real situation of antibiotic resistance in pneumonia in việt nam and guideline for initial antibiotic treatment

REAL SITUATION OF ANTIBIOTIC RESISTANCE IN PNEUMONIA IN ViỆT NAM AND GUIDELINE FOR INITIAL ANTIBIOTIC TREATMENT A.PROF Trần Văn Ngọc MORTALITY RA E IN PNEUMONIA Tử vong VPTM CHEST 2005; 128:3854–3862 Antibiotic Resistance in CAP - S.pneumoniae resistant to PNC, macrolide & quinolone - betalactamase producing H.influenzae & M.catarrhalis - CAP-MRSA - Atypical pathogens CAP pathogens in Asia S pneumoniae 29.2 K pneumoniae 15.4 H influenzae 15.1 P aeruginosa 6.7 S aureus Atypical 25% 4.9 M catarrhalis Combined 15-20% 3.1 M tuberculosis Unknown 36.5 10 20 Song JH et al Int J Antimicrob Agents 2008;31:107-14 30 40 PRSP Low (30%) Ý Irland Pháp Đức Bồ Đào Nha Tây Ban Nha Anh Hungary Cộng hòa Slovac Thụy Sỹ Canada Bungari Benelux Ác-hen-ti-na Rumani Scandinavia Brazin Thổ Nhĩ Kỳ Bắc Phi Isreal Mỹ Pê- ru Arập Saudi Mê-hi-cô New Zealand Kenia Bắc Phi Nigeria Thái Lan Philippines Nhật Singapore Hàn Quốc Australia Đài Loan Hồng Kông Việt Nam Clinical Microbiology and Infection, Volume 7, Sup 4, 2001 Resistance to Penicillin V isolates from Asia countries Quoác gia MIC50 MIC90 (mg/L) % Resistant* (mg/L) Vietnam 71.4 Korea 54.8 Hong Kong 43.0–69.9 Taiwan 38.6 Singapore 0.03 17.1–24.8 0.12 28.5 Japan * penicillin MIC ≥2 mg/L Song JH et al Antimicrob Agents Chemother In press Jacobs MR et al J Antimicrob Chemother 2003; 52: 229 PRSP and Cross Resistance Cefotaxime Erythromycin TMP/SMX Tetracycline Levofloxacin Pen S 3.2% 6.6% 1.3% 0.1% Pen I 2.8% 35.1% 49.4% 19.1% 0.3% R > thuốc : 14% (Whitney, et al NEJM 343:1917, 2000) Pen R 42.4% 61.3% 92.3% 25.5% 0.7% CLSI Criteria - 2009 Penicillin PNC oral , MIC≥2 kháng MIC≤0.06 nhạy Parenteral PNC ≥12M/ day , non-miningitis MIC≥8 kháng MIC≤2 nhạy Parenteral PNC ≥18M/ day , miningitis MIC≥12 kháng MIC≤ nhạy Antibiotic resistant S.PNEUMONIAE (SOAR Viet Nam 2011) Children’s CAP at children hospital - 2011 S pneumonia : Sensitivity : Ceftriaxone (100%); Vancomycine (100%),  Resistance : Penicilline (100%)  Hemophillus influenzae   Sensitivity : Ciprofloxacin (100%); Pefloxacin (100%); Gentamycine (100%); Cefotaxime (67%); Ceftriaxone (75%) Resistance : Ampicilline (100%) S aureus   Sensitivity : Vancomycin (100%); Gentamycin (100%) Resistance : Penicilline (100%), 2007 ATS/IDSA CAP Điều trị nội trú Khoa nội Không dùng KS trước Fluoroquinolone hô hấp hay Macrolide + ß-lactam Mandell LA, et al Clin Infect Dis 2007 Mới dùng KS Macrolide + ß-lactam hay fluoroquinolone hô hấp 2007 ATS/IDSA CAP Điều trị nội trú ICU Khơng nguy Pseudomonas khơng ßlactam dị ứng ß-lactam + macrolide hay fluoroquinolone Dị ứng ßlactam fluoroquinolone + aztreonam Mandell LA, et al Clin Infect Dis 2007 Nguy nhiễm Pseudomonas Khơng dị ứng ß-lactam Dị ứng ßlactam Anti-pseudomonal, antipneumococcal b-lactam /penem + Cipro/Levo 750 hay Anti-pseudomonal, antipneumococcal b-lactam /penem + aminoglycoside + Azithromycin Aztreonam + respiratory fluoroquinolone + aminoglycoside Antibiotic treatment Outpatient CAP : - First of choise : Amoxicillin -Second choise : Fluoroquinolon - Suspected DRSP : high dose of amoxicillin or respiratory fluoroquinolon Antibiotic ( cont ) moderate severity admitted CAP oral antibiotic s are effective in most of cases - Amoxicillin + macrolide is the first choise - Altenative : Cephalosporine II, III + clarithromycin / FQ Antibiotics (cont) severe admitted CAP : - first choise : large spectrum beta-lactam + macrolides - FQ + large spectrum beta-lactam - IV cephalosporine  co-amoxiclave oral but not cephalosporine oral Antibiotic in AECOPD  Good antibiotic in AECOPD  Cover on most causative pathogens  H.influenzae, M.catarrhalis, S.pneumoniae  Chlamydia, Mycoplasma  Trực khuẩn Gr (-) (Gram negative bacilli)  Good tissue penetration  Anti β-lactamase   simple use , good tolerability Cost – Effective Antibiotic in AECOPD Oral Nếu CĐ: β-lactam (penicillin, ampicillin/amoxicillin), tetracycline, trimethoprim/ sulfamethoxazole Group B β-lactam/β-lactamase inhibitor (Co-amoxiclav) Fluoroquinolones (gemifloxacin, levofloxacin, moxifloxacin) Group C BN nguy nhiễm pseudomonas Fluoroquinolones (ciprofloxacin, levofloxacin high dose) Parenteral use β-lactam/β-lactamase inhibitor (Co-amoxiclav) Macrolides (azithromycin, clarithromycin, roxithromycin) Cephalosporins (2nd or 3rd generation) Ketolides (telithromycin) Group A BN có triệu chứng : không nên cho KS Altenetives β-lactam/β-lactamase inhibitor (Co-amoxiclav, ampicillin/sulbactam) Cephalosporins (2nd or 3rd generation) Fluoroquinolones (levofloxacin, moxifloxacin) Fluoroquinolones (ciprofloxacin, levofloxacin - high dose) or βlactam with P aeruginosa activity From the Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2008 Available from: http://www.goldcopd.org 48 Am J Respir Crit Care Med 2005;171:388–416 Masterton RG et al J Antimicrob Chemother 2008;62:5-34 Asian HAP Working Group Am J Infect Control 2008;36:S83-92 HCAP , HAP Guidelines VN guidelines for the management of lower respiratory infections -2013 Importance of initial empiric antibiotic treatment % mortality Adequate init antibiotic 90 80 70 60 50 40 30 20 10 Inadequate init antibiotic 81 63 41.5 61.4 38 44 33.3 24.7 16.2 AlvarezLerma * 15 Rello* Luna * Kollef * Clec'h * p