抗生素ppt課件（英文精品） is resistance futile

IsResistanceFutile DonaldELowUniversityofTorontoOntarioAgencyforHealthProtectionandPromotion AchievementsinPublicHealth ControlofinfectiousdiseasesSanitationandHygieneVaccinationAntibiotics MMWR199948 29 621 Antibiotics theepitomeofawonderdrug Theintroductionofantibioticsinthe1940sconvertedillnessintoastrictlytechnicalproblem virtualeliminationofinfectiousdiseaseasasignificantfactorinsociallife BurnetFM Naturalhistoryofinfectiousdisease 2nded Cambridge CambridgeUniversityPress 1953 PrevalenceofIsolatesofMultidrug ResistantGramNegativeRodsRecoveredWithinTheFirst48hAfterAdmissiontotheHospital Pop VicasandD AgataCID2005 40 1792 8 MRSA DeLeoandChambersJCI2009adaptedfromKlevensetal JAMAI2007 Newemergingthreats HospitalsettingCarbapenemases KPCs CommunityS pneumoniaeCommunityAssociatedMRSAFluoroquinoloneresistantE coliMulti drugresistantGC ClinicalCase A73yoMwithnotravelhxLaparoscopicrightradicalnephrectomyforahypernephromawithpost oppneumoniaEmpiricallytreatedwithvariousantimicrobialsincludingthecarbapenemsCulturesfoundMDRK pneumoniae initiallyreportedasAmpC andESBL containingDiedwithpneumoniaandrespiratoryfailure SKrajden RobertoMelano andDylanR Pillai Carbapenemases Abilitytohydrolyzepenicillins cephalosporins monobactams andcarbapenemsResilientagainstinhibitionbyallcommerciallyviable lactamaseinhibitors KPC K pneumoniaecarbapenemase KPCsarethemostprevalentofthisgroupofenzymes foundmostlyontransferableplasmidsinK pneumoniaeSubstratehydrolysisspectrumincludescephalosporins suchascefotaxime KPCshavetransferredtoEnterobacterspp andinSalmonellaspp Streptococcuspneumoniae Mostimportantpathogeninmild to moderateRTIs1Greatestmorbidity2Greatestmortality2 Streptococcuspneumoniae 1FileTMJr Lancet 2003 362 1991 2001 2BartlettJG etal ClinInfectDis 2000 31 347 382 PercentageofPenicillinNon SusceptibleS pneumoniaeinCanada 1988 2008 CanadianBacterialSurveillanceNetwork Feb2009 Oralbreakpointsused Macrolide ResistantPneumococci CanadianBacterialSurveillanceNetwork 1988 2008 CanadianBacterialSurveillanceNetwork Feb2009 S pneumoniaecolonisation thekeytopneumococcaldisease NPcarriage15 19mos 10 afterageof10 3 inadultsInvasiveandmucosalinfectioninvolvesNPcolonizationwithconcurrentviralrespiratoryinfection KadiogluA etal NatRevMicro2008 PneumococcalVaccines Althoughthe23 valentvaccineisimmunogenicinadultsandchildrenolderthan5years youngchildren 2years haveaseverelyimpairedantibodyresponsetopolysaccharidevaccination Introductionofpneumococcalvaccines Ontario Oct1996 PPV23programforadultsIncreasedcoveragefrom 2 to35 inadults Invasivepneumococcaldisease elderlyMetropolitanToronto 1995 2000 PediatricinvasivepneumococcaldiseaseMetropolitanToronto 1995 2000 Pneumococcalvaccines MMWRFeb2008 InvasivePneumococcalDiseaseinChildren5YearsAfterConjugateVaccineIntroduction 1998 2005 TheoverallincidenceofIPDamongchildrenaged 5yearsdeclinedfrom99cases 100 000during1998 1999to23cases 100 000in2005 Introductionofpneumococcalvaccines Ontario Oct1996 PPV23programforadultsIncreasedcoveragefrom 2 to35 inadultsDec2001 PCV7licensedGradualincreaseinuseinchildren toabout1doseperchild or4dosesfor20 ofchildren Jan2005 provincialPCV7programNocatch up startwithbirthcohort PediatricinvasivepneumococcaldiseaseMetropolitanToronto 1995 2007 Invasivepneumococcaldisease elderlyMetropolitanToronto 1995 2001 RatesofpenicillinandamoxicillinresistanceCanada 1988 2008 CanadianBacterialSurveillanceNetwork March2008 MostCommonMDRSPNSerotypes VS MostCommonMDRSPNSerotypes P 0 0001 P 0 0009 P 0 0001 P 0 0001 VS WorldwidePrevalanceofMRSAAmongS aureusIsolates GrundmannHetal Lancet2006 368 874 MRSAinCanada 1995 2005 Source CNISP Community AssociatedMRSA SportsparticipantsInmatesincorrectionalfacilitiesMilitaryrecruitsChildrenindaycareNativeAmericans AlaskanNatives PacificIslandersMenwhohavesexwithmenHurricaneevacueesinsheltersFoalwatchersRuralcrystalmethamphetamineusers FirstOutbreaksofCA MRSA Australia 1993 UdoEEetal Geneticanalysisofcommunityisolatesofmethicillin resistantStaphylococcusaureusinWesternAustralia J Hosp Infect 1993US 1999 CDC Fourpediatricdeathsfromcommunity acquiredmethicillin resistantStaphylococcusaureus MinnesotaandNorthDakota MMWR1999Canada 2000 MulveyMRetal Community associatedMethicillin resistantStaphylococcusaureus CanadaEID2005Worldwide 2000 VandeneschFetal Community AcquiredMethicillin ResistantStaphylococcusaureusCarryingPanton ValentineLeukocidinGenes WorldwideEmergenceEID2003 EmergenceofCA MRSACanada SimoreAetal CanadianNosocomialInfectionSurveillanceProgram CMRSA7 USA400 CMRSA10 USA300 CurrentTreatmentOptionsforCA MRSAInfection MoelleringRCCID2008 Community acquiredantibioticresistanceinurinaryisolatesfromadultwomeninCanada 15 ofE coliisolatesfromadultwomenresistanttoTMP SMXFluoroquinolone resistantEcoliwas7 10 ofEcoliisolateswerefluoroquinolone resistantinwomenolderthan65yearsofage McIsaacWJetal CanJInfectDisMedMicrobiol 2006 Quinolone resistantNeisseriagonorrhoeaeinfectionsinOntario IsolatesreferredtotheOPHLbetween2002and2006FQ Rincreasedfrom4 0 in2002to27 8 in2006FQ Rstrainsweremoreresistanttopenicillin p 0 001 tetracycline p 0 001 anderythromycin p 0 001 Allisolatesweresusceptibletocefixime ceftriaxone azithromycinandspectinomycin OtaKetal CanMedAssJInPress Controllingantimicrobialresistance ReducingcolonizationandinfectionReducingvolumeofantimicrobialuseWhendecisionmadetotreatUserightdrugRightdoseRightduration Controllingantimicrobialresistance ReducinginfectionReducingvolumeofantimicrobialuseWhendecisionmadetotreatUserightdrugRightdoseRightduration Theaverageexcessage specificnumbersofoutpatientvisitsandcoursesofantibioticsper100childrenperyear NeuzilKMetal NEJM2000 TheEffectofInfluenzaonHospitalizations OutpatientVisits andCoursesofAntibioticsinChildren Controllingantimicrobialresistance ReducingcolonizationandinfectionReducingvolumeofantimicrobialuseWhendecisionmadetotreatUserightdrugRightdoseRightduration RespiratoryInfectionsarethe 1ReasonforOfficeVisits Source VerispanPDDA2004 Numberofcommonofficevisits millions NearlyTwo thirdsofallOralSolidAntibioticPrescriptionsareforSinusitisandBronchitis Source SDI FANDxRx Basedonalltablets capsuleantibioticsforthe52weeksendingApril6 2005 Telithromycin Ketek isindicatedforacuteexacerbationsofchronicbronchitis acutebacterialsinusitisandmild to moderatecommunity acquiredpneumonia UsageofantibioticsinEuropevs pneumococcalpenicillinI R1997 Felminghametal JAntimicrobChemother2000 45 191 201Carsetal Lancet2001 357 1851 1853 38 5 32 5 28 8 26 7 24 18 13 5 8 9 0 10 20 30 40 50 60 France Spain Portugal Belgium Italy UK Germany Netherlands DDD 1000 day DI RSP 1996data Controllingantimicrobialresistance ReducingcolonizationandinfectionReducingvolumeofantimicrobialuseWhendecisionmadetotreatUserightdrugRightdoseRightduration MultivariateAnalysisofRiskFactors 0 1 2 3 4 5 6 lactamw in3months Alcoholism Noninvasivedisease 5y 65y OddsRatio OtherConsiderationsImmunosuppressionIncludingsteroidsMultiplemedicalcomorbiditiesExposuretodaycarechildExposuretoanyantibiotic Clavo SanchezAJetal ClinInfectDis 1997 24 1052 1059 HarwellJI BrownRB Chest 2000 117 530 541 VanderkooiOGetal ClinInfectDis 2005 40 1288 1297 RisksforPenicillinResistanceinPneumococcus PrevalenceofErythromycinResistanceAmongPneumococcibyPriorMacrolideUse P 02 P 004 VanderkooiOGetal ClinInfectDis 2005 40 1288 1297 P 001 0 10 20 30 40 50 60 NoAntibiotic Erythromycin Clarithromycin Azithromycin RateofMacrolideResistanceinInfectingIsolates RelativeRiskforInfectionWithFluoroq