pemilihan ab pd demam neutropenia

8/18/2019 Pemilihan AB Pd Demam Neutropenia

1/21

KK I & P TPP IDAI

D

P P

P


2/21

P

I

Up to 60% febrile neutropenia episodes = infection

(microbiological or clinical)

~20% patients with ANC


3/21

P ( 50%), :

T, , , KID, ,

D N

≥38,3C 1 ATA

≥38C 1 2

12


4/21

S : ,

,

P :

S


5/21

A

( )

P

T

A .

T ;

T P

C

R

R

M


6/21

,

C , ,, , , , , &

, ,

, (BN),

,

, ,

/

P : , 6,8,

:


7/21

Changing etiology of bacteremiaIATG-EORTC 1973-2000 trials of febrile neutropenia

Gram positivedominant since mid

1980s1) More intensivechemoTx

•Mucositis2) In-dwelling catheters

• Cutaneous-IV portal3) Selective antiBxpressure

•Fluoroquinolones

• Co-trimoxazole4) Antacids

•Promote oro-oesophagealcolonisation withGPC

Gram negative resurgence

: G (

) T G (6070%:

C , , E), :

P (CLABSI),

(. ),

J


8/21

R (RSHS) JD 2012: 104 82 (78,8%) :

4 (3,8%) :

4 (3,8%) :

3 (2,8%) :

3 (2,8%) :

2 (1,9%) :

2 (1,9%) :

1 (0,9%) :

1 (0,9%) :

1 (0,9%) : 1 (0,9%) :

B ,


9/21

C

D

:

K:

F/

D

+ +++

D 7

5 20% 80 100%


10/21

P N (>14 )• H / A HSCT M C C . . B D S ( , )

O >20 R

ANC ≥ 100 /L

T < 39C

N

N

N

N

N

N

N : , , ,


11/21

A

A ..?

P ( 24 ) ?

H

P ..

A I P & R2 (, , ,) P/ P R R P

S HI P: TB, : H, H, L, T, , /C, P ,,

R

D:T≥ 38,3⁰C ≥ 38,0⁰C 1

:N< 500 /3 < 1000 /3 ≤ 500/3 48

2 :1 + 1 K B , , DK L / /

T/,


12/21

B

A :

D / ANC ≥500 /3

D :

B ,:

J

P

/ : 714 D : (): 1014 (+): 714 .: . 2 (): 1021 : 1021 :C: . 2 ()

A: . 12 : /: 710 ; ,

, : 5

( ≥ 3.3⁰) + ( 500 /

+

+

+

,

,

35


13/21

A:

S

R

D:

L ?

T

P

B (), (+) &

N ( CSF

C +

P ( )

R

S


14/21

C P (+)

B

N ,

G CSF

M B (), (+) & ESBL

P /CNS

A

G() , S. E

N,

C

G() N , (+)

G PO I

A

HO


15/21

S :

N .:

▪ S CLABSI

▪ H MRSA

▪

H /


16/21

, ()

()

≥ 500 /L

()

(+)

≥ 500/L 45

I :(1) (2) MRSA() (4) (5) M

F I / 45 ANC

>0.5

C ≥45 .

F

B , , E C

≥4


17/21

Non-bacterial infection (eg fungal, viral)

Bacterial resistance to first line therapy (MRSA,VRE)

Slow response to drug in use

Superinfection

Inadequate dose

Drug fever

Cell wall deficient bacteria (eg Mycoplasma,Chlamydia)

Infection at an avascular site (abscess or catheter) Disease-related fever

S/ : 714

S: 1021

B : 1021


18/21

:

G : 1014

G : 714

2 TEE

: ≥2

Minimum 1 week of therapy if Afebrile by day 3

Neutrophils >500/mm3 (2 consecutive days)

Cultures negative

Low risk patient, uncomplicated course

> 1 week of therapy based if Temps slow to settle (>3 days)

Continue for 4-5 days after neutrophil recovery (>500/mm3 )

Minimum 2 weeks Bacteraemia, deep tissue infection

After 2 weeks if remains neutropenic (< 500/mm3), BUT afebrile, nodisease focus, mucous membranes, skin intact, no catheter siteinfection, no invasive procedures or ablative therapyplanned…cease antibiotics and observe


19/21

B

S

AP

L

ABS

P

OB

PAB

AS

OF

S

I

P

A


20/21

H

T 1 1 ,

S , ,

,

R

M

K:

, , , RT

O :

B 46 / NC

0,9%

B . 2 /


21/21

pemilihan ab pd demam neutropenia

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