抗生素(英文)-Update-on-use-of-antibiotics-in-GP(66p)课.ppt

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,Update on use of antibiotics in GP,Dr Lau Pui Lam,Introduction,empirical therapy and the choices of antibiotics may vary a great deal even for the same provisional diagnosis.On some occasions,inadequate dose and duration were prescribed,antimicrobial guideline is an essential tool to promote rational use of antimicrobial agents with better application of existing knowledge and adherence to good practice,IMPACT was developed in 1999 towards better control of the growing problem of antimicrobial resistance in Hong Kong,a DH working group was formed in March 2001 to work out clinical guidelines on the use of antimicrobials for common infections in primary health care setting of the DH,Todays Menu,CAP,UTI,ENT,Gynaecological,URTI,Acute inflammation of nasal or pharyngeal mucosa in the absence of other specifically defined respiratory infections such as sinusitis(ICPC),cough,sore throat,acute nasal congestion,rhinorrhea and sputum,Particular attention to high-risk pt such as young children,frail elderly,immuno-compromised,and pt w/chronic illness,“Doc,I want antibiotics”,URTI,most common etiology is viral in over 80-90%of patients includes,rhinovirus,respiratory syncytial virus,influenza virus,parainfluenza virus and coronavirus.,differentiating between bacterial and viral infections may not be possible on clinical grounds alone.Also might not be as helpful as some think,primary goal to rule out serious illness,Community Acquired Pneumonia,Management in children,Aetiology and epidemiology,Streptococcus pneumonia,is the,most common,bacterial cause,Age is a good predictor,of the likely pathogens,Viruses,are most commonly found as a cause in,younger children,In,older children,when a bacterial cause is found,it is most commonly,S pneumoniae,mycoplasma and chlamydia,pneumonia,A significant proportion of cases of CAP(8-40%)represent a mixed infection,Viruses alone appear to account for 14-35%of CAP in childhood,In 20-60%of cases a pathogen is not identified,Severity assessment,Indicators for admission to hospital,Oxygen saturation 70/min in infants and RR50/min in children,difficulty in breathing,Intermittent apnoea,Not feeding well,Family not able to provide appropriate observation or supervision,General management,Home care,Information on managing pyrexia,preventing dehydration,and identifying any deterioration,Reviewed by a GP if deteriorating after 48h on treatment,Chest physio:not beneficial.should be not performed in children with pneumonia,Antipyretics and analgesics can be used to keep the child conformable and to help coughing,Antibiotic management,Macrolide antibiotics should be used if either mycoplasma or chlamydia pneumonia is suspected,Amoxicillin should be used as first line treatment at any age if S pneumonia is thought to be the likely pathogen,If Staphylococcus aureus is thought the likely pathogen,a macrolide or combination of flucloxacillin with amoxicillin is appropriate,Antibiotic management,Antibiotics administered orally are safe and effective for children presenting with CAP,Iv antibiotics for severe pneumonia include augmentin&cefuroxime.,If clinical or microbiological data suggest that S.Pneumonia is the causative organism,amoxicillin,ampicillin,or penicillin alone may be used,In a patient who is receiving iv antibiotics therapy for the treatment of CAP,oral treatment should be considered if there is clear evidence of improvement,Management in adult,Epidemiology,The annual incidence in the community is 5-11 per 1000 adult population,CAP accounts for 5-12%of all cases of adult lower RTI managed by GP in the community,The incidence of CAP requiring admission to hospital varies between 1.1 and 4 per 1000 population,Between 22-42%of adults with CAP are admitted to hospital,MCQ,25/F,fit,sudden onset of high fever,severe productive cough,70/F,ADLI,smoker,with COAD and a typical presentation of CAP,80/M OAHR bed-ridden with CAP,40/M,cough,diarrhoea,&fever.,Hx,of traveling abroad,20/F,cough 3/52,failed with,amoxil,previous visit to farm,bird contact+,C,psittaci,H,influenzae,Influenza A,Enterobacteriaceae,S,pneumoniae,Pseudomonads,S,auerus,Coag,ve,staph,M,pnuemoniae,MTB,Legionellar,sp,Aetiology,Out-patients 60 years old with or without co-morbidity:,pneumococci,H.influenzae,Gram negative organism and Staph.aureus,immunocompromised patients:,pneumococci,H.influenzae.Pneumocystis carinii,MTB,klebsiellae,pseudomonads and legionellae,Aetiology,Pneumonia COAD:,H.influenzae and Strep.pneumoniae and occasionally by Moraxella catarrhalis.,Klebsiella pneumoniae tends to cause lung infection in the debilitated elderly and alcoholic patients.,Aetiology,Frequency,of,legionella,staphlococcal,C psittaci&C bunetii,infection in patient with CAP in both the community and hospital is,low,routine enquiry about such factors is likely to be misleading,Only in those with severe illness where the frequency of legionella and staphylococcal infection is higher,may enquiry about foreign travel and influenza symptoms be of predictive value.,Mycoplasma pneumonia:epidemics spanning three winters occur every 4 years in the UK,Clinical features,Can CAP be reliably differentiated from other respiratory conditions by clinical features along?,A:The diagnosis of CAP on the basis of history and PE is,inaccurate,without a CXR.,Can the aetiology of CAP be predicted from clinical features?,A:The likely etiological agent causing CAP,cannot be,accurately predicted from clinical features.,Specific clinical features of particular respiratory pathogens,Streptococcus pneumonia,increasing age,comorbidity,acute onset,high fever and pleuritic chest pain,Legionellar pneumonia,younger patient,smokers,absence of comorbidity,diarrhea,neurological symptoms,more severe infection,evidence of multisystem involvement(e.g.abnormal LFT,elevated serum CK),Mycoplasma penumonia,younger patient,prior antibiotics,less multisystem involvement,Chlamydia pneumonia,longer duration of symptoms before hospital admission,headache,Coxiella burnetii:male sex,dry cough,high fever,CAP in the elderly of nursing home,But:,There is no evidence that the distribution of causative pathogens is different to that in other elderly with CAP.,They should be treated according to the general antibiotic recommendations,no specific antibiotic recommendation for nursing home acquired pneumonia,How to assess the severity of patient with CAP?,Severity assessment:adverse prognostic features,“Core”clinical adverse prognostic factors(,CRB-65/CURB-65,),Confusion,(Urea:7mmol/l),Respiratory rate 30/min,BP:low BP(SBP 90mmHg and/or DBP 65 yo,“Additional”clinical adverse prognostic factors,Hypoxaemia(SaO2 92%or PaO2 8 WBC/ml unspun urine)or leukocyte esterase dipstick test,Pyuria by dipstick(80-90%SN,50%SP),Bacteriuria detected by nitrite dipstick test(90%SP,30%SN).,Some suggested,urine culture,may not be necessary,in,acute uncomplicated cases,in young women,and diagnostic work-ups are not warranted,But,Urine culture is necessary when urinary tract infection occurs in,men,and in,children,or when,upper tract infection,is suspected.,Management,Relapsing infection,warrants more extensive urologic evaluation,Relapsing infection=recurrence occurring within 2 weeks of completion of treatment by the same organism.,Proteus,in urine culture warrant Ix of structural abnormalities,e.g.stone.,Urethritis shares many of the same symptoms as cystitis or vaginitis.,Herpes viruses,Chlamydia trachomatis,Ureaplasmas,Trichomonads and N.gonorrhoeae must be sought.,Bacterial count usually around 100 CFU/ml,Referral to SHC if STD is suspected,Antibiotic management,Due to resistance to ampicillin,septrin and nalidixic acid,empirical treatment of,uncomplicated UTI,in female adults:,Nitrofurantoin 50-100 mg qid x 1/52,Augmentin tab one tds x 1/52,Ofloxacin 200 mg bd x 3/7,Nalidixic acid may be another possible option.,Nitrofurantoin should not be used in,G6PD deficiency,patients,fluoroquinolone should not be used,in,children under 12 years,of age,pregnant women,and,during lactation,Recurrent Cystitis in Young Women,Definition:,More than 3 cystitis episodes,per year.,Urine culture should be done.,Empirical antibiotic therapy same as acute uncomplicated cystitis but for,7-10 days,Will you suggest prophylatic therapy?,Recurrent Cystitis in Young Women,Prophylactic treatment(National Guideline Clearing House),Three options:,Acute self treatment,Postcoital prophylaxis if related to sexual intercourse(using nitrofurantoin and fluoroquinolones).,Continuous daily prophylaxis for six months,e.g.using nitrofurantoin 50-100 mg/d or cefalexin(Keflex)250 mg/d,Acute Cystitis in Men,Urine culture,Antimicrobial therapy,same as acute uncomplicated cystitis,minimum of 7 days,.,Those with pyelonephritis or recurrent infections,urologic evaluation should be performed.,Consensus regarding need for urologic working up for single infection in young men is lacking.,Complicated UTI,E.coli,accounts for,fewer than one third,of complicated cases as compared to more than 80%of uncomplicated cases.,Urine culture is a must,Empirical therapy usually includes,fluoroquinolone x 10-14 days,follow-up urine cultures,should be performed,deal with the complicating factors,Cystitis in Children,Urine culture must be done,E.coli,is the causative organism in 85%of cases,Optimal duration of therapy is,seven days,refer for investigation,Asymptomatic Bacteriuria,The presence of significant bacteriuria(10,5,organism/ml)in the absence of symptoms.,Treatment is not necessary except in,children,pregnant women,patients with renal transplants,patients who are about to undergo genitourinary tract procedure,Asymptomatic Bacteriuria in Pregnancy,Defined as a pure culture of 10,5,organism/ml of urine of a person without symptoms,25-30%of untreated pregnant women with asymptomatic bacteriuria will develop symptomatic UTI during the pregnancy.,The sequelae of UTI in pregnancy include pyelonephritis,premature labour,PROM and increase in risk of fetal and perinatal mortality.,Treatment can significantly reduce the incidence of symptomatic UTI,low birth weight and preterm delivery,Asymptomatic Bacteriuria in Pregnancy,Screening:,The American College of Obstetrics and Gynecologists and the American Academy of Pediatrics(AAP):,urinalysis,including microscopic examination and infection screen,at the first prenatal visit,+/-additional urine culture determined by findings obtained from the history and physical examination,The Canadian Task Force:,a urine culture at 12-16 weeks of pregnancy,Treatment:,Pregnant women with asymptomatic bacteriuria should be treated with,3-7 day course of antibiotics,Treatment should be based on the results of urine culture.,MCQ,25/F,fit,dysuria&frequency 2/7,no,hematuria,/loin pain/fever,25/M,fit,dysuria&frequency 2/7,no,hematuria,/loin pain/fever,40/F,dysuria+frequency 2/7,3 previous episode this yr,80/M OAHR bed-ridden with,foley,catheter,asymptomatic,urine showed,Klebsiella,10,5,cfu/ml,30/F,pregnant,incidental found MSU,E.coli,10,5,cfu/ml,70/F,DM,gross,hematuria,&frequency,loin pain&fever 3/7,Augmentin,375mg,tds,1/52,Nitroflurantoin,100mg QID 1/52,Augmentin,375mg,tds,10/7,No need antibiotics,Augmentin,375mg,tds,3/7,Refer x AED x admission,Reference,Guidelines for the Management of Community Acquired Pneumonia in Adults 2001 Guidelines Thorax 2001;56:(suppl IV),Guidelines for the Management of Community Acquired Pneumonia in Adults 2004 Update,Guidelines for the Management of Community Acquired Pneumonia in ChildhoodBritish Thoracic Society Standards of Care Committee Thorax 2002;57:(Suppl I),Guideline on Antimicrobial Use for Primary Health Care Clinics,Department of Health HK,January 2002,