耐药不动杆菌属引起的脑膜炎的处置
The LANCET Infectious DiseasesVolume 9, Issue 4, April 2009, Pages 245-255
Review
Management of meningitis due to antibiotic-resistant Acinetobacter species
耐药不动杆菌属引起的脑膜炎的处置
Baek-Nam Kim MDa, c, Anton Y Peleg FRACPd, Thomas P Lodise PharmDe, Jeffrey Lipman MDa, b, Jian Li PhDf, Roger Nation PhDf and David L Paterson FRACPa, g, ,
aUniversity of Queensland Centre for Clinical Research, Royal Brisbane and Women's Hospital, Brisbane, Australia
bDepartment of Critical Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
cDepartment of Internal Medicine, Inje University College of Medicine, Seoul, South Korea
dDivision of Infectious Diseases, Beth Israel Deaconess Medical Center and Harvard Medical School, USA
eAlbany College of Pharmacy, Pharmacy Practice Department, Albany, New York, USA
fFacility for Anti-infective Drug Development and Innovation, Drug Delivery, Disposition and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Victoria, Australia
gCentre for Healthcare Related Infection Surveillance and Prevention, Queensland Health, Brisbane
Available online 25 March 2009.
Summary
Acinetobacter meningitis is becoming an increasingly common clinical entity, especially in the postneurosurgical setting, with mortality from this infection exceeding 15%. Infectious Diseases Society of America guidelines for therapy of postneurosurgical meningitis recommend either ceftazidime or cefepime as empirical coverage against Gram-negative pathogens. However, assessment of the pharmacodynamics of these cephalosporins in cerebrospinal fluid suggests that recommended doses will achieve pharmacodynamic targets against fewer than 10% of contemporary acinetobacter isolates. Thus, these antibiotics are poor options for suspected acinetobacter meningitis. From in vitro and pharmacodynamic perspectives, intravenous meropenem plus intraventricular administration of an aminoglycoside may represent a superior, albeit imperfect, regimen for suspected acinetobacter meningitis. For cases of meningitis due to carbapenem-resistant acinetobacter, use of tigecycline is not recommended on pharmacodynamic grounds. The greatest clinical experience rests with use of polymyxins, although an intravenous polymyxin alone is inadvisable. Combination with an intraventricularly administered antibiotic plus removal of infected neurosurgical hardware appears the therapeutic strategy most likely to succeed in this situation. Unfortunately, limited development of new antibiotics plus the growing threat of multidrug-resistant acinetobacter is likely to increase the problems posed by acinetobacter meningitis in the future.
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