抗生素英文课件 A Worldwide Crisis Inappropriate Antibiotic Use & Resistant Bacterial Infections

,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,A Worldwide Crisis: Inappropriate Antibiotic Use & Resistant Bacterial Infections,James A. Wilde MD,Associate Professor of Emergency Medicine and Pediatrics,Director Pediatric Emergency Medicine,Medical College of Georgia,Medical Director, Georgia United Against Antibiotic Resistant Disease (GUARD),What Causes Infections?,Infections are caused by 1 of 4 types of microbes (germs),Virus,75% or more of all infections,Bacteria,less than 25%,Parasites,less than 1% in the US,Fungus,less than 1% in the US,Viruses,Parasites-need other cells to provide food and means of reproducing (“sucks the life out” of a cell),Attack humans by invading cells of certain tissues,Hepatitis virus: attacks the liver cells,Encephalitis virus: attacks the brain cells,Cold virus: attacks the throat and breathing passages,Diarrhea virus: attacks the small intestine,Can live dormant in the environment for years,Difficult to treat,Multiply rapidly and easily transmitted by blood and body secretions,Antibiotics DO NOT WORK against viruses!,Bacteria,Can live and grow wherever they find food,Environment:,mountain streams, ocean water, rotting animal or plant, sewer, topsoil, food,Humans & Animals:,blood, skin, throat, lungs, urinary bladder, intestine,Good versus Bad Bacteria,Some copy and grow every 20 minutes,Makes them difficult to treat: we are outnumbered,Diseases Caused by Viruses and Bacteria,Virus,Common cold,Diarrhea (99%),Acute Bronchitis,Influenza (flu),Measles,Chicken Pox,AIDS,Rabies,Hepatitis,Bacteria,Urine infections,Strep Throat,Boils/abscesses,Gangrene,Some pneumonia,Ear infections (half),Sinus infections (,90% of cultured campylobacter resistant to quinolones,39% of enterococci in the fecal flora of pigs from the Netherlands is resistant to vancomycin,vs,0% in Sweden. (Sweden bans antibiotic additives in animal feed),ANTIMICROBIAL RESISTANCE:,The role of animal feed antibiotic additives,How does this affect me?,Animals harbor the same bacteria on their skin and in their guts as humans,The antibiotics used in animal feed are similar to those used in humans,Resistant bacteria develop in animals the same as in humans,Resistant bacteria are spread from animals to humans,EID 1999;,Vol,5,Decrease in VRE After Removing,Avoparcin,From Animal Feed,National Effort to Stop Unwarranted Antibiotics,Surveillance,Prevention and Control,Research,Product Development,Education,28 “Coalitions” in U.S.,Agency for,Health Care Research and Quality,Department of,Defense,Environmental Protection,Agency,Health Care,Financing Administration,Health Resources and Services Administration,Department of,Agriculture,Department of,Veterans Affairs,Local Efforts: GUARD Coalition,G,eorgia,U,nited,A,gainst,A,ntibiotic,R,esistant,D,isease,2002-2006,: Funded by the Centers for Disease Control and Prevention (CDC), part of “Get Smart” program,2002-Spring 2005,: Oversight by Georgia Department of Public Health,Spring 2005,: Officially became part of and managed by the Medical College of Georgia,Medical Director,: Jim Wilde, MD, FAAP (MCG faculty),GUARD Mission,The GUARD Coalition seeks to reduce antibiotic-resistant diseases by decreasing inappropriate antibiotic use through a collaboration of community partners:,GUARD Coalition Members,Medical Association of Georgia,GA chapter American Academy of Pediatrics,GA chapter American Academy of Family Physicians,Blue Cross Blue Shield,Georgia Hospital Association,GA Assn Infection Control Nurses,GA Department of Public Health,PHARMA,US Centers for Disease Control and Prevention,Medical College of Georgia,Emory University,GA PTA,many individual physicians, nurses and other health professionals,GUARD Goals,Community education about appropriate use of antibiotics,Physician education,How to recognize bacterial infections,Rising rates of resistant bacteria,New antibiotics and their proper use,Create and distribute educational materials,So, what can I do?,Educate yourself: most infections dont require antibiotics,Talk to your doctor to see if antibiotics are appropriate for you and/or your child,Dont use leftover antibiotics,Dont use someone elses antibiotics,Follow instructions-take them properly,Spread the wordnot the bacteria!,His life is in,OUR,hands,“The ravaging epidemic of AIDS has shocked the worldWe will face similar catastrophes againWe have too many illusions that we cangovern the remaining vital kingdoms, the microbes, that remain our competitors of last resort for dominion of the planet”,1988, Dr. Joshua Lederberg,Nobel Laureate,VII. A New Bug on the Block: Community Associated Methicillin Resistant Staph aureus(CA-MRSA),Staph is a common bacteria found on the skin of many people,Staph,epidermidis,Staph aureus,Designated MRSA if resistant to methicillin, a synthetic penicillin introduced in the early 1960s,In most cases this Staph does no harm,CA-MRSA,First noted as emerging problem in late 1990s,Increasing rate of MRSA infections in patients with none of the usual risk factors,Initially noted in prisons,Sports teams,Getting national attention 2002/2003,Unusual sensitivity pattern: did not exhibit multi-drug antibiotic resistance typical of earlier strains of hospital acquired MRSA (HA-MRSA),(CA-MRSA, cont),New Staph strain now referred to as Community Associated MRSA, or CA-MRSA,Primarily USA 300 clone on PFGE, also USA 400,First isolated in 2000,Many people are colonized but exhibit no symptoms (carrier),Panton,-Valentine,leukocidin,(PVL) toxin: lethal to,neutrophils, induces abscess formation,90% of CA-MRSA,90% erythromycin, clindamycin, quinolone (FQ) resistant,Different,PFGE,PVL negative,SCC mec I, II, III,Community-associated: CA-MRSA,Poorly defined risk factors (children/day care, prisons, sports teams, MSM, Native Americans),-,lactam,resistant,; often resistant to,erythromycin,; more susceptible to other agents (,clindamycin, TMP/Sulfa, FQ,),PFGE USA300, USA 400,PVL,present,SEC mec IV,CA-MRSA: Epidemiology,Has quickly become the predominant,Staph aureus,species in most communities,King, Blumberg, et al,Ann,Int,Med,Nov 2003,Surveillance Aug to Nov 2003, Atlanta (Grady Hosp),MRSA caused 72% of all skin and soft tissue infections,63% of all MRSA was CA-MRSA,Medical College of Georgia data similar by 2005,7/13 (54%),24/47 (51%),18/30 (60%),25/42 (60%),46/69 (67%),43/58 (74%),11/28 (39%),3/20 (15%),32/58 (55%),17/25 (68%),23/32 (72%),MSSA 17%,42% PVL+,31% USA300,59%,98% PVL+,97% USA300,72% 300-0114,Prevalence of MRSA as cause of SSTI in Adult ED Patients ,EMERGE,ncy,ID Net,Moran GJ, et al, SAEM 2005,Kindly provided by Rachel Gorwitz, CDC,Nasal carriage of Staph aureus,Creech et al,Ped,Inf,Dis,J,2005: Examined nasal carriage of Staph in children in Nashville,2001,29% colonized with Staph aureus,0.8% colonized with MRSA,2004,36.4% colonized with Staph,9.2% colonized with MRSA,Risk factors for CA-MRSA,Children,Breaks in Skin/abrasions,Sharing towels/razors,Incarceration,Men having sex with men,Contact sports participants,Clinical Manifestations, CA-MRSA,Vast majority are skin and soft tissue infections (SSTI),Many SSTI come in the form of abscesses,Multiple abscesses may be present,Recurrence common,*Often mistaken for a spider bite,Increasing number of invasive infections over the past 2-3 years,? Spider Bite?,Slide provided by Melissa Tobin,DAngelo, Georgia DHR,Carbuncle,Slide provided by Melissa Tobin,DAngelo, Georgia DHR,Folliculitis,Slide provided by Melissa Tobin,DAngelo, Georgia DHR,Abscess,Slide provided by Melissa Tobin,DAngelo, Georgia DHR,Cellulitis with Abscess,Slide provided by Jim Wilde MD,CA-MRSA: Changing Patterns,Seybold, Blumberg et al.,Clinical,Inf,Dis, March 2006: CA-MRSA as a cause of blood stream infections (BSI),116 cases MRSA BSI over 7 months, 2004,MRSA USA 300 accounted for 34%,20% of nosocomial MRSA BSI were USA 300,Crude in-hospital mortality 22%,(changing patterns, continued),MMWR, April 13 2007,Report of severe community acquired pneumonia due to CA-MRSA, LA and GA,10 patients, median age 17 y (eight, 30y),All had influenza-like illness, 6 confirmed flu,6/10 died, median 3.5 days after symptom onset,Five isolates studied by CDC, all USA-300,National Prevalence study of MRSA in US Healthcare Facilities: APIC Report June 2007,Survey done in 1,237 hospitals in the US,Oct/Nov 2006,Symptomatic patients (infections) and targeted high risk patients,Overall rate 4.6%,“Majority” were HA-MRSA,Invasive MRSA infections in the US.,Klevens,et al.,Journal of the American Medical Association,(JAMA) October 19, 2007,Surveillance data collected from 9 US communities,Extrapolation to US population,Estimated 18,650 deaths per year,Over 90% of deaths due to HA-MRSA,VI. Management of CA-MRSA SSTI,Abscesses should be drained,Drainage alone in many cases is definitive therapy,Strong recommendation to obtain culture,Helps to define local epidemiology/resistance pattern,Antibiotics in selected cases,Abscess greater than 5 cm diameter,Significant area of cellulitis,Systemic symptoms,For impetigo or simple cellulitis, consider antibiotic therapy directed at CA-MRSA,Most CA-MRSA infections are easily treated if managed appropriately,Suggested Antibiotics for CA-MRSA,Outpatient,Trimethoprim/Sulfamethoxisole,Cellulitis: Add beta-,lactam,to cover for strep,Clindaymcin,Doxycycline,Avoid,quinolones,if possible (,Cipro,Levofloxacin,),DO NOT use Rifampin as,monotherapy,CDC recommendation: If local CA-MRSA prevalence exceeds 15%, beta-,lactams,(,penicillins,and,cephalosporins,) should not be used as,monotherapy,for skin and soft tissue infections,Inpatient management,For severe or life-threatening infections suspected to be due to CA-MRSA, initial empiric therapy should include Vancomycin PLUS a beta-,lactamase,resistant beta-,lactam,antimicrobial agent,Oxacillin,Nafcillin,Ampicillin/Sulbactam,Ref: 2003 Red Book, American Academy of Pediatrics: page 567,Parenteral,(IV) antibiotics for MRSA: options,Vancomycin,Not as active as beta-,lactam,antibiotics against susceptible Staph aureus,Linezolid,Quinupristin/Dalfopristin,(,Synercid,),Daptomycin,Deactivated by Surfactant: Not for pneumonia,Tigacycline,Decolonization efforts,Intranasal,Mupirocin,Chlorhexidine,body washes,Efficacy data are lacking,Reacquisition common,Generally not recommended,May be reasonable in certain situations,Multiple documented recurrences,Ongoing transmission in well-defined, closely associated cohort such as a household, sports team, etc.,Infection control measures: Athletic teams,Good hand hygiene critical,Clean shared athletic equipment before use,No sharing of bath towels, soap, razors,No participation in contact sports if draining sores or impetigo are present,Keep a clean, dry bandage over draining sores,Cleanse contaminated surfaces with 1:1000 solution bleach (1 tbsp bleach/1 quart water) or EPA-registered hospital detergent/disinfectant,Public Health and CA-MRSA,CDC does NOT recommend exclusion from school for those with MRSA,Decontamination of buildings/classrooms generally not warranted unless multiple infections,Georgia MRSA Task Force fact sheet,GUARD web site:,www.guard-ga.org,State Health Department:,www.health.state.ga.us/mrsa,/,Tips for the public,See your doctor for boils or pustules or tender/red/swollen areas on the skin,Do not attempt to drain abscesses at home,If fever present, or if sore is enlarging rapidly, seek medical care immediately,Dont attempt self treatment with old antibiotics,Recurrence is common; follow up with your MD,For More Information on GUARD,Contact,Dr. Jim Wilde MD, FAAP,Director, GUARD Coalition,(706) 533-2925,jwildemcg.edu,www.guard-ga.org,