[醫學筆記] 抗生素使用 Antibiotics part.2 FQ, anti-MRSA, others

  • 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)

需要圖檔或ai檔請留下信箱,原本的綠色不是這種螢光綠啊,為什麼顏色會跑掉嗚嗚。

= Quinolone =

FQ

  GPC GNB PsA Anae Atyp
Ciprofloxacin ++ +
Levofloxacin + + +
Moxifloxacin ++ + +
  • PsA : Ciprofloxacin > Levofloxacin (anti-PsA裡唯一可口服!)
  • S.pneumoniae: Ciprofloxacin < Levofloxacin < Moxifloxacin
  • FQ類容易產生抗藥性且有TB masking的風險,在TB盛行區並不適合作為治療CAP的首選。不過因為他抗菌譜廣又一天一針,真是急診的好朋友無誤。又或者有時病人對β-lactam又過敏沒什麼藥好用只能選FQ。總之用FQ不是不行,但使用前要謹慎評估病人是否有TB的風險(發燒?久咳?乾咳?體重掉?夜間盜汗?胸痛?immune stauts? contact history? CXR 有無TB好發位置病灶?),記得留個AFS。
Ciprofloxacin (IV, Ciproxin®)
Spectrum GPC
GNB : PsA better
Atypical
Mycobacterium
=> PNA, IAI, Soft tissue/bone, UTI, prostatitis, STD, Mycobac.
Dosagekidney 400mg IV Q8-12H
AE QTc prolongation (Baseline EKG!), BM suppression, ∅ Pregnancy or age < 16, Tendon rupture, MG
Chelation (Ca++, Mg++) : to avoid, 1 hr before meal or 2 hrs after meal
Levofloxacin (IV, Cravit®)
Spectrum GPC
GNB : PsA
Atypical
Mycobacterium
=> PNA, IAI, Soft tissue/bone, UTI, prostatitis, STD, Mycobac
Dosage
kidney
250-750mg IV/PO QD
AE QTc prolongation (Baseline EKG!), BM suppression, ∅ Pregnancy or age < 16, Tendon rupture, MG  
Chelation (Ca++, Mg++) : to avoid, 1 hr before meal or 2 hrs after meal
Moxifloxacin (IV, Avelox®) – Respiratory FQ
Spectrum GPC
GNB : PsA
Anaerobes
Atypical
Mycobacterium
=> PNA, IAI, Soft tissue/bone, UTI, prostatitis, STD, Mycobac
Dosagekidney 400mg IV/PO QD
AE QTc prolongation (Baseline EKG!), BM suppression, ∅ Pregnancy or age < 16, Tendon rupture, MG  
Chelation (Ca++, Mg++) : to avoid, 1 hr before meal or 2 hrs after meal

 

= Anti-MRSA =

MRSA

Vancomycin (IV, )
Spectrum GPC: MRSA 
Dosage

kidney

Loading dose 25-30 mg/kg -> 15-20 mg/kg Q12H
Peak    : 30-40 mcg/ml
Trough : 5-15 mcg/ml, 15-20 mcg/ml for sever infection 
AE Ototoxicity, Nephrotoxicity, Redman syndrome, drug fever 
Teicoplanin (IV, Targocid®)
Spectrum GPC: MRSA 
Dosage
kidney
Loading 12 mg/kg X 3doses -> 12 mg/kg QD
(400mg Q12H X 3 doses -> 400mg QD )
AE  BM suppression, drug fever, skin rash, less nephrotoxicity

– Teicoplanin is more potent against Streptococcus spp.
– Teicoplanin is more potent against Enterococcus spp.
• Esp. for VanB phenotype VRE
– Teicoplanin has slower bactericidal activity against Gram-positive pathogens than vancomycin
– Teicoplanin is less potent against coagulase negative Staphylococci, esp. S. epidermidis, S. haemolyticus, S. hominis, S. warneri, and S. xylosus.

Daptomycin (IV, Cubicin®)
Spectrum GPC: MRSA
=> Better in soft tissue, not for PNA
Dosage
kidney
bacteremia 6-10 mg/kg/day QD 
skin/soft tissue 4mg/kg/day QD
AE myopathy (f/u CK), BM suppression, eosinophilic PNA  
Tigecycline (IV, Tygacil®)
Spectrum GP : MRSA, VRE, PRSP
GN : ESBL, PDRAB, PsA (所以會看到tigecycline + ceftazidime這種組合), proteus
=> PNA IAI, Soft tissue ; But poor serum concentration !! not for bacteremia!!打不到:Pseudomonas aeruginosa、 Proteus spp.、 Providencia spp. Morganella morganii、Burkholderia cepaci
Dosage
kidney
100mg STAT -> 50mg Q12H
AE GI (N/V/D), photosensitivity, pseudotumor cerebri, pancreatitis
∅ pregnancy, age<18 
Linezolid (IV,PO, Zyvox®)
Spectrum GPC: MRSA, VRSA, VRE, PRSP
Norcardiosis, Listeriosis, Mycobacterial infection 
Bacteriastatic to Staph, Enterococcus (嚴重感染不建議用Linezolid)
Dosage
kidney
600mg IV/PO Q12H 
AE BM suppression (Thrombocytopenia! most often >2wk), N/V, GI
MAOI (避免併用MAOI,SSRI, TCA, bronchodilator, dopamine, meperidine, 減少奶酪蛋肉類攝取) 
Lactic acidosis, Rhabdomyolysis
= Others =

others

= Aminoglycoside = 
Amikacin (IV, Acemycin®), Gentamycin,   
Spectrum GP : with beta-lactam
GN : synergestic effect 
Myco (Streptomycin) 
Dosage  Conventional
=> For IE, enterococcus
Once daily : effect not inferior (Post antibiotic effect, neutorphil-dependent), less resistance, less toxicity
GM 3-5mg/kg/day
AM 10-15 mg/kg/day
Poor in acidicity or anaerobic enviro. (PNA,BTI,CNS不適用)不能使用once daily dosing 的場合:
– Impaired renal function (ex. CCr < 60, hemodialysis, peritoneal dialysis)
– Altered volume of distribution (ex. ascites, severe burn)
– Neutropenia
– Combination with beta-lactam for GPC infection
AE Ototoxicity, Nephrotoxicity (check trough level), NM blockade
Narrow therapeutic range, cumulative toxicity (>7 days)
Trimethoprim/sulfamethoxazole (TMP/SMX) (IV Sevatrim®, PO Baktar®)
Spectrum GP: Norcardia
GN: S. maltophilia, B. cenocepacia
PJP
Dosage
kidney
8-10 mg/kg/day in 2-4 doses
PJP: therapeutic 15-20 mg/kg/day in 3-4 doses (不過學長姐是都抓12 mg/kg)
AE HyperK, GI, Psychosis, Sweet’s syndrome, BM suppression, SJS, Hepatitis   
Clindamycin (IV, Clincin®; PO, Lindacin®)
Spectrum GPC
Anaerobes 
=> for PCN allergy (想換MSSA口服但病人又對beta-lactam過敏時可用)
Dosage
kidney
0.6-2.7 g/day IV in 2-4 doses 
150~450 mg PO Q6H
AE CDAD, allergy, GI, drug fever 
Metronidazole (IV; PO, Flagyl®)
Spectrum Anaerobes 
=> CDAD, IAI
Dosage
kidney
7.5mg/kg/day IV Q6H 
500 mg PO QID
AE N/V, disulfiram reaction, 
Doxycycline (PO, Doxymycin®)
Spectrum Atypical 
Dosagekidney 100mg PO Q12H 
AE Deposition in teeth, Hepatotoxicity
∅in Pregnancy, Breast feeding, Age < 8 
Erythromycin, Azithromycin (PO, Zithromax®), Clarithromycin (PO, Colirocin®)
Spectrum Atypical
Dosage
kidney
500mg QD for 3 days 

  • clarithromycin 有 anti-inflammatory的效果,之前看過老師在COPD的病人會選用。
AE QT prolongation, Cyt-P450 inhibition (抑制藥物代謝,藥物在體內濃度升高), GI (有時用diarrhea的副作用來治療)
Colistin (IV, Colimycin®)
Spectrum  GN : PsA, AB, S.marcescens, B. cepaciae, Proteus, Provindentia
Dosage
kidney
IV/IM : Loading 5mg/kg(Max 300mg) ->  Maintainence given 24hr later (1.5 X CCr + 30) X Target (1~2.5mg/L) in 2-3 doses
IH: 33.3~66.7 mg 2~3 times daily
AE  Nephrotoxicity, Neurotoxicity
Chloramphenicol
Spectrum GP
GN
Anae 
Dosage
kidney
50-100mg/kg/day Q6H 
AE BM suppression (aplastic anemia), Gray baby syndrome

= Pathogens =

%e8%9e%a2%e5%b9%95%e5%bf%ab%e7%85%a7-2016-09-21-%e4%b8%8a%e5%8d%881-17-52

The American Journal of Medicine (2007) 120, 764-768

%e8%9e%a2%e5%b9%95%e5%bf%ab%e7%85%a7-2016-09-21-%e4%b8%8a%e5%8d%881-22-35

CID 2011;53:798

  • NFGNB:PsA, AB, S. maltophilia, B. cepacia (Culture報告有時會先發NFGNB,如過後線抗生素像penem類已經打了一陣子了,要小心是不是抗藥性跑出來或是根本沒打到)
  • Atypical pathogens:Legionella, Mycoplasma, Chlamydia, Rickettsiae
= Adverse effects =

最後再來整理一下一些著名常見的副作用

BM suppression

 β-lactams, Chloramphenicol, GM, Met, ciprofloxacin, SMX

CDAD  Broad-spectrum PCNs, Broad-spectrum cephalosporins, Clindamycin, FQs
Nephrotoxicity Vancomycin, Aminoglycoside, Colistin, cephalosporins
Hepatotoxicity Oxacillin, TMP/SMX, Ceftriaxone, Macrolides 
Seizure Carbapenem (Tienam較常見), PCN, FQ
QT prolongation FQ, macrolides
Trough/Peak   Vancomycin, Amikacin (trough看副作用,peak看therapeutic effect)

Daptomycin 易造成 myopahty 要追蹤CK, Linezolid 易造成 thormbocytopenia.

$ Money $

這部分請自行體會,臨床要考量的因素太多了。

比如某V和某T,考量副作用和使用方便下常會選用某種,但兩者價格差很大。

比如某D和某M可能抗菌效果相近,但每天用量不同價格也不同,請掐指算算。

以上內容為參考多方資料整理而來,如有缺漏或錯誤之處還請指正。請勿以上述資料取代臨床醫師診斷治療。

Ref:

成大內科及臺大內科教學講義

熱病

臨床抗生素使用手冊

 

郭查理

 

各位朋友,請不吝按讚或分享,讓我們一起為美好的二手人生努力(遠目)!

One Comment

發表迴響