Transcript 上呼吸道感染 抗生素使用原則 小兒感染科 趙雁南醫師/

上呼吸道感染
抗生素使用原則
小兒感染科
趙雁南醫師/
邱南昌醫師,李聰明醫師
Antibiotic usage in primary care units in Taiwan
(Chang SC et al Diag Micro Infect Dis 2001;40: 137-43)
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1996 ~ 1999, collect prescriptions for 1 wk in March
each year, sampled from 114~166 health stations
with 40891 ~ 53992 physician-visits each year
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Patients < 11 y/o highest (38.2%) percentage
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Antibiotic Tx in 13.4% of total visits
Common cold most frequent (32%) diagnosis for antibiotic
prescription
Among patients with the Dx of common cold,
antibiotic Tx in 31%, highest among < 16 y/o (45.5%)
Penicillin class 35%, cephalosporins 27%,
macrolides 22%, others
Six common diagnoses in which
antibiotics were prescribed
Chang SC et al Diag Micro Infect Dis 2001;40:137-43
Diagnosis
No. of patients-visits
with antibiotics
prescribed
% of total antibiotic
prescriptions
Common cold
13588
32.3
COPD or asthma
2408
5.7
Acute bronchitis
2127
5.1
Skin and soft tissue
infections
1781
4.2
Acute tonsillitis
999
2.4
Cystitis
929
2.2
Proportion (%) of patient-visits resulting in
antibiotic prescription
Chang SC et al Diag Micro Infect Dis 2001;40:137-43
Diagnosis
Age group (years)
15
16-64
65
Total
Common cold
45.5
31.5
23.1
31.3
Influenza
52.2
21.5
29.1
33.2
COPD or
asthma
44.3
27.0
19.5
23.2
Prevalence of antimicrobial resistance of
common RTI pathogens isolated from 12
major Hospital in Taiwan, 2000
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Penicillin-nonsusceptible S. pneumoniae
60~80%
Erythromycin-resistant S. pneumoniae
67~100%
Ampicillin-resistant H. influenzae 45~73%
Erythromycin-resistant beta-hemolytic
streptococcus 30~51% Methicillin-resistant S.
aureus 53~83%
(Hsueh PR et al Emerg Infect Dis 2002;8:132-7)
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為了減少門診抗生素不當使用之情形，健保局
於民國90年2月1日開始施行上呼吸道感染抗生
素使用之給付規定，明確規定“上呼吸道感染
如屬一般感冒（common cold）或病毒性感染
者，不應使用抗生素”。
在90年2月之前的上呼吸道感染病人平均每月
抗生素使用率為49.5%，90年2月之後則降為
24.1%。
研究人員：張上淳
執行期間：91年11月11日至92年2月10日
Guidelines for antimicrobial
therapy of acute upper respiratory
tract infection in Taiwan
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Seven acute URTI chosen: acute sinusitis, acute
otitis media, acute pharyngotonsillitis, acute
epiglotittis, acute bronchitis, common cold, influenza
Principles of guidelines
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From the viewpoint of primary care physicians
Antimicrobial agents suggested marketing in Taiwan
Based on local epidemiologic data and antimicrobial
resistant rate of pathogens
Antimicrobial agents suggested mainly oral formulation
Guidelines for antimicrobial therapy of acute URT
in Taiwan
診
斷
首
選
另
選
急性鼻竇炎
(Acute sinusitis)
Amoxicillin (high dose)
Ampicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam
2o or 3o cephalosporins
(oral)
急性中耳炎
(Acute otitis media)
Amoxicillin (high dose)
Ampicillin
Amoxicillin/clavulanate
Ampicillin/sulbactam
2o or 3o cephalosporins
(oral)
急性咽扁桃腺炎
Penicillin V
Clindamycin
(Acute pharyngotonsillitis) Benzathine penicillin (IM) Macrolides
1o cephalosporins
急性支氣管炎(Acute
bronchitis)
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感冒(Common cold)
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Principles of Appropriate
Antibiotic Use for Treatment of
Acute Respiratory Tract Infections
in Adults
Annals of Internal Medicine. March 20, 2001
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Nonspecific Upper Respiratory Tract Infections
Acute Rhinosinusitis
Acute Pharyngitis
Uncomplicated Acute Bronchitis
Appropriate Abx Use for Tx of
Nonspecific URTI in Adults
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Recommendation 1.
The diagnosis of URTI should be used to denote
an acute infection that is typically viral in origin
and in which sinus, pharyngeal, and lower
airway symptoms, although frequently present,
are not prominent [B]
 greatest concentration of virus in the nasal
secretions: sneezing, nose blowing,
contamination with nasal secretions
Appropriate Abx Use for Tx of
Nonspecific URTI in Adults
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Recommendation 2.
Antibiotic treatment of adults with nonspecific
upper respiratory tract infection does not
enhance illness resolution and is not
recommended [A].
Appropriate Abx Use for Tx of
Nonspecific URTI in Adults
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Recommendation 3.
Purulent secretions from the nares or throat
(commonly observed in patients with
uncomplicated upper respiratory tract
infection) predict neither bacterial infection
nor benefit from antibiotic treatment
[A].(unless it persists for > 10 to 14 days ?)
Appropriate Abx Use for Tx of
Nonspecific URTI in Pediatrics
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Controlled trials of antimicrobial treatment
failed to change the course or outcome
No evidence of a protective effect for
antimicrobial treatment to prevent LRTIs
(Gadomski AM et al PIDJ 1993;12:115-20)
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Chemoprophylaxis can help prevent AOM in
some high-risk child
(Rosenstein N et al Pediatrics 1998;101:181-4)
Appropriate Abx Use for Tx of
Acute Rhinosinusitis in Adults
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Most cases of acute rhinosinusitis diagnosed
in ambulatory care are caused by
uncomplicated viral URTI [A].
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Sinus radiography is not recommended for
diagnosis in routine cases [B].
Appropriate Abx Use for Tx of
Acute Rhinosinusitis in Adults
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Bacterial and viral rhinosinusitis are difficult to
differentiate on clinical grounds [B].
Acute Bacterial Sinusitis:
Symptoms lasting 7 days or more,
unilateral maxillary pain,
maxillary toothache,
unilateral tenderness of the maxillary sinus
mucopurulent nasal discharge
Gold standard: Sinus aspiration , grow at least 105
organisms/ml
Appropriate Abx Use for Tx of
Acute Rhinosinusitis in Adults
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Sinusitis in radiography
complete opacification and air-fluid level
 Sensitivity: 80% (71-87%), specificity: 85%(76-91%)
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various degrees of mucosa thickening
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Specificity: 40~50%
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Absence of all three findings
 Sensitivity: ~90%
Appropriate Abx Use for Tx of
Acute Rhinosinusitis in Adults
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Who should not be treated:
Acute bacterial sinusitis (mild or moderate)
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Who should be treated:
severe or persistent (more than 7 days)
moderate symptoms + specific findings of
bacterial sinusitis
Appropriate Abx Use for Tx of
Acute Rhinosinusitis in Adults
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For initial treatment,the most narrowspectrum agent active against the likely
pathogens,Streptococcus pneumoniae and
Haemophilus influenza should be used
High dose Amoxicillin (most favored)
 Augmentin, Fluroquinolones, Telithromycin
X Erythromycin
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Appropriate Abx Use for Tx of
Acute Pharyngitis in Adults
An inflammatory illness of mucous membranes
and underlying structures of throat
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Frequently involve nasopharynx, uvula, soft
palate
Erythema, exudate, ulceration
Usually acute, sore throat
Common causes of pharyngotonsillitis
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Group A beta-hemolytic streptococci ,Epstein-Barr
virus ,Adenovirus ,Influenza viruses ,
Enteroviruses , Parainfluenza viruses
Appropriate Abx Use for Tx of
Acute Pharyngitis in Adults
Appropriate Abx Use for Tx of
Acute Pharyngitis in Adults
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The large majority of adults with acute
pharyngitis have a self-limited illness, for
which supportive care only is needed.
Antibiotic treatment of adult pharyngitis
benefits only those patients with GABHS
infection.
Complications: Acute Rheumatic Fever, Acute
Glomerulonephitis, Peritonsillar abscess,
Disease contagion
Diagnosis of Strep. pharyngitis
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Throat culture
Rapid antigen test
Centor criteria :
history of fever, tonsillar exudates, no cough ,
and tender anterior cervical lymphadenopathy
(lymphadenitis)
Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K.
The diagnosisof strep throat in adults in the emergency room.
Med Decis Making.1981;1:239-46.
Throat cultures
Does not always correlate with
antistreptolysin titers
 Produces results that vary depending on
technique
 Throat cultures also fail to distinguish acute
infection from the carrier state.
 Not recommended for the routine primary
evaluation of adults with pharyngitis or for
confirmation of negative results on rapid
antigen tests
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Indications of Throat Cultures
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Investigations of outbreaks of GABHS
disease
Monitoring the development
and spread of antibiotic resistance
When such pathogens as gonococcus are
being considered.
Rapid Antigen Tests
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Approximately the same sensitivity and
greater specificity for predicting results of
throat culture
“Medicalize” pharyngitis because
patients would need to see a physician for the
test to be performed.
Appropriate Abx Use for Tx of
Acute Pharyngitis in Adults
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Principle 1. Clinically screen all adult patients
with pharyngitis for the presence of the four
Centor criteria
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Principle 2. Do not test or treat patients with
none or only one of these criteria. These
patients are unlikely to have GABHS
infections [A].
Appropriate Abx Use for Tx of
Acute Pharyngitis in Adults
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Principle 3. For patients with two or more criteria, the
following strategies are appropriate:
a) Test these patients by using a rapid antigen test,
and limit Abx to patients with positive results
b) Abx for patients with four criteria, and patients with 2~3
criteria plus rapid test (+)
c) Limit Abx to those with 3~4 criteria only
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Principle 4. Administer appropriate analgesics, antipyretics,
and supportive care to all patients with pharyngitis [A].
Appropriate Abx Use for Tx of
Acute Pharyngitis in Adults
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Drug of Choice:
Single dose of intramuscular penicillin
( 1.2 MU for adults)
Penicillin VK 500mg orally 2~3 times per day for 10
days
Alternative: 1o generation cephalosporins,
macrolides, clindamycin
Neither repeat bacterial test of patients or testing of
asymptomatic household contacts recommended
A small percentage have a recurrence
Bisno AL et al Clin Infect Dis 2002;35:113-25)
The above guildlines do not
apply to:
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Patients of rheumatic fever, valvular heart disease,
immunosuppression,
recurrent or chronic pharyngitis (symptoms≥7days),
or to patients whose sore throats have a cause
other than acute infectious pharyngitis.
A known epidemic of acute rheumatic fever or
streptococcal pharyngitis or in nonindustrialized
countries in which the endemic rate of acute
rheumatic fever is much higher
Appropriate Abx Use for Tx of
Acute bronchitis in Adults
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The evaluation of adults with an acute cough
illness (< 3 weeks) should focus on ruling out
serious illness, particularly pneumonia.
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Pneumonia: abnormalities in vital signs (HR≥
100 beats/min, RR≥ 24 breaths/min, or temp
≥ 38 °C), CXR(eg. Focal consolidation), rales,
egophony, and fremitus
Appropriate Abx Use for Tx of
Acute bronchitis in Adults
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Technically definition: inflammation of
bronchial respiratory mucosa, resulting in
productive cough
Clinical definition : not well established,
usually cough with or without fever or sputum
production
Lack of a standardized case definition
(O’brien KL et al Pediatrics 1998;101:178-81)
Pathogens of Acute bronchitis
Viral
pathogens account for the majority of agents
Parainfluenza viruses, RSV, influenza viruses
20% adults with rhinovirus colds continue to cough > 14 days
(Gwaltney JM et al JAMA 1967;202:494-500)
Mycoplasma
pneumoniae, Chlamydia pneumoniae,
recognized pathogens in children >5y/o
Neither production of sputum nor character of sputum
predictive of a bacterial etiology for cough
Nasopharyngeal culture poor predictors of true bacterial pathogens
Fever
not indicate cough related to a bacterial
infection
(O’brien KL et al Pediatrics 1998;101:178-81)
Pathogens of Acute bronchitis
The
majority of prolonged cough illness are
allergic, postinfectious, or viral in nature
Reactive airway disease one of the most common causes, respond to
bronchodilators
Pertussis,
particularly among older children and
adults
Mycoplasma Pneumoniae , in school children
No specific or pathognomonic signs of cough
A macrolide small effect on shortening the duration of cough
(O’brien KL et al Pediatrics 1998;101:178-81)
Appropriate Abx Use for Tx of
Acute bronchitis in Adults
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Routine antibiotic treatment of uncomplicated
acute bronchitis is not recommended,
regardless of duration of cough.
Antimicrobial treatment for prolonged cough
(>10 days) may be indicated occasionally
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Pertussis
Mycoplasma pneumoniae, usually in children > 5
y/o, a macrolide agent
Underlying chronic pulmonary disease with acute
exacerbation
Diagnosis of Acute Otitis Media in
Children
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Pediatrics. 113(5):1451-65, 2004 May.
A history of acute onset,
Identify signs of middle-ear effusion (MEE),
Evaluate for the presence of signs and
symptoms of middle-ear inflammation.
Managements of AOM in Children
Pediatrics. 113(5):1451-65, 2004 May
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Assessment of “pain”: If pain is present, the clinician should
recommend treatment to reduce pain. (strong
recommendation)
Observation in a child with uncomplicated AOM is an option
for selected children
Managements of AOM in Children
Pediatrics. 113(5):1451-65, 2004 May
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Observation is an appropriate option only when
follow-up can be ensured and antibacterial agents
started if symptoms persist or worsen.
Nonsevere illness is mild otalgia and fever <39oC in
the past 24 hours.
Severe illness is moderate to severe otalgia or fever
≥39oC.
A certain diagnosis of AOM meets all 3 criteria
(rapid onset, signs of MEE, signs and symptoms of
middle-ear inflammation)
Managements of AOM in Children
Pediatrics. 113(5):1451-65, 2004 May
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If a decision is made to treat with an antibacterial agent, the
clinician should prescribe amoxicillin 80 to 90 mg/kg/day for
most children
Treatment course:
10 days : younger children, children with severe disease
5~7 days :children 6 years of age and older with mild to
moderate disease
If the patient fails to respond to the initial management
within 48 to 72 hours  Reassessment
Recommended Antibacterial Agents
Pediatrics. 113(5):1451-65, 2004 May
Managements of AOM in Children
Pediatrics. 113(5):1451-65, 2004 May
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Clinicians should encourage the prevention of
AOM through reduction of risk factors (strong
recommandation)
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Ex: genetic predisposition, premature birth, male
gender, presence of siblings in the household,
and low socioeconomic status, supine bottlefeeding (“bottle propping”), pacifier use in the
second 6 months of life, exposure to passive
tobacco smoke
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