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抗生素的該用與不該用

抗生素的該用與不該用. 衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官. 問題一 : 有長細菌就要用藥嗎 ?. Ans: 那要看細菌由那裡長出來. From sterile site contaminant pathogen: symptomatic or asymptomatic From potential contaminated site quantitative culture From contaminated site. 問題二 : 沒長細菌就不能用藥嗎 ?. 各種器官感染之微生物學診斷率.

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抗生素的該用與不該用

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  1. 抗生素的該用與不該用 衛生署 疾病管制局 中區傳染病防治醫療網 王任賢 指揮官

  2. 問題一:有長細菌就要用藥嗎?

  3. Ans: 那要看細菌由那裡長出來 • From sterile site contaminant pathogen: symptomatic or asymptomatic • From potential contaminated site quantitative culture • From contaminated site

  4. 問題二:沒長細菌就不能用藥嗎?

  5. 各種器官感染之微生物學診斷率 • Septic shock: 80-90% • Cellulitis: 20-50% • Bacterial meningitis: 60-90% • Infective endocarditis: 60-70% • Acute cholecystitis: 50-70% • Urinary tract infection: 30-40% (B) • Community-acquired pneumonia: 25%

  6. 問題三:(還)沒長細菌時該如何用藥?

  7. Antimicrobial spectrum of penicillin G • Streptococcus spp. • Anaerobes • Neisseria spp.

  8. Second generation penicillins • Anti-Staphylococcus penicillins Streptococcus, Staphylococcus • Ampicillin and derivatives Streptococcus, anaerobes, Neisseria, E. coli, P. mirabilis, Salmonella, Shigella, H.influenzae, Listeria monocytogenes • Amoxicillin/clavulanic acid (augmentin) Ampicillin/sulbactam (unasyn)

  9. Third generation penicillins • Lilacillin • Ticarcillin • Piperacillin • Piperacillin/tazobactam Ticarcillin/clavulanic acid

  10. First generation cephalosporins • Staphylococcus • Streptococcus • E. coli • P. mirabilis • K. pneumoniae

  11. 第一代與第二代cephalosporins的分野Hemophilus influenzae

  12. 第二代與第三代cephalosporins的分野CNS penetration

  13. 問題四:選擇用藥只需看敏感性試驗嗎?

  14. Antimicrobial tests • Tests that predict the effectiveness of therapy • Tests that monitor the effectiveness of therapy

  15. Gram-positive bacteria Staphylococcus spp. Enterococcus spp. S. pneumoniae Streptococcus spp. other than S. pneumoniae Gram-negative bacteria Enterobacterioceae P. aeruginosa Acinetobacter spp. Haemophilus spp. N. gonorrhoeae V. cholerae 可由紙錠擴散法獲得可靠藥物敏感性測試結果的細菌

  16. Gram-positive bacteria Streptococcus viridans Listeria spp. Corynebacterium spp. Bacillus spp. Nocardia spp. Rhodococcus spp. Lactobacillus spp. Others Gram-negative bacteria N. meningitidis M. catarrhalis Non-aeruginosa Pseudomonas GNFGNBs Campylobacter spp. Aeromonas spp. Others 不能由紙錠擴散法獲得可靠藥物敏感性測試結果的細菌

  17. Staphylococcus spp.的紙錠法判讀準則 • Penicillin-susceptible susceptible to all b-lactam antibiotics • Penicillin-resistant, oxacillin-susceptible resistant to b-lactamase-labile penicillins susceptible to b-lactamase-stable penicillins, cephems, carbapenems, b-lactamase inhibitor combinations • Oxacillin-resistant only susceptible to vancomycin & teicoplanin

  18. Enterobacterioceae的紙錠法藥敏試驗 • Intestinal isolates of Salmonella & Shigella ampicillin a quinolone TMP/SMX • Extraintestinal isolate of Salmonella plus chloramphenicol a third generation cephalosporin • Enterobacter, Citrobacter, and Serratia在治療 過程中極易產生抗藥性，治療過程中同樣的 isolate 亦必須作藥敏試驗

  19. Inducible b-lactamase of GNB • Richmond-Sykes group 1 b-lactamase • Chromosomally mediated • Found in: Enterobacter species Serratia species Citrobacter freundii indole-positive Proteus species Providencia species Morganella species Pseudomonas aeruginosa Acinetobacter baumanii

  20. 問題五:用藥都必須由第一線開始嗎?

  21. Acceptable antibiotics in IAI • Community-acquired infections of mild-to-moderate severity monotherapy cefoxitin cefotetan cefmetazole ampicillin-sulbactam ticarcillin-clavulanic acid combination therapy anti-anaerobe plus aminoglycoside

  22. Acceptable of antibiotics in IAI • Severe infection monotherapy carbapenems piperacillin-tazobactam combination therapy anti-anaerobe plus 3rd generation cephalosporin or aminoglycoside clindamycin plus aztreonam ciprofloxacin plus metronidazole

  23. 問題六:抗生素需要合併使用嗎?

  24. Combination is exception

  25. Indications for combination • Pseudomonas group infection • Severe sepsis • Unknown etiology • Mixed infection • Anti-TB treatment

  26. Median SBAs* of ceftazidime with or without amikacin Organism Dose SBA 1 h 6 h K. pneumoniae ceftazidime 2.0 g 1:512 1:64 amikacin 0.5 g 1:32 1:4 ceftazidime 2.0 g + amikacin 0.5 g 1:512 1:64 P. aeruginosa ceftazidime 2.0 g 1:64 1:8 amikacin 0.5 g 1:2 <1:2 ceftazidime 2.0 g + amikacin 0.5 g 1:64 1:8 *: serum bactericidal activity Antimicrob Agents Chemother 1983;23:435-9

  27. 問題七:抗生素該使用多久呢?

  28. 問題八:抗生素的劑量該如何選擇?

  29. 抗生素一般使用原則 • 盡量用narrow spectrum的藥物 • 一種細菌用一種藥物治療 • 必須以足量藥物治療 • 最佳治療時間為七至十四天

  30. 問題九:感冒何時需要使用抗生素?

  31. 感冒何時需要使用抗生素? • Bacterial tonsillitis • Bacterial pharyngitis • COPD with acute exacerbation • Pneumonia & bronchopneumonia • Sinusitis & otitis media

  32. 問題十:那些抗生素用量增加時該查?

  33. 那些抗生素用量增加時該查? • 所有口服抗生素 • Tetracyclines • Erythromycins • Quinolones • 第一線 b-lactam 抗生素

  34. Indications for tetracycline • Chlamydial diseases • Rickettsial diseases • Brucellosis • Relapsing fever • Tularemia

  35. 問題十一:發燒不退就該改藥嗎?

  36. 用上合適抗生素後發燒不退的原因 • Superinfection • Resistant strain • Abscess formation • Drug fever

  37. Thank you for your attention

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