革兰阴性菌耐药折点问题.ppt

革兰阴性菌耐药折点问题 2012主要变化 肠杆菌科 修订厄他培南折点 增加环丙沙星折点（伤寒沙门菌和胃肠外沙门菌） 绿脓杆菌 降低 哌拉西林、哌拉西林/他唑巴坦、替卡西林、替卡西林/克拉维酸折点 降低 亚胺培南、美罗培南折点；增加多利培南折点 葡萄球菌 增加金葡菌青霉素抑菌圈周边试验检测（ penicillin disk zone edge test） β-内酰胺酶产生 肠杆菌科：碳靑霉烯类 为何多次进行修改? 2011 breakpoints primarily based on: MIC distributions PK/PD (conservatively went with ≤0.25 μg/ml) Very limited clinical data (no patients with MICs at 0.5 μg/ml) 2012 breakpoints primarily based on: Additional surveillance data showed isolates with MICs of 0.5 μg/ml did not have carbapenemases Further review of PK/PD Additional clinical data (including ESBL-producing E. coli with 0.5 μg/ml MICs suggested clinical response) Also, lowest ertapenem concentration on some commercial panels is 0.5 μg/ml thus allowing labs to use CLSI ertapenem breakpoints (following verification) if breakpoint is ≤0.5 μg/ml but not if ≤0.25 μg/ml Modified Hodge Test (MHT) (Table 2A Supplemental Table 2 and 3) “NOTE: Not all carbapenemase-producing isolates of Enterobacteriaceae are MHT positive and MHT-positive results may be encountered in isolates with carbapenem resistance mechanisms other than carbapenemase production.” 4 Select CRE Examples: Carbapenem MICs MHT ?-Lactam Resistance Mechanism 碳青霉烯类药物MIC 报告策略 绿脓杆菌 2012年CLSI 绿脓杆菌折点变化 Section III. Therapy-Related Comments “In cases where specific dosage regimens are important for proper application of breakpoints, the dosage regimen is listed. These dosage regimen comments are not intended for use on individual patient reports.” Pseudomonas aeruginosa Penicillins +/- β-lactamase Inhibitors  P. aeruginosa breakpoints originally set higher than those for Enterobacteriaceae based in part on FDA label noting that these drugs should be considered in combination therapy with aminoglycoside Deleted comment from Table 2B-1 - “Rx: The susceptible category for penicillins, β-lactam/β-lactamase inhibitors implies the need for high-dose therapy for serious infections caused by P. aeruginosa. For these infections, monotherapy has