抗生素Antibiotics

1、Coventry and Warwickshire PathologyAntibioticsJames ClaytonConsultant MicrobiologistCoventry and Warwickshire PathologyAntibiotic groups -Lactams Penicillins Penicillin, Amoxicillin, Flucloxacillin PO/IV Penicillins + -lactamase inhibitor Co-amoxiclav (Amoxicillin + clavulanate) PO/IV Tazocin (Piper

2、acillin + tazobactam) IV Cephalosporins PO/IV Carbapenems Meropenem, Ertapenem IVCoventry and Warwickshire Pathology Other antibiotics: Aminoglycosides Gentamicin, (Amikacin) IV Macrolides Erythromycin, Clarithromycin PO/IV Glycopeptides Vancomycin, (Teicoplanin) IV Tetracyclines Doxycycline PO Othe

3、rs Trimethoprim, Nitrofurantoin PO Rifampicin, Clindamycin PO/IV Ciprofloxacin POCoventry and Warwickshire PathologyCoventry and Warwickshire PathologyStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumCommon bacteria of medical importanc

4、eCoventry and Warwickshire PathologyStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesANAEROBESClostridiumAerobes vs AnaerobesCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM

5、 NEGATIVESHaemophilusPseudomonasBacteroidesClostridiumGram Positives vs Gram NegativesCoventry and Warwickshire PathologyStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumDoxycycline (tetracycline)Coventry and Warwickshire PathologyStrep

6、tococci Group A streptococci Skin & soft tissue infection Necrotising fasciitis Tonsillitis Toxic shock, sepsis Group B streptococci Neonatal infection, UTI Other streptococci Endocarditis, abscessCoventry and Warwickshire PathologyStreptococci & Enterococci Strep. pneumoniae URTI, pneumonia Enteroc

7、occus faecalis / E.faecium UTI, endocarditisCoventry and Warwickshire PathologyStaphylococcus Staph. aureus Skin & soft tissue infection Abscess Bone & joint infection Line infections Severe pneumonia Remember MRSA (Meticillin resistant S.aureus)Coventry and Warwickshire PathologyE.coli & coliforms

8、E.coli, Klebsiella, Proteus UTIs Intra-abdominal infection E.g. cholangitis, sepsis Hospital-acquired infection Remember ESBLsCoventry and Warwickshire PathologyNeisseria & Haemophilus N. meningitidis Meningitis N. gonorrhoeae Gonorrhoea H. influenzae Respiratory tract infection Meningitis (rare)Cov

9、entry and Warwickshire PathologyPseudomonas P. aeruginosa UTIs (usually complicated / catheter) Hospital acquired infectionsAnaerobes Intra-abdominal infections Skin & soft tissue infections AbscessCoventry and Warwickshire Pathology7 casesCoventry and Warwickshire PathologyCase 1 John, 18 yrs old S

10、ore throat for 2 days, feverish Exudate on tonsils when examined by GP Tonsillitis diagnosed. What organisms cause tonsillitis? What antibiotics are appropriate?Coventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemoph

11、ilusPseudomonasBacteroidesANAEROBESClostridiumUpper Respiratory Tract InfectionCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumPenicillinCoventry and Warwickshire

12、PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumUpper Respiratory Tract InfectionStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClost

13、ridiumPenicillinStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumErythromycin / ClarithromycinStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAmoxicillinCoventry and Warwi

14、ckshire PathologyCoventry and Warwickshire Community Antibiotic GuidelinesCoventry and Warwickshire PathologyTonsillitis Majority caused by Group A streptococci Group A streptococci Penicillin susceptibility 100% Erythromycin susceptibility 80% Penicillin preferred to Amoxicillin as: Narrower spectr

15、um EBV / glandular fever reaction Oral antibiotics in a community settingCoventry and Warwickshire PathologyCase 2 Bob, 70 years old COPD. 60 pack year smoking history. Retired engineer. 3 day history of cough, green sputum, malaise, raised temperature o/e crepitations, reduced air entry CXR extensi

16、ve consolidation CURB-65 = 2 No allergiesCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumCommunity Acquired PneumoniaAnd Atypicals!Coventry and Warwickshire Pathol

17、ogyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumCommunity Acquired PneumoniaStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAntibi

18、otic AStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAntibiotic BStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAntibiotic CCoventry and Warwickshire PathologyStreptoco

19、ccusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumCommunity Acquired PneumoniaStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumPenicillinStreptoc

20、occusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAmoxicillinStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAmoxicillin-clavulanate (Co-amoxiclav)Coventry and Warwickshire Patholo

21、gyCoventry and Warwickshire Treatment Guidelines (Hospital)Coventry and Warwickshire PathologyCommunity acquired pneumonia Strep. pneumoniae 30 - 40% Haemophilus influenzae 5 - 10% Staph. aureus 0.5 - 5% Severity of infection (CURB-65 score) Determines need for IV or oral treatment Determines need f

22、or broad vs narrow coverCoventry and Warwickshire PathologyDont forget atypicals in CAP! Legionella pneumophila 1 - 5% Mycoplasma pneumoniae 1 - 10% Chlamydophila pneumoniae 10% ? Chlamydia psittaci, Coxiella 2% Viruses including Influenza 15% Addition of Macrolide e.g. erythromycin or clarithromyci

23、n Tetracycline e.g. doxycycline (Ciprofloxacin)Coventry and Warwickshire PathologyCase 3 Katie, 25 years old Presents to A&E with history of dysuria, frequency Previously wellCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NE

24、GATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumUrinary Tract InfectionsCoventry and Warwickshire PathologyDo all antibiotics get into urine?These do: Penicillins (most) Amoxicillin, co-amoxiclav Cephalosporins Carbapenems Gentamicin Trimethoprim Nitrofurantoin Ciprofloxacin VancomycinTh

25、ese dont: Penicillins (few) Flucloxacillin (poorly only) Macrolides Erythro & Clarithromycin Tetracyclines Doxycycline ClindamycinCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAER

26、OBES ClostridiumUrinary Tract InfectionsStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumBStreptococcusEnterococcusStaphyl

27、ococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumCCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumUrinary Tract InfectionsStreptoc

28、occusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumTrimethoprimStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumNitrofurantoinStreptococcusEnterococcusStaphylococcusE.coliOther colif

29、ormsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAmoxicillinCoventry and Warwickshire PathologyCoventry and Warwickshire Treatment Guidelines (Hospital)Coventry and Warwickshire PathologyUTI Usually Gram-negatives as a cause E.coli Other coliforms (proteus, klebsiella) Less commonly enteroco

30、cci, staphylococci Pseudomonas Mainly in catheterised patients or those with underlying urinary tract disordersCoventry and Warwickshire PathologyCase 4 Stephen, 17 years old Admitted through A&E Lethargic, drowsy, unwell High fever Photophobia & stiff neck No allergiesCoventry and Warwickshire Path

31、ologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumMeningitisCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHae

32、mophilusPseudomonasBacteroidesANAEROBES ClostridiumMeningitisStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumAStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumBStreptococc

33、usEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumCCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumMeningitisS

34、treptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumPenicillinStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumCeftriaxoneStreptococcusEnterococcusStaphylococcusE.coliOther col

35、iformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumMeropenemCoventry and Warwickshire PathologyCoventry and Warwickshire Treatment Guidelines (Hospital)Coventry and Warwickshire PathologyMeningitis Neisseria menigitidis (meningococcus) Strep. pneumoniae (pneumococcus) Haemophilus influenzae

36、(HiB) Listeria (extremes of age, immunocompromise) Need IV therapy Need antibiotics with good meningeal penetrationCoventry and Warwickshire PathologyCase 5 Albert, 82 years old Had total hip replacement 5 days ago On review today, unwell, coughing mucky sputum Poor Oxygen sats, febrile WCC 18, CRP

37、280 CXR widespread opacity No allergies, no previous microbiology samplesCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumHospital acquired pneumoniaCoventry and Wa

38、rwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumHospital acquired pneumoniaStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemo

39、philusPseudomonasBacteroidesANAEROBES ClostridiumAmoxicillin-clavulanate (Co-amoxiclav)StreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumPiperacillin-tazobactam (Tazocin)StreptococcusGRAM POSITIVESEn

40、terococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumGentamicinCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANA

41、EROBES ClostridiumCo-amoxiclav + GentamicinStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumAmoxicillin-clavulanate (Co-amoxiclav)StreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseri

42、aGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumGentamicinCoventry and Warwickshire PathologyCoventry and Warwickshire Treatment Guidelines (Hospital)Coventry and Warwickshire PathologyCase 6 Ivy, 82 year old #neck of femur Had a DHS 3 days ago. Now has some erythema around the

43、wound Tender and wound feels hot. Well otherwise Determined to be non-severe wound infection Recent MRSA screen negative Penicillin allergic (previous rash)Coventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusP

44、seudomonasBacteroidesANAEROBESClostridiumSkin, soft tissue, bone and jointCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumSkin, soft tissue, bone and jointStrepto

45、coccusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumFlucloxacillinStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumErythromycin / ClarithromycinStreptococcusEnterococcusStaphylococcu

46、sE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumDoxycycline (tetracycline)Coventry and Warwickshire PathologyCoventry and Warwickshire Treatment Guidelines (Hospital)Coventry and Warwickshire PathologyCase 7 Rose, 75 year old Has been on medical ward for 2 weeks Diabetic,

47、hypertensive Catheterised to measure urine output Today, unwell, high temperature, hypotensive, MEWS score = 7. No obvious cause chest OK, abdo normal. No known allergiesCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIV

48、ESHaemophilusPseudomonasBacteroidesANAEROBESClostridiumSepsisCoventry and Warwickshire PathologyStreptococcusGRAM POSITIVESEnterococcusStaphylococcusE.coliOther coliformsNeisseriaGRAM NEGATIVESHaemophilusPseudomonasBacteroidesANAEROBES ClostridiumSepsisStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumMeropenemStreptococcusEnterococcusStaphylococcusE.coliOther coliformsNeisseriaHaemophilusPseudomonasBacteroidesClostridiumPenicillin + Gentamicin + MetronidazoleStreptococcusEnterococcusStaphylococcusE.coliOther coliform