【已修改】[推选]革兰阴性菌耐药折点问题PPT文档.ppt

1、革兰阴性菌耐药折点问题文档pptM100-S22M100-S22Partial Table of ContentsPartial Table of ContentsM100-S22.Page 9.M100-S22.Page 9.44更新的更新的的总结的总结M100-S22.Page 13.M100-S22.Page 13.55主要变化v 肠杆菌科修订厄他培南折点增加环丙沙星折点（伤寒沙门菌和胃肠外沙门菌）v 绿脓杆菌降低 哌拉西林、哌拉西林/他唑巴坦、替卡西林、替卡西林/克拉维酸折点降低 亚胺并且使用并且使用新的新的“降低的降低的”折点折点以治以治疗为疗为目的目的报报告告药药敏敏结结果果 不更改不更改“敏感敏感”结结果果仅仅以感染控制和流行病学研究以感染控制和流行病学研究为为目的目的进进行特殊的行特殊的耐耐药药机制机制检测试验检测试验分离出分离出肠肠杆菌科菌杆菌科菌Courtesy of Dr.Jean Patel CDCCourtesy of Dr.Jean Patel CDCCLSI M100-S20-U 表 1A修订的碳青霉烯类药物折点和对应的药物剂量修订的碳青霉烯类药物折点和对应的药物剂量S I RS I RS。

2、培南、美罗培南折点；增加多利培南折点v 葡萄球菌增加金葡菌青霉素抑菌圈周边试验检测（penicillin disk zone edge test）-内酰胺酶产生66M100-S22.P22年后折点年后折点变化过程变化过程77CLSI Breakpoint Additions/Revisions Since Antimicrobial AgentDate of Revision*(M100 version)CommentsEnterobacteriaceae AztreonamJanuary 2耐药药机制的初机制的初筛试验筛试验(MIC(MIC升高至接近升高至接近“敏感敏感”折点折点为为“可疑可疑”)”)进行耐药机制的特异确证试验进行耐药机制的特异确证试验若若检测检测到耐到耐药药机制机制则则更改更改药药敏敏报报告告发现发现一种新型一种新型-内内酰酰胺胺酶酶(如如ESBLESBL或碳青霉或碳青霉烯烯酶酶)旧的模式ESBLESBLMHTMHTCourtesy of Dr.Jean Patel CDCCourtesy of Dr.Jean Patel CDC新的模式进进行行药药敏敏试验试验。

3、010(M100-S20)CefazolinJanuary 2010(M100-S20)January 2011(M100-S21)Breakpoints were revised twice since 2010CefotaximeJanuary 2010(M100-S20)CeftazidimeJanuary 2010(M100-S20)CeftizoximeJanuary 2010(M100-S20)CeftriaxoneJanuary 2010(M100-S20)DoripenemJureted with current breakpoints2 Anderson,KF et al.ICAAC.D-719.3 Limbago,BM.CLSI Agenda book.January.4 MHT positive only with ertapenem disk5 MHT same result with ertapenem and meropenem(and imipenem)disks6 Carbapenemases(metallo-lactamases)3939进进行耐行。

4、ne 2010(M100-S20U)No previous CLSI breakpoints for doripenemErtapenemJune 2010(M100-S20U)January 2012(M100-S22)Breakpoints were revised twice since 2010.ImipenemJune 2010(M100-S20U)MeropenemJune 2010(M100-S20U)Cipro Salmonella onlyJanuary 2012(M100-mples:Carbapenem MICs&MHT&-Lactam Resistance MechanismOrganismMIC(g/ml)1MHTResistancemechanismErtapImipMeroE.coli216 R4 R4 RPos4Plasmid ampCK.pneumoniae216 R0.25 S8 RPos5ESBL blashvE.coli316 R8 R16 RNeg5NDM-16K.pneumoniae32 R1 S2 IPos5IMP-461 Interp。

5、S22)CLSI AST Standards for Routine ASTPages 52 and 56.January 2012(M100-S22)与临床预后相关的MIC年后折点变化过程and Ciprofloxacin(MIC升高至接近“敏感”折点为“可疑”)MIC(g/ml)June 2010(M100-S20U)CLSI Agenda book.Pages 52-60.临床实验室可以使用 CLSI 或 FDA 折点碳青霉烯酶筛选试验阳性and Fluoroquinolones细菌耐药ay be encountered in isolates with carbapenem resistance mechanisms other than carbapenemase production.”M100-S22.Table 2A Supplemental Tables 2 and 3.Pages 53 and 57.M100-S22.Table 2A Supplemental Tables 2 and 3.Pages 53 and 57.36364 Select CRE Exa。

6、监测和药敏谱统计的规范方法pneumoniae2M100-S20U(June 2010)CLSI Breakpoint Additions/Revisions Since Antimicrobial AgentDate of Revision*(M100 version)CommentsPseudomonas aeruginosaPiperacillin-tazobactamJanuary 2012(M100-S22)Ticarcillin-clavulanateJanuary 2012(M1mm Res.:2 g/ml/18 mm VM=0.0%Ma=0.0%Mi=6.1%FOR NEW BREAKPOINTS APPROVED June Modified Hodge Test(MHT)(Table 2A Supplemental Table 2 and 3)“NOTE:Not all carbapenemase-producing isolates of Enterobacteriaceae are MHT positive and MHT-positive results m。

7、00-S22)TicarcillinJanuary 2012(M100-S22)PiperacillinJanuary 2012(M100-S22)肠杆菌科：碳靑霉烯类 碳靑霉烯类耐药肠杆菌科（CRE）的分布黄色：KPC酶；蓝点：IMP、VIM黄点：NDMCLSI使用以下数据建立/修订折点v“野生菌群”或常规菌群的MIC分布野生菌群=未携带获得性“耐药”机制v 与临床预后相关的MIC对于老药很少有“新”数据v 药物代谢-药效学(PK-PD)分析CLSI M23-A3()“CLSI M23-A30.5 g/ml thus allowing labs to use CLSI ertapenem breakpoints(following verification)if breakpoint is 0.5 g/ml but not if 0.25 g/ml2929CLSI Agenda Book June CLSI Agenda Book June 3030CLSI Agenda Book June CLSI Agenda Book June 3131Susc.:0.5 g/ml/22 。

8、“体外药敏实验标准和质量控制参数的发展体外药敏实验标准和质量控制参数的发展;批批准的指南准的指南”描述了描述了CLSICLSI建立和修订折点的过程。
建立和修订折点的过程。
Piperacillin-tazobactamPiperacillin-tazobactam MIC distribution exampleMIC distribution exampleBlue=wild type isolatesBlue=wild type isolatesRed=isolates with acqs with MICs of 0.5 g/ml did not have carbapenemasesv Further review of PK/PDv Additional clinical data(including ESBL-producing E.coli with 0.5 g/ml MICs suggested clinical response)v Also,lowest ertapenem concentration on some commercial panels is 。

9、uired“R”mechanismRed=isolates with acquired“R”mechanism1010SSeerruummCCoonncceennttrraattiioonn(gg/mmll)Time(hours)MMIICCTTiimmeeaabboovveeMMIICCdosedosedosedoseCCmmaaxx(ppeeaakkccoonncceennttrraattiioonn)PK/PD Goal(“Target”)for-lactams=(%T MIC)12122828为何多次进行修改?v breakpoints primarily based on:v MIC distributionsv PK/PD(conservatively went with 0.25 g/ml)v Very limited clinical data(no patients with MICs at 0.5 g/ml)v breakpoints primarily based on:v Additional surveillance data showed isolate。

10、Organism%Time MIC肠杆菌科35%绿脓30%年CLSI 绿脓杆菌折点变化Some difficulties readingPages 52 and 56.June 2010(M100-S20U)细菌耐药监测和药敏谱统计的规范方法Dosage commentsJune 2010(M100-S20U)(MIC升高至接近“敏感”折点为“可疑”)lugdunensisTable 2A Supplemental Tables 2 and 3.(M100 version)碳靑霉烯类耐药肠杆菌科（CRE）的分布病原菌的分子进化研究进展January 2010(M100-S20)DMID 年CLSI DocumentMIC(g/ml)Disk Diffusion(mm)SuscIntResSuscIntResM100-S20(Jan.2010)*2481916-1815M100-S20U(June 2010)0.250.512320-2219M100-S22(Jan 2012)*0.51.022219-2118肠杆菌科 厄他培南CLSI 折点更新过程*目前和FDA折点相同NewNew。