Guidelines on Antimicrobial Therapy of Pneumonia in Taiwan ????????????? ??????

1
Guidelines on Antimicrobial Therapy of Pneumonia
in Taiwan???????????????????
2

• ??????????
• ??????????????
• ??????????????????
• ??????????????????
• ?????

3

• ????????,???????,??????????,?????????????????????
  ???????????
• ???????????,?????????,?????????????????????????,?
  ?????????????????????

4

• ????,?????????????????????????????????????????
  ??????????????????????????????88?3?7???????????
  ?91?4? revise.

5

• ??????????????????????????????????????????????????
  ??????????????????????????????????,???????????????
  ??????

6

• ?????????????????,????????????
• (?)??????????
• (?)??????????????
• (?)????????????????????????, ??????????????,?????
  ???????????,????????,???????????????

7
?????

• ?.????
• ??????????,???????????48?????.
• ?.????
• ????48???,????????14?????????????.

8
Risk factors and common pathogens

• gt65yr Streptococcus pneumoniae
• Alcoholism gram(-) bacilli,
  Legionella sp.
• COPD S. pneumoniae ,
  S.aureus, Haemophilus
  influenzae
• DM, CRF, Chronic liver disease Gram (-)
  bacilli,Legionella sp.
• History of hospital stay
• 1yr b/4 disease Streptococcus pneumoniae
• 2-4 wk b/4 gram(-) bacilli, S.
  pneumoniae
• Aspiration anaerobes, gram(-)
  bacilli, S.aureus

9
Streptococcus pneumoniae Penicillin MIC
lt 1 µg/mL 2 µg/mL
? 4 µg/ml

• Penicillin
• Ampicillin ? amoxicillin
• Penicillin ( ??? )
• Ampicillin ? amoxicillin
• 3?a?4?cephalosporins
• Vancomycin ? teicoplanin

1cephalosporins 3?a?4?cephalosporins
Vancomycin ? teicoplanin Rifampicin
10
Haemophilus influenzae ß - lactamase (-) ß -
lactamase ()
Ampicillin ? amoxicillin 2?cephalosporins Ampicil
lin/sulbactam Amoxicillin/clavulanate
New macrolidesb TMP/SMX 3?cephalosporins New
macrolidesb Fluoroquinolones
11
Erythromycin ? new macrolides 3?cephalosporins F
luoroquinolones Erythromycin ? new macrolides
Rifampicin Tetracyclines Fluoroquinolones
Moraxella catarrhalis Legionella species
2?cephalosporins Ampicillin/sulbactam Amoxicillin/
clavulanate Erythromycin ? new macrolides
12
Mycoplama pneumoniae Chlamydia pneumoniae
Tetracyclines Fluoroquinolones Fluoroquinolones
Erythromycin ? new macrolides Tetracyclines Eryt
hromycin ? new macrolides
13
Community-acquired pneumonia
Young infants (lt 2 m) Infants ? young
children (2 m 5 y)
Ampicillin cefotaxime Erythromycinc Ceftazidim
ed Aminoglycosides
Ampicillin aminoglycosides Ampicillin/sulbact
am Amoxicillin/clavulanate 2?cephalosporins
14
Children (5 y 18 y) Adults (lt 60 y)
2?cephalosporins Ampicillin/sulbactam Amoxicillin/
clavulanate 2?cephalosporins Tetracyclines Ampi
cillin/sulbactam Amoxicillin/clavulanate Fluoroqui
nolones
Penicillin Erythromycin ? new
macrolides Penicillin Erythromycin ?
new macrolides
15
Elderly (? 60 y ) Mild-moderate
Penicillin ? 2?cephalosporins
Erythromycin ? new macrolides
Tetracyclines Ampicillin/sulbactam Amoxicillin/cla
vulanate Fluoroquinolones
16
Severee
Fluoroquinolones ? Ticarcillin/calvulanate
? Piperacillin/tazobactam ? 4?cephalosporin
Aminoglycosides
Erythromycin ? new macrolides
3?cephalosporins? Ureidopenicillins
Aminoglycosides Erythromycin ? new
macrolides
17

• Severe peumonia ???
• 1. Admission to the ICU
• 2. Respiratory failure (mechanical
  ventilation or FiO2 gt 0.35
• to keep saturation gt 90 )
• 3. Rapid radiographic progression, multilobar
  pneumonia, or cavitation of a lung
  infiltrate
• 4. Evidence of sepsis with hypotension and/or
  end-organ dysfunction Shock
  Vasopressor requirement ( gt 4 hours), Urine
  output (UO) lt 20 mL/h or total U/O lt 80
  mL over 4 hours, Acute renal failure
• (requiring dialysis)

18
Aspiration pneumonia ( ?? lung abscess )
Penicillin metronidazole 2?cephalosporinsf Am
picillin/sulbactam Amoxicillin/clavulanate
Penicillin Clindamycin
19
Hospital-acquired pneumonia
Mild-moderate
Ticarcillin/clavulanate ? Piperacillin/tazobactam
? Aztreonam ? Fluoroquinolones
Aminoglycosides
2?? 3?Cephalosporins ? Ampicillin/sulbactam
? Amoxicillin/clavulanate ? Ureidopenicillins
Aminoglycosides
20
Severee
Ticarcillin/clavulanate ? Piperacillin/tazobactam
? Aztreonam ? Imipenem ? meropenem
? 4?cephalosporin Aminoglycosides
Erythromycin ? new macrolides
Vancomycin ? teicoplanin
3?cephalosporins ? Ureidopenicillins
? Fluoroquinolones Aminoglycosides
Erythromycin ? new macrolides
Vancomycin ? teicoplanin
21
Ventilator-related pneumonia
Ticarcillin/clavulanate ? Piperacillin/tazobactam
? Aztreonam ? Imipenem ? meropenem
? 4?cephalosporin Aminoglycosides
Vancomycin ? teicoplanin
3?cephalosporins ? Ureidopenicillins
? Fluoroquinolones Aminoglycosides
Vancomycin ? teicoplanin
22

• a Ceftriaxone, cefotaxime
• b Clarithromycin, azithromycin
• c ?? afebrile pneumonitis syndrome ? Chlamydia
  trachomatis ???
• d ?? Pseudomonas aeruginosa ??
• e Severe peumonia ???
• 1. Admission to the ICU
• 2. Respiratory failure (mechanical
  ventilation or FiO2 gt 0.35
• to keep saturation gt 90 )
• 3. Rapid radiographic progression, multilobar
  pneumonia, or cavitation of
• a lung infiltrate
• 4. Evidence of sepsis with hypotension and/or
  end-organ dysfunction Shock
• Vasopressor requirement ( gt 4 hours),
  Urine output (UO) lt 20 mL/h or total
• U/O lt 80 mL over 4 hours, Acute renal
  failure (requiring dialysis)
• f Cefoxitin, cefmetazole, cefotetan

23
THANK YOU FOR YOUR ATTENTION