introduction of antibacterial agent课件

Introduction of Antibacterial Agent - rapid approach,By ID R4 Shang-Yi Lin,Class of Antibacterial Agent,-Lactams Penicillins Cephalosporins Aztreonam Carbapenems (Meropenem) Aminoglycosides Glycopeptides (Vancomycin, Teicoplanin),Fluoroquinolones Marcolide Trimethoprim-sulfamethoxazole Metronidazole Tetracyclines Oxazolidinones,抗生素的分類及作用機轉,PK/PD,Concentration-dependent Aminoglycosides, Quinolones, Metronidazole, Amphotericin B Time-dependent Beta-lactam, Glycopeptide, Clindamycin, Macrolides,Penicillins,Natural Penicillin Penicillin G Benzathine penicillin G Antistaphylococcal penicillins Oxacillin; dicloxacillin Aminopenicillins Ampicillin ; amoxicillin Aminopenicillin + b lactamase inhibitor Unasyn, Augmentin Extended spectrum penicillins Peperacillin, ticarcillin Extended spectrum penicillins + b lactamase inhibitor Piperacillin-tazobactam, ticarcillin-clavulanate,Indication of Natural Penicillins,Gram positive bacteria and anaerobes only S. pyogens cellulitis Viridans streptococci infective endocarditis Neisseria meningitis - meningococcus Streptococus pneumoniae ? Spirochetes syphilis Actinomyces israelii Clostridium spp. Pasteurella multocida Leptospira interrogans leptospirosis,LYMPHANGITIS with group A streptococcus cellulitis in the knee,Penicillin G could be considered ,Bulla or pustule formation Staphylococcus spp,.,Oxacillin could be considered,Augmentin vs Unasyn,Amoxicillin/clavulanic acid (Augmentin) v.s Ampicillin/sulbactam (Unasyn) V.S Acinetobacter baumannii Cost ,Extended spectrum penicillins + b lactamase inhibitor,Piperacillin (Pipril) Ticarcillin/clavulanic acid (Timentin) Piperacillin/tazobactam (Tazocin) Indication: All can cover Pseudomonas aeruginosa (P.a) Pipril: P.aeruginosa+ streptococcus Ticarcillin/clavulanic acid (Timentin) P.aeruginosa+ Stenotrphomonas maltophilia Tazocin: P.aeruginosa+ anaerobic,Adverse effects of penicillins,Hypersensitivity: 3-10% Mild rash to life-threatening anaphylaxis Penicillin skin test Hematological reactions Thrombocytopenia, bleeding tendency Neutropenia Eosinophilia Gastrointestinal disturbances Nausea, vomiting, diarrhea hepatitis Central nervous system toxicities Seizures, hallucinations, coma Drug fever Proteinuria, pyuria,Cephalosporin,1st generation Cephalosporins 2nd generation Cephalosporins 3rd generation Cephalosporins 4th generation Cephalosporins,1st generation Cephalosporins,Cefazolin (12 g IV/IM q8h) Oral form: Nakacef 2# qid Indication: staphylococci, streptococci, Escherichia coli, Klebsiella, Proteus species.,2nd generation Cephalosporins,Cephamycins: cefmetazole: below-the-diaphragm Non-cephamycins: Cefuroxime above the diaphragm. KEP (K.p, E.coli, Proteus mirabilis) Citrobacter, Haemophilus influenzae, Moraxella catarrhalis, Morganella morganii,2th Cephalosporins,Cephamycins V.S Non-cephamycins GPC + + Enterococci - - H.influenza + + Enterobacteiacae + + Anaerobes + -,2th cephalosporins V.S Augmentin,Cephamycins V.S Augmentin GPC + + Enterococci - + H.influenza + + Enterobacteiacae + + Anaerobes + +,3rd generation Cephalosporins,Ceftriaxone (12 g IV/IM q1224h), Cefotaxime (12 g IV/IM q412h), Ceftazidime (12 g IV/IM q8h): Pseudomonas indication: Bacterial CNS infection Salmonlosis & gonorrhea Severe community acquired infection,4th generation Cephalosporins,Cefepime (maxipime) Cefpirome (cefrom) Cefepime v.s Cefpirome Pseudomonas aeruginosa v.s Streptococcus pneumoniae Pseudomonas aeruginosa+ Streptococcus pneumoniae,Resistance to Cephalosporins,Enterococci Listeria monocytogenes Legionella Inducible b lactamase production, except Cephamycin for ESBL-pathogen 4th Cephalosporin for AmpC- pathogen 1,2nd Cephalosporin for Samonella Acinetobacter baumannii,Aztreonam,Aztreonam (12 g IV/IM q612h) Monobactam that is active only against aerobic GNB including P. aeruginosa, no gram-positive or anaerobic activity. useful in patients with known PCN or cephalosporin allergies,Carbapenem,Imipenem Seizure (3%) increase BUN/Cr Allergy,N/V,Diarrhea,Meropenem Less seizure Less increase BUN/Cr,Notably resistant bacteria: ampicillin-resistant enterococci, ORSA , Stenotrophomonas maltophilia, Clostridium difficile,Ertapenem not effective to Pseudomonas & A-B,Aminoglycosides,Gentamicin Traditional dosing is an initial loading dose of 2 mg/kg IVD (3 mg/kg in the critically ill) followed by 1.01.7 mg/kg IVD q8h Once-daily dosing is 5 mg/kg, Amikacin Unique role for mycobacterial and Noracrdia Streptomycin Drug resistent tuberculosis Adverse effect Nephrotoxicity and ototoxicity,Indicated for Combination Therapy,Prevention of the emergence of resistant mutants. anti-TB, anti-HIV, P. aeruginosa, K. pneumonia, Enterobacter spp., Citrobacter spp. Synergistic or additive activity Infective endocarditis Therapy directed against multiple potential pathogens- mixed infections Febrile, leukopenic patients,Glycopeptide,Vancomycin (15 mg/kg IV q12h; 30 mg/kg IV q12h for meningitis Check trough level after 3rd or 4th dosage Teicoplanin Loading: 400 mg( 6mg/kg) q12h x 3 Maintain: 400 mg( 6mg/kg) qd,Glycopeptide,Vancomycin IV, oral Red man syndrome Oral form CSF data Q7 day Ototoxicity renal toxicity,Teicoplanin IV No oral form CSF no data Renal toxicity less expensive,Indication of Glycopeptides,Serious infections by ORSA Serious infections by ampicillin-resistant enterococci Serious infections by G(+) bacteria in patients who are allergic to all other appropriate therapies Oral treatment of Clostridium difficile colitis not responded to two courses (10 days each) of metronidazole failing metronidazole with a potentially life-threatening colitis,Oxazolidinones: Linezolid (Zyvox),ORSA or MRSA (oxacillin or Methicillin- resistant S.aureus) VRE (Vancomycin- resistant Enterococcus) GISA (glycopeptide intermittent staphylococcus aureus) VRSA (vancomycin resistant staphylococcus aureus),Fluoroquinolones,1st generation GNB Nalidixic acid 2nd: fluoroquinolones Ciproxacin, Ofloxacin,: GNB atypical (Mycoplasma,Legionella, Rickettsiae, Mycobateria tuberculosis) 3rd: Levofloxacin :GNB, PRSP,atypical 4th : Moxifloxacin, gemifloxacin, gatifloxacin,Common reasons of FQ use,Better tissue penetration Prostatitis, abscess, osteomyelitis Cover Pseudomonas Oral form B lactams allergy Atypical infection Legionella, mycoplasma, chlamydiae tuberculosis,Quinolones,Pseudomonas aeruginosa: Ciproxin LevofloxacinMoxifloxacin Pneumococcus (Streptococcus pneumoniae) : Ciproxin LevofloxacinMoxifloxacin,Ciprofloxacin and Levofloxacin,the most active quinolone against P. aeruginosa and is the quinolone of choice for serious infections with that pathogen poor activity against gram-positive cocci and anaerobes second-line agents for TB therapy Levofloxacin: 1) 750 mg - a) TB therapy b) P.aeruginosa c)Stenotrphomonas maltophilia 2) 500mg- Other infection,Anti-P. aeruginosa antibiotics,Piperacillin (Pirpil) Ticarcillin/clavulanic acid (Timentin) Piperacillin/tazobactam (Tazocin) Ceftazidime, Cefoperazole Cefepime, Cefpirome Ciprofloxacin (400mg q12h-q8h) Levofloxacin (750 mg qd IVD),Carbapenem Meropenem Imipenem Aztreonam Moxalactam Aminoglycoside,Metronidazole,greater activity against gram-negative than gram-positive anaerobes but is active against Clostridium perfringens and difficile. Pseudomembrane colitis : metronidazole, fusidic acid,vancomycin oral form, Protozoan infections that are routinely treated with metronidazole include Blastocystis hominis 2# tid x 10 days or Trichomonas vaginalis, Giardia, Entamoeba histolytica,Azithromycin, clarithromycin,bind to the 50S subunit of bacterial ribosomes SPECTRUM erythromycin-sensitive S. pneumoniae, Haemophilus spp, M. catarrhalis, and atypical pneumonia pathogens including Legionella pneumophila, Chlamydophila pneumoniae, and Mycoplasma pneumoniae Escherichia coli, Salmonella spp, Yersinia enterocolitica, Shigella spp, Campylobacter jejuni, Vibrio cholerae, Neisseria gonorrhoeae, and Helicobacter pylori. Mycobacterium avium complex,The timing of antibiotics prescription,抗生素是否需要?,infectious vs non-infectious disease 微生物學檢查證實 (True pathogen vs colonization) 臨床症狀懷疑細菌感染 預防性抗生素 Pre operation For rheumatic fever, meningococcal meningitis, malaria, some virus infection For AIDS patients: PCP, cryptococcus For immunocompromised host: BMT For infective endocarditis (AHA 2009 guideline),Ten questions about antibiotics therapy,1. 有需要用嗎? 2. 適當適量的標本送檢了嗎? (染色