门诊病人抗生素的使用(英文)Outpatient-antibiotic-use课件.ppt
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- 门诊 病人 抗生素 使用 英文 Outpatient antibiotic use 课件
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1、Outpatient antibiotic useCarlos A.DiazGranados,MD,MSDirector,Antimicrobial UtilizationGMHCase 1 48 yo male,HIV on ARV,VL 75 k,CD4=120,comes to the clinic complaining of nasal congestion with yellow-thick discharge,cough,postnasal drip and headache for 4 days.Physical exam reveals normal vital signs,
2、tenderness to pressure in maxillary sinus and yellow postnasal drip.WBC 4k,Crypto AG negative.What is the diagnosis?What is antimicrobial should be given?Acute sinusitisACP Guidelines High-risk(50%)of bacterial sinusitis if 2 or more of the following present:Symptoms 7 days.Facial pain.Purulent disc
3、harge.If low risk,do not prescribe antibiotics.If high-risk and mild symptoms,defer antibiotic therapy.If no improvement after 7-10 days of symptomatic therapy,consider antibiotic therapy.If high-risk and severe symptoms,consider immediate antibiotic therapy.The antibiotic of choice is Amoxicillin.A
4、ssess the probability of bacterial sinusitis and treat if high and symptoms severe.Otherwise,defer antibiotic Rx.Red flagsconsider early/immediate antibioticsSinusitis AB duration Unclear RCT have used 5-10 days.Case 2 24 yo male,recently diagnosed with HIV,CD4 is 180 on Bactrim prophylaxis,started
5、ARV 2 months prior.Comes to the clinic with 3 days of mild shortness of breath,productive cough of yellow/green sputum.PE afebrile,lungs with few bilateral wheezes.O2 sat 99%RA before and after activity.LDH normal,CXRay negative.What is the diagnosis?What is the first line antibiotic choice?Acute br
6、onchitisAntibiotics NOT recommendedCase 3 35 yo male,h/o HIV,CD4 150,VL undetectable,comes with a 5 days history of SOB,productive cough,and low-grade fever.Adherence 100%.Meds:Atripla,Bactrim.PE:T=100,RR=22,HR=98,BP=110/70.Decrease breath sounds and rales RLL.O2sat 94%RA.Labs:PaO2 72.WBC=12.LDH=180
7、.What is the likely diagnosis?What would be your recommended therapy?Community-acquired pneumoniaPCP vs.BacterialPCP vs.BacterialCAPCID 2007;44:Suppl 2.Site of care decisionsPSI ScoringCURB 65 ScoreConsider ruling out TB all patients that you treat for bacterial pneumonia with quinolone monotherapyC
8、ase 4 52 yo male with HIV,CD4 350,VL undetectable,chronic tobacco use,history of chronic bronchitis/COPD,comes to the clinic with 5 days of worsening shortness of breath,increase in the amount of the sputum which has become darker in color.PE shows tachypnea,normal temperature,mild tachycardia,hypov
9、entilated lungs bilaterally.CXRay shows lung hyperinflation,no infiltrates.What is the diagnosis?What are the antibiotic options?Acute exacerbations of chronic bronchitisAntibiotic options:Amoxicillin Doxycycline Bactrim Macrolides(azithromycin,clarithromycin)LevofloxacinCase 5 36 yo male,HIV,CD4 30
10、0,on ARVs,VL undetectable.Comes to the clinic with 2 day history of fever,sore throat and odynophagia.Similar clinical picture in house-hold family member.Denies recent sexual activity.Physical exam shows Temp of 38.7,tachycardia,thick exudate in bilateral tonsils and cervical lymphadenopathy.What i
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