硕腾皮肤病chn脓皮病pyoderma noli

1、Dr. Chiara NoliDVM, Dip ECVDServizi Dermatologici VeterinariPeveragno (CN), Italy硕腾学苑皮肤病高级班培训课件 Usually caused by staphylococci通常由葡萄球菌引起 S. pseudointermedius假中间型葡萄球菌金黄色葡萄球菌施氏葡萄球菌 S. Aureus S. Schleiferi coagulase negative staphylococci凝固酶葡萄球菌 Less frequently by streptococci,Pseudomonas, Proteus, E.

2、Coli由链球菌硕、腾假学苑单皮胞肤菌病、高级变班形培杆训菌课件和大肠杆菌引起的脓皮症较少见 Involves the superficial horny layer涉及浅表的角质层 pyotraumatic dermatitis (hot spot)脓性创伤性皮炎（湿疹） skin fold pyoderma 皮褶处脓皮症硕课件腾学苑皮肤病高级班培训硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件Involves the epidermis涉及表皮层puppy pyoderma (impetigo)幼犬脓皮症（脓疱病）细菌性毛囊炎bacterial folliculitis硕课件腾学

3、苑皮肤病高级班培训硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件 In dermis and/or subcutis真皮层内和/或皮下组织cne 下巴痤疮pododermatitis 爪部皮炎acral lick granuloma 肢端舔舐性肉芽肿callus pyoderma胼胝性脓皮症furunculosis疖病German shepherd pyoderma德国牧羊犬脓皮症硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件病史 Hi

4、story Skin scrapings and trichogramme皮肤刮片检查和毛发镜检 Cytology 细胞学检查 Bacterial culture and susceptibility细菌培养和药敏试验test（活检） (Biopsy)硕腾学苑皮肤病高级班培训课件 Cytology 细胞学检查硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件 superficial: bacteria in neutrophils浅表性：中性粒细胞内细菌硕腾学苑皮肤病高级班培训课件 deep: macrophages, few bacteria深部：巨噬细胞、

5、少量细菌硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件 Pyodermas are nearly always secondary to an underlying cause脓皮症几乎都继发于某种潜在病因 If the underlying causes are not identifiedand corrected the pyoderma will relapse若未查找和纠正潜在病因，脓皮症会复发硕腾学苑皮肤病高级班培训课件%Seconday pyodermaNoli继发性脓皮症. 2006Atopic dermatitis 异位性皮炎24,7%Adverse reactio

6、ns to food不良反应15,5%50Flea bite allergy 跳蚤叮咬性过敏15,2%Demodicosis 蠕形螨6,0%Cushings syndrome 库综合征2,1%Hypothyroid硕ism腾甲学减苑皮肤病高级班培训课件1,5% Pyoderma is most often secondary to allergies, which are difficult to cure and keep under control脓皮症最常继发于过敏，难以治愈和 30% of pyodermas have an unknown underlying causes 30%的

7、脓皮症具有未知的潜在病因àFrequent relapses of the pyoderma脓皮症常见复发 Repeated antibotic courses are necessary有必要重复使用抗生素治疗à Increased risk of developement of bacterial产生细菌耐药性的风险升高硕腾学苑皮肤病高级班培训课件 Acquisition ofduring therapy seems to be frequent治疗期间似乎经常产生耐药性 Colonisation with resistant bacteria persists eve

8、n after theresolution of the pyoderma即使在脓皮症痊愈后耐药菌也持续定植Bec硕k苑. V皮e肤t D病e高rm级2班01培2训课件Prevalence of MRSP post therapy治疗后MRSP的流行率Skin皮肤Nose/rectum鼻部/直肠Dogs with pyoderma non-MRSP非MRSP性脓皮症的犬28,3%26,7%Dogs with pyoderma by MRSPMRSP性脓皮症的犬45,2%47,6% MRSP Meticillin-R S. Pseudintermedius耐甲氧假中间型葡萄球菌 R to all

9、 penicillins, cefalosporins, carbapenems对所有青霉素、头孢菌素和碳青霉烯类抗生素耐药 MRSA Meticillin-R S. Aureus耐甲氧金黄色葡萄球菌 R to all penicillins, cefalosporins, carbapenems对所有青霉素、头孢菌素和碳青霉烯类抗生素耐药 Danger for human health should be reported to family doctor威胁人类健康 应报告给家庭医生 MDR multi-drug resistant多重耐药菌 Resistant 硕to a腾t le学as

10、t 3皮an肤tib病ioti高c f级am班ilie培s训课件至少对3类抗生素耐药Frequent use of AB of “last generation classes” as first line antibiotics (lets try the new drug!)经常将“最高等级”抗生素作为一线抗生素使用（让我们试试新药吧！）Frequent use of quinolones, more than in other countries (20%) (lets usethe AB that kills them all!)经常使用喹诺酮类，比其他使用频繁（20%）（让我们使用能

11、杀死所有细菌的抗生素吧！）Low rate of bacterial culture and sensitivity testing (lets save somemoney!)进行细菌培养和药敏试验的频率较低（让我们省些钱吧！） Frequent use of human antibiotics (lets use the cheaper ones!) 经常使用人用抗生素（让我们用比较便宜的药吧！）(SalaEscher. Not Ist Super Sanità, 2006. J Antimicrob Chemother, 2011)硕腾学苑皮肤病高级班培训课件Escher. U

12、se of antimicrobials in companion animal practice: aretrospective study in a veterinary teaching hospital in Italy. （伴侣动物临床中抗生素的使用：意大利一家兽医教学医院的回顾性研究） J AntimicrobChemother, 20硕11腾学苑皮肤病高级班培训课件AB class抗生素级别Pyoderma脓皮症Gastro- enteric 胃肠道UTI下泌Respiratory infections 呼吸道1st choice首选75%3%31%11%2nd choice第二

13、选择11%4%13%20%Last resort终极选择13%-51%- Important increase of antibiotic-Pseudintermedius假中间型葡萄球菌的抗生素耐药性显著提高 In the last 4-5 years在过去的4-5年中 20-50% in 2°-3° opinion derm practice 20-50%在皮肤病临床中为第二至第三选择 1-5% in first opinion general practice 1-5%为全科临床中的首选by S.à The problem is reaching t sin

14、ce about 1 yeareral practitioners涉及到全科临床工作者已有1年时间硕腾学苑皮肤病高级班培训课件 The majority of methicillin-R Staph. pseudintermediusare also multi-R大部分耐甲氧假中间型葡萄球菌也是多重耐药菌 R against all penicillins, cephalosporins, quinolones, lincosamides, macrolides, TMP-sulphonamides对所有青霉素、头孢菌素、喹诺酮类、酯类、三甲氧苄氨磺胺嘧啶耐药 Emergency AB pa

15、nel:抗生素组合：胺类、大环内 Chloramphenicol, rifampin, phosphomicin, amikacin and other aminoglucosides氯霉素、利福平、磷霉素、阿米卡星和其他氨基糖苷类抗生素硕腾学苑皮肤病高级班培训课件 Necessary clinical monitoring for:有必要对下列情况进行临床监测： Haepatotoxicity of rifampin 利福平的肝毒性 Nephro- and ototoxicity of aminoglycosides氨基糖苷类的肾毒性和耳毒性 Lack of veterinary (and

16、human) formulations缺少（和人用） Difficult TID or SC administration难以三次获皮下注射给药 Increase in R towards chloramphenicol and rifampin对氯霉素和利福平的耐药性增加硕腾学苑皮肤病高级班培训课件硕腾学苑皮肤病高级班培训课件 Surface pyoderma表面脓皮症 Topical therapy only仅外用药治疗 Superficial pyoderma 浅表性脓皮症 Try topical therapy first for 2 weeks先尝试外用药治疗2周时间 If no r

17、esponse or partial response若无效或部分有效 reconsider diagnosis, consider underlying disease重新，考虑潜在病因 add oral antibiotic增加口服抗生素 Deep pyoderma深部脓皮症 Systemic antibiotic after susceptibility test药敏试验后全身用抗生素硕腾学苑皮肤病高级班培训课件 Shampoo 香波removes bacteria, debris, crusts, dirt清除细菌、碎屑、结痂、污垢10-15 min contact time! 10-

18、15min接触时间!rinse very well, use conditioner冲洗干净，使用润肤剂2-3 times per week, then less frequently每周2-3次，之后频率降低as maintenance 1-2 times per month, it can prevent recurrencies维持期每月1-2次，可防止复发硕腾学苑皮肤病高级班培训课件 Lotion/spray for sparsely haired areas乳液/喷剂用于毛发稀疏的部位 Creams for localized problems乳膏用于局灶性 intertrigo,

19、hot spot, acne, pododermatitis擦烂、湿疹、粉刺、爪部皮炎 avoid licking for 10 minutes用药后10分钟内防舔硕腾学苑皮肤病高级班培训课件 Avoid antibiotics! 避免使用抗生素！Chlorhexidine 0,5 - 4% (+ Malassezia!)0.5-4%氯己定（+Ethyl lactate 10% 10%乳酸乙酯色菌！）Sulphur 2%-salycilic acid 2%2%硫磺-2%水杨酸Benzoyl peroxyde 0,5% 0.5%过氧化苯甲酰Octopirox piroctolamine吡啶酮乙醇

20、胺盐硕腾学苑皮肤病高级班培训课件Efficacy of topical therapy外用疗法的效果Cephalexin (Group1) or chlorhexidine4% shampoo and spray(Group 2) for 28 day in dogs with superficial pyoderma对浅表性脓皮症患犬给予头孢氨苄（组1）或4%氯己定香波和喷剂（组2），持续28天No significant statistical differences between the twotreatment groups2个治疗组之间没有显著的统计学差异Topical thera

21、py equally successful in MSSP and MRSP.外用药治疗对于MSSP和MRSP的治疗率一致(Effectiveness of a combined 4% chlorhexidine digluconate shampoo andsolution protocol in canine superficial pyoderma. Borio Congress 2014)., ESVD-ECVD硕腾学苑皮肤病高级班培训课件 Empyric therapy经验性治疗 First occurrence superficial pyoderma首次发生浅表性脓皮症 Foll

22、owing susceptibility test根据药敏试验结果细胞学发现杆菌深部脓皮症Rods on cytology Deep pyoderma“Empyric” antibiotic gave no effect“经验性”抗生素无效New lesions during AB therapy抗生素治疗期间出现新病灶Several recurrencies多次复发Several antibiotics used in the past过去使用过多种抗生素硕腾学苑皮肤病高级班培训课件 Pustule 脓疱 Rupture the pustule with a fine needle用细针挑破

23、脓疱 Collect pus from the needle or从针上或病灶上结痂脓汁lesion Crusts Lift crust and collect pus from underthe crust掀起结痂并结痂下的脓 Collarette 环形脱屑 Roll a sterile swab on the borders ofthe lesion在病灶边缘滚拭无菌棉签硕腾学苑皮肤病高级班培训课件 Papules, nodules丘疹、结节 Skin biopsy皮肤活检 Fine needle aspiration and blow content of sterile swab细针抽

24、吸和吹下无菌棉拭子上的样本 Fistulae 瘘管 Squeeze lesions and collect material with a sterile swab or insert swab in the fistula挤压病变，使用无菌棉拭子样本，或将棉拭子瘘管进行采样硕腾学苑皮肤病高级班培训课件 Put in transport medium and send to lab within 48 hours放入转运培养基并在48小时内寄送到àRisk to isolate more resistant not necessarily significant bacteria有风

25、险会分离出耐药性更强但并无明显意义的细菌 Keep refrigerated until shipping前保持冷藏àRefrigerated shipping is not necessary无须冷藏硕腾学苑皮肤病高级班培训课件 Methodology: Kirby-Bauer diffusion disks (acceptable)K-B纸片扩散法（可以接受） Minimum inhibitory concentrations (better)最小抑菌浓度（更好） Information you absolutely need from your laboratory:你肯定需要

26、从获得的信息： Bacterial speciation 细菌种类 Methicillin/oxacillinor susceptibility对甲氧/苯唑的耐药性或药敏试验结果硕腾学苑皮肤病高级班培训课件红霉素、四环素（霉素环素）Erythromycin, clindamycin Tetracycline (doxicicline) TMP-sulphametoxazole增效磺胺甲基异唑Gentamicin (for all aminoglicosides)庆大霉素（所有氨基糖苷类）Cephalotin (for cefalexin and cefadroxil)头孢噻吩（头孢氨苄和头孢羟

27、氨苄）Cefpodoxime (for all 3° generation ceph.)头孢泊肟（所有3代头孢类抗生素）酸甲氧Amoxicillin-clavulanic acidOxacillin (for meticillin)苯唑（）Enrofloxacin (for all quinolones)恩诺沙星（所有喹诺酮类抗生素）硕腾学苑皮肤病高级班培训课件利福平环素 Rifampin Minociclin Choramphenicol氯霉素磷霉素阿米卡星 Fosfomicin Amikacin硕腾学苑皮肤病高级班培训课件Veterinary Record January 201

28、3硕腾学苑皮肤病高级班培训课件Veterinary Dermatology June 2014硕腾学苑皮肤病高级班培训课件Good first line antibiotics only if there are compliance or administration problems:仅在配合度或给药有时可以选用的一线抗生素：Cefovecin, cepoxidime头孢维星、头孢西丁Good first line antibiotics:可用的一线抗生素：Clindamycin, lincomycin, cefalexin, cefadroxil, amoxicillin/clavula

29、nic acid, TMP-sulphonamides霉素、林可霉素、头孢氨苄、头孢羟氨苄、西拉维酸、增效磺胺类 Broad spectrum drugs important for animals and humans, may not be licensed for animals对于人和动物重要的广谱抗生素，可能并未用于动物 Development ofof greater concern耐药性的发展已引起较大关注 Safety and efficacy data may be limited安全性与有效性的研究数据有限 Should only be used if there is c

30、ulture evidence that first line drugswill not be effective 应该只在培养结果显示一线抗生素无效时使用硕腾学苑皮肤病高级班培训课件Second line antibiotics: 二线抗生素Enrofloxacin, marbofloxacin, pradofloxacin, Tylosin, azithromycin, clarithromycin, Doxycycline, minocycline恩诺沙星、沙星、沙星、菌素、霉素、克拉霉素、环素、环素 Drugs very important to animals and humans

31、对于人和动物很重要的 Treatment of multi-drug resistant organisms治疗多重耐药菌of great concern耐药性已引起极大关注 Most drugs are not licensed for animals大多数未用于动物 Safety and efficacy data very limited 安全性和有效性的数据非常少 Must only be used when there is culture evidence of sensitivity, no second line antibiotics and topical antimicr

32、obials are not effective 只能在培养结果和药敏试验结果显示，二线抗生素和外用抗生素均无效时才能使用Third line antibiotics 三线抗生素Aminoglycosides, Chloramphenicol, Florphenicol, Tiamphenicol, Imipenem, Rifampin, Phosphomycin, Piperacillin, Ceftazidime,Ticarcillin 氨基糖苷类、氯霉硕素腾、氟学苯苑尼皮考、肤甲病砜高霉级素班亚培胺训培课南、件利福平、磷霉素、哌拉、头孢他啶、羟基噻吩青霉素 bactamase-sensi

33、tive penicillins内酰胺类敏感的青霉素类抗生素 ex. penicillin, ampicillin, amoxicillin例如：盘尼、氨苄、 insufficient cutaneous distribution皮肤分布不良 ex. streptomycin, tetracycline例如：链霉素、四环素 AB important for human health对于人类健康重要的抗生素 vancomycine, linezolid, teicoplanin, carbapenems万古霉素硕、苑唑酮皮、肤拉级宁班培碳训青课霉件烯类 Always weigh the anim

34、al 永远对动物称重 Always round the dose up to the nearest ½ or ¼ tablet计算药量算到离剂量最接近的½或¼片不要向下舍入不要给药不足 Never round down Never underdose Make sure the owner understands the dosing interval确定理解给药间隔 Use precise terms使用准确的说法 Every 12 hours instead of twice daily使用“每12小时一次”，而不要用“每天2次” Dont give out more tablets than required给药时不要超出需求量硕腾学苑皮肤病高级班培训课件 Treat to clinical cure and not following label indication不要按照说明书指示给药，治疗至临床症状痊愈