- 學位論文
南區某醫學中心成人Acinetobacter 腦膜炎之體外藥物敏感性與臨床用藥探討
Preliminary Analyze in Vitro Susceptibilities of Antimicrobial Agents and Antibiotic Treatment of Adult Acinetobacter meningitis in a Medical Center in Southern Taiwan
摘要
以往Acinetobacter species 並不是成年人細菌性腦膜炎的常 見致病菌。近年來， Acinetobacter species 所造成的成年人腦膜炎 有增加的趨勢，特別是接受過神經外科治療的病患有較大的機會受到 感染。其中除少數例外，大部分是院內感染性腦膜炎。影響使用抗生 素治療成年人Acinetobacter baumannii 細菌性腦膜炎的用藥，在 臨床上出現包括對第3 代頭孢子菌素(cephalosporins)不具感受的 抗藥性菌種產生和易於在抗生素使用中很快產生新的抗藥性。這些現 象造成初始治療及治療中抗生素選擇之挑戰性。 在這個研究中，我們將檢驗從1998-2003 年共18 個本院成年人 腦膜炎病患的腦脊髓液所分離出來的21 組Acinetobacter species 對多種抗生素的MIC 值。而被檢驗的抗生素則選擇一般臨床醫師常使 用於治療的抗生素，其中包括imipenem，meropenem， ceftazidime， ceftriaxone，cefepime，aztreonam，ciprofloxacin，與 ampicillin/sulbactam。本研究的結果顯示此類Acinetobacter腦膜 炎之致命性與潛在疾病及臨床症狀無直接明顯關係，而臨床醫師在依 培養結果用藥後，有少數病例沒有很好療效且因反覆感染延長用藥， 增加住院天數，因此依本研究之體外試驗MIC 值結果，建議神經外科 術後感染腦膜炎若考慮致病菌為Acinetobacter species 則 III carbapenem 類藥物如imipenem， meropenem 是較好之經驗療法首選 用藥，而第3 代cephalosporin 類藥物如ceftazidime，ceftriaxone 則是較差之選擇。但carbapenem 類藥物中imipenem 在使用治療劑量 2 克每6 小時一次時易產生癲癇副作用，因此meropenem 是較好的選 擇用藥，使用劑量為2 克每8 小時一次。且病人如果是複合性感染則 更容易因此增加用藥複雜性，影響療效，延長住院天數，因此除了正 確選擇用藥外，如果能加強頭部外科手術病人之照護，避免感染並做 好院內感控，應該可以減少醫療資源之使用。
並列摘要
Previously, adult bacterial meningitis infection due to Acinetobacter species is uncommonIn recent years, the incidence of adult meningitis due to Acinetobacter species infection is increasing, especially in those patients with post-neurosurgical state. With rare exception, most of the adult cases of Acinetobacter species meningitis develop nosocomially. The pharmacological characteristics of Acinetobacter baumannii strains isolated from CSF of adult meningitis patients produced initial multi-resistant rapidly. These characteristics have caused a therapeutic challenge in the choice of initial empiric antibiotics or the use of antibiotics for maintenance therapy. We conduct this study from 1998 to 2003 totally eighteen patients, including twenty-one of the Acinetobacter strains isolated from CSF specimens of adult patients with meningitis to examine the antibiotics MIC data. The antibiotics used in this study are those that physicians usually used to treat adult bacterial Acinetobacter meningitis, and they include V ceftazidime, ceftriaxone, cefepime, imipenem, meropenem, aztreonam, ciprofloxacin and ampicillin/sulbactam. In this study,the results of in vitro activity show these antibiotics MIC data : imipenem MIC90% : 2, meropenem MIC90% : 4, cefepime MIC90% :>16, ceftriaxone >64, ceftazidime MIC90% :>128. From these datas, carbapenem are better choice than the third and fourth cephalosporins. Among the carbapenem (imipenem, meropenem ), imipenem had more tendency to induce seizure attack in therapeutic dose than meropenem. We suggest meropenem as empiric antibiotic to treat nosocomially-infected post-neurosurgical Acinetobacter meningitis. And then according to culture result choosing antibiotc for maintenance therapy. Despite the prognosis of other adult bacterial meningitis can be influenced by many factors. The result of this study, we do not find any significant factors including underlying diseases or clinical signs that increase patient’s mortality. This study may let the physicans have a better understanding in choosing a proper antibiotic for the management of adult Acinetobacter meningitis and improve the VI therapeutic result of this potentially fatal CNS infection. Besides, if the medical care after surgery procedure can be well controlled to prevent the Acinetobacter infection , that will save a lot of medical costs.