Caspofungin, Micafungin, Anidulafungin, Ketoconazole
抗生素治療天數
= 下泌尿生殖道感染、輕微皮膚組織感染:3~7天
= 一般感染、血流、呼吸道、上泌尿道、腸胃道感染:10~14天
= 骨骼、心臟血管、內臟膿瘍:4~6週
= 特殊細菌(如結核菌治療):6~12月
= 另外還需要考量病人免疫功能、藥物反應等來決定最終治療天數
抗生素造成的發燒
可以參考藥物造成的發燒、藥物熱 Drug Fever
http://teachingcenter1.pixnet.net/blog/post/352697768
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