抗生素的应用（英文）

Case 1 An8 year oldboyisseeninFebruarybecauseoffever headache sorethroat andmalaise He shadnorhinorrhea cough orhoarseness Physicalexaminationrevealsatemperatureof103 5 exudativepharyngitis andtendercervicaladenopathy Howwillyoutreathim Ispenicillinstillthedrugofchoicefortreatmentofstreptococcalpharygitis AAPrecommendsoralpenicillinV2 3timesdailyfor10days asingledoseofbenzathinepenicillin oramoxicillin250mg kgtidfor10daysLargerdosesofpenicillinoncedailyresultinmorerelapses Breese 1965 Gerber 1989 Oncedailydosing RecommendedbytheFDA azithromycin Zithromax cefixime Suprax cefdinir Omnicef cefadroxil Ultracef Duracef ceftibutin Cedax Amoxicillin 750mgoncedaily Feder Pediatrics 1999 Shortercourses ApprovedbytheFDAfor5 dayregimen cefpodoxime Vantin cefdinir Omnicef azithromycin Zithromax Whataboutthepenicillin allergicchild Erythromycinestolate 20 40mg kg ddividedbid orethylsuccinate 40mg kg ddividedbid Azithromycin 12mg kg dx5d clarithromycin 15mg kg ddivq12hrs clindamycin 20mg kg ddivq6 8hrs Whypenicillinmight fail Non adherancetoprescribedtherapyfailuretorecognizecarriers beta lactamaseproductionbyotherpharyngealfloranewstreptococcalinfection Case 2 A13 year oldboyhashadfeverandsorethroatfortwodays Henowpresentswithacough Onexaminationhehasatemperatureof104 RR22 O2saturationof98 retractions andcracklesovertheposteriorleftlowerlung Chestx rayconfirmsaleftlowerlobepneumonia Whatdoyouthinkiscausinghispneumonia Howwillyoutreathim CommonCausesofCommunity AcquiredPneumoniainOtherwiseHealthyChildren VirusesRespiratorysyncytialvirusInfluenzaAandBParainfluenza1 2 and3AdenovirusRhinovirusesMeaslesvirusMycoplasmaMycoplasmapneumoniaeChlamydiaChlamydiapneumoniaeChlamydiatrachomatis BacteriaStreptococcuspneumoniaeMycobacteriumtuberculosisStaphylococcusaureusHaemophilusinfluenzaetypebnon typableH influenzae McIntosh K NEJM2002 346 429 Likelihoodthatthepneumoniaisbacterialisgreaterif Feveris 39degreesCThepatient lookssick Therearealveolarinfiltratesonchestx rayWBCis 15 000NB Bloodcultureispositiveinabout10 ofinfantsandchildrenwithbacterialpneumoniaandmorelikelyinthose 2yrs Bacterialpneumoniaaccordingtoage 28days GroupBstreptococcus Gramnegativeenterics CMV listeria3wks 3months Ctrachomatis RSV parainfluenza S pneumoniae B pertussis Staphaureus4months 4years respiratoryviruses S pneumoniae M pneumoniae H influenzae TB5 15years M pneumoniae S pneumoniae C pneumoniae TB Antibioticsforpneumonia accordingtoage 28days ampicillinandgentamicin1month 3months macrolide afebrile cefotaxime ceftriaxone fever 4months 4years NOANTIBIOTICSFORVIRALINFECTIONAmoxicillin 80 100mg kg ddividedtid ORampicillin200mg kg ddividedq6hrs ORcefuroximeorcefotaxime5 15years macrolide IVampicillinORcefuroximeORcefotaxime Beta lactam resistantS pneumoniae Intermediateresistance MIC 0 1 1microgram mlHighlevelresistance MIC 2micrograms ml100 000units kgofpenicillinGyieldsaserumconcentrationofabout10micrograms ml500mgofamoxicillinyieldsaserumconcentrationofabout8micrograms ml Importanceofbeta lactam resistantS pneumoniae Highestriskinchildren 3yearsdaycarerecentantibioticsCanbeovercomebyhighdosesofpenicillin ampicillinImpactofPrevnarforimmunizedchildren 11 fewerepisodesofpneumonia 33 fewerwithabnormalx ray 73 fewerwithextensivedisease WhatifhisRRwas35 hisO2saturationwas85 andhehadaneffusiononchestx ray Don tforgetStaphylococcusaureusandgroupAstreptococcusinchildrenwithlargeeffusionswholookverysick IVclindamycinshouldbeaddedforthesechildren Case 3 Atwo month oldgirlisbroughttoyourofficebecauseofa5 dayhistoryofrhinorrheaandcough Shehasbeenafebrile Onexamshehasrhinorrheaandcoughsfrequently Therearescatteredcracklesandwheezesthroughoutherlungfields Whatisthecauseofherrespiratorysymptoms Howwillyoutreather Antibioticsforpneumonia accordingtoage 28days ampicillinandgentamicin1month 3months macrolide afebrile cefotaxime ceftriaxone fever 4months 4years NOANTIBIOTICSFORVIRALINFECTIONAmoxicillin 80 100mg kg ddividedtid ORampicillin200mg kg ddividedq6hrs ORcefuroximeorcefotaxime5 15years macrolide IVampicillinORcefuroximeORcefotaxime Thinkabout PertussisAnycontactswithcoughillness Isthecoughparoxysmal Chestx ray pertussisonlyrarelyisassociatedwithpulmonaryinfiltratesCBCtolookforlymphocytosisChlamydiaMaternalhistoryofchlamydia Andthinkabout VirusesContacts Season RSV influenza parainfluenza enteroviruses Antibiotic Theonlyclassthatmakessenseismacrolides erythromycinestolate clarithromycin azithromycin Case 4 Afour year oldgirlhashadrhinorrhea cough andintermittantfeverfor12days Hermomthinkstherehasbeennoimprovementinhersymptomsduringthattime Onexamshehasatemperatureof100 5 rhinorrhea andcough Whatisyourdiagnosis AAPClinicalPracticeGuideline September 2001 Diagnoseacutesinusitisbaseduponpersistentsymptoms noneedforradiologicstudiesTreatwithantibioticsasperacuteotitismediarecommendationsBUT FindingsfromGarbutt JM etal Pediatrics 2001 107 619inastudyof161patients1 18yearsold 50 7yrs withsymptomsbetween10 28days CriticismofGarbuttstudy ChildrenincludedwereonlymildlyillDiagnosiswasn tconfirmedbyx rayInclusionofolderchildrenwhosediseasewaslikelymildSymptomatictherapywaspermittedAntibioticdosesprescribedmayhavebeeninadequate Wald letter Pediatr2002 109 166 Case 5 A6 yearoldgirldevelopedvaricella7daysago Shehadfeverforthefirst4daysofherillness Feverresolvedbutreturned1dayago Nowshecomplainsofpaininherleftleg Onexamshehasatempof102 5 scabbedvaricellalesionsoverhertrunk face andextremities andtendernessoverherleftankleregion Thereisalsorednessandtendernessaroundoneofthescabbedlesionsonherabdomen Whatisyourmajorconcern MMWR 1997 46 944 Casesofvaricellaatachildcarecenter bydateofonset Boston MAJanuary February1997 CasesofgroupAstreptococcusatachildcarecenterbydateofonset Boston MA January February 1997 Bacterialcomplicationsassociatedwithvaricella TreatforgroupAstreptococcalinfection butkeepStaphylococcusaureusinmind Case 6 An18 month oldgirlpresentswithcontinuingsymptomsafter4daysoftreatmentwithamoxicillinforacuteotitismedia Sheisstillcomplainingofearpain shehasatemperatureof38 8degreesC andsheisirritable OnexamyoufindthatherTMiswhiteandbulgingwithdecreasedmobility Whatis arethelikelycause s ofherpersistentfindings Howwillyoutreather Appropriatequestions Whatdoseofamoxicillinwasprescribed Didshetakeit Whatisthelikelihoodofinfectionwithresistantpneumococcus Whatotherbacteriadoyouwanttotreat RiskthatthisinfectionisduetoS pneumoniae AcuteotitismediaduetoS pneumoniaeisleastlikelytoresolvespontaneouslyRiskfactorsforinfectionwithresistantS pneumoniae 3yearsdaycareattendance Treatmentoptions Continuecurrenttherapy thereisnodirectrelationshipbetweenthepersistenceofsymptomsandtheviabilityofinfectingbacteria Increaseamoxicillinto80 90mg kg day increaseactivityagainstresistantS pneumoniae Increaseactivityagainstbeta lactamase producingorganisms H influenzaeandM catarrhalis Enhancedtreatmentagainstbeta lactamase producers Addclavulanate couldalsoenhanceactivityagainstresistantS pneumoniaebyincreasingamoxicillincomponent Alternatechoices cefdinir Omnicef cefuroximeaxetil Ceftin IMceftriaxone Rocephin azithromycin Zithromax Otherapproaches Enhancecompliance reduceddailydosing bettertaste parenteral ceftriaxone therapyTympanocentesisandculture Case 7 A2 montholdboy bornatterm isbroughttotheEDbecauseoffever irritability andpoorfeedingforthepast24hours Onexamtheinfanthasatempof101 RR50 O2saturation95 Heismoderatelyirritable buthisexamisotherwisenormal Howwillyouevaluateandtreathim Afterblood urine andCSFcultureshavebeenobtained Treatmentshouldbeaimedatwhichbacterialorganisms S pneumoniaeGroupBstreptococcusH influenzaeE coliandotherenterics inclsalmonellaListeria What swrongwithampicillinandgentamicin Nothing aslongastheCSFdoesn trevealpleocytosis Ifitdoes useampicillinandceftriaxone cefotaxime andconsidervancomycinpendingcultures Case 8 A15 year oldboywaswrestlingwithhisneighbor sdogandwasbittenonthearm Onexamhehasa2cmjaggedlacerationonhisrightforearm Whatarethebacterialagentstoconsider Whatantibiotic s willyouuse Bacteria Staphylococcusaureus ampplusclav Pasturellamultocida penicillin ampicillin Eikenellacorrodens ampicillin StreptococcusandStaphylococcusspeciesDon tforgettowashthewoundandgivetetanusprophylaxisifindicated A14 year oldgirlis