P. aeruginosa pneumonia 항생제 선택
항생제 감수성 결과가 나올 때까지 P. aeruginosa pneumonia가 의심되거나 확인된 환자에서 단일 항생제로 시작합니다. 패혈증 또는 약제 저항성 감염 위험이 있다면 다른 종류의 항생제 2개를 사용합니다. The IDSA and the ATS on the empiric management of community-acquired and hospital-acquired pneumonia 가이드라인에 따른 권고는 ㉠ antipseudomonal beta-lactam PLUS an antipseudomonal quinolone ㉡ antipseudomonal beta-lactam PLUS an aminoglycoside ㉢ antipseudomonal quinolone PLUS an aminoglycoside입니다. Antipseudomonal beta-lactams에는 piperacillin-tazobactam, ceftazidime, cefepime, imipenem, meropenem, doripenem이 있고 페니실린 알레르기가 있는 경우는 aztreonam을 사용합니다. Antipseudomonal quinolonesdpsms에는 ciprofloxacin, levofloxacin (750 mg)이 있습니다. Aminoglycoside에는 tobramycin, gentamicin, amikacin, plazomicin이 있습니다.
Antibiotics used for the treatment of Pseudomonas aeruginosa infections in adults
|
Class |
Agent |
Dose |
|
Penicillin-beta-lactamase combinations* |
Ticarcillin-clavulanate (not available in the United States or Canada) |
3.1 g every 4 hours |
|
Piperacillin-tazobactam |
4.5 g every 6 hours¶ |
|
|
Cephalosporins |
Ceftazidime |
2 g every 8 hours |
|
Cefepime |
2 g every 8 or 12 hoursΔ |
|
|
Cefoperazone |
2 g every 12 hours |
|
|
Advanced beta-lactamase inhibitor combinations◊ |
Ceftazidime-avibactam |
2.5 g every 8 hours |
|
Ceftolozane-tazobactam |
1.5 to 3 g every 8 hours§ |
|
|
Imipenem-cilastatin-relebactam |
1.25 g every six hours |
|
|
Monobactams |
Aztreonam |
2 g every 8 hours |
|
Fluoroquinolones¥ |
Ciprofloxacin |
400 mg every 8 hours |
|
Levofloxacin |
750 mg once daily |
|
|
Carbapenems‡ |
Imipenem |
500 mg every 6 to 8 hours† |
|
Meropenem |
1 g every 8 hours |
|
|
Doripenem |
500 mg every 8 hours |
|
|
Aminoglycosides** |
Tobramycin |
Dosing of aminoglycosides is discussed in detail in a dedicated topic |
|
Gentamicin |
||
|
Amikacin |
||
|
Plazomicin |
||
|
Polymyxins¶¶ |
Colistin |
Dosing of polymyxins is discussed in detail in a dedicated topic |
|
Polymyxin B |
Doses refer to intravenous administration. Doses listed are for patients with normal renal function; dose adjustments may be warranted for renal impairment.
MIC: minimum inhibitory concentration.
* Ticarcillin (3 g every four hours) and piperacillin (4 g every four hours) each have antipseudomonal activity but are not available in the United States as single agents without the beta-lactamase inhibitor.
¶ Piperacillin-tazobactam is generally infused over 30 minutes. Some evidence suggests that an extended infusion (eg, 3.375 g or 4.5 g over four hours every eight hours) may be associated with better outcomes among critically ill patients. Refer to other UpToDate content on prolonged infusions of beta-lactam antibiotics.
Δ We aim to use the higher dose, particularly for severe infections or neutropenic patients, but dosing should take into account the condition treated, the MIC of the isolate, the potential for toxicity, and other patient specific factors.
◊ Combination agents that include a cephalosporin or carbapenem plus a beta-lactamase inhibitor are generally reserved for specific types of infections (such as complicated intra-abdominal or complicated urinary tract infection) resistant to other agents. The addition of vaborbactam to meropenem does not enhance the clinical activity of meropenem against carbapenem-resistant P. aeruginosa.
§ Pulmonary infections are treated with the 3 g every eight hour dose.
¥ Fluoroquinolones are the only class of antibiotics with antipseudomonal activity that have an oral formulation.
‡ Carbapenems given as a single therapy have the propensity to induce resistance during treatment.
† Imipenem can be given up to a dose of 1 g every six to eight hours for severe infection.
** Aminoglycosides are generally used in combination with a beta-lactam and should NOT be used as a single agent for infections other than those of the lower urinary tract. When using an aminoglycoside as part of therapy for an infection with a high risk of P. aeruginosa, we favor tobramycin over gentamicin as it has greater intrinsic antipseudomonal activity; however, it may not be widely available.
¶¶ Polymyxins are generally reserved for the treatment of serious infections caused by P. aeruginosa isolates resistant to other agents. In such cases, they are often administered in combination with other antimicrobial agents and with a loading dose preceding the standing dose. Refer to other UpToDate content for more details on polymyxin dosing.
REF. UpToDate 2020.05.16
