32.有關腹膜透析導致之bacterial peritonitis，下列敘述何者正確？
(A)診斷之依據為腹膜透析液中WBC＞500 /mm3且neutrophils＞50%
(B)經驗性抗生素首選為ceftazidime單一治療
(C)經驗性抗生素首選為vancomycin單一治療
(D)以intraperitoneal給藥比intravenous給藥更適當

SBP(Spontaneous Bacterial Peritonitis)原發性腹膜炎

(一)診斷:透析液中的PMN>250

(二)常見菌種:

G(+):S. pneumoniae and other Streptococcus species(20%)

G(-):E. coli (most common)、K. pneumoniae、Enterococcus species(5%)

(三)經驗性治療:

首選:三代Cefa(Cefotaxime or Ceftriaxone) -->較安全也比較有效

次之:Ampicillin+Aminoglycoside類-->若病患肝硬化，不可用Aminoglycoside類

對β-lactam過敏:Levofloxacin or moxifloxacin-->不建議使用Ciprofloxacin

Continuous Ambulatory Peritoneal Dialysis(CAPD)–Associated Peritonitis

(一)診斷:透析液成混濁狀

               WBC>100

               Neutrophilic>50%

(二)常見菌種:

G(+): Staphylococcus species:

             S. epidermidis (60%~80%)、Staphylococcus aureus

             Streptococcus species

G(-): E. coli (15~30%),Klebsiella species,Enterobacter species, Proteus species,and P. aeruginosa.

(三)經驗性治療:一律建議IP(Intraperitoneal)注射

合併用藥-->為了同時coverG(+)及G(-)的菌種

殺G(+)可以選用1.Vancoomycin-->考慮MRSA and methicillin-resistant S. epidermidis (MRSE),

        2.Cefazolin

殺G(-)可以選用:1.Aminoglycoside類

               2.Ceftazidime, cefepime

               3.Carbapenem

若對β-lactam過敏或無法使用AMG類則用:Aztreonam

61.經腹膜透析液培養為Staphylococcus epidermidis infection，下列何者為最合適的治療藥品？ 
(A)steroids 
(B)metronidazole 
(C)vancomycin 
(D)cefazolin 

Ceftazidime與Cefoperazone為專制Pseudomonas aeruginosa的第三代Cefa-對抗G(+)不比第一代好，對抗G(-)又不比其他第三代好

(A) Bacterial peritonitis generally is accompanied by an elevated dialysate WBC count greater than 100/μL with greater than 50% neutrophils.

(B) (C) (D) Empiric antibiotics(經驗性抗生素) must cover both gram-positive and gram-negative organisms. The increasing prevalence of vancomycin-resistant organisms has resulted in a shift in empiric therapy away from vancomycin, toward first-generation cephalosporins (cefazolin or cephalothin). Without a Gram stain, therapy should be initiated with a combination of cefazolin or cephalothin (to cover gram-positive organisms) and ceftazidime (to cover gram-negative organisms), coadministered in the same dialysate solution at a dose of 1 g/bag for both drugs, once daily, given intraperitoneally

ref. Koda-Kimble and Young's Applied Therapeutics：The Clinical Use of Drugs, 10th Edition, P.808 
 

補7F 題目的最佳解

9 下列何種療法不適合做為較輕微的社區感染腹膜炎之初始治療？ 
(A) Cefoxitin 
(B) Cefotetan 
(C) Cefuroxime 
(D) Piperacillin and Tazobactam 

最佳解!
	Yes 小三下 (2016/06/21)     73      第二代cepha：cefoxitin, cefotetan, cefuroxime當中，cefuroxime抗菌範圍不包括厭氧的GNB(gram negative bacilli) [reference：熱病Sanford guide]

想請問根據8F的uptodate提到可以使用ciprofloxacin替代使用，是否跟最佳解有矛盾？

最新uptodate

Other antibiotics — Other antibiotics can be used for the treatment of SBP. Whenever possible, the alternative antibiotic should have been studied for the treatment of SBP. Ciprofloxacin can be used for patients who cannot take a cephalosporin, although it does not penetrate into ascitic fluid to the same extent as cefotaxime. We give ciprofloxacin at a dose of 400 mg intravenously twice daily to patients with normal renal function.