重症病患抗生素使用961113

4,754 views
4,640 views

Published on

Published in: Health & Medicine, Business
1 Comment
3 Likes
Statistics
Notes
  • Fioricet is often prescribed for tension headaches caused by contractions of the muscles in the neck and shoulder area. Buy now from http://www.fioricetsupply.com and make a deal for you.
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total views
4,754
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
131
Comments
1
Likes
3
Embeds 0
No embeds

No notes for slide
  • 重症病患抗生素使用961113

    1. 1. 重症病患之抗生素使用原則 財團法人為恭紀念醫院 感染科 曾政尹 醫師 C.Y.T.
    2. 2. 抗生素使用 <ul><li>一般原則 </li></ul><ul><li>重症病患使用原則 ( 降階治療 ) </li></ul><ul><li>重症感染 </li></ul><ul><li>抗藥性問題 </li></ul><ul><li>結語 </li></ul>
    3. 3. 抗生素一般使用原則 <ul><li>Narrow spectrum </li></ul><ul><li>一種細菌用一種藥物治療 </li></ul><ul><li>足量藥物治療 </li></ul><ul><li>完整療程 </li></ul><ul><li>- Balance between Efficacy and Collateral </li></ul><ul><li>damage ! </li></ul>C.Y.T.
    4. 4. Choice of proper antimicrobial agent <ul><li>Identity of the infecting ORGANISM </li></ul><ul><li>Information about the ANTIMICROBIAL </li></ul><ul><li>SUSCEPTIBILITY </li></ul><ul><li>HOST FACTORS </li></ul>C.Y.T.
    5. 5. Golden Triangle Antimicrobial agent Microorganism Host Immune system Microbiological profile Pharmacokinetics C.Y.T.
    6. 6. Host factors <ul><li>HISTORY of previous ADVERSE reactions to </li></ul><ul><li>antibiotics. </li></ul><ul><li>AGE </li></ul><ul><li>GENETIC or METABOLIC ABNORMALITIES </li></ul><ul><li>PREGNANCY </li></ul><ul><li>RENAL and HEPATIC function </li></ul><ul><li>SITE of infection </li></ul>C.Y.T.
    7. 7. Initial Selection of Antibiotics SUSPECTED DIAGNOSIS CLINICAL EVALUATION (site of infection, host, lab. data) C.Y.T.
    8. 8. Initial Selection of Penicillin-G <ul><li>PENUMOCOCCAL INFECTION </li></ul><ul><li>STREPTOCOCCAL INFECTION </li></ul><ul><li>MENINGOCOCCAL INFECTION </li></ul><ul><li>GONOCOCCAL INFECTION </li></ul><ul><li>ANAEROBIC GRAM + & GRAM - BACTERIAL INFECTION † </li></ul><ul><li>ACTINOMYCOSIS </li></ul><ul><li>ANIMAL BITE ( Pasteurella multocida ) </li></ul><ul><li>DIPHTHERIA </li></ul><ul><li>SYPHILIS </li></ul><ul><li>LEPTOSPIROSIS </li></ul><ul><li>† Except B. tragilis </li></ul>C.Y.T.
    9. 9. Third Generation Cephalosporins <ul><li>Resistant Gram-negative microorganisms </li></ul><ul><li>( Nosocomial infections ) – </li></ul><ul><li>Serratia, Citrobacter, Enterobacter, </li></ul><ul><li>Pseudomonas, β -lactamase producing </li></ul><ul><li>H. influenzae . </li></ul><ul><li>Better BBB penetration among cephalosporins </li></ul><ul><li>(except cefoperazone) </li></ul>C.Y.T.
    10. 10. Indications of Third-generation Cephalosporins <ul><li>Absolute indication </li></ul><ul><li>~ GNB meningitis </li></ul><ul><li>Relative indication </li></ul><ul><li>~ nosocomial infections (mainly GNB ) </li></ul>C.Y.T.
    11. 11. Extended-spectrum  -lactamase (ESBL) <ul><li>1963~ E.coli : TEM-1,4,6,12,19 、 SHV-1 …. </li></ul><ul><li>1984~ K. pneumoniae : TEM-3, 5, 8, 9, 10, </li></ul><ul><li>11… 、 SHV-3, 4, 5 </li></ul><ul><li>1969~ P. aeruginosa : TEM-2 </li></ul><ul><li>1990~ M. morganii : TEM-13 </li></ul><ul><li>Proteus mirabilis </li></ul>Antimicrobial Agents And Chemotherapy 1131-1136, 1989 C.Y.T.
    12. 12. 抗生素使用 <ul><li>一般原則 </li></ul><ul><li>重症病患使用原則 ( 降階治療 ) </li></ul><ul><li>重症感染 </li></ul><ul><li>抗藥性問題 </li></ul><ul><li>結語 </li></ul>
    13. 13. Getting It Right From Start To Finish The Role of De-escalation Therapy C.Y.T.
    14. 14. De-escalation therapy ( 降階治療 ) <ul><li>Stage 1 </li></ul><ul><li>- improve outcomes </li></ul><ul><li>↳ decrease mortality </li></ul><ul><li>prevent organ dysfunction </li></ul><ul><li>decrease length of stay </li></ul><ul><li>Stage 2 </li></ul><ul><li>- minimize resistance </li></ul><ul><li>- improve cost-effectiveness </li></ul>C.Y.T.
    15. 15. De-escalation therapy ( 降階治療 ) <ul><li>適當的起始治療 是決定重症病患治療結果的一項 </li></ul><ul><li>重要因子。 </li></ul><ul><li>以「適當」 (appropriate) 治療涵蓋「足夠」 </li></ul><ul><li>(adequate) 治療的概念。 </li></ul><ul><li>目標:「 在提供給高危險群病患足夠的起始抗生 </li></ul><ul><li>素治療,和避免會造成抗藥性的不必要抗生素使 </li></ul><ul><li>用,兩者之間取得平衡 。」 </li></ul>C.Y.T.
    16. 16. Initial Appropriate Therapy <ul><li>Serious infection : empiric broad-spectrum </li></ul><ul><li>therapy </li></ul><ul><li>Antibiotic: coverage of all likely pathogens . </li></ul><ul><li>Hitting hard: </li></ul><ul><li>- local microbiological data </li></ul><ul><li>- correct pathogens will be covered </li></ul><ul><li>( 每一個醫療機構都要根據當地最新的微生物數據 </li></ul><ul><li>,以評估可能的感染性病原菌和敏感性型態。 ) </li></ul>C.Y.T.
    17. 17. Local microbiological data
    18. 18. De-escalate <ul><li>Culture results </li></ul><ul><li>Clinical response </li></ul>C.Y.T.
    19. 19. Choose broad-spectrum, empiric treatment regimen based on clinical symptoms and unit-specific antibiogram data and guidelines . Obtain culture prior to antibiotic administration. Obtain and analyze microbiological data Modify regimen accordingly Reassess patient Process for Initial Appropriate Therapy C.Y.T.
    20. 20. Factors in Selecting Initial Appropriate Therapy <ul><li>Patient features </li></ul><ul><li>~ based on site and severity of infection </li></ul><ul><li>~ assessment of deterioration and mortality </li></ul><ul><li>Local susceptibility and epidemiology </li></ul><ul><li>Initial antibiotic therapy dosing and duration </li></ul><ul><li>Combination vs. monotherapy </li></ul><ul><li>~ broad enough coverage </li></ul><ul><li>~ avoid emergence of resistance </li></ul><ul><li>~ have the potential for synergy </li></ul>C.Y.T.
    21. 21. Indications for Combination <ul><li>SYNERGISM </li></ul><ul><li>Pseudomonas group </li></ul><ul><li>infections </li></ul><ul><li>Severe sepsis </li></ul><ul><li>Initial therapy/Unknown </li></ul><ul><li>etiology </li></ul><ul><li>Mixed infection </li></ul><ul><li>(Polymicrobial infections) </li></ul><ul><li>Anti-TB treatment </li></ul><ul><li>Immunocompromised </li></ul><ul><li>host </li></ul><ul><li>Decreased toxicity </li></ul><ul><li>Prevention of emergence </li></ul><ul><li>of resistant organism </li></ul>C.Y.T.
    22. 22. Initial Empiric Antibiotic Therapy <ul><li>Early onset or late onset </li></ul><ul><li>Different antibiotic class: if recent </li></ul><ul><li>exposure to a class of antibiotics </li></ul><ul><li>Appropriate & adequate antibiotic dosage </li></ul><ul><li>Local antibiotics susceptibility patterns </li></ul><ul><li>( regular update ) </li></ul><ul><li>De-escalation therapy </li></ul>Am J Respir Crit Care Med, Vol. 171; 388-416, 2005 C.Y.T.
    23. 23. Initial Inadequate Therapy <ul><li>The antibiotic did not cover the infecting </li></ul><ul><li>pathogen(s). 1,2 </li></ul><ul><li>The pathogen was not susceptible to the </li></ul><ul><li>antibiotic due to resistance. 1,2 </li></ul><ul><li>Dosing was not adequate. </li></ul><ul><li>Further consideration: combination therapy was </li></ul><ul><li>not used, if indicated. </li></ul><ul><li>-> increase mortality </li></ul>1 Kollef MH et al. Chest 1999;115:462-474. 2 Ibrahim EH et al. Chest 2000;118:146-155 . C.Y.T.
    24. 24. Appropriate Therapy Leads to Lower Mortality in Gram-Negative Sepsis <0.001 49% (47-51%) 28% (22-32%) Total <0.001 29% (23-31%) 10% (0-13%) Non-fatal <0.001 67% (63-72%) 42% (39-45%) Ultimately fatal NS 85% (71-100%) 84% (80-86%) Rapidly fatal P-value Mortality without appropriate therapy Combined data (range) Mortality with appropriate therapy Combined data (range) Underlying Disease Bochud P-Y et al. Intensive Care Med 2001;27:S33-S48. C.Y.T.
    25. 25. Mortality Associated With Initial Inadequate Therapy In Critically Ill Patients With Serious Infections in the ICU 0% 20% 40% 60% 80% 100 % Luna, 1997 Ibrahim, 2000 Kollef, 1998 Kollef, 1999 Rello, 1997 Alvarez-Lerma,1996 Initial appropriate therapy Initial inadequate therapy *Mortality refers to crude or infection-related mortality Alvarez-Lerma F et al. Intensive Care Med 1996;22:387-394. Ibrahim EH et al. Chest 2000;118L146-155. Kollef MH et al. Chest 1999; 115:462-474 Kollef MH et al. Chest 1998;113:412-420. Luna CM et al. Chest 1997;111:676-685. Rello J et al. Am J Resp Crit Care Med 1997;156:196-200. Mortality* C.Y.T.
    26. 26. Reassess therapy when <ul><li>Etiologic agent identified </li></ul><ul><li>Antibiotic sensitivities established </li></ul>C.Y.T.
    27. 27. 抗生素使用 <ul><li>一般原則 </li></ul><ul><li>重症病患使用原則 ( 降階治療 ) </li></ul><ul><li>重症感染 </li></ul><ul><li>抗藥性問題 </li></ul><ul><li>結語 </li></ul>
    28. 28. Empirical Broad-Spectrum Antimicrobial Therapy <ul><li>~ Critically ill patients with serious infections </li></ul><ul><li>Ventilator-associated pneumonia (VAP) </li></ul><ul><li>Nosocomial pneumonia </li></ul><ul><li>Severe community-acquired pneumonia </li></ul><ul><li>Bloodstream infection ( BSI ) </li></ul><ul><li>Meningitis </li></ul>C.Y.T.
    29. 29. Hospital acquired infection - 定義 <ul><li>An infection found to be active , or under active treatment at the time of the survey, which as not present on admission . </li></ul><ul><li>In general: after 48 hours of admission. </li></ul><ul><li>Established infection which has resulted from an earlier admission (incubated on admission) </li></ul>C.Y.T.
    30. 30. Patients With VAP Suffer Excess Morbidity and Mortality <ul><li>32.3% relative risk increase in mortality </li></ul><ul><li>Significantly longer duration of hospital </li></ul><ul><li>stay (19 v.s. 14 days, p<0.001) </li></ul><ul><li>Trend towards longer attributable length </li></ul><ul><li>of stay in the ICU with infection caused by </li></ul><ul><li>high risk organisms (9.1 vs. 2.9 days) </li></ul>Heyland DK. Am J Respir Crit Care Med 1999;159:1249-1256. C.Y.T.
    31. 31. Spectrum of Potential Pathogens in Hospital-Acquired Pneumonia* Based on Severity of Illness Campbell GD et al. Am J Respir Crit Care Med 1996;153:1711-1725 * Excludes patients with immunosuppression. ** Includes severe HAP without risk factors (early onset) *** Severe HAP with risk factors (onset any time) or severe HAP without unusual risk factors (late onset) Mild-to-Moderate (With risk factors) Severe*** Core Organisms Enteric GNB Core Organisms, Plus Anaerobes Core Organisms , Plus P. aeruginosa (Non-pseudomonal) (recent abdominal • Enterobacter surgery; witnessed Acinetobacter • E. coli aspiration) species • Klebsiella • Proteus Consider MRSA • Serratia marcescens Haemophilus influenzae S. aureus (including MRSA if coma, head trauma, DM, renal failure) Methicillin-sensitive Legionella Staphylococcus aureus (high-dose steroids) Streptococcus pneumoniae P. aeruginosa (prolonged ICU, steroids, antibiotics) structural lung disease, Mild-to-Moderate (No unusual risks)** C.Y.T.
    32. 32. HAP: risk factors for resistant pathogens <ul><li>Late onset ( ≥ 5 days) </li></ul><ul><li>Prior antibiotic use </li></ul><ul><li>Comorbid illness </li></ul><ul><li>Intensive care unit (ICU) </li></ul>C.Y.T.
    33. 33. Risk Factors for Resistance in VAP <ul><li>Use of antibiotics within 15 days 1 </li></ul><ul><li>Duration of hospitalization 2 </li></ul><ul><li>Duration of mechanical ventilation ≥ 7 days 1 </li></ul>1 Trouillet J-L et al. Am J Respir Crit Care Med 1998;157:531-539. 2 Lautenbach E et al. Clin Infect Dis 2001;32:1162-1171. C.Y.T.
    34. 34. Risk Factors for Resistance in VAP Adapted from Trouillet J-L et al. Am J Respir Crit Care Med 1998;157:531-539. MRSA, P. aeruginosa , A. baumannii , S. maltophilia More sensitive bacteria than in Group 2 More resistant bacteria than in Group 3 Antibiotic-sensitive organisms (e.g., pneumococci, H. influenzae ) MV ≥7 days; prior use of antibiotics MV ≥7 days; no prior antibiotics MV <7 days; prior use of antibiotics MV <7 days; no prior antibiotics Group 4 Group 3 Group 2 Group 1 C.Y.T.
    35. 35. ATS recommendations: I <ul><li>Early onset VAP & no risk factors Pathogens: S. pneumoniae , H. influenzae , S. aureus , non-resistant GNB Regimen: cephalosporin II or III quinolone III or IV  -lactam/  -lactamase inhibitor Monotherapy is adequate </li></ul>C.Y.T.
    36. 36. ATS recommendations: II <ul><li>Late onset VAP, early onset VAP with risk factors </li></ul><ul><li>Pathogens: resistant GNB, P. aeruginosa , MRSA Regimen: Carbapenem, Tazocin, Ceftazidime, + quinolone or aminoglycoside +/- vancomycin </li></ul><ul><li>Combination therapy is better </li></ul>C.Y.T.
    37. 37. 血流感染 ( Bloodstream Infection) <ul><li>病人 住院以後 , 血流遭受微生物侵入所引起 </li></ul><ul><li>之感染。 </li></ul><ul><li>Mortality rate : 15% </li></ul><ul><li>- In critically ill patient: 12 ~ 25% </li></ul><ul><li>Vascular catheters : 87% in critically-ill </li></ul><ul><li>patients </li></ul>Prevention and Control of Nosocomial Infections, 4 th ed. P.281-2 C.Y.T.
    38. 38. Resistant Pathogens Account for High Number of Bloodstream and Nosocomial Infections Kollef MH et al. Clin Inf Dis 2000;31(Suppl. 4):S131-S138. Coagulase-negative Staphylococci P= .001 0 10 20 30 40 50 Bloodstream infection Nosocomial pneumonia Urinary tract infection Invasive device present Percentage occurrence P. aeruginosa P= .002 A. baumannii P= .006 E. coli P= .023 C. albicans P= .009 Invasive device absent C.Y.T.
    39. 39. CVC-Associated Bloodstream Infection <ul><li>Skin commensals: ≥ 2 blood cultures </li></ul><ul><li>Diphtheroids </li></ul><ul><li>Bacillus spp. </li></ul><ul><li>Propionibacterium spp. </li></ul><ul><li>Coagulase-negative staphylococci </li></ul><ul><li>Micrococci </li></ul>C.Y.T.
    40. 40. 敗血性休克 (Septic shock) <ul><li>Correlation with mortality : SIRS criteria and TNF </li></ul><ul><li>No difference in mortality and morbidities: septic shock with or without positive blood cultures </li></ul>- Prevention and Control of Nosocomial Infections, 3rd ed. P.714 C.Y.T.
    41. 41. 抗生素使用 <ul><li>一般原則 </li></ul><ul><li>重症病患使用原則 ( 降階治療 ) </li></ul><ul><li>重症感染 </li></ul><ul><li>抗藥性問題 </li></ul><ul><li>結語 </li></ul>
    42. 42. 抗藥性細菌增加的原因 <ul><li>抗藥性細菌 產生增加 ( 抗生素選擇性壓力 , </li></ul><ul><li>selection pressure ): 由於醫師過多的使用抗 </li></ul><ul><li>生素 , 造成對 基因突變 及 抗藥基因轉移 的抗藥 </li></ul><ul><li>性細菌進行了篩選。 </li></ul><ul><li>抗藥性細菌 傳播增加 : 透過 醫護人員 ( 尤其 手 ) </li></ul><ul><li>的接觸 , 細菌在病患間交叉寄生 , 造成在 醫院 </li></ul><ul><li>內 傳播 ; 之後並經由宿主病人的轉移 , 在 醫院 </li></ul><ul><li>間 甚至 社區 進行傳播。 </li></ul>C.Y.T.
    43. 43. 抗生素的抗藥性 (ICU, 2004 NNIS Report)
    44. 44. 抗生素的抗藥性 (2004 NNIS Report)
    45. 45. 哪些抗生素的附加損害 (collateral damage) 最大 ? <ul><li>Cephalosporin </li></ul><ul><li>Fluoroquinolone </li></ul><ul><li>Carbapenem </li></ul><ul><li>β -lactam/ β -lactamase inhibitor </li></ul><ul><li>Aminoglycoside </li></ul><ul><li>Macrolide </li></ul>C.Y.T.
    46. 46. Collateral damage <ul><li>~ High risk </li></ul><ul><li>2 nd /3 rd Gen. cephems: </li></ul><ul><li>ESBLs </li></ul><ul><li>Fluoroquinolones: </li></ul><ul><li>MRSA, ESBLs, </li></ul><ul><li>MDR P. aeruginosa </li></ul><ul><li>Carbapenems (imipenem, meropenem): </li></ul><ul><li>MDRAB, MDRPA </li></ul><ul><li>~ Low risk </li></ul><ul><li>β -lactam/ β -lactamase </li></ul><ul><li>inhibitor </li></ul><ul><li>4 th Gen. cephems </li></ul>C.Y.T.
    47. 47. Multidrug-Resistant Organisms (MDROs) <ul><li>- Gram-positive : </li></ul><ul><li>S. aureus </li></ul><ul><li>Coagulase-negative staphylococcus </li></ul><ul><li>Streptococcus pneumoniae </li></ul><ul><li>- </li></ul><ul><li>Enterococcus spp. </li></ul><ul><li>- VRE </li></ul><ul><li>- Gram-negative : MDR-GNB </li></ul><ul><li>P. aeruginosa </li></ul><ul><li>E. coli </li></ul><ul><li>K. Pneumoniae </li></ul><ul><li>Enterobacter spp. </li></ul><ul><li>- 3 rd cephem </li></ul><ul><li>- Quinolone </li></ul><ul><li>- Carbapenem </li></ul>- MRSA, VISA, VRSA - MRCNS MDRSP C.Y.T.
    48. 48. Most Frequently Reported Pathogens from ICU Patients with Nosocomial Pneumonia 1. Pseudomonas aeruginosa 2. Staphylococcus aureus 3. Enterobacter spp. 4. Klebsiella pneumoniae 5. Acinetobacter spp. Richards MJ et al. Crit Care Med 1999; 887-892. C.Y.T.
    49. 49. 95 年 TNIS 加護病房院內感染最常見菌株前三名 <ul><li>醫學中心 : Pseudomonas aeruginosa </li></ul><ul><li>Escherichia coli </li></ul><ul><li>Acinetobacter baumannii </li></ul><ul><li>區域醫院 : Pseudomonas aeruginosa </li></ul><ul><li>Klebsiella pneumoniae </li></ul><ul><li>Acinetobacter baumannii </li></ul>C.Y.T.
    50. 50. Preventing the emergence and transmission of MDROs <ul><li>Administrative involvement and measures </li></ul><ul><li>Education and training of personnel </li></ul><ul><li>Judicious antibiotic use </li></ul><ul><li>Comprehensive surveillance for targeted MDROs </li></ul><ul><li>Application of infection control precautions </li></ul><ul><li>Environmental measures </li></ul><ul><li>Decolonization therapy when appropriate </li></ul>– The prevention and control of MDROs is a national priority. C.Y.T.
    51. 51. <ul><li>Control of antibiotic resistance will mandate </li></ul><ul><li>more effective nosocomial infection control </li></ul><ul><li>and </li></ul><ul><li>more restrictive use of anti-infectives . </li></ul><ul><li>- Ann Intern Med . 2002;136:834-44. </li></ul><ul><li>- Ann Intern Med. 2006;145:582-591. </li></ul>C.Y.T.
    52. 52. 抗生素使用 <ul><li>一般原則 </li></ul><ul><li>重症病患使用原則 ( 降階治療 ) </li></ul><ul><li>重症感染 </li></ul><ul><li>抗藥性問題 </li></ul><ul><li>結語 </li></ul>
    53. 53. Summary <ul><li>Initial inadequate therapy : </li></ul><ul><li>Inadequate initial empiric therapy leads to increased mortality in patients with serious infection. </li></ul><ul><li>Initial appropriate therapy : </li></ul><ul><li>Means starting with a broad-spectrum antibiotic and then focusing based on clinical and microbiological data. </li></ul><ul><li>Should be based on patient stratification , and local epidemiology and susceptibility patterns . </li></ul><ul><li>Includes use of appropriate drug , dose , and duration . </li></ul>C.Y.T.
    54. 54. De-escalation Therapy <ul><li>Get It Right The First Time </li></ul><ul><li>Prevent rapid decline </li></ul><ul><li>Avoid resistance </li></ul><ul><li>Save lives </li></ul>C.Y.T.
    55. 55. Considerations for choosing empirical therapy  In vitro activity of drugs against likely pathogens  Local resistance burden  Pharmacologic and pharmacodynamic properities of antimicrobials  Safety and tolerability C.Y.T.
    56. 56. Major pathway of antibiotic excretions <ul><li>Antibiotics primarily Antibiotics primarily excreted by </li></ul><ul><li>excreted by the liver the kidneys </li></ul><ul><li>Cefoperazone Aminoglycosides </li></ul><ul><li>Chloramphenicol Aztreonam </li></ul><ul><li>Clindamycin Cephalosporins ( other than cefoperazone ) </li></ul><ul><li>Doxycycline Imipenem </li></ul><ul><li>Erythromycin Norfloxacin and ciprofloxacin </li></ul><ul><li>Metronidazole Penicillin and penicillin derivatives </li></ul><ul><li>Nafcillin Trimethoprim </li></ul><ul><li>Rifampin Tetracycline </li></ul><ul><li>Sulfamethoxazole Vancomycin </li></ul>C.Y.T.
    57. 57. Antibiotic Therapy <ul><li>Know your bugs </li></ul><ul><li>Adhere to antibiotic guidelines </li></ul><ul><li>Give appropriate dosage </li></ul><ul><li>Narrow spectrum once culture and </li></ul><ul><li>susceptibility is available </li></ul><ul><li>Treat for shorter periods </li></ul>C.Y.T.
    58. 58. Antibiotic Therapy <ul><li>In the current era of resistance, drugs can </li></ul><ul><li>no longer be held “In Reserve” </li></ul><ul><li>Don’t use those antibiotics implicated in </li></ul><ul><li>collateral damage </li></ul>C.Y.T.
    59. 59. Therapy and Infection Control <ul><li>Isolation of patient and contact precaution </li></ul><ul><li>or cohort care </li></ul><ul><li>Treat infection, not colonization </li></ul><ul><li>Aseptic technique and hand washing </li></ul><ul><li>MDRAB : carbapenem + sulbactam, </li></ul><ul><li>tigecycline, colistin. </li></ul>C.Y.T.
    60. 60. An Art in Medicine Balance An Evidence-Based Problem: Mortality with Inadequate Therapy A Theoretical Dilemma: Concern of Resistance with Broad-Spectrum Therapy Evans RS et al. N Engl J Med 1998;338:232-238. Gruson D et al. Am J Respir Crit Care Med 2000;162:837-843. Raymond DP et al. Crit Care Med 2001;29:1101-1108. ⋆ Clinical evidence showing lack of resistance with heterogeneous use of broad-spectrum therapy C.Y.T.
    61. 61. C.Y.T.
    62. 62. 結語 <ul><li>照顧重症病患的工作人員必須要有高度的 </li></ul><ul><li>警覺心,以能及時思考感染的診斷正不正 </li></ul><ul><li>確。 </li></ul><ul><li>Use culture data and clinical response to </li></ul><ul><li>focus therapy and shorten the duration of </li></ul><ul><li>therapy, or stop therapy. </li></ul>C.Y.T.
    63. 63. Thank you for your attention !

    ×