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

• 2018/07 修正antifungal部分，區分Efc和Efm
• 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 =

	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.
Dosage	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	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
Dosage	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 =

Vancomycin (IV, )
Spectrum	GPC: MRSA
Dosage	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	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	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	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	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 =

= 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	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	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	7.5mg/kg/day IV Q6H  500 mg PO QID
AE	N/V, disulfiram reaction,

Doxycycline (PO, Doxymycin®)
Spectrum	Atypical
Dosage	100mg PO Q12H
AE	Deposition in teeth, Hepatotoxicity ∅in Pregnancy, Breast feeding, Age < 8

Erythromycin, Azithromycin (PO, Zithromax®), Clarithromycin (PO, Colirocin®)
Spectrum	Atypical
Dosage	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	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	50-100mg/kg/day Q6H
AE	BM suppression (aplastic anemia), Gray baby syndrome

= Pathogens =

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

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

 

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