!!

Safety Efficacy Economic Convenience

A. WBC CRP PCT B.

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orVAP (PSB) BAL (QEA)Chest 2002;122;662-668

HAP CID 2010; 51:S939

HAPCID 2010; 51:S939

(which antibiotic?) (possible pathogens on site of infection) (antibiotics requirement) -/////(PK/PD)( physiologic and pathophysiology) ///(advanced age/children/pregnant women/breast feeding) //(renal/heptic dysfunction/combined)(other considerations) /// (cidal vs static/ mono vs combination/ IV vs PO/ duration) VS VS 3-

20063-

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2008 P-14 + + + 68% 14% 10% 7% 3-

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3- -----MDRMDR

ATSMDRATS MDRHAPATS. Am J Respir Crit Care Med.2005;171:388-416MDR:HAP:

MDR90 5/HCAP902 ()30/

IDSAMDRFreifeld AG et al. Clinical Infectious Diseases 2011;52(4):e56e93MRSAVREESBLsKPCsE2010IDSA-

ESBLG-71.6%G-2010CHINETG-(%)ESBLESBL***G-..2011;11(5):321-329

ESBL-1ICUESBLKang CI et al. Ann Hematol. 2012 Jan;91(1):115-21.156ESBL

ESBL(n=37)-ESBL(n=119)P24 (64.9)50 (42.0)0.015 21 (56.8)32 (26.9)0.001 8 (21.6)8 (6.7)0.02533(89.2)77 (64.7)0.00425 (67.6)85 (71.4)0.6532 (5.4)4 (3.4)0.57218 (48.6)69 (58.0)0.31817 (45.9)66 (55.5)0.311ICU9 (24.3)6 (5.0)0.00215 (40.5)32 (26.9)0.114

ESBL-2ICUESBL(OR=6.21,95%CI=1.9120.25,P=0.003 )(OR=2.93,95%CI=1.18-7.30,P=0.021 ) -ESBLWu UI et al. J Microbiol Immunol Infect 2010;43(4):310316ESBL

(n=91)(n=91)OR(95%CI)P>1434 (37.4)9 (9.9)5.43 (2.4212.20)< 0.001ICU13 (14.3)1 (1.1)1.92 (1.92117.27)0.001/29 (31.9)10 (11.0)3.79 (1.728.36)< 0.00132 (35.2)6 (6.6)7.68 (3.0219.53)< 0.00145 (49.5)14 (15.4)5.38 (2.6710.86)< 0.00115 (16.5)1 (1.1)17.76 (2.29137.59)< 0.00158 (63.7)16 (17.6)< 0.001

()>14ICU(/)

1.Kang CI et al. Ann Hematol. 2012 Jan;91(1):115-21. 2.Wu UI et al. J Microbiol Immunol Infect 2010;43(4):310316ESBL

MDR-1ICUMDRAnunnatsiri S et al. Southeast Asian J Trop Med Public Health. 2011 ;42(3):693-703.MDR

MDR-AB(n=25)MDR-AB(n=24)OR(95%CI)P4 (16) 11 (45.8) 4.42 (1.17-16.92)0.02 3 (0-50) 15.5 (0-94) 1.04 (1.002-1.08)0.008 ICU3 (12) 9 (37.5) 4.40 (1.02-18.99)0.04 14 (56) 24 (100)

MDR-2MDRShih MJ et al. J Microbiol Immunol Infect.. 2008;41:118-123MDR

(n=63)(n=63)OR(95%CI)P17 (27.0)3 (4.7)7.99 (2.1-30.6)0.00258 (92.1)44 (69.8)6.10 (1.2-29.9)0.0262.6 1.51.8 1.71.35 (1.0-1.8)0.02624 (38.1)8 (12.7)4.17 (1.6-11.1)0.004

(15)ICU()(2)(APACHE II 24)1.Anunnatsiri S et al. Southeast Asian J Trop Med Public Health. 2011 ;42(3):693-703.2.Shih MJ et al. J Microbiol Immunol Infect.. 2008;41:118-123MDR

MDRMDRTumbarello M et al. Epidemiol. Infect. .2011;139:17401749.

MDR(n=40)(n=212)OR(95%CI)P13 (32.5)26 (12.2)3.44 (1.437.93)0.00119 (47.5)27 (12.7)6.19 (2.7413.80)

(20)()Tumbarello M et al. Epidemiol. Infect. .2011;139:17401749. MDR

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2

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ESBLESBL..2011;27(5):340-347Mohnarin 2009 114 ESBL>99%ESBL>98%

ESBLsClinical Infectious Diseases 2003; 39:317

ESBLs30 Thirty-day mortality rates 12.9% (8 of 62) 26.9% (7 of 26)26.9% (7 of 26)

ESBLsBloodstream Infections Due to Extended-SpectrumBeta-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae:Risk Factors for Mortality and Treatment Outcome, with SpecialEmphasis on Antimicrobial Therapy. AAC. 2004, 48,(12),p. 45744581

ESBLESBL2010DrugsESBLPitout JDD. Drugs 2010; 70 (3): 313-333

ESBLs1. 2. 3. 4. 85%50%

1.39/2.40/3.41/4.Garnacho-Montero J et al. Curr Opin Infect Dis.2010;23:33233939-41/HAPEHAP/

MDR+/25MDR(XDR)://+ Kiratisin P et al. International Journal of Antimicrobial Agents.2010; 36:243246FICIs()=MIC/MIC+MIC/MIC

(%)OR = 0.58P = 0.496OR = 0.27P= 0.204OR = 0.23P = 0.012/ +/(n=12)(n=5)(n=26)(n=29)(n=24)(n=17).Kuo LC et al. Clin Microbiol Infect 2007; 13: 196198.MDR2003-200555MDR/ MDR

TapperHilfMendelsonIgraKuikkaDoes combination antimicrobial therapy reduce mortality in Gram-negative bacteraemia A meta-analysis Lancet Infect Dis 2004; 4: 5192768.1826.5726.6713.3326.8379.4146.5144.4414.29400102030405060708090100%

*+50%50%24() (FICIs) FICIs=MIC/MIC+MIC/MICFICIs0.5 0.5< FICIs1.0 1.0< FICIs4.0 4.0< FICIs MIC50/90: 64/128mg/L;64/512mg/L;32/1024mg/LSong W et al. International Journal of Antimicrobial Agents .2003;21: 8-12

Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia Crit Care Med 2008 Vol.36,No.3

G-VAPn=17+n=39%18.884.228%29.451.328%29.464.11510.7ICU21.214.2111.45528%29.425.6ICU%29.423.1%41.233.3

Drugs 2007; 67 0 ) : 351-368

Antibiotic Combinations for Resistant Bacteria CID 2006:43 (Suppl 2)PDRPAB///

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MDR

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