16. Antibiotics Adults
(≥ 20 years old)
(n=140)
Children
(< 20 years old)
(n=61)
Penicillin 57 (40.7) 22 (36.1) 0.535
Cefotaxime 127 (90.7) 39 (65.0) < 0.001
Cefepime 120 (85.7) 39 (66.1) 0.002
Vancomycin 140 (100.0) 61 (100.0) NA
Linezolid 140 (100.0) 60 (98.4) 0.303
Clindamycin 121 (86.4) 51 (83.6) 0.601
Erythromycin 78 (55.7) 21 (34.4) 0.006
Data from Catholic BMT Center [in press]
Viridans Streptococci Bacteremia in
NF
17. 초기 항균요법 (1)
In contrast to western countries, Gram-negative bacteria are the
prevailing etiological agents of infections in neutropenic fever
patients in Asia.
Because of the reported etiologic bacteria and their antimicrobial
resistance rates causing neutropenic fever vary widely by times,
area, even wards, every hospital should continue to monitor the
changing patterns of etiology and adjustment of empirical
antibiotics may be necessary.
What is the major etiologic agents of neutropenic feverWhat is the major etiologic agents of neutropenic fever
in Asia?in Asia?
26. Role of Aminoglycoside in NF (3)
While the addition of an aminoglycoside has not been shown to
be of clinical advantage compared with beta-lactam
monotherapy in systematic reviews, there are particular
circumstances where the choice of aminoglycoside may be
important. These include severe sepsis where there is a risk
of resistance in Gram-negative bacilli and in
Pseudomonas infection.
Intern Med 2011;41:90-101 [Australian Guideline]
27. 초기 항균요법 (1)
We still use the beta-lactam + aminoglycoside combination
strategy for empirical therapy of NF. When ESBL is not proven,
aminoglycoside is only used for 3-5 days.
Adjustment for inadequate empirical therapy can lead to a
reduction of mortality. For example, combination therapy with
aminoglycoside…
in high incidence of ESBL producingin high incidence of ESBL producing
Enterobacteriaceae area…Enterobacteriaceae area…
28. PKs in Neutropenia
Reduced serum, tissue, and body fluid concentrations of
antibacterial agents have been reported in neutropenic patients
and animal models, potentially reducing the bactericidal
activities of these agents.
PK changes in neutropenic patients are probably not only
related to neutropenia per se, but also to the severity of sepsis,
as has been in ICU patients. host defense mechanism…
Lancet Infect Dis 2008;8:612-20
30. What can we learn from studies
comparing Linezolid with
Vancomycin in neutropenic patients
when vancomycin doses are not
optimized?
Clin Infect Dis 2006;42:1813-4
1. PK of vancomycin therapy in neutropenic patients is different.
; 3-fold increases of initial Vd, shorted half-life (vs. healthy
volunteer)
2. Achievement of trough serum conc. ≥15 mg/L?
3. T>MIC 100%
4. 1 g iv q12hrs fixed dose 30 mg/kg/day
32. Antimicrob Agents Chemother 2001;45:2460-7
Continuous vs. Intermittent
Infusion of Vancomycin in
Severe Staphylococcal
InfectionFrance, Prospective study, CIV (plateau 20-25 mg/L), IIV (trough 15-20 mg/L)
N= 119, Hospital acquired infection, bacteremia 35%, pneumonia 45%
33. Empirical Teicoplanin in Neutropenic
Fever in Korea: Comments
TPV 400 mg qd and then 200 mg qd
; is that enough?
1. Only one strains of S. aureus,
2. CNS can be affected by catheter
removal
3. Four out of 6 strains of E. faecium
were vancomycin resistant.
4. Viridans streptococci would be
susceptible with cefepime.
Infect Chemother 2004;36:83-91
37. 초기 항균요법 (1)
PK of glycopeptides in neutropenic patients is different with that of
normal volunteers. We need their PK data!!!
may need higher doses than usual
Vancomycin trough concentrations 15-20 mg/L or AUC/MIC >400
would be required in neutropenic fever as well as in severe
staphylococcal infection.
Teicoplanin PK/PD magnitude for neutropenic fever is not
established yet (trough >10 or 20 mg/L, AUC/MIC >345??).
However, TDM would be needed for monitoring TAR. Teicoplanin
dose would be needed more than we usually prescribe.
When using glycopeptide to NF patients, Consider…When using glycopeptide to NF patients, Consider…
38. Summary
Etiology of NF is different according to the area, time, even the
wards in the same hospital. We need to continue monitoring the
changing patterns.
ESBL producing organisms are common. High index of suspicion
(prior use of beta-lactams, Hx of long hospital stay…) is important.
For empirical Tx against ESBL organisms, consider the
susceptibility patterns and adjust for inadequate antibiotics…
PK of glycopeptides in neutropenic patients is different with that of
normal volunteers. We need their PK data!!! Population PK
