1、預(yù)防性抗生素 & 合理運(yùn)用抗生素賴定國(guó)門診抗生素運(yùn)用情形合理u有需求才用抗生素u運(yùn)用抗生素時(shí), 病例上應(yīng)說(shuō)明用藥的理由及預(yù)期效果u普透明顯急性感冒不可運(yùn)用抗生素u抗生素運(yùn)用期間合理u如有異常時(shí)應(yīng)於病歷上說(shuō)明u抗生素運(yùn)用種類合理u抗生素運(yùn)用劑量合理u並有考慮病人體重及腎臟機(jī)能 PathogenAntibiotics of first choiceStaphylococcus aureus or S. epidermidis Non-penicillinase producing Penicillinase producing Methicillin-resistantStreptococ

2、ci Group A,C,G Group BEnterococcus Penicillin Oxacillin or Nafcillin Vancomycin Penicillin Penicillin Penicillin( or ampicillin)Antibiotics of choice for common pathogenPathogenAntibiotics of first choiceNeiseria gonorhoeaeNeiseria meningitidesMoraxellaListeria monocytogenesBacteroides spp.B. fragil

3、is strainEnterobacter sppE.coliCeftriaxone or cefixime or ciprofloxacin Penicillin GTMP-SMXAmipcillin with or without gentamycinPenicillin G or clindamycinMetronidazoleImipenem or meropenemTMP-SMX or ciprofloxacinAntibiotics of choice for common pathogenDiagnosisDuration of TherapyMeningococcal meni

4、ngitisPneumoncoccal meningitisH. Influenzae type B meningitisStreptococcal group A pharyngitisOtitis mediaBacterial sinusistisPneumococcal pneumoniaGram-negative pneumoniaMycoplasma pneumoniaLegionella pneumoniaEndocarditis Viridans streptococci StaphylococcalPeritonitisEptic arthritisosteomyelitis

5、7-1010-1410-1410 7-1010-14? optimal? 2114212828-4210-1414-2128-42預(yù)估肌干酸濾清率Ccrn(140-age) x weight / 72 x serum creatininen女性: 85 % n理想體重:n男性:50 kg +2.3 kg/inch over 5 feetn女性:45.5 kg +2.3 kg/inch over 5 feetn肥胖病人運(yùn)用理想體重評(píng)估CcrClassic Streptocccal PharyngitisViral PharyngitisSeason AgeSymptomsSignLater wi

6、nter or early spring5-11 yrSudden onsetSore throat, may be severeHeadache Abdominal pain, nausea,Vomiting Pharyngeal erythema and exudatesTender, enlarged ant cervical nodesPalatal petechiaeTonsillar hypertrophyScarlet fever rashAbsence of cough, rhinitis,Hoarseness, conjunctivitis, and diarrheaAll

7、seasonsAll agesOnset variesSore throat, often mildFever variesMyalgia, arthralgiaAbd painCharacteristic enanthemsOften have cough, rhinitis, hoarseness, conjunctivitis, or diarrheaDifferentiating features of pharyngitis caused by group A streptococci and virusesClinical Practice Guidelines Compendiu

8、mIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic Acute bacterial sinusitisStreptococcus pneumoniae, nontypeable Hemophilus influenza, Moraxella catarrhalis, mainly viral pathogensWhen not to treat with an antibiotic: nearly all cases resolve without antibiotics. Antibiotic use

9、 should be reserved for moderate symptoms that are not improve after 10 days or that worsen after 5 to 7 days, and sever symptomsAntibiotic duration: 10 daysFailure to respond after 72 hours of antibiotics: reevaluate patient and switch to alternate antibioticsFirst-line therapyamoxicillinAlternativ

10、e therapy: Agmentin, gatigloxacin levofloxacin, moxifloxacinClinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic Acute bacterial sinusitisStreptococcus pneumoniae, nontypeable Hemophilus influenza, Moraxella catarrhalis, mainly viral pathogens

11、When to treat with an antibioc: diagnosis may be made in adults with symptoms of a viral upper respiratory infection that have not improved after 10 days or that worsen after five to seven days. Diagnosis may include: nasal drainage, facial pressure or pain, Postnasal discharge, hyposmia anosmia, fe

12、ver, cough, fatigue, maxillary dental pain, ear pressure or fullnessAntibiotic duration: 10 daysFailure to respond after 72 hours of antibiotics: reevaluate patient and switch to alternate antibioticsFirst-line therapyamoxicillinAlternative therapy: Augmentin, gatifloxacin levofloxacin, moxifloxacin

13、Clinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic PharyngitisStreptococcus pyogenes, routine respiratory virusesWhen not to treat with an antibiotic: most pharyngitis cases are viral in origin. The presence of the following is uncommon with

14、 group A streptococcal infection: conjunctivitis, cough, rhinorrhea, diarrhea and absence of feverClinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic PharyngitisStreptococcus pyogenes, routine respiratory virusesWhen to treat with an antibioc

15、: S. pyogenes. Symptoms of sore throat, fever, headache, Physical finding include fever, tonsillopharyngeal erythema and exudates palatal petechiae, tender and enlarged anterior cervical lymph nodes and absence of cough. Group A streptococcal infection, antibiotic duration: 10 daysFailure to respond

16、 after 72 hours of antibiotics: reevaluate patient and switch to alternate antibioticsFirst-line therapyPenicillin V Penicillin G benzathine Alternative therapy: amoxicillin, macrolides, oral cephalosporins, clindamycin Clinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic

17、 treatmentTreatmentAntibiotic Acute bronchitisBordetella pertussis, Chlamydia pneumoniae, Mycoplasma pneumoniaeWhen not to treat with an antibiotic: 90 % of cases are nonbacterial. Literature fails to support use of antibiotics in adults without history of chronic bronchitis or other comorbid condit

18、ionUncomplicated: Not indicated Clinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic Acute bronchitisBordetella pertussis, Chlamydia pneumoniae, Mycoplasma pneumoniaeWhen to treat with an antibioc: antibiotics not indicated in patients with un

19、complicated acute bacterial bronchitis. Sputum characteristics not helpful in determining need for antibiotics. Treatment is reserved for patients with acute bacterial exacerbation of chronic bronchitis and COPDUncomplicated: Not indicatedChronic bronchitis and COPD: amoxicillin, TMP-SMX, doxycyclin

20、eOther: erythromycin or doxycycline Clinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic Nonspecific upper respiratory infectionViral When not to treat with an antibiotic: Antibiotics not indicted. However nonspecific upper respiratory infecti

21、on is a major etiologic cause of acute respiratory illnesses presenting to primary care physicians. Patients often expect treatmentNot indicated None Clinical Practice Guidelines CompendiumIllness/pathogenIndication for antibiotic treatmentTreatmentAntibiotic Influenza Influenza virusWhen not to tre

22、at with an antibiotic: Antibiotics not indicted. for acute treatment. Supportive and symptomatic care is the standard. Characterized by abrupt onset of constitutional and respiratory signs and symptoms such as fever, myalgia, headache, rhinitis, severe malaise, nonproductive cough and sore throatAnt

23、ibiotic not indicated, but patients often expect treatmentAntiviral medications available for acute relief of symptoms and for prevention in some cases預(yù)防性抗生素u需用預(yù)防性抗生素時(shí)應(yīng)在手術(shù)劃刀前一小時(shí)內(nèi)應(yīng)給第一劑預(yù)防性抗生素u剖腹產(chǎn)則在臍帶結(jié)紮切除後, 即應(yīng)立刻給予預(yù)防性抗生素u選藥時(shí)應(yīng)符合國(guó)內(nèi)外抗生素指引u劑量應(yīng)與體重相符u手術(shù)中視必要追加抗生素u普通清淨(jìng)手術(shù)後於術(shù)後不再繼續(xù)運(yùn)用抗生素u艱苦手術(shù)24小時(shí)候不再運(yùn)用抗生素非控制性抗生素運(yùn)用情形

24、合理(一)有關(guān)病人運(yùn)用非控制性抗生素運(yùn)用之情況應(yīng)於病歷中詳載病人有多重器官嚴(yán)重疾病或感染能夠之危急病人, 無(wú)正當(dāng)理由依然運(yùn)用第一代狹效抗生素未依感染部位而運(yùn)用適當(dāng)之抗生素如腹腔內(nèi)的厭氧菌在其他醫(yī)院治療感染癥無(wú)效而轉(zhuǎn)入本院, 無(wú)正當(dāng)理由依然運(yùn)用第一代狹效抗生素為第一線抗生素院內(nèi)感染肺炎, 無(wú)正當(dāng)理由依然運(yùn)用第一代狹效抗生素非控制性抗生素運(yùn)用情形合理(二)有關(guān)病人運(yùn)用非控制性抗生素運(yùn)用之情況應(yīng)於病歷中詳載社區(qū)感染, 無(wú)正當(dāng)理由依然運(yùn)用明顯療效缺乏的抗生素有免疫不全現(xiàn)象, 無(wú)正當(dāng)理由依然運(yùn)用第一代狹效抗生素第一代狹效抗生素運(yùn)用 3 天無(wú)效, 無(wú)正當(dāng)理由依然繼續(xù)運(yùn)用運(yùn)用的劑量未考慮病人體重及肝腎機(jī)能控

25、制性抗生素運(yùn)用情形合理有關(guān)病人運(yùn)用控制性抗生素運(yùn)用之情況應(yīng)於病歷中詳載臨床狀況明顯為輕癥或無(wú)癥狀, 但運(yùn)用廣效第三, 四代抗生素, 且無(wú)正當(dāng)理由者無(wú)正當(dāng)理由者同時(shí)運(yùn)用 3 種以上抗生素運(yùn)用藥物的種類不符合國(guó)內(nèi)外抗生素治療指引之原則運(yùn)用的劑量未考慮病人體重及肝腎機(jī)能Surgical ProcedureRecommended RegimenBiliary tract surgery High risk: 60 years Obstructive jaundice Acute cholecystitis Cholangitis Common duct stone Previous biliary s

26、urgery Nonfunctioning gall bladder Low riskCefazolin 1-2 g IV x 1 dose or gentamicin 1.7 mg/kg iv q8h x 1 or 2 doses Not recommended Recommended antimicrobial regimens Recommended antimicrobial regimensSurgical ProcedureRecommended RegimenElective colorectalNonelective colorectal Neomycin 1g po and

27、erythromycin base 1 g po given at 1 PM, 2 PM, 11 PM on day prior to surgery with or without cefoxitin 2 g IV x 1 dose or metronidazole 500 mg IV and gentamicin 1.7 mg/kg IV q8h x 1 or 2 doses Cefoxitin or cefotetan or metronidazole and gentamicin Recommended antimicrobial regimensSurgical ProcedureR

28、ecommended RegimenGastroduodenal procedures High risk: GI bleeding, gastric ulcer or malignancy, decreased gastric acidity, obesity, obstruction Low riskCefazolin 1-2 g IV x 1dose Not recommended Recommended antimicrobial regimensSurgical ProcedureRecommended RegimenAppendectomy Cefoxitin 2 g IV q6h

29、 x 1-3 doses or cefotetan 2 g IV q12h x1 or 2 doses or metronidazole 500mg IV q8h and gentamicin 1.7 mg/kg IV q8h x 1-3 dosesRecommended antimicrobial regimensSurgical ProcedureRecommended RegimenHysterectomy ( abdominal or vaginal)Cesarean section High-risk patient Low risk Therapeutic abortionCefa

30、zolin 1-2 g IV x 1dose or doxycycline 200mg IV1 or clindamycin 900 mg IV x 1 Cefazolin 1-2 g IV x 1dose or metronidazole 500mg IV x 1 dose Not recommended Cefazolin 1-2 g IV x 1doseRecommended antimicrobial regimensSurgical ProcedureRecommended RegimenHead and neck surgery Incision through oral or p

31、haryngeal mucosa UncomtaminatedClindamycin 600 mg IV x 1 and gentamicin 1.7 mg/kg IV x 1 dose or ampicillin-sulbactamNot recommendedRecommended antimicrobial regimensSurgical ProcedureRecommended RegimenNeurosurgery CSF shunt CraniotomyNot recommendedCefazolin 1 g IV x 1dose or VancomycinRecommended

32、 antimicrobial regimensSurgical ProcedureRecommended RegimenOrthopedics Closed reduction of fracture Open reduction of a fracture Prosthetic joint replacement Amputation Laminectomy & spinal fusion Hardware implantation No hardware implantationNot recommendedCefazolin 1-2 g IV x 1doseCefazolin 1

33、-2 g IV q6h or Vancomycin IV up to 24hCefoxitin 2 g IV x 1doseCefazolin 1-2 g IV x 1doseNot recommendedRecommended antimicrobial regimensSurgical ProcedureRecommended RegimenUrologic surgery If the urine is sterile If the urine is infected Transrectal prostate biopsyNot recommendedSterilize urine be

34、fore surgeryCiprofloxacin 500mg po or 400 mg IV to 48hDenatl procedures and endocarditis prophylaxisEndocarditis Prophylaxis RecommendedDental extractionsPeriodontal procedures including surgery, scaling and root planningDental implant placement and reimplantation of avusled teethEndodontic instrume

35、ntation or surgery only beyond the apexSubgingival placement of antibiotic fibers or stripsIntraligmentary local anesthetic injectionsProphylactic cleaning of teeth or implants where bleeding is anticipatedOther procedures and endocarditis prophylaxisEndocarditis Prophylaxis RecommendedRespiratory t

36、ract Tonsillectomy and/or adenoidectomy Surgical operation that involve respiratory mucosa Bronchoscopy with a rigid bronchoscopeGastrointestinal tract Sclerotherapy for esophageal varices Esophageal stricture dilatation Endoscopic retrograde cholangiography with biliary obstruction Biliary tract su

37、rgery Surgical operation that involve intestinal mucosaGenitourinary tract Prostatic surgery Cystoscopy Urethral dilationRecommended chemoprophylaxis for high-risk contacts and index cases of invasive meningococcal meningitisInfants, children and adultDoseDurationEfficacy(%)Rifampin 1mo 1moCeftriaxo

38、ne 12 yr 12 yrCiprofloxacin 18 yr5mg/kg PO q12h10mg/kg PO q12h20mg/kg PO q24h125 mg IM250 mg IM500 mg PO2 days2 days4 daysSingle doseSingle doseSingle dose72-90 9790-95可直接運(yùn)用第二線藥物的情形u嚴(yán)重感染u敗血癥, CNS感染, CPR 回來(lái)的病人u嚴(yán)重感染經(jīng)感染科照會(huì)者u手術(shù)中發(fā)現(xiàn)明顯感染病灶者u脾切除後發(fā)燒者u臟器穿孔者u污染傷口的病人u早產(chǎn)及新生兒感染者u疑有混合厭氧及嗜氧菌感染者u運(yùn)用第一線藥物一星期治療無(wú)效者u運(yùn)用第一

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