Pitfallsandproblemsusingantibioticsincats貓的抗生素應(yīng)用缺陷與Pitfallsandproblemsusingantibioticsincats貓的抗生素應(yīng)用缺陷與問(wèn)Dr.BiankaSchulzDipl.ECVIM-CAAntibiotictherapy–basic????indicationAntibiotictherapy–basic????indicationfortherapydetectionofpathogensentitivitytestingchoiceofantibiotic??Distributiondose/durationofsideeffects?Antibiotictherapy–basic????indicationfordetectionofsentitivityAntibiotictherapy–basic????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideIndicationsfor治療的適應(yīng)?therapyofdiagnosedbacterial治療已經(jīng)確診為細(xì)菌感Indicationsfor治療的適應(yīng)?therapyofdiagnosedbacterial治療已經(jīng)確診為細(xì)菌感->baseduponcultureandsensitivity基于細(xì)菌培養(yǎng)和藥敏試empiricaltherapy:suspected經(jīng)驗(yàn)療法：懷疑感?->發(fā)燒/低體->leukocytosis/leukopeniawithleft白細(xì)胞增多/白細(xì)胞減少并伴隨核左signsofsepsis敗血癥征?Antibiotictherapy–basic????indicationfordetectionAntibiotictherapy–basic????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideDetectionofbacterial病原菌的發(fā)?samplingbeforestartofantibioticDetectionofbacterial病原菌的發(fā)?samplingbeforestartofantibiotic??pleuraleffusionpulmonaryaspirate???assessmentofcultureincorrelationwithcytologyspecialculturemediaforcertainMycoplasmaspp.,Chlamydophilafelis支原體，衣LRTculturesofwithrespiratory呼吸道癥狀貓的系呼吸道培Neg革蘭氏陰Bord.博得特Strep鏈球菌Staph.葡萄球E.ColiLRTculturesofwithrespiratory呼吸道癥狀貓的系呼吸道培Neg革蘭氏陰Bord.博得特Strep鏈球菌Staph.葡萄球E.Coli大腸桿Past.巴斯德%0(n=(n=(n=(n=(n=(n=BacterialisolatesfromlowerrespiratorytractofhealthyBacterialisolatesfromlowerrespiratorytractofhealthyStreptococcusspp.MicrococcusE.PasteurellaKlebsiellaspp.EnterobacterProteusHaemophilusGreene,Whendowetreatinapatientwithpositiveculture?培養(yǎng)結(jié)果陽(yáng)性時(shí)我們Whendowetreatinapatientwithpositiveculture?培養(yǎng)結(jié)果陽(yáng)性時(shí)我們?cè)撟鍪裁?LRTnotbacterialconcentration<104colonyformingunits/mlhealthy健康貓的細(xì)菌集落形成濃度104單位signsoforopharyngealassessinformationfromhistory,PE,laboratorywork,radiographs,cytologyandculturetomakedecisionBAL支氣管肺泡灌洗液細(xì)胞BAL支氣管肺泡灌洗液細(xì)胞courtesyofDr.I.Oropharyngeal口咽部感??epithelialSimonsiellaspp.Oropharyngeal口咽部感??epithelialSimonsiellaspp.courtesyofDr.I.Antibiotictherapy–basic抗生素療法-基本考????indicationfordetectionAntibiotictherapy–basic抗生素療法-基本考????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideSensitivity藥敏試?resistancepatternoftenfrequentlyresistantSensitivity藥敏試?resistancepatternoftenfrequentlyresistantbacteriaPseudomonasspp.,Enterobacterspp.,EcoliProteus*?*Papich,2001;Oluochetal.,Whentosuspectresistant什么時(shí)候懷疑細(xì)菌Whentosuspectresistant什么時(shí)候懷疑細(xì)菌耐藥????recurringinfectionschronicunderlyingdiseasenosocomialinfectionscatheterassociatedinfections??poorhealingwoundspre-treatmentwithinsufficientantibioticdoseanddurationSensitivity藥敏試??agardiffusiontestMICtestingSensitivity藥敏試??agardiffusiontestMICtestingantibiotictarget-orientedantibioticAntibiotictherapy–basic抗生素療法-基本考????indicationfordetectionAntibiotictherapy–basic抗生素療法-基本考????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideAntibiotic?ifavailable,basedoncultureandsensitivity?Antibiotic?ifavailable,basedoncultureandsensitivity?ifnot:whichpathogendoIexpect我該懷疑哪種病->gram->gram->->Antibioticexamplecephalosporinsgram+--Antibioticexamplecephalosporinsgram+--+++AntibioticbactericidalorbactericidalordependingonimmunestatusofBactericidalAntibioticbactericidalorbactericidalordependingonimmunestatusofBactericidalBacteriostatic抑菌Penicillines青霉Cephalosporines頭孢SulfonamidesAminoglycosidesChloramphenicol氯霉Fluoroquinolonesmacrolides(dose-dependentBacterialisolatesfromcatswithnasalNeg陰性菌Bord.StaphE.ColiPast巴氏桿菌0SchulzetBacterialisolatesfromcatswithnasalNeg陰性菌Bord.StaphE.ColiPast巴氏桿菌0Schulzetal,VetRec(n=(n=(n=(n=(n=(n=LRTculturesofcatswithrespiratory(n=Neg陰(n=(n=Staph(n=LRTculturesofcatswithrespiratory(n=Neg陰(n=(n=Staph(n=(n=E.Coli大腸桿(n=Past.%0Schulzetal,VetRecResultssensitivitytesting結(jié)果-overallefficacyin94.6Enrofloxacinn205)恩諾沙89.6Cephalexin(n48)Gentamicinn205)慶大霉85.9Amoxicillin/Clav.acid(n=Resultssensitivitytesting結(jié)果-overallefficacyin94.6Enrofloxacinn205)恩諾沙89.6Cephalexin(n48)Gentamicinn205)慶大霉85.9Amoxicillin/Clav.acid(n=83.8阿莫西林/克拉81.5Chloramphenicol(n205)氯霉81.3Kanamycin(n176)Doxycycline(n200)強(qiáng)力霉73.0Trimethoprim/Sulfon.(n=磺胺甲71.2Ampicillin/Amoxicillin(n=氨芐青霉素/68.3Schulzetal.,VetRecFelinepyothoraxwhatdoweknowfrom???Felinepyothoraxwhatdoweknowfrom???polymicrobialinfectionssimilartooropharyngealfloraobligateandfacultativeanaerobic?<20%ofbacteriaotherthan<20%的細(xì)culturemediaforantibiotictherapyshouldbedirectedagainstanaerobicbacteria抗生素治療直接選擇針對(duì)厭氧菌AntibioticsfortreatmentoffelinePenicillinGpotassium/sodium20,000–40,000AntibioticsfortreatmentoffelinePenicillinGpotassium/sodium20,000–40,000IU/kgIVq6青霉素G/鉀/納20,000–40,000IU/kgIVq6Ampicillin20–40mg/kgIVq6–8h氨芐青霉素20–40mg/kgIVq6–8hAmoxicillin10–20mg/kgIVq12h10–20mg/kgIVq12hTicarcillin–clavulanicacid40–50mg/kgIVq6–8h替卡西林-克拉維酸40–50mg/kgIVq6–8Ampicillin–sulbactam50mg/kg(combined)IVq8阿莫西林-舒巴坦50mg/kg(聯(lián)合使用)IVq8hAmoxycillin–clavulanicacid12–20mg/kg/SC/IM/IVq12h阿莫西林克拉維酸acid12–20mg/kg/SC/IM/IVq12Antibiotic抗生素選?combinationtherapyindicatedin(pneumonia,聯(lián)合療法適用于嚴(yán)重的感染（肺炎，敗血癥?usefulcombinations?-Antibiotic抗生素選?combinationtherapyindicatedin(pneumonia,聯(lián)合療法適用于嚴(yán)重的感染（肺炎，敗血癥?usefulcombinations?-??-?Antibiotictherapy–basic抗生素療法-基本考????indicationfordetectionAntibiotictherapy–basic抗生素療法-基本考????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideDistribution分布標(biāo)?dependingoncharge,size,lipophiliccharacteristicsofantibioticanatomicalDistribution分布標(biāo)?dependingoncharge,size,lipophiliccharacteristicsofantibioticanatomicalbarriers?bloodbrainbarrierProstate前列Eye眼tracheobronchial-pulmonaryepithelialliningfluidEpithelialliningfluidtototalplasmaconcentrationratiosofantibioticsinhumansELF/P-ratio1ELF/PEpithelialliningfluidtototalplasmaconcentrationratiosofantibioticsinhumansELF/P-ratio1ELF/PAminoglycosides,?-lactams,glycopeptides(e.g.氨基糖苷類(lèi)，?-內(nèi)酰胺類(lèi)，糖肽類(lèi)（萬(wàn)古霉素??ELF/P-ratioELF/Pmacrolides,azithromycin,ELF/P-ratiohighlyvariablein?-lactams(penicillins,cephalosporins,carbapenemsRodvoldetal.,JClinPharmacokinet?Distribution分布標(biāo)Distribution分布標(biāo)fluoroquinolonesmacrolidesazithromycin普多沙??newgenerationfluoroquinolonelicensed普多沙??newgenerationfluoroquinolonelicensedfordogsandapprovedforFURTI(pyoderma,??improvedefficacyagainstStreptococcusspp.andanaerobescomparedtoolderfluoroquinolonesonlymildgastrointestinalsideeffects25mg/mlsuspension(dose:5mg/kgq2425mg/ml懸浮液（5mg/kgq24hr15mgtablets(dose:3mg/kgq24?阿奇霉?goodefficacyagainstgram-pos.andMycoplasmafair阿奇霉?goodefficacyagainstgram-pos.andMycoplasmafairefficacyagainstgram-neg.andhighoralbioavailabilityaccumulationinmacrophages200-在巨噬細(xì)胞中的積累濃度可達(dá)到200-500??????longhalflifeincatsdosingevery2nd/3rddaypossible每2-3天調(diào)整劑量welltoleratedinlongtermtreatment長(zhǎng)期治療耐受性較chronicinfections(rhinitis,pneumonia)慢性感染(鼻炎,肺炎Antibiotictherapy–basic抗生素療法-基本考????indicationfordetectionAntibiotictherapy–basic抗生素療法-基本考????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideAntibiotic抗生素劑?timedependentefficacy->?-lactams,Antibiotic抗生素劑?timedependentefficacy->?-lactams,?-increaseintervalforbetter?concentration-dependentefficacy->fluoroquinolones,increasedoseforbetterefficacy(withintherapeutic增加劑量以產(chǎn)生更好的療效(在治療加量范圍內(nèi)Routeof給藥途oralorparenteralRouteof給藥途oralorparenteralparenteralapplicationif:以下情況腸外poorgeneralconditionfeverdehydratationvomiting/diarrhea嘔吐/lowenteralabsorption(e.g.腸內(nèi)吸收差（如氨基糖苷類(lèi)Durationof治療持續(xù)時(shí)?uncomplicatedURTI:7Durationof治療持續(xù)時(shí)?uncomplicatedURTI:710daysusuallysufficient一般7-10pneumoniapyothorax?3–4clinical,radiographicalre-antibiotictherapyatleast1weekcontinuedafterdisappearanceofclinicalsignsGismo,DSH,4y,Gismo,DSH4Gismo,DSH,4y,Gismo,DSH4y雄性去Antibiotictherapy–basic抗生素療法-基本考????indicationfordetectionAntibiotictherapy–basic抗生素療法-基本考????indicationfordetectionofsentitivitychoiceof??dose/durationof?sideSide副作???ownereducationageofthepatientSide副作???ownereducationageofthepatient(tetracyclines動(dòng)物年齡（四環(huán)素laboratoryre-checks(sulfonamides,實(shí)驗(yàn)室復(fù)查（磺胺類(lèi)藥物，多西環(huán)素inhaledapplicationofaminoglycosidestoreducesystemictoxicity?enrofloxacinin?Reductionofside減少副作?nephro/ototoxicityReductionofside減少副作?nephro/ototoxicityreducedifgivenonlyoncepatientmustberehydratedbeforestartof?tetracyclines:decreasedGIirritationifgivenwithHowtopilla怎樣給貓Howtopilla怎樣給貓喂藥丸PickupcatandcradleitinPickupcatandcradleitinthecrookofyourleftarmasifholdingaPositionrightforefingerandthumboneithersideofcat'smouthandgentlyapplypressuretocheekswhileholdingpillinrighthand.Ascatopensmouth,poppillintomouth.AllowcattoclosemouthandRetrievepillfromfloorandcatfrombehindsofa.Cradlecatinleftarmandrepeatprocess.Retrievecatfrombedroom,andthrowsoggypillTakenewpillfromfoilwrap,cradlecatinleftarm,holdingrearpawstightlywithlefthand.Forcejawsopenandpushpilltobackofmouthwithrightforefinger.Holdmouthshutforacountoften.Retrievepillfromgoldfishbowlandcatfromtopofwardrobe.CallspouseinfromKneelonfloorwithcatwedgedfirmlybetweenknees,holdfrontandrearpaws.Ignorelowgrowlsemittedbycat.Getspousetoholdheadfirmlywithonehandwhileforcingwoodenrulerintomouth.Droppilldownrulerandrubcat'sthroatvigorously.Retrievecatfromcurtainrail.Getanotherpillfromfoilwrap.Makenotetobuynewrulerandrepaircurtains.Carefullysweepshatteredfigurinesandvasesfromhearthandsettoonesideforgluinglater.Wrapcatinlargetowelandgetspousetolieoncatwithheadjustvisiblefrombelowarmpit.Putpillinendofdrinkingstraw,forcemouthopenwithpencilandblowdowndrinkingstraw9.Checklabeltomakesurepillnotharmfultohumansanddrinkonebeertotaketasteaway.Applyband-aidtospouse'sforearmandremove9.Checklabeltomakesurepillnotharmfultohumansanddrinkonebeertotaketasteaway.Applyband-aidtospouse'sforearmandremovebloodfromcarpetwithcoldwaterandRetrievecatfromneighbor'sshed.Getanotherpill.Openanotherbeer.Placecatincupboard,andclosedoorontoneck,toleaveheadshowing.Forcemouthopenwithdessertspoon.Flickpilldownthroatwithelasticband.Fetchscrewdrive