《革兰阴性菌耐药折点问题》.ppt
《《革兰阴性菌耐药折点问题》.ppt》由会员分享,可在线阅读,更多相关《《革兰阴性菌耐药折点问题》.ppt(57页珍藏版)》请在三一文库上搜索。
1、革兰阴性菌耐药折点问题,北京大学人民医院检验科 王辉 ,CLSI AST Standards January 2012,M100-S22 Tables (2012)* M02-A11 Disk Diffusion Method (2012)* M07-A9 MIC Method (2012)* M11-A7 Anaerobe MIC Testing (2007),New!,3,M100-S22 Partial Table of Contents,M100-S22. Page 9.,4,更新的 的总结,M100-S22. Page 13.,5,2012主要变化,肠杆菌科 修订厄他培南折点 增加环
2、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) -内酰胺酶产生,New!,6,M100-S22. P22,2010年后折点变化过程,New!,7,CLSI Breakpoint Additions / Revisions Since 2010,CLSI Breakpoint Additions / Revisions Since 2010,肠杆菌科: 碳靑霉烯类,美
3、国碳靑霉烯类耐药肠杆菌科(CRE)的分布,黄色:KPC酶; 蓝点:IMP、VIM 黄点:NDM,CLSI使用以下数据建立 / 修订折点,“野生菌群” 或常规菌群的MIC分布 野生菌群= 未携带获得性“耐药”机制 与临床预后相关的MIC 对于老药很少有“新”数据 药物代谢-药效学 (PK-PD) 分析,CLSI M23-A3 (2008) “体外药敏实验标准和质量控制参数的发展; 批准的指南” 描述了CLSI建立和修订折点的过程。,Piperacillin-tazobactam MIC distribution example Blue = wild type isolates Red = is
4、olates with acquired “R” mechanism,www.eucast.org,10,Serum Concentration (g/ml),Time (hours),MIC,Time above MIC,dose,dose,Cmax (peak concentration),PK/PD Goal (“Target”) for -lactams = (%T MIC),12,DMID 2009年,肠杆菌科 厄他培南 CLSI 折点更新过程,*目前和FDA折点相同,New,New!,28,为何多次进行修改?,2011 breakpoints primarily based on:
5、 MIC distributions PK/PD (conservatively went with 0.25 g/ml) Very limited clinical data (no patients with MICs at 0.5 g/ml) 2012 breakpoints primarily based on: Additional surveillance data showed isolates with MICs of 0.5 g/ml did not have carbapenemases Further review of PK/PD Additional clinical
6、 data (including ESBL-producing E. coli with 0.5 g/ml MICs suggested clinical response) Also, lowest ertapenem concentration on some commercial panels is 0.5 g/ml thus allowing labs to use CLSI ertapenem breakpoints (following verification) if breakpoint is 0.5 g/ml but not if 0.25 g/ml,29,CLSI Agen
7、da Book June 2011,30,CLSI Agenda Book June 2011,31,Susc.: 0.5 g/ml / 22 mm Res.: 2 g/ml / 18 mm VM = 0.0% Ma = 0.0% Mi = 6.1%,FOR NEW BREAKPOINTS APPROVED June 2011,Modified Hodge Test (MHT) (Table 2A Supplemental Table 2 and 3),“NOTE: Not all carbapenemase-producing isolates of Enterobacteriaceae a
8、re MHT positive and MHT-positive results may be encountered in isolates with carbapenem resistance mechanisms other than carbapenemase production.”,M100-S22. Table 2A Supplemental Tables 2 and 3. Pages 53 and 57.,New!,36,4 Select CRE Examples: Carbapenem MICs & MHT & -Lactam Resistance Mechanism,1 I
9、nterpreted with current breakpoints 2 Anderson, KF et al. 2009. ICAAC. D-719. 3 Limbago, BM. CLSI Agenda book. January 2011. 4 MHT positive only with ertapenem disk 5 MHT same result with ertapenem and meropenem (and imipenem) disks 6 Carbapenemases (metallo -lactamases),39,进行耐药机制的初筛试验 (MIC升高至接近“敏感”
10、折点为 “可疑”),进行耐药机制的特异确证试验,若检测到耐药机制则更改药敏报告,发现一种新型-内酰胺酶 (如ESBL或碳青霉烯酶),旧的模式,ESBL,MHT,Courtesy of Dr. Jean Patel CDC,新的模式,进行药敏试验并且使用 新的“降低的”折点,以治疗为目的报告药敏结果 不更改“敏感”结果,仅以感染控制和流行病学研究为目的进行特殊的耐药机制检测试验,分离出肠杆菌科菌,Courtesy of Dr. Jean Patel CDC,CLSI M100-S20-U 表 1A 修订的碳青霉烯类药物折点和对应的药物剂量,S I R,S I R,(22)解释标准基于每8小时一次
11、,每次500mg的给药方案。 (23)解释标准基于每天一次,每次1g的给药方案。 (24)解释标准基于每6小时一次,每次500mg或每8小时一次,每次1g的给药方案。 (25)解释标准基于每8小时一次,每次1g的给药方案。,M100-S22. Table 2A Supplemental Tables 2 and 3. Pages 52-60.,(旧折点),(当前折点),MHT检测碳青霉烯酶,35,碳青霉烯类药物MIC 报告策略,*对常规病人的报告不必做改良霍奇试验; 可以为感染控制目的而进行该试验 但不要把 “敏感” 或“中介” 改为 “耐药”,折点 (g/ml),如果用 旧折点 和 碳青霉烯
12、酶筛选试验阳性,如果用 当前折点 和 需要流行病学的需要,进行MHT,进行MHT,为何做 MHT?,M100-S22. Comment (23) Page 47. Table 2A Supplemental Tables 2 and 3. Pages 52 and 56.,40,绿脓杆菌,57,Pseudomonas aeruginosa Breakpoint (MIC g/ml) Revisions,1 Corresponding disk diffusion breakpoints also revised,M100-S22. Table 2B-1. Page 63.,New!,58,Ps
13、eudomonas aeruginosa,M100-S22. Table 2B-1. Page 63.,Dosage comments (3 g every 6 h also for piperacillin and for ticarcillin),59,2012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 i
14、s listed. These dosage regimen comments are not intended for use on individual patient reports.”,M100-S22. Instructions. Page 28.,New!,60,Pseudomonas aeruginosa Penicillins +/- -lactamase Inhibitors,P. aeruginosa breakpoints originally set higher than those for Enterobacteriaceae based in part on FD
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- 革兰阴性菌耐药折点问题 阴性 耐药 问题
链接地址:https://www.31doc.com/p-3072157.html