[醫學筆記] 抗生素使用 Antibiotics part.1 概論+β-lactam

一樣是整理成一張標籤貼紙圖表,若有需要圖檔或ai檔請留下信箱。歡迎取用。

  • Enterococcus裡還有分faecalis跟faecium,因為排版塞不下了,請再查一下熱病。
  • 之前Tigecycline標錯atypical pathogen,應該是susceptible(2017/02改)

抗生素使用的5D如下

Diagnosis Drug Dosage Duration De-escalation

要先判斷有沒有感染!當然臨床上可能燒個半天有沒有感染分攏分袂清,或是突如其來個血壓掉無法排除敗血性休克,這時先壓上個Antibiotic也是合情合理。只是記得要隨時評估揪竟現在有沒有感染(有很多評估的方法例如 Vitals, S/Sx, WBC, DC, CRP?, PLT, Ferritin, Glucose, Procalcitonin,treatment response, image change….),如果有microbiological evidence請及早降階調整抗生素,如果根本不是感染請考慮停掉抗生素吧(打到天荒地老又跑來個drug fever攪和一下…)。

至於到底要選哪種抗生素,我自己是用SPAM(這單字完全暴露年齡,遙想e-mail剛問世的年代)的順序去記,先決定抗菌譜,再來選擇穿透力和組織濃度較好的,評估病人肝腎狀況和副作用,最後考慮成本 :

Spectrum → Penetration → Adverse effect → Money

= Spectrum =

這裡先列出一些特別要考慮的菌種和常見的抗藥性菌株,同時附上相對應的治療選擇。詳細每個抗生素的抗菌譜和副作用請繼續往下。

最愛問的我想就是Anti-pseudomonal。

Amp-C β-lactamase GNB Tazocin, Ceftazidime, Cefepime, Cefpirome, Cipro, Levo, Tienam, Meropenem, Aztreonam
ESBL 4th Cepha, Carbapenems, TG, fosfomycin
MRSA  Vancomycin, Teicoplanin
Daptomyxin, Linezolid, Tigecycline,  
PsA  Tazocin, Ceftazidime, Cefepime, Meropenem, Imipenem, Doripenem, Ciprofloxacin, Levofloxacin,Aztreonam, AG 
VRE  Daptomycin, Linezolid, Tigecycline 
MDRAB  Carbapenem, Unasyn, Brosym, Colistin 
PRSP  Ceftriaxone, Vancomycin, Teicoplanin, Tigecycline
Anaerobes Metronidazole, Unasyn, Tazocin 

= Penetration/Tissue concentration =

  • 過BBB: PCN, Ampicillin, Oxacillin, 3rd-4th Cephalosporin, Moxifloxacin, Vancomycin, Chloramphenicol, Rifampin, Imipenem, Meropenem
  • Prostatitis/Epididymo-orchitis: Ceftriaxone, Doxycycline, FQ, TMP-SMX
  • Endophthalmitis: 3rd Cepha, Vancomycin 

未命名-10

一定愛用 -cidal : immunocompromised, meningitis, IE, osteomyelitis, abscess, neutropenic fever, bacteremia, septic shock

= adverse effect =

$ Money $

 

kidney renal liverhepatic

= Penicillin =

列印

=Natural penicillin=

PCN-G, PCN-V
Spectrum GPC (Actinomyce), GNB (spirochetes!), Anaerobes (Actinomycosis)
IE, Neurosyphilis
Dosage 2-4MU IV Q4H
AE Allergy, Anaphylaxis, BM suppression
Benzathine PCN 
Spectrum GPC, GNB (spirochetes!), Anaerobes (Actinomycosis)
Primary and secondary syphilis
Dosage 2.4 MU IM QW
AE Allergy, drug fever, myelosuppression, CDAD

= Penicillinase-resistant PCN =

Oxacillin (IV) / Ducloxacillin (PO) / Cloxacillin (PO)
Spectrum GPC, MSSA 首選!(比Vanco,Cefa更好!)
Dosageliver 1-2g IV Q4-6H 
PO 吸收差 (50%) => 改Cephalexin (90%)
AE Allergy, drug fever, myelosuppression, CDAD, Hepatitis,

= Aminopenicillin =

  • 加上β-lactamase inhibitor後可cover HMN
Ampicillin / Ampicillin + Sulbactam (Unasyn®)
Spectrum
  • GPC: Listeriosis (過BBB), Enterococcus,
  • GNB: PEcK, H. influ, Shigella, Salmonella , A.baumannii (sulbactam, even for PDRAB)
  • Anaerobes

** Amp-C β-lactamase GNBs  : Enterobacter, Citrobacter, S. marcenscens, M. morganii, PsA, P vulgaris **

Dosage
kidney
1g IV Q6-8H  
3g IV Q6H for AB
Renal adjustment
AE
  • Allergy, drug fever, myelosuppression, CDAD
  • maculopapular rash in pts. with viral illness, infectious mononucleosis, and lymphocytic leukemia.
Amoxicillin / Amoxicillin + Clavulanate (Augmentin®)
Spectrum GPC, GNB, anaerobes
=> URTI, H.P
Dosage
kidney
Amoxicillin  250mg~1gm PO TID
Augmentin 875/125mg  PO BID
AE Allergy, drug fever, myelosuppression, CDAD

= Antipseudomonal PCN=

 Piperacillin-tazobactam (Tazocin®)
Spectrum – GPC 
– GNB : + PsA (Anti-PsA 遜於 Cefepime ) and Amp-C β-lactamase GNB
– Anaerobes
Dosage
kidney
– 3gm~4gm IV Q6H (For PsA 4.5g Q6H IVD, combine AG for FN)
– Prolonged infusion for ICU patients, immunocompromised pts, and MIC ≥ 8
AE – Allergy, drug fever, myelosuppression, CDAD
– Na 2.79mEq/gm of PIP : Tazocin高鹽含量!用在dysnatremia或是fluid overload的病人要注意。

關於副作用中過敏反應還有兩個問題是臨床上常碰到的
= To PCN test or not to PCN test ???? =

其實就目前的文獻證據來看,PCN test並無實證證明能預測anaphylaxis(也就是我們最擔心的狀況),而另一方面則甚至有PCN造成anaphylaxis的案例。
“若未有盤尼西林過敏反應病史,建議不需要做皮膚測試,但是在給藥中及給藥後的過程中應注意是否發生過敏反應,並準備完善的急救措施。”
盤尼西林過敏反應與盤尼西林皮膚測試之 回顧與實務建議
http://www.tma.tw/se_dis/01files/7795-%E5%AE%89%E5%85%A8%E5%93%81%E8%B3%AA%E8%A8%8E%E8%AB%96%E6%9C%83%E7%B3%BB%E5%88%971.PDF
恩,不過…法官大大會怎麼解讀呢?護理師問你要不要做PCN test,你會不會做呢?

=Cross-allerginicity ?? =

如果病人已知有PCN allergic reaction,可以給其他β-lactam類的抗生素嗎??
臨床常見的實務做法是若病人之前是anaphylaxis,那還是別用結構類似的β-lactam類藥物,不過如果之前只是皮疹等輕微反應,還是可以用其他β-lactam類藥物,但建議密切監控過敏反應。真的不行就只好換其他種類的藥物,如Aztreonam(誒不過好像很多地方沒這個藥了)或者FQ。

= Cephalosporin =

Cefa

  • 從一代到三代的抗菌力對GPC越來越差,對GNB則越來越好。四代則是對GPC和GNB都有效。
  • 3rd以上過BBB (Brosym較弱)
  • 3rd中ceftriaxone不能用來對抗PsA, ceftazidime不能用於GPC。
  • cephamycin有NMTT side chain可對抗anaerobes,但會有出血風險。
  • Cephalosporin的罩門:Enterococcus, Listeria, Anaerobes (Cephamycin除外)

= 1st generation =

Cefazolin (IV), Cephradine (IV, U-save®), Cephalexin (PO, Ulex®)
Spectrum GPC: MSSA + PSSP
GNB: PEcK
=> UTI, Soft tissue infection, Surgery phrophylaxis
Dosage
kidney
1~1.5gm IV Q8H
500mg PO Q6H
AE Allergy, drug fever, myelosuppression, CDAD

= 2nd generation =

Cefuroxime (IV, Zinacef®, Furoxime®; PO Zinnat®), Cefaclor
Spectrum GPC: 比一代弱
GNB: PEcK + HMN
=> CAP (COPD w/ AE),Dosage
Dosage

kidney

750mg-1.5gm IV Q6-8H
500mg PO Q8-12H
AE Allergy, drug fever, myelosuppression, CDAD
Cefmetazole (IV,Cetazone®), Cefoxitin(IV,Cexitin®)
Spectrum GPC
GNB: PEcK + HMN
Anaerobes (不過對Bacteroides效果不佳,應改用Metronidazole)
* 對ESBL雖有in vitro susceptibility,不過in vivo效果如何目前無定論。(熱病:Do not use as there are no clinical data for efficacy)=> IAI
Dosage
kidney
1-2g IV Q6-12H
No PO form
AE hypoprothrombinemia (老人,低白蛋白,肝腎功能差)
disulfiram-like reaction (No alcohol drinking!)

Allergy, drug fever, myelosuppression, CDAD

= 3rd generation =

Ceftriaxone (IV, Rocephin®), Cefotaxime(IV, Claforan®), Cefixime(Cefspan®), Ceftibuten (PO, Seftem®)
Spectrum GPC
GNB : Neiserria, PsA
=> CAP, meningitis, BTI
Dosage
kidney liver
Ceftriaxone: 1-2g/day IV in 1-2 doses, meningitis: 2g IV Q12H
Cefotaxime: 2gm IV Q8H
AE Pseudocholelithiasis, kernicterus
Allergy, drug fever, myelosuppression, CDAD
Ceftazidime (IV, Fortum®, Tatumcef®)
Spectrum GPC: MSSA↓, PSSP ≅ 1st Cepha

GNB: PsA
=> health-care associated, hospital acquired infection for PsA coverage

Dosage
kidney
1-2g IV Q8-12H

如果是針對PsA empirical coverage,一開始就應該先用full dose

AE Allergy, drug fever, myelosuppression, CDAD
Flomoxef (IV, Flumarin®) ≅ ceftriaxone + metronidazole ??? 
Spectrum GPC
GNB : ESBL?, PsA
Anaerobe
=> LRTI, UTI, Mixed infection
Dosagekidney  1-2g/day IV in 2 doses ~ 4g/day in 2~4 dosesAE
AE side chain NMTT->HTT:較少NMTT副作用
Allergy, drug fever, myelosuppression, CDAD
Cefoperazone-sulbactam (IV, Brosym®)
Spectrum GPC
GNB : PsA, AB
Anae
=> BTI, PID
Dosagekidney 500mg-2g IV Q12H
AE hypoprothrombinemia
disulfiram-like reaction (No alcohol drinking!)
Allergy, drug fever, myelosuppression, CDAD

= 4th generation =

Cefepime (Maxipime®), Cefpirome
Spectrum GPC : Cefpirome > Cefepime
GNB : Amp-C btalactamase GNB ; Cefpirome < Cefepime
Anae
=> Febrile neutropenia
Dosage
kidney
Cefepime: 2g IV Q8-12H
Prolonged infusion: MIC≥4, Immunocompromised, crititcal pts
AE Allergy, drug fever, myelosuppression, CDAD

 

= Carbapenem =

penem

  • Penem類雖然神通廣大,不過有四隻殺不了:MRSA, E. faecium, S. maltophilia, B. cepacia.
    GPC Imipenem > Doripenem  ≅ Meropenem
    PsA Doripenem > Meropenem > Imipenem
    AB Doripenem ≅  Imipenem > Meropenem
Ertapenem (Invanz®)
Spectrum GPC
GNB : PsA, AB
Anaerobes
=> IAI, ESBL, Amp-C β-lactamase
Dosage
kidney
1g IV QD
AE Seizure
Allergy, drug fever, myelosuppression, CDAD
Imipenem-Cilastatin (IV, Tienam®)
Spectrum GPC
GNB : PsA, AB
Anaerobes
Dosage
kidney
500mg-1g IV Q6-8H Max 50mg/kg/day (Renal dose相當複雜直接對表…)
Continuous infusion: MIC≥2, immunocompromised, critical
AE Seizure 風險在penem中較高, Cilastin降低imipenem腎毒性,
Allergy, drug fever, myelosuppression, CDAD
Meropenem (Mepem®)
Spectrum GPC
GNB : PsA, AB
Anae
Dosage
kidney
1g IV Q8H
Meningitis 2g IV Q8H
AE Seizure
Allergy, drug fever, myelosuppression, CDAD
Doripenem (IV, Finibax®)
Spectrum GPC
GNB : PsA, AB
Anaerobes 

=> 在PNA還沒有拿到適應症
Dosage
kidney
500mg IV Q8H
AE Less resistance
Allergy, drug fever, myelosuppression, CDAD

= Monobactam =

Aztreonam
Spectrum GNB: PsA 
=> Use for allergy to PCN or Cepha.
Dosagekidney 2g IV Q8H 
AE

篇幅太長其他的抗生素請看下回分曉

首圖:

 

郭查理

 

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81 Comments

          1. 您好:懇請惠賜超神的抗生素使用速查(抗生素使用 Antibiotics part.1 概論+β-lactam)圖檔,感謝您!

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