Infections Book

ISBN 978-960-88929-2-7
2007
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2007
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ISBN
978-960-88929-2-7
Copyright 2007

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Neisseria gonorrhoaeae
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Arcanobacterium haemolyticum
Yersinia enterocolitica
Yersinia pestis
Francisella tularensis

,
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2. 1.
Rhinovirus
Coronavirus
Adenovirus
HSV 1 2
Parainfluenza virus
Coxsackievirus
EBV
CMV
HIV
Influenza A B
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12/10/07 1:00:07 PM
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10
1.
Bisno AL., Gerber MA., Gwaltney JM. Jr., Kaplan EL., Schwartz RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. ClinInfect Dis, 2002;35:113-25.
2. Gerber MA., Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev, 2004;17:571-80.
3. Bourbeau PP. Role of the microbiology laboratory in diagnosis and management of pharyngitis. J
Clin Microbiol, 2003;41:3467-72.
4. Centro RM., Witherspoon JM., Dalton HP., Brody CE., Link K. The diagnosis of strep throat in adults
in the emergency room. Med Decis Making 1981;1:239-46.
5. McIsaac WJ., Kellner JD., Aufricht P., Vanjaka A., Low DE. Empirical validation of guidelines for the
management of pharyngitis in children and adults. JAMA, 2004;291:1587-95.
6. Vincent MT., Celestin MT., Hussain AN. Pharyngitis. Am Fam Physician, 2004;69:1465-70.
7. Singh S., Dolan JG., Centor RM. Optimal management of adults with pharyngitis a multi-criteria
decision analysis. BMC Medical Informatics and Decision Making, 2006;6:14.
8. Humair JP., Fevaz SA., Bovier P., Stalder H. Management of acute pharyngitis in adults: Reliability of
rapid streptococcal tests and clinical findings. Arch Intern Med, 2006;166:640-44.
9. Cooper RJ., Hoffman JR., Bartlett JG., Besser RE., Gonzales R., Hickner JM., Sande MA. Principles
of appropriate antibiotic use for acute pharyngitis in adults: Background. Ann Intern Med,
2001;134:509-17.
10. Bisno AL. Are cephalosporins superior to penicillin for treatment of acute streptococcal pharyngitis? Clin Infect Dis, 2004;38:1535-7.
11. Pichichero M., Casey J. Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis. Eur J Clin Microbiol Infect Dis,
2006;25:354-64.
10
12/10/07 1:00:07 PM

12. Casey JR., Pichichero ME. Meta-analysis of short course antibiotic treatment for group A streptococcal tonsillopharyngitis.Pediatr Infect Dis J, 2005;4:909-17.
13. Casey JR., Pichichero ME. Meta-analysis of cephalosporin versus penicillin treatment of group A
streptococcal tonsillopharyngitis in children. Pediatrics, 2004;113:866-82.
14. Casey JR., Pichichero ME. Meta-analysis of cephalosporins versus penicillin for treatment of group
A streptococcal tonsillopharyngitis in adults. Clin Infect Dis, 2004;38:1526-34.
15. Grivea IN., Al-Lahham A., Katopodis GD., Syrogiannopoulos GA., Reinert RR. Resistance to erythromycin and telithromycin in Streptococcus pyogenes isolates obtained between 1999 and 2002
from Greek children with tonsillopharyngitis: Phenotypic and genotypic analysis. Antimicrob
Agents Chemother, 2006;50:25661.
16. Zachariadou L., Papaparaskevas J., Paraskakis I., Efstratiou A., Pangalis A., Legakis Nj., Tassios PT.
Predominance of two M-types among erythromycin-resistant group A streptococci from Greek
children. Clin Microbiol Infect, 2003;9:310-4.
17. ., ., ., ., ., .
Streptococcus pyogenes -. 30 , 2004.
. 251.30 , 2004. . 251.
18. Syrogiannopoulos GA., Bozdogan B., Grinea IN., Ednie LM., Kritikou DI., Katopodis GD., Beratis NG.,
Applebaum PC. Hellenic Antibiotic-Resistant Respiratory Pathogens Study Group. Two dosages of
clarithromycin for five days, amoxicillin/clavulanate for five days or penicillin V for ten days in acute
group A streptococcal tonsillopharyngitis. Pediatr Infect Dis J, 2004;23:857-65.
19. Esposito S., Bosis S., Begliatti E., Droghetti R., Tremolati E., Tagliabue C., Bellasio M., Blasi F., Principi
N. Acute tonsillopharyngitis associated with atypical bacterial infection in Children: Natural history
and impact of macrolide therapy. Clin Infect Dis, 2006;43:206-9.
11
12/10/07 1:00:07 PM
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12/10/07 1:00:08 PM

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19
12/10/07 1:00:08 PM
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8.
9.
Gwaltney JM. et al. Computed tomographic study of the common cold. NEJM, 1994;330:25-30.
American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics,
2001;108:798-808.
Talbot GH. et al. Rigid nasal endoscopy versus sinus puncture and aspiration for microbiologic
documentation of acute bacterial maxillary sinusitis. Clin Infect Dis 2001;15:1668.
Scheid DC., Hamm RM. Acute bacterial rhinosinusitis in adults (part II). Am Fam Physician,
2004;70:1711-12.
Piccirillo JF. Acute bacterial sinusitis. NEJM, 2004;351:902-10.
Scheid DC., Hamm RM. Acute bacterial rhinosinusitis in adults (part I). Am Fam Physician,
2004;70:1685-92.
Anon JB. et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol
Head Neck Surg, 2004;130(1 Suppl.):1-45.
Fendrick AM. et al. Diagnosis and treatment of upper respiratory tract infections in the primary
care setting. Clin Ther, 2001;23:1683-706.
Wong DM. et al. Guidelines for the use of antibiotics in acute upper respiratory infections. Am Fam
Physician, 2006;70:1685-92.
20
12/10/07 1:00:08 PM

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12/10/07 1:00:08 PM
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ATS-ERS)].
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80% ,
20%
.

(40-50%), (30-50%) () (5-10%) ( 1). , , 10-20% ,

.
3.

, ( 2).
22
12/10/07 1:00:08 PM

1.
.
(%)
(30-50)
Influenza A B
Parainfluenza 1, 2 3
Rhinovirus
Coronavirus
Adenovirus
Respiratory syncytial virus (RSV)
()
(5-10)
Chlamydophila pneumoniae
Mycoplasma pneumoniae
(40-50)
Haemophilus influenzae ( )
Haemophilus parainfluenzae
Pseudomonas aeruginosa
(Escherichia coli, Klebsiella
pneumoniae)
:
-
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2. .

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23
12/10/07 1:00:08 PM
3
1.
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FEV1<1,00 L .
24
12/10/07 1:00:09 PM

4.5.

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, . PaO2 <50 mmHg, PaCO2>70 mmHg
p<7,30, .
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12/10/07 1:00:09 PM
3
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27
12/10/07 1:00:09 PM
3
5.2.4.
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>25

(, , )
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28
12/10/07 1:00:09 PM

8. .

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29
12/10/07 1:00:09 PM
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30
12/10/07 1:00:09 PM

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31
12/10/07 1:00:09 PM
3
10. , ,
.
: 500 mg x 1 3
: 500 mg x 2 ER 1000 mg x 1
: 150 mg x 2 300 mg x 1
-
: 500 mg x 2
: 500 mg x 2
: 1 g x 2
: 400 mg x 2
: 400 mg x 2
-
: 400 mg x 1
o: 100 mg x 2
: 400 mg x 1
: 500 mg x 1
1: 750 mg x 2
: 1 g x 3
/: 875/125 mg x 2 500/125 mg x 3
: 750 mg x 2
(. 9).
1.
2.
3.
4.
Global Initiative for Obstructive Lung Disease. Global strategy for the diagnosis, management, and
prevention of chronic obstructive pulmonary disease [executive summary]. Updated 2004.
Balter MS., La Forge J., Low DE., Mandell L., Grossman RF. Chronic Bronchitis Working Group; Canadian Thoracic Society; Canadian Infectious Disease Society. Canadian guidelines for the management
of acute exacerbations of chronic bronchitis: executive summary. Can Respir J, 2003;10:248-58.
Balter MS., La Forge J., Low DE., Mandell L., Grossman RF. Canadian Thoracic Society; Canadian
Infectious Disease Society. Canadian guidelines for the management of acute exacerbations of
chronic bronchitis. Review. Can Respir J, 2003;10 (Suppl B):3-32.
Woodhead M., Blasi F., Ewig S., Huchon G., Leven M., Ortqviste A., Schaberg T., Torres A., van der
Heijden G., Verheij TJM. Guidelines for the management of adult lower respiratory tract infections.
Eur Respir J, 2005;26:1138-80.
32
12/10/07 1:00:09 PM

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12/10/07 1:00:09 PM
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Streptococcus pneumoniae aemophilus infuenzae
, Mycoplasma
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.
S. pneumoniae ,
, 40%. ,
(0,5%)
(1%) .

34
12/10/07 1:00:10 PM

, (~50%)
(53% ,
) . , . H. infuenzae,

15%,
/ - .
1.
.

Streptococcus pneumoniae (~40%)

Haemophilus influenzae
- Escherichia coli, Klebsiella pneumoniae

Staphylococcus aureus1
Mycoplasma pneumoniae
Chlamydophila pneumoniae
Legionella sp.
Influenza A and B
Respiratory syncytial virus (RSV)
1
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35
12/10/07 1:00:10 PM
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36
12/10/07 1:00:10 PM

.
2. CURB-65 index. .
-

>65
(8 )
30/min
<90 mmHg, <60 mmHg
12
34
1,2%
8,15%
31%
-

65
(8 )
>40 mg/dl
30/min
<90 mmHg, <60 mmHg
01
1,5%
9,2%
22%
: CURB-65
.
37
12/10/07 1:00:10 PM
4
5.
5.1.
.
5.2.
(,
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12/10/07 1:00:10 PM

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- 800 mg x 1, 5

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- 400 mg x 1, 10
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6.
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2. :
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39
12/10/07 1:00:10 PM
4
3. :
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).
7.

7.1.
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(>500 ml).
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,
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, 85% 58%.
40
12/10/07 1:00:10 PM

-
, .
,
.
5.
, .
1.
.
2. Gram, Ziehl-Neelsen
.
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: >25
<10 .
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(RSV).
7. (M. pneumoniae, C. pneumoniae,
Legionella sp.)
.
:
PCR ycoplasma pneumoniae, Chlamydophila
pneumoniae Legionella sp.
8.

.
2-4
.
,
,
,
.
6, 7 8.
S. pneumoniae
, 5-38%
.
41
12/10/07 1:00:10 PM
4

Gram (-) Pseudomonas sp.
:
) /,
) ,
)
) .
.
. (.
7 8),
. 5-10
( ), Legionella sp.
14 .
.

,
.
:
)

)
.
,

7 .
9.

,
. . , 48
, 72
.
.
42
12/10/07 1:00:10 PM

6. .
( ).

. 1
-,
3
+
. 2
, 3
4
-,
2
+
.
, -
.
3
Streptococcus
pneumoniae.
4
,
.
,
, .
1
2
7.
( ).
Pseudomonas aeruginosa1
- -2
- + ,
- -2 +
M Pseudomonas aeruginosa1
-
- -
- 3
+
-
: ) /,
) , )
) ( ).
2
, .
3
. , ,
( -) P.
eruginosa.
1
43
12/10/07 1:00:11 PM
4
8.
, .

-
-
-
- /
3 ( )
-
-

-
- K
-

-
- /
- /
-
-
-

-
-

-
600 mg x 3, IV
500 mg x 1, IV, 5
500 mg x 2, V, 7-10
3 g x 4, IV, 7-10
2 g x 1, IV, 7-10
2 g x 4, IV, 7-10
2 g x 3, IV
2 g x 3, IV
2 g x 4, IV
5,2 g x 4, IV
4,5 g x 4, IV
1 g x 3, IV
2 g x 3, IV
1 g x 1, IV
750 mg x 1, IV, 5 *
400 mg x 1, IV, 7-10
400 mg x 3, IV 600 mg x 2, IV
* .
- , 500 mg x 2, IV.
10.

, :
10.1.
:
) ,
) ( , , )
)
.
44
12/10/07 1:00:11 PM

( )
.
,
, ,
.
,
. ,

.
10.2.

.
, .
1.
2.
3.
4.
5.
6.
7.
8.
9.
File T.M. Jr, Tan J.S. International guidelines for the treatment of community-acquired pneumonia
in adults: the role of macrolides. Drugs, 2003;63:181-205.
Fine M.J., Auble T.E., Yealy D.M., Hanusa B.H., Weissfeld L.A., Singer D.E., Coley C.M., Marrie T.J., Kapoor W.N. A prediction rule to identify low-risk patients with community acquired pneumonia. N
Engl J Med, 1997;336;243-50.
Lim WS., van der Eerden M., Laing R., Boersma W.G., Karalus N., Town G.I., Lewis S.A., Macfarlane J.T.
Defining community acquired pneumonia severity on presentation to hospital: an international
derivation and validation study. Thorax, 2003;58:377-82.
Mandell LA., Bartlett J.G., Dowell S.F., File T.M., Jr., Musher D.M., Whitney C. Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults.
Clinical Infectious Diseases, 2003;37:1405-33.
Woodhead M., Blasi F., Ewig S., Huchon G., Leven M., Ortqviste A., Schaberg T., Torres A., van der Heijden G., Verheij T.J.M.. Guidelines for the management of adult lower respiratory tract infections.
Eur Respir J, 2005;26:113880.
Zissis NP., Syriopoulou V., Kafetzis D., Daikos G.L., Tsilimingaki A., Galanakis E., Tsangaropoulou I. Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae causing invasive
infections and acute otitis media in children. Eur J Pediatr, 2004;163:364-8.
Kanavaki S., Mantadakis E., Karabela S., Anatoliotaki M., Makarona M., Moraitou H., Pefanis A., Samonis G. Antimicrobial resistance of Streptococcus pneumoniae isolates in Athens, Greece. Eur J Clin
Microbiol Infect Dis, 2005;24:693-6.
Volonakis K., Souli M., Kapaskelis A., Baziaka F., Grammelis V., Ziakas PD., Giamarellou H. Evolution of
resistance patterns and identification of risk factors for Streptococcus pneumoniae colonisation in
daycare centre attendees in Athens, Greece. Intern J Antimicrob Agents, 2006;28:297-301.
Paraskakis I., Kafetzis DA., Chrisakis A., Papavasilliou H., Kirikou H., Pangalis A., Tzouvelekis LS., Athanasiou ., Legakis N.J. on behalf of the National Surveillance Network for Pneumococcal Resistance. Serotypes and antimicrobial susceptibilities of 1033 pneumococci isolated from children in
Greece during 2001-2004. Clin Microbiol Infect, 2006;12:478-95.
45
12/10/07 1:00:11 PM
12/10/07 1:00:11 PM

: E.
: .

E.
.
.
.
.
.
.
.
.
12/10/07 1:00:11 PM
I.
1.
(Hospital Acquired Pneumonia HAP

) 48
.
19% . 5-10
1.000 . 48-72
(
Ventilator Associated Pneumonia - VAP),
(Health Care
Associated Pneumonia - HCAP). HAP
30% 70%.
2.
HAP, >65 ,
, , , .
.
48
12/10/07 1:00:11 PM

,
, .
3.
, ,
. 1.
HAP
:
1.
2. >5
3. >2
4.
5.
6.
7.
8.
9.
10. ,
11. FEV1<30%, ,
.
4.
,
VAP,
( ) 2 3 : >38C, (>10.000 )
(<4.000 ), .
.

49
12/10/07 1:00:11 PM
5
, /
. (.. ),
(BAL) (PSB).
, ,

,
. , ,
, , ARDS.
5.

,

.
.

,

. ,
.
,
. .
VAP,
8-10 ,
P. aeruginosa, (14
) .

1, 2 3.
50
12/10/07 1:00:11 PM

1.
,
.

Staphylococcus aureus
Gram :
Escherichia coli
Klebsiella pneumoniae
Enterobacter sp.
Proteus sp.
Serratia marcescens
/
+
o .
, .
2.
.

Klebsiella pneumoniae (ESBL+)
Acinetobacter sp.
(, )
-/
-
(, , )
(MRSA)
, .
ESBL + K. pneumoniae, Acinetobacter
, (, , ).
P. aeruginosa . L. Pneumophila,

.
whonet.hellas (WWW.WHONET.GR)
30%-60%.
MRSA
MRSA.
51
12/10/07 1:00:11 PM
5
3.
, ,
.
-/
/
/
/

1-2 g 8
2 g 8
1 g 8
1-2 g 8
1 g
4,5 g 6
5,2 g 6
3 g 6
7 mg/kg 24
7 mg/kg 24
15-20 mg/kg 24
600 mg 12
400 mg
500 mg 12
15 mg/kg 12
600 mg 12
10 mg/kg
(trough) 1 g/ml 4 g/ml.

1.00 .. ( , 1,7 mg/kg 8 2
mg/kg 7,5 mg/kg 12).
, trough 15-20 g/ml.
, , 10 mg/kg
24 10 mg/kg 12 .
6.
.
, PaO2/FiO2 ,

.

52
12/10/07 1:00:11 PM

, /
(de-escalation therapy),
.

, , .
1.
2.
3.
Kollef MH. Appropriate empiric antimicrobial therapy of nosocomial pneumonia: The role of carbapenems. Respir Care, 2004;49:1530- 41.
Baughman RP. Nosocomial pneumonia: the gorilla in the ICU. J Intensive Care Med, 2003;
18:227-8.
American Thoracic Society. Guidelines for the Management of Adults with Hospital-acquired, ventilator associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005;388-416.
53
12/10/07 1:00:12 PM
.

(VAP)
1.
1.1.

ATS/IDSA (Am J Resp Crit Care Med, 2005;171:388-416) (VAP),
.
,
:
. ,
,

,
.
.
1.2. (Ventilator-associated pneumonia, VAP)
48 .
VAP: VAP 4 , .
VAP: VAP 5 , .
1.3. VAP
(9-27%), >50%
54
12/10/07 1:00:12 PM

(30-70%)
(33-50%) . ( 4 13 ).
VAP 4-10
.
1.4. VAP , ,
.
VAP.
.

. H
(
). , .
2.
2.1. VAP :
.
. :
>38C <36C
>12.000 <4.000
.
/
. ARDS
.
VAP.
2.2. VAP .
( ),
( - BAL, - PSB),
.
55
12/10/07 1:00:12 PM
5
.
72 .
.

.
BAL 120 ml ,
3-6 . ,

50%. .
1 ml
.
, BAL .
Gram Giemsa.
, .
/

VAP .
. .
.

VAP 106 , 104 BAL 103
PSB.
72
.

.
56
12/10/07 1:00:12 PM

2.3.
,
VAP .

3 , .
VAP.
Clinical Pulmonary Infection Score (CPIS) ( 1) 1
3 ,
Singh et al. (Am J Resp Crit Care Med, 2000;162:50511). CPIS 6 ,
.
CPIS (, , /
, ). ( ).
CPIS<6
VAP.
2.4. , ,
, .

,
. , .
, ,
.
57
12/10/07 1:00:12 PM
5
1. Clinical Pulmonary Infection Score (CPIS).
Clinical Pulmonary Infection Score (CPIS):
C
>36,5 <38,4
>38,5 <38,9
>39 <36
>4000 <11000
() <4000 >11000
>50%

>240 ARDS
,
<240 ARDS
PaO2/FiO2
( )

(
ARDS)
/ (103)
(104)
Gram
0
1
2
0
1
+ 1
0
1
2
0
2
0
1
2
0
2
0
1
+ 1
Singh et al., Am J Resp Crit Care Med, 2000;162:505-11.
2.
(WHONET) ( 2005).

.
/
.
Acinetobacter ( )
.
Klebsiella sp. Enterobacter sp.
.
S. aureus VAP (<2%)
.
ESBL .
Enterobacter sp. -.

Gram ( P. aeruginosa
).
MRSA (Methicillin Resistant Staphylococcus Aureus) VRE (Vancomycin Resistant
Enterococci).
58
12/10/07 1:00:12 PM

3. .

VAP ( 5 )
5

(>10 mg
>700 mg)

(healthcare-associated pneumonia).

2

(..
)
V (FEV1<30% predicted),
,
3.

(VAP).
3.1.
(, ) .
3.2. .
WHONET ( 2), , ,
.
3.3.

( 3).
59
12/10/07 1:00:12 PM
5
Pseudomonas aeruginosa. 2 .
3.4. VAP

.
1.
VAP
(4 )
Moraxella
Methicillin - sensitive S. aureus
:
(E. coli, K. pneumoniae, Enterobacter sp.
Proteus sp., Serratia marcescens)
VAP
(5 )
K. pneumoniae (ESBL+)
Acinetobacter sp.
Gram (-)
MRSA
3.5.
.

:
(..
),
.
(..
VAP).
3
Pseudomonas aeruginosa.
Gram
Gram .

.
.
60
12/10/07 1:00:12 PM

3.6. ,

. . .
. 4
VAP.
3.7. ,
,
3-5 .
3.8. (, )
.
3.9.
:
<9

.
, .
(MSSA), , .
3.10. VAP
.
:

.
(, ), /, /
,
.
3.11. Candida sp. VAP. ,
. Candida sp.

.
61
12/10/07 1:00:12 PM
5
4.
VAP.
IV
IV
IV
IV
IV
IV
2 g/12
2 g/8
2 g/8
2 g/8
2 g/8
1 g/8
IV
IV
IV
IV
IV
IV
IV
IV
2 g/8
750 mg /24
400 mg/24
400 mg/8
600 mg/12
15-20 mg/kg/24
7 mg/kg/24
7 mg/kg/24
3 g/6
2 mg/kg/24-48
2 mg/kg/24-48
2 mg/kg/24-48
3 g/8-12
IV
4,5 g/6
2,25-3,375 g/6
IV
1 g (15 mg/
kg)/12
10 mg/kg/ 24
600 mg/12
50 mg/12
3000000 IU/8
1 g/24-48
(methanesulphonate)
IV, IM
IV
IV
IV
500.0001000000/12
CRRT**
(CID 2005;41:1159-66)
2 g/12-24
2 g/12
2 g/12
2 g/12
2 g/12
250-500 mg/6
500 mg/8
1 g/12
250 mg/24
400 mg/24
200-400 mg/12
600 mg/12
2,5 mg/kg/48
(1 mg = 12500 IU)
* .
**Continuous Renal Replacement Therapy.
500 mg.
o 3 mg/kg,
10 mg/kg. (trough) <1
g/ml 4-5 g/ml.
(. . , .
. . )
, ,
.
15-20 g/ml.
15-20 mg/kg.
12.
100 mg.
70 (10 mg/kg/24 3 ) 1 mg = 12500 IU.
62
12/10/07 1:00:13 PM

Aspergillus sp. BAL, ,
.
3.12. [
WHONET ( 2) 2005].
2.
.
. VAP (early onset)
/ +
. VAP (late onset)

* /
**
* = , .
** 10
( 10
).
:
S. aureus .

MRSA.

.
3.13. :
.
72 (CPIS <6
).
8
P. aeruginosa.
63
12/10/07 1:00:13 PM
5
3. VAP.
(VAP)
BAL
48-72 (, ,
, , ,
, )
( )
CPIS
(-)
(+)
(-)
(+)

,
,

+

,
,

CPIS <6 (
1 )

(CPIS <6)
P. aeruginosa,

P. aeruginosa
, 14
64
12/10/07 1:00:13 PM

4.
VAP
4.1. VAP.
1. ,
( ) .
2. ,

.
3.
.
4.
.
5. .
6. >20 cm H2O.
7.
.
8. (
weaning).
9.
(..
).
10.
.
11. 30-45, .
12. .
13. stress
2 ( VAP
).
14.
65
12/10/07 1:00:13 PM
5
(.. 7 g Hb) .
15. 80-110 mg/dl ( , , ,
).
- 4.2.

VAP.

VAP, .
.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
American Thoracic Society. Guidelines for the Management of Adults with Hospital-acquired, ventilator associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med, 2005;388-416.
Chastre J. Conference summary: Ventilator-associated pneumoniae. Respir Care, 2005;50:975-83.
Luna CM., Aruj P., Niederman MS. et al. Appropriateness and delay to initiate therapy in ventilatorassociated pneumonia. Eur Respir J, 2006;27:158-64.
Kollef MH., Shorr A., Tabak YP. et al. Epidemiology and outcomes of health-care-associated pneumonia: Results from a large US database of culture-positive pneumonia. Chest, 2005;128:3854-62.
Singh N., Rogers P., Atwood CW. et al. Short-course empiric antibiotic therapy for patients with
pulmonary infiltrates in the intensive care unit: A proposed solution for indiscriminate antibiotic
prescription. Am J Resp Crit Care Med, 2000;162:505-11.
Trotman RL., Williamson JC., Shoemaker DM. Antibiotic Dosing in Critically Ill Adult Patients Receiving Continuous Renal Replacement Therapy. Clin Infect Dis, 2005;41:1159-66.
Blot S. MRSA pneumonia: Better outcome through continuous infusion of vancomycin? Crit Care
Med, 2005;22:2127-8.
Rello J., Sole-Violan J., Sa-borges M. et al. Pneumonia caused by oxacillin-resistant staphylococcus
aureus treated with glycopeptides. Crit Care Med, 2005;33:1983-7.
Paul M., Benuri-Silbiger I., Soares-Weiser K. et al. lactam monotherapy versus lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients: Systematic review and
meta-analysis of randomized trials. BMJ 2004;328:668.
Wunderink RG., Rello J., Cammarata SK. Linezolid vs vancomycin: Analysis of two double-blind
studies of patients with methicillin-resistant Staphylococcus aureus nosocomial pneumonia.
Chest 2003;124:1789.
Kollef MH., Rello J., Cammarata SK. et al. Clinical cure and survival in Gram-positive ventilator-associated pneumonia: Retrospective analysis of two double-blind studies comparing linezolid with
vancomycin. Intensive Care Med, 2004;30:388-94.
Ioanas M., Lode H. Linezolid in VAP by MRSA: a better choice? Intensive Care Med, 2004;30:343-6.
Nseir S., Di Pompeo C., Pronnier P. et al. Nosocomial tracheobronchitis in mechanically ventilated
patients: incidence, aetiology and outcome. Eur Respir J, 2002;20:1483-9.
Nouira S., Marghli S., Belghith M. et al. Once daily oral ofloxacin in chronic obstructive pulmonary
disease exacerbation requiring mechanical ventilation: a randomised placebo-controlled trial. Lancet, 2001;358:2020-5.
66
12/10/07 1:00:13 PM

: . .
: .
.
.
.
.
. .
.
.
.
12/10/07 1:00:13 PM
1.
,

, /
.
( )
3 .
,
, .
7 , 7 ,
. 30
.
72 .
2.
.
, , 744 1
5 .
3.

,
68
12/10/07 1:00:13 PM

(PCR),
. , , 2-40%.

Salmonella, Shigella, Campylobacter, Escherichia coli O157:H7 Clostridium
difficile, Caliciviruses (Norwalk-like and related viruses), Rotaviruses, Enteric
adenoviruses (Giardia, Cryptosporidium Entamoeba
Hystolytica).
CDC (Center for Diseases Control and Prevention) 2002,
13% (37,4 ) 100.000 : Salmonella 16,1, Campylobacter 13,4,
Shigella 10,3, E. coli O157:H7 1,7, Cryptosporidium 1,4, Vibrio, Yersinia, Listeria
Cyclospora <1.
,
1.
1. .
**
Campylobacter sp.
Salmonella sp.

Shigella sp.
Yersinia pseudotuberculosis
Aeromonas hydrophila
Plessiomonas sp.
Clostridium difficile ( in vivo)
E. coli ( )
(HEC, Shigella toxin producing-STEC, Verotoxin producing-VTEC,
E. coli O:157 H:7)
(C)
(EIEC)
(EPEC)
(enteroaggregative - EaggEC)

Vibrio cholerae
**
.
,
: Giardia lamblia
: Enterobius vermicularis ()
69
12/10/07 1:00:13 PM
6
4.
4.1.
,
, ( 2).
,
,
.
6 , Bacillus cereus . 6
24 , Clostridium perfringens
Bacillus cereus. , , 16
72 , . : 1) , 2)
, 3) (..
, , , ..),
4) ,
5)
, 6)
(.. , ,
..), 7) ,
(, , ),
8) [ (), , , -
], 9)
, 10) (
).
4.2.
, .
. (diagnostic yield) 1,5 5,6%.
,
,
.
.

70
12/10/07 1:00:13 PM

( ). :
24 .
,
, (, , ), , , /
,
, .
3 .
,
, , .
, ,
, , .
/ , ( 3
), ( 7 )
.
.
/
,
,
Salmonella, Shigella, Campylobacter.
Vidal
. (
) ,
Shiga , E. coli 157:H7.
(, , ), .
.
pseudotuberculosis.
71
12/10/07 1:00:14 PM
6
2. .
-
(>24 )

(,
, ),
,

: , ,
, , ..
: , , , ,

( ,
, )
:
24

salmonella,
shigella, campylobacter
E. coli 0157-7 (

)
clostridium difficile
(
,
, )
clostridium
difficile

salmonella, shigella,
campylobacter (
,
>65
, ,

)
E. coli 0157-7 (
)
: Giardia,
,
cyclospora,
isospora belli
:
,
Mycobacterium
avium, (MAC),
72
12/10/07 1:00:14 PM

3.
.
Campylobacter ,

Shigella
,

E. coli 0157:H7
Clostridium
difficile
,
Yersinia
,

,
,
Cyclospora
Giardia lamblia ,
,
IgA

,
, ,
,
Salmonella
73
12/10/07 1:00:14 PM
6
B.

, ,
Clostridium difficile, .
65 , , , ,
.
. ( 7 ,
)
( 7 ) / ,

/
, Clostridium difficile,
, Giardia lamblia ,
.

.
(
) ,
Cyclospora cayetanensis Isospora belli. ( CD4 50
) ,
, , cyclospora, isospora,
/ (Mycobacterium avium
complex-MAI) (CMV). , , .
, , . ,
, , , , , ,
Whipple, , ,
, , .
4.3.

4.
74
12/10/07 1:00:14 PM

4.
.
(, )
(, , , >48 ,
>50 , >70 , )

( )
Norwalk, Rotavirus, C. perfringens,

S. aureus, B. cereus, Giardia lamblia,
,
Campylobacter, Shigella, Salmonella,

Enterohemorrhagic E. coli, C. difficile

.
C. difficile

:

8

>1

75
12/10/07 1:00:14 PM
6
, , .
.
,
(, , , ).
. ,
shock , .
, 90 mM Na, 20 mM K, 80 mM Cl, 30 mM HCO3 111 mM
.
.
,
3,5 gr (NaCl), 2,5 gr (NaHCO3), 1,5 gr (KCl) 20 gr ,
1 lt.
per os , ,
.
, ,
.
, .

(, , , , ), ,
.
,
.
4.3.1.
,
. ,
. , ,
, C.
difficile - E. coli Shiga,
.
(-, ..)
.
76
12/10/07 1:00:14 PM

4.3.2.
Lactobacillus , , . , C. difficile.
.
4.3.3.
,
,
( Shiga),

,
.
4.3.4.

, , ,
, .
,
,
.
4.3.5.

.
,

.
4.3.6. ( 5)
:
1. : 2,5 .
.
.
2. Campylobacter sp.: ,

. ,
,
.
77
12/10/07 1:00:14 PM
6
Campylobacter sp. , .
3. :
, .
. , 65
, , , , AIDS, ,
, ,
E. coli O 157: H7. ,

hamburgers.
5.
.
Salmonella
per os
3-5
Shigella
per os
5
per os
5
TMP-SMX
per os
1-3
per os
5
per os
7-10
per os
TMP-SMX
TMP-SMX
TMP-SMX
Campylobacter
EHEC
ETEC
EIEC
Yersinia
V. parahaemolyticus
.
. TMP-SMX
.
( )
TMPSMX

.

78
12/10/07 1:00:14 PM

5
C. difficile
E. histolytica
Giardia lamblia

,
500 mg x 3 per 125 mg x 4 per . iv
os 10 os 10 per
os
IV

750 mg x 3
per os 10

( 650 mg
x 3 20
per os x 3 7 ).

250-750 mg x 3 2 gr ,
per os 7-10 HCL,
200-400 mg
per os x 2 3
TMP-SMX 2x2
per os 3-5
TMP-SMX 2x4
per os 10

1x2
3

Cyclospora
Isospora belli
S. aureus
B. cereus
,
,

.

HIV (+) CD4 >150 /L

AIDS

.
. TMP-SMX
.

79
12/10/07 1:00:15 PM
6
4.3.7.
, ,

(VRE). .
, ,
.
4.3.8.
.
.
Giardia, ,
.
4.4.
4.4.1.
1-2 gr (
, ).
,
( Stuart ).
,
.
2-3 . ,
.
4.4.2.
.
4.4.3.
,
1. H . ,
, .
, Salmonella, Sigella, E. coli , .
, ( rota-) .
80
12/10/07 1:00:15 PM

rota- (EPEC)
(enteroaggregative - EaggEC) ,
.
, ()

Clostridium dfficile.
4.4.4. ( )
:
C. difficile. .
Io Rota. .
VIDAL
.
4.4.5.

:
1. .

.
2. ,
.
:
1. Salmonella sp., Shigella sp. E. coli:
. : , , .
. , , anamycin,
, , , .
2. Campylobacter: , / , , , .
6.
5.
Salmonella, Shigella
E. coli (VTEC)
, /
/ ().
, - (
).
81
12/10/07 1:00:15 PM
6
6. .
S. enteritidis* S. typhymurium*
./.
% NS
3,3
1,3
0,4
0,7
0
0
0
0
0,2
1,5
0,8
2
1,2
0,2
20,2
0
% NS
22,9
12,4
1
1
0
0
3,1
0
21,8
89,6
8,3
12,9
45,8
16,7
0
13,5
0
Shigella** Campylobacter**
*
% NS
3,5
2,1
0
2,1
0
0
1,4
0,7
7
75,7
3,5
4,2
14,6
6,9
0
12,5
0,7
% NS
%NS
52,9
2,5
83,2
54,6
50,4
47,1
31,1
% NS
35,4
3,5
5,2
31,3
31,3
* www.mednet.gr/whonet.
** /.
*** : .
1.
2.
3.
4.
5.
6.
7.
8.
Cheng
AC
., McDonald
JR
., Thielman
NM
. Infectious
diarrhea in developed and developing countries. J Clin Gastroenterol, 2005;39:757-73.

OMGE Practice Guideline: Acute diarrhea in adults. 2005 http://www.omge.org/guides/g_data1_
en.htm.
Pardi DS. Gastrointestinal infections. In: Haser SC, Pardi DS, Poterucha JJ (eds): Mayo Clinic Gastroenterology and Hepatology Board Review. Mayo Clinic Scientific Press, CRC Press, 2004:129-37.
Thielman NM., Guerrant RL. Acute infectious diarrhea. N Eng J Med, 2004;350:38-47.
Graman PS., Betts RF. Gastrointestinal and abdominal infections. In: Betts RF., Chapman SW., Penn
RL. (eds): Reese and Betts: A Practical Approach to Infectious Diseases. Fifth edition. Lippincott
Williams & Wilkins, 2003:403-76.
Surawicz CM, Lee SD. Infectious causes of chronic diarrhea. Gastroenterol Clin North Am,
2001;30:679-92.
DuPont HL. Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee
of the American College of Gastroenterology. Am J Gastroenterol, 1997;92:1962-75.
Avery ME., Snyder JD. Oral therapy for acute diarrhea. N Eng J Med, 1990;323:891-4.
82
12/10/07 1:00:15 PM

: .
:
.
.
.
.
. o
.
.
.
.
.
.
12/10/07 1:00:15 PM

.
,

(IDSA), (EAU)
(ESCMID), .
1.

, , .
, .

,
.

, 1-2% .
(recurrent infection) ,
, 6-8

.
E (reinfection)
,
84
12/10/07 1:00:15 PM

.
1.
1.
.
1.

,
, ,
,

4

10 /ml

2.
3.

-
-
, ,
,

1
2

103 /ml

10 /ml

104 /ml

10 /ml
105 /ml ,

104 /ml ,

85
12/10/07 1:00:15 PM
7
2.
,
.
, (.. Escherichia coli ). ,
,
.
1-2% .
100% 3-4 .

, Staphylococcus aureus,
Candida, Salmonella, ,
.
, ,
75% 95%
. , , ,
,
, .
2 Escherichia coli
,
, .
3.

,
6,1 , 2,4 , 1,2 0,5 .
,
,

.
86
12/10/07 1:00:15 PM

2. . coli
(WHONET Greece, 2005).

A
A/
/
/
/
T/
34,8
9,9
*
11,5
7,5
2,7
2,2
1,4
1,1
1,1
12,0
3,0
0,2
0,3
8,9
6,9
6,4
28,0
22,3
* A/ .
3.

.
625 mg tid/1 g bid

250 mg bid
500 mg od
250 mg od
200 mg bid
400 mg bid
50-100 mg qid
160/800 mg bid
()
5
3
3
3
3
3
7
3-5
qid: , tid: , bid: , od:

, R: .
87
12/10/07 1:00:16 PM
7

,

.
,
:
. ,
. Chlamydia trachomatis, eisseria gonorrhoeae
,
. Candida sp. Trichomonas vaginalis.

,

.
3.

,
.

24
. 3 (, , , ). - (.. , ), ,
7 .
1-2 ,
.
4.

10-20% .
, , . , .
( 3 6), 88
12/10/07 1:00:16 PM

, .

50 mg/24 240 mg/24. 6 1 ,
50-60%.

250 mg/ 200 mg/ 125-250
mg/ 100 mg/ ( ).
, o 50 mg, 240 mg . ,
, ,
.
5.
, 4% 7% 20% 40%
.
9 17

.
,
, 7 . 1 2

15.
, , / - (/, / ).
, -.
,
89
12/10/07 1:00:16 PM
7
, 5-7
.

125-250 mg
G6PD, 50 mg
. . ,
.
6.
,
, 1-2%
Gram .
, , , ,
, .
18,7% , .
, C- , , , 10% .
, Escherichia coli
(.. Klebsiella sp., Proteus sp.).
Proteus sp. nterococcus sp.
. ,
,
Gram ,
(.. Pseudomonas
aeruginosa).

, , .*

1.
* ,

90
12/10/07 1:00:16 PM

,
,
. ,
, ,
72 .
1.
.
-

- /
- A/
- 2
+/- A

- A* *

(72 ),

- 3
- 4
- /
- /
- ,
+/- A

- A* *

7-10 . T

, ,

. , , ,

.
91
12/10/07 1:00:16 PM
7
, , , , , , ()
, 7-10
.
7.
, (105 cfu/ml) .
,

( 4 ).
4.
(CID, 2005;40:643-54).

50-70

-
-
70
-
-

-
-

-
-
1-5
1,9-9,5
2,8-8,6
9,0-27
0,7-11
10,8-16
3,6-19
25-50
15-40
23-89
28
9-23
100
.
,
92
12/10/07 1:00:16 PM

100% 3-4 .
Escherichia coli, Klebsiella, Proteus, Enterococcus, Enterobacter, Pseudomonas,
Serratia Candida.
.

. , , 24 105 cfu/ml . ,
105 cfu/ml .

, , ,
.
, , ,
.

,
..
. ,
,
,

. ,
, ,
.

, .
:
.
.
. , . ,
48
5-7 .
, .
93
12/10/07 1:00:16 PM
7
,

5.
5.
.
1. .
2. (
,
).
3. .
4.
.
5.
.
6. (
).
8.
Candida .
, .
, Candida sp.,
.
Candida albicans 50% . Candida glabrata 25%
, Candida tropicalis.
5% Candida.
.
.
, 2-4 % .
.
(fungus ball) .
,
( 2).
94
12/10/07 1:00:16 PM

6 7.
2. .
(+)
(-)
1. Candida sp.
2. U/S CT

1. ,

2.

1.
2.
(+)
/

* ,
, , , ,
, (, ).
9.

,
. ,
, o Reiter,
Behcet Wegener. 8
.
95
12/10/07 1:00:16 PM
7
6. .
1. A

2.

3.
. 7-14
4.

7. .
400 mg
800 mg
7-14
A B 0,3-1,0 mg/kg
10.
1-7
,
3 . National
lnstitute of Diabetes, Digestive and dney Diseases (NIDDK)/National
Institutes of Health () ( 9).
. ,

( 10, 11, 3).
,
.
96
12/10/07 1:00:17 PM

, , - .
(, , ) 30 .
8. .
eisseria
gonorrhoeae
400 mg
p.o.
Gram

250 mg
im
500
mg p.o.
O 400 mg
p.o.
Chlamydia
trachomatis
Trichomonas
vaginalis
Mycoplasma
genitalium
Ureaplasma
urealyticum
:
1 g
p.o. 100
mg p.o. x 2/24
7 .
:
500
mg p.o. x 4/24
500
mg x 2/24
7 .
200mg p.o.
x 2/24 7
2 g p.o.
500 mg x 4/24
500 mg x 2/24
7
97
12/10/07 1:00:17 PM
7
:
Mycoplasma hominis .
To Ureaplasma urealyticum .
H .

/ .
9.
NIDDK/NIH.
1. :
()
2. :
()
3.
. (Mycoplasma, Ureaplasma,
Chlamydia)
, /
. ()
/ /
4. ( )

/.

. , 4-6
( 12).

.
C. trachomatis (.. , ).
. C. trachomatis, 200 mg/ 2
. , , .
C. trachomatis,
.
98
12/10/07 1:00:17 PM

10. .

, ..

/ 46%
/ 39%
6%
6%
2%
11. .

-

, ,
Stamey-Mears ( 3)

, .. -
12. .
960 mg x 2 p.o.
100 mg x 2 x 2
750 mg-1g
x 2 p.o.
500 mg x 2 x 2
(200 mg x 2)
(750 mg x 1)
4-6
. ( ) 2
.
99
12/10/07 1:00:17 PM
7
3. Stamey-Mears.
VB1 VB2 EPS VB3
(VB1)
(VB2)
(EPS) (VB3) ( )
: EPS / VB3>VB2
1 log (
).
1.
Bjerklund Johansen TE., Griineberg RN., Guibert J., Hofstetter A., Lobel B., Naber KG., Palou-Redorta
J., van Cangh PJ. The role of antibiotics in the treatment of chronic prostatitis: consensus statement. EurUrol, 1998;34:457-66.
2. Center for Disease Control and Prevention. 1998 Guidelines for treatment of sexually transmitted
diseases. Morb Mortal Wkly Rep, 1998;47:1-111.
3. Fihn SD. Acute uncomplicated urinary tract infection in women. N Engl J Med, 2003;349:259-66.
4. Kunin CM. The concept of significant bacteriuria. In: Detection, Prevention and Management of
UTIs, 4th edition. Lea & Febiger: Philadelphia, 1994.
5. Lundstrom T., Sobel J. Nosocomial candiduria: review. Clin Infect Dis, 2001;32:1602-7.
6. Naber KG. Experience with the new guidelines on evaluation of new anti-infective drugs for the
treatment of UTIs. Int J Antimicrob Agents, 1999;11:189-96.
7. Nicolle LE. A practical guide to the management of complicated UTI. Drugs, 1997;53:583-92.
8. Nicolle LE., Bradley S., Colgan R., Rice J., Schaeffer A., Hooton TM. Infectious Diseases Society of
America Guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin
Infect Dis, 2005;40:643-54.
9. Stamm WE. Scientific and clinical challenges in the management of urinary tract infections. T Am
J Med, 2002;113:1S-4S.
10. Wagenlehner FM., Naber KG. Fluoroquinolone antimicrobial agents in the treatment of prostatitis
and recurrent urinary tract infections in men. Curr Infect Dis Rep, 2005;7:9-16.
11. Warren JW., Abrutyn E., Hebel JR., Johnson JR., Schaeffer AJ., Stamm WE. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women
(IDSA). Clin Infect Dis, 1999;29:745-58.
100
12/10/07 1:00:17 PM

: .
: .
.
.
.
.
.
.
.
.
.
.
.
.
12/10/07 1:00:17 PM
.
1.
(Foley)

.
.
,
.
2. ()
-
: ,
.
2.1.
. .
. .
(.. 2 g ).
. .
( ).
.
( ).
.
3.

(), .
102
12/10/07 1:00:17 PM

.
3.1. 2-3
. preterm or
prelabor rupture of fetal membranes (pPROM): IV/p.o. + -
7 (IV/p.o.).
3.2. -
- ( )
-
()
1. 3 (+/- ) +
2.
3. -/
4.

.
7-10 .
3.3. -
- (
)
- /
- : 10-15 .
3.4.
400 mg p.o. x 2 500 mg x 1 + 500 mg x 2 p.o. 14 .
3.5.
,
.
/.
3.6.
- ( 1 2
-/)
-
MRSA
.
3.7.
(non-puerperal mastitis)
.
103
12/10/07 1:00:17 PM
8
4.
FDA:
A: : .
B: : , : : .
C: : , :
> .
D: .
X: , > .
.
: - (-
-, , , , , , , , ).
KATH C: , , , , , .
D: , .
. -/
: , , ( )
, , .
C: , ,
, (INH/RIF/PZA/EMB).
: , , , ().
5.
: (), , . ,
(HIV, HBV, HCV) test .
: 125 mg IM SD ( ) + 2000 mg SD + 1 g p.o. SD.
HBV, HIV.
.
(GU) (NGU)
( !) .
30-40% NGU Chlamydia trachomatis. (HSV) Trichomonas vaginalis. ,
Ureaplasma urealyticum.
104
12/10/07 1:00:17 PM

: Gram
. >5 /1000x .
(-
Gram- ).
- : , , -, Reiter (-).
1. .

NSU, ,
HSV, Candida
C. trachomatis, N. gonorrhoeae, HSV, - - .

: (
) 102 E. coli/ml .
.
STD ( , >1
).
1.
125 mg IM 500 mg
p.o. 400 mg p.o. , 250 mg
.
:
100 mg x 2 x 7 1 g p.o. .
.
105
12/10/07 1:00:18 PM
8
2.
100 mg x 2 x 7 1 g .
, 500 mg x 4 x 7 300 mg
x 2 x 7 500 mg x 1 x 7 .
.
3.
2,0 g + 500 mg x 4 x 7 .
4.
125 mg IM ( ) 500 mg
p.o. SD 400 mg p.o. SD, 250 mg ,
2 g IM SD, [ PPNG*<4%] 3
g p.o. SD + (Benemid) 500 mg p.o. SD. (*PPNG: PenicillinaseProducing Neisseria gonorrheae)
:
100 mg x 2 x 7 1 g p.o. SD.
.
5.
100 mg x 2 x 7 1000 mg .
, 500 mg x 4 x 7 300 mg
x 2 x 7 500 mg x 1 x 7 .
.
6.

(Bacterial vaginosis)
, pH>4,5.
500 mg x 2 x 7 . , x 7 .
.
7.
, , pH<4,5.
p.o.: 150 mg 200 mg x 2 x
1 . , ( 1-14 )
14 .
106
12/10/07 1:00:18 PM

8.
, pH>4,5.
2000 mg 500 mg x 2 x 7 . ,
2,0 g .
2000 mg .

.
: , Staphylococcus epidermidis,
Gardnerella vaginalis, , , Bacteroides sp., ( ), Escherichia coli, Proteus sp., Eubacterium
sp., Veillonella sp., Fusobacterium, Clostridium sp., Candida sp., Torulopsis sp.
Gram , Staphylococcus aureus, Streptococcus
agalactiae, ( ).
V.
1.
MA (Haemophilus ducreyi)
: A 1 g p.o.
250 mg im 500 mg x 2 p.o. 3 500 mg x 3 p.o. 7 .
: , 3-7 ,
.
: 10
.
HIV-: . , .
2.

(Calymmatobacterium granulomatis)
: 100 mg x 2 p.o. 21
/ (800/160 mg) x 2 p.o. 21 .
, 750 mg x 2 p.o. 21 500 mg x 4 p.o. 21 1 g p.o. 3 .
: , .
: 60
.
HIV-: .
107
12/10/07 1:00:18 PM
8
3.

(Chlamydia trachomatis, serovars L1, L2, L3)
: 100 mg x 2 p.o. x 21 .
, 500 mg x 4 p.o. 21 1 g
p.o. 3 .
: , .
: 30
.
HIV-: .
4.
MH
: 1 g p.o.
100 mg x 2 p.o. x 7 .
, 500 mg x 4 p.o. x 7 300
mg x 2 p.o. x 7 500 mg x 1 p.o. x 7 .
: 60
.
:
, 2 g p.o.
+ 500 mg x 4 p.o. x 7 .
5.
(Neisseria gonorrhoeae)
:
, , .
5.1. , ,
. . , .
5.2.
: 125-250 mg im 500 mg p.o. .
, ,
1 g p.o. 100 mg x 2 p.o. x
7 .
: 10
( 60 ).
HIV-: .
108
12/10/07 1:00:18 PM

5.3.
: 1-2 g x 2 iv x 10-14 .
5.4.
: 1-2 g x 2 iv 4
.
6.
(Syphilis, Treponema pallidum)
6.1.
(, ,
)
: G 2.400.000
im ( : iv Solucortef 250
mg Jarish-Herxheimer).
( ), 100 mg x 2 x 14
1 g x 1 (im iv) x 10 .
: 6 12
( : VDRL 4 ).
: , 90
. , ( ) 90
.
HIV-: . 3, 6, 9, 12 24
. HIV .
6.2.
, , (, )
: G 2.400.000
im , 3 .
( ), 100 mg x 2 x 28
.
: 6, 12 24 . ( : VDRL >1/32,
4 . VDRL <1/32,
).
: , ,
.
HIV-: . HIV
.
109
12/10/07 1:00:18 PM
8
6.3.
: 18-24.000.000 , iv 4 (3-4.000.000 x 6 iv)
10 .
, 2 g x 1 (im iv) 10-14 .
: 6 . :
6 , VDRL
2 .
HIV-:
7.
(Sarcocoptes scabiei)
: Benzyl benzoate 25% .

, Sulfur precipitate 5-6% .
: 30
.
.
: . Benzyl benzoate
.
HIV-: .
8.
(Phthirus pubis)
: Benzyl benzoate 25% (emulsion)

malathion (lotion+shampoo) permethrin + malathion + piperonyl
butoxide (spray) phenothrin (lotion, shampoo, gel) .
, Sulfur precipitate 5-6% .
: 10
. .
: . Benzyl benzoate
.
HIV-: .
9.
9.1. -
5 .
- .
.
.
110
12/10/07 1:00:18 PM

p.o. 200 mg x 5 x 10 , p.. 250 mg x 3
500 mg x 2 10 , p.o. 500 mg x 2 x 10
.
iv 10 mg/kg
8.

.

.
:
-
-
-
.
9.2. ()
24 .
.
p.o. 200 mg x 5 x 5 , p.o. 125 mg x 2 x
5 , p.o. 500 mg x 2 5 .
. .
9.3.
p.o. 200 mg x 4 400 mg x 2
p.o. 250 mg x 2
p.o. 500 mg x 1.
: 6-12 , .
9.4. ()

-.

.
111
12/10/07 1:00:18 PM
8
V.

(Human Papillomavirus, HPV)
1.
(Human
Papillomavirus, HPV) (99,7%). HPV,
, 15 40 . 2/3 HPV 16 (51%)
18 (16,2%). HPV
.
HPV
( , , cervical intraepithelial neoplasia CIN1/2/3).
HPV
. HPV
( ),
.
HPV , .
2.
HPV (HPV DNA TESTING)
HPV . HPV .
(low-grade
intraepithelial lesions, LSIL) , .
HPV . HPV (HPV DNA testing PCR )

.
, , . , HPV
DNA , , ,
.
HPV ,

112
12/10/07 1:00:18 PM

~1:1000.
HPV DNA ~99100%. ,
HPV DN,
3 ( ,
).
3.
HPV
HPV DNA testing

1.
ASC-US
2.

HPV
DNA
test
4.

HSIL
3. screening
30 ( )
: HPV (<24
), .
HPV .
4.
HPV
, .
5.
HPV

1) HPV 16, 2) HPV 16 18 3) 6,
11, 16 18. 3 (0,
1 3 ). .
HPV
CIN>97%. .
. .
.
,
.
113
12/10/07 1:00:18 PM
8

ASC
ASCU
ASC-H
LSI
HSI
6 12
HPV DNA test

:
ASC
HPV DNA test,
ASC-H, LSIL
6 12
PV DNA test 12
HPV
DNA
:
ASC, LSIL, HSIL
CIN-I
LSIL
HSIL
laser,
loop

:
) 6
2 PV DNA test
6
)
12
: CIN2/3. ( )
. , ,
6-12 .

ASC (Atypical squamous cells): .
ASC-H (Atypical squamous cells cannot exclude):
.
ASCU (Atypical squamous cells of undetermined significance):
.
CIN1 (Cervical intraepithelial neoplasia 1):
.
.
114
12/10/07 1:00:19 PM

in situ.
HSIL (High grade squamous intraepithelial lesions):
.
LSIL (Low grade squamous intraepithelial lesions):
.
.:
Bethesda.
1.
2.
3.
Kimberlin DW.et al. Genital herpes N Engl J Med,2004;350:1970-77.

ACOG, HPV. Obstet Gynecol, 2005;105:905-18.
STD treatment guidelines. MMWR, 2006;55:1-96.
115
12/10/07 1:00:19 PM
12/10/07 1:00:19 PM

: .
: .
.
.
.
.
.
. .
.
.
.
.
12/10/07 1:00:19 PM
I.
1.
.
.
. ,
.
,
.. .

.
.
2.

. ,
1978 1981, 3 100.000 . 1995, , Haemophilus influenzae
( 2,9 100.000 0,2 100.000
).
, 15
. , ,

.
,

.
118
12/10/07 1:00:19 PM

1,2
, 135.000 .
.
, -
2005, 641 , 98 , 3 , 69 .
H. influenzae

. 3%-6%
.
(, , , , , , , ,
).
. meningitidis

3%-13%.
.
, (clusters)
C.
,
( 1 2).
1.
1997
1998
1999
2000
2001
2002
2003
2004
2005
. meningitidis
225
393
640
855
1429
702
518
544
641
147
262
215
261
234
233
131
89
98
Streptococcus
H. influenzae
pneumoniae
8
26
37
51
53
50
53
71
69
1
5
2
6
5
4
6
8
3
1
38
124
131
125
80
102
146
185
68
62
262
406
984
276
188
199
232
, (67,5%
2004) C ( 2).
119
12/10/07 1:00:19 PM
9
2. N.
meningitidis.
.
2002
2003
2004
2005
No (%)
174
101
63
80
W-135
No (%)
75 (43,1)
53 (52,5)
43 (68,2)
54 (67,5)
No (%)
11 (6,3)
2 (2,0)
0 (0)
3 (3,8)
No (%)
19 (10,9)
17 (16,8)
3 (4,8)
4 (5,0)
No (%)
20 (11,5)
6 (5,9)
0 (0)
2 (2,5)
No (%)
49 (28,1)
23 (22,8)
17 (27,0)
17 (21,2)

:
) ().
) .
) (C5, C6, C7, C8, C9).
) . 36%
6% .

(47% ), 19%-26%.
, 1999-2005, 373
, 194 (52%) :
<1-4 26,5% (99/373)
>60 25,5% (95/373). 179 .
, ,
, , , , .
.
,
.
Listeria monocytogenes
8% ,
15%-29% . <1
(11%) >60 . , , , ,
, ,
, .
120
12/10/07 1:00:19 PM

, ,
.
Streptococcus agalactiae
52%
. 7%27% .
.

.
Listeria monocytogenes.
Gram (+)
,
.

(35%). , ,
, . 14% 77%.

shunt.
. Treponema pallidum
, 5%-9% .
4 :
1. ( ) 0,3%-2,4%
.
2. (11%-12%)
.
3. ,
10-20 .
4. , .
. Borrelia burgdorferi
T 11%-15%
Lyme.
121
12/10/07 1:00:19 PM
9
(Shunt)
, -, -,
- .

.
2,7% >60 .
<6 16,5%.
,
.

shunt
(5,5% 1,1%).
3.

() , . (, , ,
), .
,
. .
1. ()
,
. (<2%)
,
. ,
,
C/T :

( HIV )
( )

.
122
12/10/07 1:00:19 PM

2.

, :
i. (.. 200-500 mm H2O):
, .
ii. : , , , / .
iii. :
1000-5000 WBC/mm3 ( : <100
>10.000). (80-90%),
~10% .
iv. : <40 mg/dL,
/ ( : 0,4
0,6 ).
v. :
.
. , ~70-80%.
, , :
i. Gram : ~60-90% 97%. (25%
<103 CFUs/mL/97% >105 CFUs/mL). (90%), (75%)
(50%).
ii. (
Latex, ..): 78100% b, 67-100%
, 50-93% .
gram .
iii. PCR: . , (broad-based PCR).
3. -
gram ,
,
. , CRP
(PCT) .
123
12/10/07 1:00:19 PM
9
4.
4.1.

,
,
.
(.. ),
. ,
,
(.. 2 gr )
,
C
/
T
. , , .
4.2.
gram , ,
,
,
, . (/), .
,
( )
.
>50 Listeria
monocytogenes. H
. 3.
4.3.
: . gram .
, . 4.
5.
4.4.
10 mg 0,15 mg/kg 6 4

124
12/10/07 1:00:20 PM

.

.
.
, .
4.5. /
24 . ( ) . meningitides

gram
. .
3.
( = ).
<1
S. agalactiae, E. coli,
L. monocytogenes,
Klebsiella sp.
+ +
1-23
S. pneumoniae,
+
N. meningitidis, S. agalactiae,
H. influenzae, E. coli
2-50
N. meningitidis,
S. pneumoniae
S. pneumoniae,
N. meningitidis,
L. monocytogenes,
gram (-)
>50
+
+ +
*
* .
125
12/10/07 1:00:20 PM
/
, ,
/

, , ,
, ,
G/

+
+
G/

/ G
/ G
+
+
N. meningitidis
: MIC<0,1
C0,1
L. monocytogenes
S. agalactiae
E (. coli ..)
P. aeruginosa
H. influenzae
- (-)
- (+)
S. aureus
SSA
MRSA
S. epidermidis
Enterococcus sp.

, , ,
, ,
/
/
()
()
S. pneumoniae
: MIC<0,1
C: 0,1-2,0
MIC2,0
: MIC1,0
4. ( = ).
126
12/10/07 1:00:20 PM

5.
.
300 mg/kg
60 mg/kg
150 mg/kg
225-300 mg/kg
150 mg/kg
80-100 mg/kg
120 mg/kg
200 mg/kg
0,3 mU/kg
10-20 mg/kg
12 g
60 mg/kg ()*
6g
8-12 g
6g
4g
6g
9-12 g
24 mU
600 mg
* 15 mg/kg ().
()
1.
() Gram ().
2.
Gram , 1 /1.000 /
().
:
:
:

:
:
:
11-27/100.000
5.202 85.143.562
/ , 85.000
300
(, , )
, -
, -
, ,
, , , ,
127
12/10/07 1:00:20 PM
()
,
, .

11-12%.
6.
6. .
Mollaret
1 2,
, echo, coxsackie A, B
, , ,
Epstein-Barr, , HIV influenza,
parainfluenza, HTLV-1
Cryptococcus neoformans, Borrelia
Burgdorferi, Whipple, ,
, ,
, ,

,

, , ,
, ,
, ,
3 ,
,
(FMF),

(), ,
,
, ,
Vogt-Kyanagi-Harada,
-Behcet

, IgG
3
Ferreol-Besnier,

(HaNDL)
128
12/10/07 1:00:20 PM

7. .
(.. ),
.

: , Lyme,
,

( ,
, )

(, , )

Mollaret
3.
:
-
-
-
-
*
*
* .
8.
129
12/10/07 1:00:20 PM
9
8. .
, , ,
, ,
OKT3, IVIG,
, ,
, , ,
, ,
, ,

(FMF),
Behcet

,
/
Borrelia Burgdoferi (
Lyme)
Ferreol-Besnier
Behcet
, Behcet
, Behcet
130
12/10/07 1:00:20 PM
Behcet

, FMF
-

*

(.. , ,
)

,

Lyme,

/,

(..
AVM)
Mollaret ,
Gram, AF

PCR

/TB

HSV, EBV, ,
Borrelia Burgdorferi, TB
HSV, EBY, Borrelia Burgdorferi
VDRL
: , , AF,
ACE
131
12/10/07 1:00:20 PM
9
8
:

()
IgG3 :

C3b/C4b

()
Borrelia, (VDRL/FTAAb),
HSV, EBV, HIV
TBC
ANA, RF
ACE -

PCR

PPD

MRI

, ..

CT

(RICA)
Face/
Profile

4.
, TBC
FMF,
(V)
(HSV)

Pleconaril 5 mg/kg p.o. x 3 7
15
PCR HSV DNA
p.o. , Valacyclovin,
Famcyclovir
132
12/10/07 1:00:20 PM
(HHV6)
HHV7

, Cidofovir

Arbo

(, ,
)
30 mg/kg/ 7-14
(VZV)
(,
)
Epstein-Barr

(EBV)

5 mg/kg/2
(CMV)
90 mg/kg/2
14-21
Borrelia Burgdorferi
2 g 2 14-28
G 5-6 . 6 p.o.
200 mg/
AM Whipple p.o. 1 x 2
p.o. 250 mg x 4
2 g x 2
(FMF)

(, ,
cyclophosphamide)
,
. ( 9).
133
12/10/07 1:00:21 PM
9
, PCR
.
. ,
.
1.
.
9. .
- (echo, polio, coxsackie)
- Arbo , (WNV), LaCrosse (LAC)

- ( 2)
-
- , Epstein-Barr,
-
-
- HIV
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Ali ., Safriel ., Sohi J., Llave ., Weathers S. West Nile virus infection: MR imaging fndings in the
nerous system. AJNR Am J Neuroradiol, 2005;26:289-97.
DeBiasi RL., Tyler KI. Recurrent aseptic meningitis In: L.E. Davis and P.G.E. Kennedy Infections Diseases of the Nervous System. Butterworth-Heinemann, 2000;444-79.
2005
( ).
Fishman RA. Cerebrospinal fluid in diseases of the nervous system. Philadelphia: Saunders, 1992.
Ginsberg I. Difficult and Recurrent Meningitis. J Neural Neurosurg Psych, 2004:75(Suppl):116-21.
Hasbun R., Abrahams J., Jekel J. et al. Computed tomography of the head before lumbar puncture
in adults with suspected meningitis. N Engl J Med, 2001;345:1727-33.
Procop GW, Yen-Lieberman ., Prayson RA., Gordon SM. Mollaret-like cells in patients with West
Nile virus infection. Emerg Infect Dis, 2004;10:753-4.
Scott, T.F. (1993). Neurosarcoidosis: Progress and clinical aspects. Neurology, 43:8-12.
Sekul, E.A., Cupler, E.J. and Dalakas, M.C. (1994). Aseptic meningitis associated with high-dose intravenous immunoglobulin therapy: frequency and risk factors. Ann Intern Med. 121:259-62.
Tunkel AR., Hartman BJ., Kaplan SL. et al. Practice guidelines for the management of bacterial meningitis. CID, 2004;39:1267-84.
Van Crevel H., Hijdra A., De Gans J. Lumbar puncture and the risk of herniation: When should we
first perform CT? J Neurol, 2002;249:129-37.
Van der Beek D., De Gans J., Tunkel AR., et al. Community-acquired bacterial meningitis in adults. N
Engl J Med, 2006;354:44-53.
Van der Beek D., De Gans J., McIntyre P. et al. Steroids in adults with bacterial meningitis: A systematic review. Lancet Infect Dis, 2004;4:139-43.
134
12/10/07 1:00:21 PM
10

: .
: .
.
.
.
.
.
.
.
.
.
.
.
.
12/10/07 1:00:21 PM
10
1.
() .
( ) (
). ,
,
. , : )
, ) , ,
) , , .
2.
, ,
. . , ,
.
, ,

.
136
12/10/07 1:00:21 PM

3.
3.1.
3-12.
3.2.

1. ().
2. ().
:
) : 60 ( 1 ). .
) : 2-12 .
) : 12 . .
3.
4. .
4.
4.1.

1.
1. .
:

.
/ / (.. ).
.
( 13).
.
.

.
(Osler Janeway) / , ,
( Roth) .
, (
).
(, , ) .

.
.
, , .
137
12/10/07 1:00:21 PM
10
4.2. Duke

Duke ( 2).
2. Duke .

1)
)
, .
, Streptococcus bovis, HACEK,
Staphylococcus aureus (
, )
) ,
:
12 , ,
(
)
) Coxiella burnetii
Q ( IgG I Coxiella burnetii >1:800)
2)
) .

) , :
,
, ,
.

1. .
2. 38,0C.
3. : , ,
, , ,
Janeway.
4. : , Osler, Roth,
.
5. : (
)

.
, :
138
12/10/07 1:00:21 PM

1)
)
()

,
() ,

.
)
2
1 3
5 .
2) ( )
1 1
3 .
3) E
) .
)
,
)
,
.
) .
Duke
.
4.3.

( - transthoracic
echocardiography). ( transesophageal echocardiography) :
) ( ).
) ,
.
) .
) .
)
) .
, .
139
12/10/07 1:00:21 PM
10
.
: ) ,
, )
(shunt, fistula) ) , .

, , , ,
.
4.4.
. ,
. ,
. 1-5 ml ,
10 ml
ml
. , 10
,

1/5 1/10. .
.
.
( , )
.
, ,
. , ,
,
.

. 24 ,
. , 48 ,
140
12/10/07 1:00:21 PM

, .
Coxiella burnetti, Clamydiae sp., Bartonella sp.,
.
HACEK (Haemophilus parainfluenzae,
Haemophilus aphrophilus, Haemophilus paraphrophilus, Haemophilus
influenzae, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis,
Eikenella corrodens, Kingella kingae, Kingella denitrificans)
.
4.5.

. HACEK, Propionobacterium sp., Neisseria sp., Brucella,
Abiotrophia, Campylobacter ,
(>6 ) .
,
, ,
. (PCR)

.
5.
:
1. ( ) .
2. (4-6 ).
3. .
4. in vitro in
vivo .
5. MIC
6. .
5.1.

3-12.
141
12/10/07 1:00:21 PM
10
3.
(viridans group streptococci).
(MIC0,12 mg/L)
<65 ,
,

Abiotrophia, Gemella
Granulicatella
G: 12-18x106
iu/24, IV, 6
, 2

: 1 mg/kg 8, IV,
2
: 2 g/24, IV ,
2

: 1 mg/kg 8, IV,
2
>65
/
<30 mL/min
G: 12-20x106
iu/24, IV, 4-6
, 4
( ),
: 2 g/24, IV ,
4
: 15 mg/kg, 12, IV,

4
(MIC>0,12 mg/L 0,5 mg/L)

( S. bovis)
G: 24x106
iu/24, IV, 4-6
, 4

: 1 mg/kg 8, IV,
2
: 2 g/24, IV ,
4

: 1 mg/kg 8, IV,
2
: 15 mg/kg, 12, IV,
4
(MIC>0,5 mg/L)*
( 5)
* (HLR) (MIC>8 mg/L) HLR
(MIC>500 mg/L) (MIC>4 mg/L)
. test .
142
12/10/07 1:00:21 PM

4.
Streptococcus bovis.
(MIC0,12 mg/L)
(
<30 mL/
min,
)
G: 24x106
iu/24, IV, 4-6
, 6

: 1 mg/kg 8, IV,
2
: 2 g/24, IV ,
6

: 1 mg/kg 8, IV,
2
: 15 mg/kg, 12, IV,
6
M (MIC>0,12 mg/L 0,5 mg/L)

G: 24x106
iu/24, IV, 4-6
, 6

: 1 mg/kg 8, IV,
6
: 2 g/24, IV ,
6

: 1 mg/kg 8, IV,
6
: 15 mg/kg, 12, IV,
6
(MIC>0,5 mg/L)
( 5)
143
12/10/07 1:00:22 PM
10
5.
.
(MIC<8 mg/L),
(MIC<500 mg/L)

G: 18-30x106 iu/24, IV,

6 , 4-6 *

: 1 mg/kg 8, IV, 4-6 *
: 2 g 4, IV, 4-6 *

: 1 mg/kg 8, IV, 4-6 *
*6 >3

: 15 mg/kg, 12, IV, 6

: 1 mg/kg 8, IV, 6
,
, (MIC>500 mg/L)

G: 18-30x106 iu/24, IV,

6 , 4-6 *

: 7,5mg/kg, 12, IV ,
4-6 *
: 2 g 4, IV, 4-6 *

: 7,5 mg/kg, 12, IV ,
4-6
*6 >3

: 15 mg/kg, 12, IV, 6

: 7,5 mg/kg, 12, IV ,
4-6
(MIC>8 mg/L)

-: 3 g, 6, IV,
6

: 1 mg/kg 8, IV, 6
: 15 mg/kg, 12, IV, 6

: 1 mg/kg 8, IV, 6
144
12/10/07 1:00:22 PM

5
MIC
>500 mg/L MIC >2000 mg/L

G: 30x106 iu/24, IV,

6 , 8-12
: 3 g 4, IV, ,
8-12 ( 50%)
G: 30x106 iu/24, IV,

6 , 8-12

: 2 g, 12, IV, 8-12
: 3 g 4, IV, ,
8-12

: 2 g, 12, 8-12
,
(MIC >500 mg/L)
(MIC 4-16 mg/L)
E. faecium
: 600 mg, 12, IV p.o., 8
-: 7,5 mg/kg, 8, IV,

8
E. faecalis
: 600 mg, 12, IV p.o., 8
: 500 mg, 6, IV, 8

: 3 g 4, IV, 8
: 3 g 4, IV, 8

: 2 g, 12, IV, 8
145
12/10/07 1:00:22 PM
10
6.
.
(SSA)
(MIC : S. aureus 2 mg/L, CoNS 0,25 mg/L)

(IVDA),
(
): 2 g 4, IV,
6

: 1 mg/kg 8, IV,
3-5
: 2 g 8, IV,
6

: 1 mg/kg 8, IV,
3-5
(
): 2 g 4, IV,
2

: 1 mg/kg 8, IV,
2
: 15 mg/kg, 12, IV,
6

: 1 mg/kg, 8, IV,
3-5

,
: 12 mg/kg 24 IV
6

,
*: 6 mg/kg/24, IV ,
6
: 600 mg, 12, IV p.o.,

6
-: 7,5 mg/kg,
8, IV, 6
* .
146
12/10/07 1:00:22 PM

6
(RSA)
(MIC : S. aureus >2 mg/L, CoNS >0,25 mg/L)

: 15 mg/kg, 12, IV,

6

: 1 mg/kg, 8, IV,
3-5
*: 6 mg/kg 24, IV
, 6

,
: 12 mg/kg 24 IV
6

,
*: 6 mg/kg/24, IV ,
6
: 600 mg, 12, IV p.o.,

6
-: 7,5 mg/kg,
8, IV, 6
* .
147
12/10/07 1:00:22 PM
10
7.
.
(SSA, CoNS)
(MIC : S. aureus 2 mg/L, CoNS 0,25 mg/L)

(
): 2 g 4, IV,
6

: 1 mg/kg 8, IV,
2

: 300 mg 8, IV
, 6
*: 15 mg/kg, 12, IV,

6

: 1 mg/kg 8, IV,
2

: 300 mg 8, IV
, 6
(RSA, CoNS)
(MIC : S. aureus >2 mg/L, CoNS >0,25 mg/L)

*: 15 mg/kg, 12, IV,

6

: 1 mg/kg 8, IV,
2

: 300 mg 8, IV
, 6
*E
,
: 6 mg/kg 24, IV
12 mg/kg 24 IV
148
12/10/07 1:00:22 PM

8. .

: 15 mg/kg, IV, 12

: 1 mg/kg, IV, 8,

*: 400 mg 12, IV.
750 mg 12, p.o.
-: 3 g, IV, 6

: 1 mg/kg, IV, 8
4-6
*
HACEK.
: 15 mg/kg, IV, 12,

6

: 300 mg, p.o, 8,
6

*/*: 1 g, IV, 6
*: 2 g, IV, 8,
6

: 1 mg/kg, IV, 8,
2
*
.
149
12/10/07 1:00:22 PM
10
9.
HACEK.

: 2 g, IV, 24
-: 3 g, IV, 6

: 1 mg/kg, IV, 8
: 4 00 mg, IV, 12 750

mg, p.o., 12
4

6
10. ( ).
Coxiella burnetii ( Q)

*:100 mg IV , p.o.
12,

: 200 mg, p.o., 8
18-36

: 100 mg, p.o., 12

, 3

Bartonella species
*: 100 mg IV , p.o.
12 4-6
50%

: 1 mg/kg, IV, 8
2

*: 100 mg, p.o., 12
4-6

: 300 mg, p.o.,
12 4-6
*
. .
3-6 .
150
12/10/07 1:00:22 PM

11. Brucella sp.

3-4
*: 100 mg, IV p.o., 12

: 1 g, IM, 24

: 600-900 mg, p.o.,
6 ( 12) :
*: 100 mg, p.o., 12

: 300 mg, p.o., 8

-: 1DS tabl.
8 12

: 400 mg, IV, 12
: 400 mg, IV, 12 750 mg, p.o.,
12
* .
.
12. .
Candida sp., ..

: 3-5 mg/kg
, IV

: 25-37,5 mg/kg , IV
( : peak: 70-80 mg/L, trough: 30-40
mg/L)
) : 800 mg IV

) :1 : 6 mg/kg
12 IV. 4 mg/kg 12 IV

: 1 : 70 mg
IV. 50 mg IV

8-10 .
,
,
151
12/10/07 1:00:22 PM
10
5.2.
(trough) 1
g/ml (peak) 3-4 g/ml, .
2-4 MIC .
10 mg/L
30 mg/L.
,
2-3
.
5.3.
(IVDAs) 60-70% (MSSA). 70%.

.
.
, Candida . IVDAs
/ ,
.
5.4.

. , , .
.
,
( 72 ). , ,
, .
3-4 .
152
12/10/07 1:00:23 PM

5.5.

:
.
8-10 .
, , , ,
( ).

, .

(.. , Brucella sp., Coxiella)
(.. Staphylococcus lugdudensis, S. aureus
Gram Pseudomonas Serratia
sp.),
.
10 mm
,
,
.
.
20 mm
.
5.6.

:
() ( 2
).
,
, ,
(10 mm),
.
, .
153
12/10/07 1:00:23 PM
10
6.

,
.

,
.
( 13).
13. .

,

,
(.. , ,
, Fallot)
(shunt)

(
ASD),
,

:
(.. ,
, ).

14.
15.
16.
. ,
17.
154
12/10/07 1:00:23 PM

14. .

( 17)

/

1, 1
(ERCP),
1
1

1

,
( - TUR)

(
)
1
( 13). ( ),
.
15. .

,
, 6
(bypass)
( >45
)

Kawasaki

155
12/10/07 1:00:23 PM
10
16. .

1

*
,
*
*
stent
*
*, *
, , ,
,

1
,
.
* .
6.1.
, , HACEK , ,
Streptococcus
bovis ( 18).
.
, (.. ),

.

,
.
,
10-14 ,
.
156
12/10/07 1:00:23 PM

17. .
. 1

,
,

.
2 ( )
3
( )

( 13).
2
()
.
3

.
1
157
12/10/07 1:00:23 PM
10
18.
.
. , ,
: 2 g p.o. .
: 2 g IM IV
:
600 mg p.o.
1 2 g p.o.,
500 mg p.o.

p.o.:
600 mg IV,
1 1 mg 30
500 mg V
500 mg IV
. ( )
2:
2 g + 3 1,5 mg/kg ( 120 mg) IM IV,
, 1 g IM IV 1 g p.o.,

2, :
3 1 g IV + 3 1,5 mg/kg ( 120 mg) IM IV.
( 1-2 )

2:
3 2 g p.o., , 3 2 g IM IV,
.
2, :
3 1 g IV 1-2 ,

1

(, , , ). -
.
2
13.
3
.
* : 50 mg/kg p.o., 50 mg/kg IM
IV, 20 mg/kg p.o. IV, 25 mg/kg IM IV, 50 mg/kg p.o.,
15 mg/kg p.o., 20 mg/kg IV, 1,5 mg/
kg IM IV. .
158
12/10/07 1:00:23 PM
1.
Horstkotte D., Follath F., Gutschic E. et al. Guidelines on Prevention, Diagnosis and Treatment of
Infective Endocarditis. The Task force on Infective Endocarditis of the European Society of Cardiology. Executive Summary. Eur Heart J, 2004;25:267-76.
2. Badour LM., Wilson WR., Bayer AA. et al. Infective Endocarditis: Diagnosis, antimicrobial therapy,
and management. A statement for healthcare professionals from the committee on rheumatic
fever, endocarditis, and Kawasaki disease, Council on Cardiovascular disease in the Young and
Councils on Clinical Cardiology, Stroke and Cardiovascular surgery and Anesthesia. AHA. Executive
Summary. Circulation, June 2005;14:3167-84.
3. Mylonakis E, and Calderwood SB. Infective endocarditis in adults. N Engl J Med, 2001;345:1318-30.
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159
12/10/07 1:00:23 PM
12/10/07 1:00:23 PM
11
2

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12/10/07 1:00:23 PM
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12/10/07 1:00:23 PM

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,

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.
.
.
.

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.
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A.
.
E ,
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.
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A.

.

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,
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.
catheter-PICC)

( 20 cm)
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163
12/10/07 1:00:24 PM
11
1

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) (nontunneled
central venous catheter)
( 8 cm)

(pulmonary
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.
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).

.
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164
12/10/07 1:00:24 PM

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.

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165
12/10/07 1:00:24 PM
11
3.
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anitratus, Pseudomonas aeruginosa, E. coli, Pseudomonas cepacia .
, (, ,
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.
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12/10/07 1:00:24 PM

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2
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167
12/10/07 1:00:24 PM
11
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. 2
168
12/10/07 1:00:24 PM

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.
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,
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)
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-

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&

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.
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.

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:
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*: .
** .
*** .
169
12/10/07 1:00:24 PM
11
4.
().
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,
,
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).
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7

ALT*
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.
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.
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.
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.
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14
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,
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,
, , (MRSA). , , , ,
170
12/10/07 1:00:24 PM

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test (de-escalation step-down therapy).
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,

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).
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171
12/10/07 1:00:25 PM
11
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12/10/07 1:00:25 PM

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)
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.
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,
173
12/10/07 1:00:25 PM
11
>80% . ,
.

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.
174
12/10/07 1:00:25 PM

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.
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.
S. aureus

.
,
.

. ,

().
, , 14 .

175
12/10/07 1:00:25 PM
11
S. aureus ,
, antibiotic lock 14 .
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.
Gram
Gram
, ,
10-14 .
, Gram ,
,
14 antibiotic lock
.
, ,
test ,
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, .
Pseudomonas aeruginosa,
Burkholderia cepacia, Stenotrophomonas sp., Agrobacterium sp.
Acinetobacter baumannii,
, ,
,
.
Gram P. aeruginosa,
.
, ,
,
4-6 .
, M.
fortuitum M. chelonae .
Candida sp.
.
.
176
12/10/07 1:00:25 PM

.

.
14
.
Candida krusei
, .
E , Candida sp. .
E
, antibiotic lock
30% .
IDSA 2004,
, . ,
,
, , ,
, .
, in vitro
( ),

,
. ,
, , "shunts"
"biofilms".
FDA /, / ,
C. albicans non-albicans
. , ABLC
177
12/10/07 1:00:25 PM
11
3.
.

, .
,
,
,
, .

, .

.

,
.

(4-6 ).
.
Candida sp.,

.
.

.

tunnel.
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,
, , 4
.

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( ) ,
.
, Candida sp.

.
178
12/10/07 1:00:25 PM

mbisome
. , , . ,
non-albicans (C. krusei, C. glabrata),
,
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.
.
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shock, .
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, .
. ,
, ( 3).
1.
2.
3.
5.
6.
Mermel LA, et al. Guidelines for the Management of Intravascular Catheter-Related Infections. Executive Summary. CID, 2001:32;1249-72.
O Grady NP. et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections. CID,
2002;35:1281-307.
Kuhn DM. et al. Antifungal Susceptibility of Candida biofilm: Unique efficacy of amphotericin B
lipid formulations and echinocandins. Antimicrob Agents Chemother, 2002;46:1773-80.4. Pappas
PG. et al. IDSA. Guidelines for treatment of candidiasis. CID, 2004;38:161-89.
Mora-Duarte J. et al. Comparison of caspofungin and amphotericin B for invasive candidiasis. N
Engl J Med, 2002;347:2020-29.
Bacuzzi A. et al. Recommendations and reports about central venous catheter-related infections.
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179
12/10/07 1:00:25 PM
12/10/07 1:00:25 PM
12

: .
: .
.
.
.
.
.
.
.
.
.
.
.
.
12/10/07 1:00:26 PM
12

.
,
. ,
, . 10%
.
. , Staphylococcus aureus,

, .
, (15% 1,1%, . p<0,01).1
1.
, .2
: (55%),
(55%), (36%), (23%) , (32%)
,
(42%). ,
.
1.3
182
12/10/07 1:00:26 PM

1.
.3

(
Duke)

(%)
100
33
23
8
20
5
86
43
41
70
74
20
16
23
26
39
20
22
10
15
13
21
35
33
2.

Duke,
.4
Duke
.3 , , , ( )
.
(definite) ,
, .5
2.1.
( 60 ) Staphylococcus
aureus. Staphylococcus epidermidis, Candida .
( 60 ) S. epidermidis,
S. aureus, , Gram- .6
183
12/10/07 1:00:26 PM
12
7 92% . , 38% . ,
, .
.
>2 , ( ) >90%. , 90%

, 20% >2 .3 25%
. ,
.
,
.3
2.2.

. 7 ,
( , ,
),
80%. ,
,
.
2.3.
, () (). . ,5
, 92% 95%, , 7% 30%. ,2 95%,
30%. 8 .

(p=0,003), .
184
12/10/07 1:00:26 PM

: Duke. , Duke
.
, ,
.

.
. (
)
.
3.
3.1.

. 8 , ,
.
,
.

,
(13%). .9,10

,
. ,2 1 117
. , 50% (3 6)
.
7 , 1 97
.
, 50% (4 8)
(p<0,001). ,
. ,11 98% 189
. , 3 87,5% 224
. ,
185
12/10/07 1:00:26 PM
12
( )
.

,

Dumont .6
:
:
1.
-
-
-
-
- (extrusion)
2.
-
-
-
/ (
).
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.
.
186
12/10/07 1:00:26 PM

2. .
(-)
(+)
+
-
/ *
, , **
(-)
(-)
+
-
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(+)
+
-
/ *
/
(+)
(-)
+
-
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/

* Dumont et al.6 , 83%

.
** 75%
S. aureus (SAB) 28,5% SAB.
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. , SAB,
,
. SAB :
, SAB,
SAB .
( ) SAB
4 .13
3.2.

-
,
. ,
10 mm
(laser ). , 10 mm
.14,15 . ,
5 . ,
. , , 30%

10 mm.
16,17
187
12/10/07 1:00:26 PM
12
.

. 18 <6
. ,
>6 .
. , ,
.10 (
)
.
:
.
(laser ). , (>30 mm)
, .
3.3.
. ,
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, .
6 .19 11
67% . 13 ( ) .
7
(p<0,0001).
: . ,
. ,
,
. ,
6 .
.

,
188
12/10/07 1:00:26 PM

, .

, .
3.4.
: () ()
;

in vitro. ,

.
.
. ,
, 14 (
)
. 11
S. aureus (28 )
,
- 14
.
:
S. aureus (MRSA) S. epidermidis (MRSE),
(15 mg/kg x 2, IV) (10
mg/kg x 1, IV IM). MRSE.
/ MRSA,
MRSE (VRE),
. (15 mg/kg x 2, IV)
(300 mg X 3, p.o.) (6 mg/kg x 1, IV)
(300 mg X 2, p.o.).*
.
,

.
* ,
, , .
189
12/10/07 1:00:26 PM
12
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
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2005;149:322-8.
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Bracke FA, Meijer A, van Gelder LM. Lead extraction for device related infections: a single-centre
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190
12/10/07 1:00:27 PM
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.
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.
.
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.
12/10/07 1:00:27 PM
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.
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12/10/07 1:00:27 PM

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193
12/10/07 1:00:27 PM
13
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, .
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194
12/10/07 1:00:27 PM

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).
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.
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.
MRSA (Methicillin Resistant Staphylococcus Aureus),
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.
ELISA, 2-3
, (
) . B,D .
PCR .
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,
. ,
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.
195
12/10/07 1:00:27 PM
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100
100

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.

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5
5
3
5
4
4
3
3
2
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21
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*
16 .
, 100,

.
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196
12/10/07 1:00:27 PM

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.
,
, ,
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24
.
3.
3.1.
,

. .
, ,
.
3.2.
.
:
[ ESBL (Exteneded Spectrum -Lactamases),
MRSA VRE, , E. coli , P. aeruginosa].
( , Gram- ,
).
( ,
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,
, .
197
12/10/07 1:00:27 PM
13
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15 Gram .
, , Gram
. , Gram- <50%, P. aeruginosa . ,
Gram- P. aeruginosa
( ).

, ( )

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ESBL . 24 ( 3)
.
, .

.
.
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.
.
/, .
198
12/10/07 1:00:27 PM

- , ,
.
3.
.
(methanesulphonate)

IV
IV
IV
IV
IV
IV/p.o.
IV
p.o.
IV
IV
IV
IV
IV
IV
IV
IV
*
2 g/8
2 g/8
2 g/8
1 g/8
1 g/8
2 g/8,
400 mg/24
400 mg/8
600 mg/12
750 mg 1 g/12
15 mg/kg/24
7 mg/kg/24
7 mg/kg/24
4,5 g/6
1 g (15 mg/kg)/12
10 mg/kg/24
600 mg/12
3000000 IU/8
* .
( MIC), 3 g/8.
3 mg/kg, , ,
10 mg/kg. (trough) <1
g/ml 4-5 g/ml.
12 24.
70 (10 mg/kg/24 3 ) 1 mg = 12500 IU.
3.5.
Gram-
-
Gram- (
)
.
, Gram-,
. . ,
199
12/10/07 1:00:27 PM
13
Gram- .
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:
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).

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,
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VRE.
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( ,
,
, , ,
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500.
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12/10/07 1:00:28 PM

, ,

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,
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).
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4.2.
72 , 24

, , (, ) (,
, , ..) ( ,
, GVHD, , , ..).
CT
.
,
, .
.

, . . ,
.
,
2 , .
,
5
.
201
12/10/07 1:00:28 PM
13
1. .

MASCC score 21

24

/

v

MASCC score 21
3-5
, MRSA, Gram .

-=, , /
=, .
202
12/10/07 1:00:28 PM

2.
.
3-5

(FUO)

( 37,8C)

,
5

CT
,
U/s
FUO
5

FUO
FUO
203
12/10/07 1:00:28 PM
13
3. .

3-5
*ANC 500
X 2
48
ANC <500
7

5-7
- ANC <100
-
-
FUO
ANC 500
ANC <500
4-5
,
ANC 500

FUO

5-7 .
/ >100.
* .
5.
5.1.
.
Candida sp. (2-3 ) Aspergillus sp. (3 ).
1
.
,

(GVHD, ). Mucor,
204
12/10/07 1:00:28 PM

Scedosporium, Acremonium, Trichosporon, Alternaria .., nonalbicans Candida non-fumigatus Aspergillus.
5.2.
,
.
, .
. ,
7 , . ,
CT (
),
-
, ,
, (>104 CFU/ml)
Candida sp., ,
.
5.3.
.

( ).
5.4.
/ , , ,
. . <50 ml/min. Mucor
,
. ,
,
( ),
. Candida
205
12/10/07 1:00:28 PM
13
. ,

Candida albicans, parapsilosis tropicalis. Candida
glabrata
Candida krusei . ,
Candida, ( 4 5
).
4.
.
()

Ambisome
Abelcet

IV
IV
IV
IV/p.o.
p.o. (solution)
IV/p.o.
p.o.
IV
IV
0,6-1 mg/kg/24
3-10 mg/kg/24
5 mg/kg/24
200-800 mg/24
200 mg/12
4 mg/kg/12
200 mg/6 400 mg/12
50 mg/24
150 mg/24
: , 5 mg/kg
7-10 mg/kg .
200-400 mg - 800 mg (10-12 mg/kg)/24 . 400 mg/24.
6 mg/kg/12 24.
<50 ml/h.
70 mg 24.
, 35 mg/24 .
50 mg/24, Candida albicans 100

mg/24. .
206
12/10/07 1:00:28 PM

5.
.

( )
Candida sp.

Candida albicans, tropicalis,
parapsilosis
Candida glabrata, krusei
(Aspergillus sp.)

,
,
(Fusarium sp.)
/
(zygomycetes sp./mucorales sp.)
Scedosporium prolificans, Alternaria,

Bipolaris, Curvularia Exophiala ..
Scedodporium apiospermum
Penicillium sp.

+
(2 .)

+
(2
.)

,
,

,

.
(Ambisome), (ABELCET).
207
12/10/07 1:00:28 PM
13
5.5.
,
.

, 2 .
, .
,
, .
5.6.

. , .
6.
6.1.

, ,

.
1 2 (HSV1, HSV2), - (VZV)
(CMV), , , (HSV1, HSV2, VZV CMV)
(CMV). (RSV)

.
6.2 -
- , ,
.
(),
HSV, VZV () CMV ()
RSV (, ) (
). ,
208
12/10/07 1:00:29 PM

,

,
.
CMV ( 6 - ).
7.
7.1.
,
, .
, .

.
, ,

, . , .
7.2.

(7-10 ) (>40%).

,
.
8.
8.1.
,
. , ,
-
2004, , Gram209
12/10/07 1:00:29 PM
13
,
. ,
,
, .

.
2005 - ,
, (7 ).

.
8.2.
,
,
7 ,
, ,
,
Gram- .
. H (>500)
.
<7 , ,
(.. ,
) .
8.3.
(PCP),

, , , , ,
210
12/10/07 1:00:29 PM

, 480 960 mg/24. .
8.4. Gram

(Hickman) . , ,
(
).
9.
9.1.

,
, 400
mg/24
(engraftment).
9.2.
, , ,

, , ,
. ,
, .
2005
, ,
, GVHD IV
(>7 )
.
.

.
211
12/10/07 1:00:29 PM
13
9.3.
,

[.. ,
()].
(
) .
, .
10.
10.1.
800 mg/12
(
- 8 +28) GVHD .
, 200 mg/8

.
11.
11.1.
HEPA (High Efficiency Pariculate Air)

.
(>12 )
.
.
11.2.
(laminar air flow)
.
11.3.
,
,
.
212
12/10/07 1:00:29 PM

, .
(..
).
.
, .
. .

, ,
. .
.

. ,
, ,
.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hughes WT., Armstrong D., Bodey GP. et al. 2002 Guidelines for the use of antimicrobial agents in
neutropenic patients with cancer. Clin Infect Dis, 2002;34:730-51.
Link H., Bohme A., Cornely OA. et al. Antimicrobial therapy of unexplained fever in neutropenic
patients. Guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of
Hematology and Oncology (DGHO) Study Group Interventional Therapy of Unexplained Fever.
Ann Hematol, 2003;82(Suppl 2):S105-17.
Rolston KV. The Infectious Diseases Society of America 2002 guidelines for the use of antimicrobial
agents in patients with cancer and neutropenia: Salient features and comments. Clin Infect Dis,
2004;39(Suppl 1): S44-8.
Klastersky J., Paesmans M., Rubenstein EB. et al. The Multinational Association for Supportive Care
in Cancer risk index: A multinational scoring system for identifying low-risk febrile neutropenic
cancer patients. J Clin Oncol, 2000;18:3038-51.
Caillot D., Couaillier JF., Bernard A. et al. Increasing volume and changing characteristics of invasive pulmonary aspergillosis on sequential thoracic computed tomography scans in patients with
neutropenia. J Clin Oncol, 2001;19:253-9.
Persson L., Soderquist B., Engervall P. Assessment of systemic inflammation markers to differentiate
a stable from a deteriorating clinical course in patients with febrile neutropenia. Eur J Haematol,
2005;74:297-303.
Jimeno A., Garia-Velasco A., del Val O. et al. Assessment of procalcitonin as a diagnostic and prognostic marker in patients with solid tumors and febrile neutropenia. Cancer, 2004;100:2462-9.
Giamarellos-Bourboulis EJ., Grecka P., Poulakou G. et al. Assessment of procalcitonin as a diagnostic marker of underlying infection in patients with febrile neutropenia. Clin Infect Dis,
2001;32:1718-25.
Wisplinghoff H., Seifert H., Wenzel RP. et al. Current trends in the epidemiology of nosocomial
blood stream infections in patients with haematological malignancies and solid neoplasms in
hospitals in the United States. Clin Infect Dis, 2003;36:1103-10.
213
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13
10. Paul M., Soares-weiser K., Leibovici L. lactam monotherapy versus lactam-aminoglycoside combination for fever with neutropenia: Systematic review and meta-analysis. BMJ, 2003;327:1111-21.
11. Aiken SK., Wetzstein GA. Once-daily aminoglycosides in patients with neutropenic fever. Oncol
Pharm, 2002;9:426-31.
12. Chamilos G., Bamias A., Efstathiou E. et al. Outpatient treatment of low-risk neutropenic fever in
cancer patients using oral . Cancer, 2005;103:2629-35.
13. European Organization for Research and Treatment of Cancer (EORTC) International Antimicrobial
Therapy Cooperative Group, National Cancer Institute of Canada-Clinical Trials Group. Vancomycin
added to empirical combination antibiotic therapy for fever in granulocytopenic cancer patients.
J Infect Dis, 1991;165:951-8.
14. Cometta A., Kern WV., De Bock R. et al. Vancomycin versus placebo for treating persistent fever in
patients with neutropenic cancer receiving piperacillin-tazobactam monotherapy. Clin Infect Dis,
2003;37:382-9.
15. Menichetti F. The role of teicoplanin in the treatment of febrile neutropenia. J Chemother,
2000;12(Suppl 5):S34-9.
16. Walsh TJ., Finberg RW., Arndt C., Hiemenz J., Schwartz C., Bodensteiner D. et al. Liposomal amphotericin B for empirical therapy in patients with persistent fever and neutropenia. National Institute
of Allergy and Infectious Diseases Mycoses Study Group. N Eng J Med, 1999;340:764-71.
17. Walsh TJ., Teppler H., Donowitz GR. et al. Caspofungin versus liposomal amphotericin B for empirical antifungal therapy in patients with persistent fever and neutropenia. New Engl J Med,
2004;351:1391-402.
18. Walsh TJ., Pappas P., Winston DJ. et al. Voriconazole compared with liposomal amphotericin B for
empirical antifungal therapy in patients with neutropenia and persistent fever. New Engl J Med,
2002;346:225-34.
19. Kern WV. Modifications of therapy. Int J Antimicrob Agents, 2000;16:139-41.
20. Gafter-Gvili A., Fraser A., Paul M. et al. Meta-analysis: Antibiotic prophylaxis reduces mortality in
neutropenic patiets. Ann Intern Med, 2005;142(12 Pt 1):979-95.
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in neutropenic afebrile oncology patients: A systematic review of randomised controlled trials.
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22. Paul M., Yahav D., Fraser A, Leibovici L. Empirical antibiotic monotherapy for febrile neutropenia:
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2006;57:176-89.
23. Jaksic B., Martnelli G., Peez-Oteyza J. et al. Efficacy and safety of linezolid compared with vancomycin in a randomized, double-blind study of febrile neutropenic patients with cancer. Clin Infect Dis,
2006;42:597-607.
24. Dykewicz CA. Hospital infection control in haematopoietic stem cell transplant recipients. Emerg
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therapy for invasive aspergillosis in solid organ transplant recipients: A prospective, multicenter,
observational study. Transplantation, 2006;81:320-6.
26. Ullmann AJ, Lipton JH, Vesole DH, et al. Posaconazole or fluconazole for prophylaxis in severe graft
-versus-host disease. N Engl J Med. 2007; 356:335-47.
27. Cornery OA, Maertens J, Winston DJ, et al. Posaconazole vs. fluconazole or itraconazole prophylaxis
in patients with neutropenia. N Engl J Med. 2007; 356:348-59.
28. Smith TJ, Khatcheressian JL, Lyman GH et al. 2006 Update of recommendations for the use of
white blood cell growth factors: An evidence-based clinical practice guideline. J Clin Oncol
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29. Wingard JR. New approaches to invasive fungal infections in acute leukemia and hematopoietic
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214
12/10/07 1:00:29 PM
14
: .
: E.

.

.
12/10/07 1:00:29 PM
14

,
. ,
( 1). , , ,
.
2 8, ,
, ,

.
1. .

, :
-
-
-
: , ,
:
, ..
.
:
-
-
-
-

-
()
-
216
12/10/07 1:00:29 PM

2. --.
:
:
:
: Staphylococcus aureus

-
(
1 g x 3 p.o.)
- 500 mg x 3
p.o.
- 600 mg x 3 p.o.
:
1. .
2. Staphylococcus
aureus, .
S. aureus
:
. Mupirocin X 7 (2-3 /24)
.
.

().
3.
(.. ) 5-14
.
4. : Pseudomonas aeruginosa
.
217
12/10/07 1:00:30 PM
14
3. -.
,
()
()
: - , C G
Staphylococcus aureus (10%)
- V 1,5 iu x 4 p.o. (
)
G
3 iu X 4 iv ( )
- +
1000 mg x 2 p.o.
-
150 mg x 2 p.o.
500 mg x 2 p.o.
500 mg/24,
- 600 mg x 3 p.o.
.
(2 12 )

(. )
2,4-3,6
iu IM (1,2-1,8 iu
) 3
, 12-18 .
:
- V 1,5 iu p.o.,
12 ( )
(12-18 )
:
1. ,
IV. ,
.
2. G, , / ,
.
218
12/10/07 1:00:30 PM

4. .

( )
-
(90%)
(10%)

: (
):
<24 (. )
(10 )
V
p.o.
(. )
+

1000 mg x 2 x 3 p.o.
600 mg x 3 p.o.
:
,
,
, S. aureus
.
219
12/10/07 1:00:30 PM
14
5. .
.
:
( . 269)
.
(Flesh eating disease):
,

: -
(super-antigens)
S.O.S ,
,
.
shock ( 80-100%)
: ( )
CPK
:
-
- G (5 ui x 6 iv) + (600 mg x 3 iv
30 iv)
- G (G iv 400 mg/kg/24 x 5 )
220
12/10/07 1:00:30 PM

.
:
- -

(Clostridium perfrigens)
, ,
, , ,
, .
:

:
G (5 . ui x 6 iv) +
(600-900 mg x 3 iv 30)
(400 mg x 3 iv)
:
1. .
2. Gram (-)
.
3. .
221
12/10/07 1:00:30 PM
14
. ( Fournier)

, ,
( )

,
(. , . 270)
222
12/10/07 1:00:30 PM

.

, , ,

-
Mucor,
Rhizopus, Absidia (

)
Candida sp.

Pseudomonas aeruginosa.

,

.
.
:

(5 mg/kg/24)
.
S.O.S

5 mg/kg/24
400
mg x 2 iv (
Candida albicans)

70 mg 1

50 mg
(
2 g x 3 /
4,5 g x 4
/
5,2 g x 4
223
12/10/07 1:00:30 PM
14
6. .

.

Pasteurella multocida
( ), Staphylococcus aureus, Streptococcus sp.
Capnocytophaga canimorsus [Gram (+) ,
Fusobacterium sp., Bacteroides sp., Prevotella sp., Gram (-)
]
+

(. 2):
+ 1000 mg x 3 p.o. x 5 .
:
+
224
12/10/07 1:00:30 PM

7. .

~ 50% :
, , , HIV

( )

1. (
)
2. :
.. (3 g x 4 iv)
/ (800 mg x 2 iv)
(600 mg x 3 iv)
( 2)
( MRSA ):
(1 g x 2 iv 60) (10 mg/24 iv im)
(600 mg/12 iv p.o.) (4-6 mg/kg/24 iv)
:
1. iv

.
2. (400 mg x 3 iv 1 g x 2 p.o.)
(400 mg x 2 iv p.o.) (400 mg iv p.o.).
3. , 10
, ,
.
4. CPK

,
..
, CPK
.
225
12/10/07 1:00:30 PM
14
1. .

3
<3
TIG

Td
TIG
>5 .
>10 .
(<6 ), , , .
d: - .
TIG: .
:
1. (
24) 22
.
2. ,

.
226
12/10/07 1:00:30 PM
15

: .
: .
.
.
.
.
.
.
.
.
12/10/07 1:00:30 PM
15
1.
, , , .
.
2.
Waldvogel:
1. ( )
2. ( )
.
. .
1. .

Streptococcus sp.
Staphylococcus epidermidis
Pseudomonas aeruginosa ( )
Salmonella sp. ( ) ..
228
12/10/07 1:00:31 PM

3.
3.1.
20%
, .
.
3.2.

. ,

. S. aureus.

1. : , CRP, .

.
2. 50%
.

.
,
>5
( 43-84%, 9397%). .
3. :
: 2 . , , .
: ,
.
:
99mTc-MDP , 2-3
. (.. 67Ga 111In).
PET Scan FDG.
:
, .
: ( )
.
.
229
12/10/07 1:00:31 PM
15
3.3.
2.
.
S. aureus (
(..
- MSSA) 2 g/4 V) 1 g/6 p.o.
* 600-900 mg/8 IV 30
/ 160/800 mg/12 IV
600 mg/12 400 mg/8 IV 7501000 mg/12 p.o.
S. aureus (
* 600-900 mg/8 IV 30
- MRSA) / 160/800 mg/12 IV
1 g/12 IV
10 mg/kg x 1 IV I
600 mg/12 IV p.o.**

(.
)
Streptococcus sp.
G 3-4.000.000 IU/4 IV
2 gr/6 IV
Enterococcus sp.
/ 3 g/6 IV +/- 1 mg/

kg/8 IV
Gram (-)
P. aeruginosa
( )
(.. 400 mg/12 IV)
/ 3 g/6 IV
/ 1 g/8 IV
/ 4,5 g/6 IV
/ 5,2 g/6 8 IV
- (.. 2 g/24
IV I, 2 g/8 IV, 2 g/8 IV
2 g/8 IV)
2 g/8 IV
(/ 1 g/8 IV,
2 g/8 IV, 2 g/ IV)
Pseudomonas
aeruginosa

( ) (
)
* Saccharomyces
boulardii (2 8 ).
** , (, ),
.
230
12/10/07 1:00:31 PM

1. /
().
.
2. :
1, .
3. : (. 1). : 4-6 ( 2
).
3.4.

.
:
- (Bone debridement)
- (Reconstruction & Dead space management)
- (Bone stabilization)
- (Soft tissue coverage).
4.
4.1.
3. .
Coagulase negative staphylococci
Gram (-) (.. Escherichia coli)
50-70 %,
30-50%,
25%,

50%,
(.. ), IV
<20%,
<20%,
5% ,
Salmonella sp. (.. S. enteritidis)

231
12/10/07 1:00:31 PM
15
1. .

( )

(, ,
)

, CRP
( ,

)
A 1
MRI (
95%, 88% -
)
o
99mTc-MDP
( 95%, 33%)
(
)
(
,
, )
67Ga
( 81%, 69%
99mTc-MDP)
/ ( ,
)

111I n ( 88%, 85% )

1. (3) ( )
. 2

2.

.
.
.
6 , 3 , 6 ,
( ).
232
12/10/07 1:00:31 PM

1:
S. aureus, :
+
+
+ 2
+ 2,3
+
: + 2, 5
Gram : .
: S. aureus,
3 .
:
1. (. ):
600 mg x 3 V p.o., 300 mg x 4 p.o.
960 mg x 3 x 2, IV, p.o.
500 mg x 3, IV, p.o.
600 mg + 300 mg
600 mg x 2 (400 mg x 3) IV, 750 mg x 2 (1 g x 2
) p.o.
B 500 mg x 4 (1 g x 2) IV
10 mg/kg V, ( 400 mg 12
)
600 mg x 2, IV, p.o.
2. ,
.
.
3.
. ,

.
4. p.o.
.

(, , )
>15 .
.
.
1.
(consensus statement)
.
233
12/10/07 1:00:31 PM
15
2.
Y >1.500.000 20.000
50.000 $ 20.000 .
0,5-1% , 0,5-2% 5% .
.

(, revisions)
4-8
.

(5,9/1.000 -), (2,3/1.000 -
8 ). ,
4, 5 6.
4. .

.
(OR 35)
/
,

(OR 3)

(OR 2)
(

)

(

)
5. .
(CNS)
Gram-
Streptococcus sp.
Enterococcus sp.

Candida sp., Brucella sp. ,
Mycobacterium tuberculosis, P. acnes

20-43%
20-25%
10-19%
3-11%
8-10%
3-7%
2-10%
8-19%
234
12/10/07 1:00:31 PM

6. .
29-45 2-4 .
( <2 .
(early)
3 ,
-

-

)
S. aureus
Streptococcus sp.

(delayed)
23-41 4 .-2
( 3
2 ,

)
,
S. aureus
Propionibacterium
sp.,
,
,
, ,
<30%,

(late)
30-33 >2
Streptococcus sp.
S. aureus
Gram
,

..
,
,

3.
(Gram
,

/

(,
,

),

H , ,
,
.
.

(. 6).
.
.
235
12/10/07 1:00:31 PM
15
.

. .
(CRP-TKE)
, .
,
, .. .
, CRP.

.
.

( )
.
(<50%).

.
: 1) , .. 2) .
(CT) (MRI)
.
MRI
, CT.
H CT ,
.
,
(artifacts) . H MRI , .. .
:
- (multislice CT)
(interface).
.

.

( 7).
236
12/10/07 1:00:32 PM

7.
.

(99m Tc MDP)

(67Ga)
100% 40% 20%

100%

75%
50-70%

( 66%
81%)

1

( - 111,
HMPAO)
60%
73%

83%

Tc-sulfur colloid

95%
, ,
,

(99m Tc-anti-NCA 90, 99m Tc
Sulesomab, Leukoscan)

(99m Tc- ciprofloxacin, Infecton)

18
F (PET Scan)
67-91%,
81-99%
81%
, , ,
237
12/10/07 1:00:32 PM
45-100%
67%
100%
84%
6-19%
Gram
<26-32%
97%
Gram
94%
o 65%
<44%
93-96%
93%
96%
97-99,7%
82-97%
>97%
89%
88%
>1,7x109/l
70-88%
67%
93%
94%
73%
98%
82%
100%
99%
98%
-
-
- (sonication)
= >5

(x 400). >50%
10

.
S. aureus
8. .
15
238
12/10/07 1:00:32 PM

3

0
1
2
3

3,4%
13,3%
20,4%
94,8-99,6%
:
1. 14
14-28 .
2. 5-6
.
.
3. .
4.
.
: PCR .
239
12/10/07 1:00:32 PM
15
2.
.
(, )

(3-6)

/
Gram

<3

:
1.

(. ). ,
, CNS Corynobacterium sp.
2. , , ,
.
, CNS Corynobacterium
sp. ,
/ .
3.
(Gram )
.
4. , ,
.
5.
.
240
12/10/07 1:00:32 PM

4.
:
1.
2.
3. .
. , .
:
. (
). .
, , 3
.
( ) 15
.
.
.
,
(. ).
.
. , 1 2 (
3).

1. 28
(
).
2. .
3. per os
.
4.
.
241
12/10/07 1:00:32 PM
15
3. .
;
1.
7
2.
3.

:
-
, ..
,
-
(3-6 )
, ..
+ + IV

p.o. ( 1)

(
)

( 1, 3, 6,12, 24 )

(TKE, CRP)
242
12/10/07 1:00:32 PM

4. ( 7 , , ).
2
-
-
- PMMA,
(spacer)
-
+
- 6
( iv 2 )

, CRP
( 9)
-
(3 spacer 3
)
,
15
-

(.
5)

,

6

(1, 3, 6, 12, 24 )
: 3
6

- CRP

( 9)
243
12/10/07 1:00:32 PM
15
5. ( 4).
( )
+
6
( iv 2 )
. (/CRP)

(1, 3, 6, 12, 24 )
(. 9)
:
1. ,
(
- ).
(CRP TKE).
2. ,
. ,
CRP
. ,
.
3.
,
,
(<4 ).

(4 ).
4. 2
.
5. PMM spacer,
.
MRSA, ,
,
.
, 4 g
40 g PMMA. , .
6.
.

.
244
12/10/07 1:00:32 PM

(.. >15% MRSA) ,
( iv,
iv im ).
7. ,
. ,
, . (PMMA), .
8.
: ) (host A),
)
) .
9.
,
,
.
6.
(>1 -2
) ( 9).
9. .
:
(..
- ..).
.
,
.
.
.
:
33-80%.

.
1 >4 .
,
.
7.
1.000.000 .
0,4-1%.
:
245
12/10/07 1:00:33 PM
15

-
-
-
-
- .
: .
:
-
-
- Gram .
:
-
- CRP.
: .
( ):
-
- ,
.
: 2
p.o., CRP.
.
10. .
-
: .
:
-.
/
.
2-7% .
15-20%, 35%, 50%.
(>25%)

(HIV , ).
246
12/10/07 1:00:33 PM

11. .
S. aureus
CoNS1
Streptococcus sp.2
Enterobacter sp.
Salmonella sp.
M3
Mycobacterium tuberculosis
Brucella sp.
(60% )

Coagulase negative staphylococci

b-hemolytic streptococci group B and G, S. pneumoniae, Enterococcus sp.
Candida sp., Aspergillus sp., Cryptococcus sp.
1
2
3
:
, , (.. ,
, ),
.
12. .

<30%
>90%
WBC
CRP

20-50% *
20-50%

15%
30%
>90%
<50%
>90%
<25%

,
*
Mantoux
PCR -Koch **
* .
** .
1.
1.

.
().
247
12/10/07 1:00:33 PM
15
2. (MRI)
.
.
(.. , ).
3. (CT)
/ .
(multi-slice CT) CT
.
: , multi-slice CT MRI
.
4.
, .
6. .

, TBC (. . 250, 251)
, CRP
(+)
Rx, MRI, Te99 3
(-)
(-)

(+)
(+)
/
(-)
CT
(+)
(Gram, Ziehl Neelsen, Giemsa)

, , -Koch,

:
1. , 15 ,
.
2. ,
248
12/10/07 1:00:33 PM

,
, .

.
2.
1. >1 / .
.
.
2. .
3. 6-8 3-6 .
4. .
5.
, (TKE, CRP).
6. :
)
) .
3.
1.
.
2. .
3. .
4. .
5. , .
4.
4.1.

( , ablation)
(.
).
249
12/10/07 1:00:33 PM
15
4.2.
,
/ , .
( 6 ). ,
.
. .
5.
.
50% .
.
(Potts disease).
40-70%. .
.
.
10-30% .
. .
: Wright >1:160.
IgM, IgA, IgG
, . , .
/ .

.
(3-6 ).
( 100 mg
x 2 p.o. + 1 gr 45 21 , + 900 mg QD p.o. 45 ) 3 : (,
) .
250
12/10/07 1:00:33 PM

13. .
600 mg/24h
12
(
6)
300 mg/24
12
15-20 mg/Kg
20-25 mg/Kg
2
MDR (.)
ALT, AST, GT, ALP,

ALT, AST, GT, ALP,

: MDR 24
(, , , ). .
V.
1.

, .
14. ( 88%
).

, ,

anti-TNF
80
2.
: 51 .
: 2,6%.
: (45%), (15%), (10%).
()
.
251
12/10/07 1:00:33 PM
15
15. .
Gram (+)
( 90%)
Gram (-)

Streptococcus pyogenes
Neisseria gonorrhoeae
Neisseria meningitidis
( )
Gram (-)
Mycobacterium
tuberculosis
Brucella sp.
3.
: , ,
, .
: >50.000/mm3
( 65%) .
Gram : Gram (+) ,
71%.
: , <50% ( , ,
). , >90%.
.
: 30% .
:
: .
:
. .
CT & MRI:
.
252
12/10/07 1:00:33 PM

7. .

:
,
(Gram , iehl-Neelsen, Indian Ink )

Gram (-)
Gram
(2 g/24 IV)
(2 g/8 IV)
*
(400 mg/12
IV)
(2 g/24 IV)
(2 g/8 IV)
+/
(1 g/12 IV)
(10 mg/
kg/24 IV)

Gram
(1 g/12 IV)
/
Gram
Gram(+)
(4,5 g/6 IV)
(5,2 g/6-8 IV)

(1 g/12 IV)
(1 g/12 IV)
*
(400 mg/12
(10 mg/
IV)
kg/24 IV)
(2 g/24 IV)
*
(400 mg/12
IV)
Gram(+)
* -.
:
1. .
2. : 21-28 .
3. : 7-10 .
4. ,
.
5. ,
.
6. .
7. , 5-7 , .
253
12/10/07 1:00:34 PM
15
V.
.
16. .

(IV)
1) 1 g
10 mg/kg
2) 1-2 g
3) 1,5 g
1-2
1
1-2
1-2
(
Gustilo)
I & II
1,5 g/8
600 mg/8
III
1,5 g/8 +
500 mg/8
/
3 g/6
/
1 g/8
:
1. . 8 .
2. : )
(MRSA MRSE) >20%
) -. H 1 1 . 12 .
3. >3
, .
4. Gustilo:
. <1 cm.
II. >1 cm.
254
12/10/07 1:00:34 PM

. a. +
.
. b. + .
. c. .
, , .
, 3
6-8 . (.. , ),
3 . .
, -, IV 600 mg/8 500 mg/8
600 mg/12 .
5. .
6. (tourniquet), 20 min .
7. , .
8. , , ,
<2 , .
1.
. . : , .
., , 2005, . 689-721.
2. Zimmerli W, Trampuz A, Ochner P. Prosthetic joint infections. N Engl J Med, 2004;351:1645-54.
3. Lew DP, Waldvogel F. Osteomyelitis. Lancet, 2004;364:369-79.
4. Sia I, Berbari E, Karchmer A. Prosthetic joint infections. Infect Dis Clin N Amer, 2005; 19:885-913.
5. Lidgren L, Knutson K, Stefansdottir A. Infection of prosthetic joints. Best Pract Res Clin Rheumatol,
2003;17:209-18.
6. Zimmerli W, Ochner P. Management of infection associated with prosthetic joints. Infection,
2003;31:99-108.
7. Osmon D, Hanssen A, Patel R. Prosthetic joint infection: Criteria for future definitions. Clin Orthop
Relat Res, 2005;437:89-90.
8. Trampuz A, Zimmerli W. Prosthetic joint infections: Update in diagnosis and treatment. Swiss Med
Wkly, 2005;135:243-51.
9. Lubbeke B, Stern R, Bru J et al. Value of preoperative investigations in diagnosing prosthetic joint
infection: Retrospective cohort study and literature review. Scand J Infect Dis, 2004;36:410-6.
10. Love C, Tomas M, Mawin S et al. Role of nuclear medicine in diagnosis of infected joint replacement. Radiographics, 2001;21:1229-38.
11. Iyengar Kp, Vinjamuri S. Role of 99mTc Sulesomab in the diagnosis of prosthetic joint infections.
Nucl Med Commun, 2005;26:489-96.
12. Swanson AN, Pappou IP, Cammisu FP, Girardi FP. Chronic infections of the spine: Surgical indications and treatments. Clin Orth relat Res, 2006;444:100-6.
255
12/10/07 1:00:34 PM
15
13. . . : , .
., , 2005, . 689-721.
14. Mc Henry et al. Vertebral osteomyelitis: Long term outcome for 253 patients from 7 Cleveland area
hospitals. CID, 2002;34:1342-50.
15. Pertuiset E, Beaudreuil J, Lide F et al. Spinal tuberculosis in adults: A study of 103 cases in a developed country, 1980-1994. Medicine, 1999;78:309-20.
16. Carragee EJ. The clinical use of MRI in pyogenic vertebral osteomyelitis. Spine, 1997;22:780-85.
17. Berbani EJ, JM Steckelberg, Osmon Dr. Osteomyelitis In: Principles and Practice of Infectious Diseases. Mandell G, Benett JE, Dolin R. Eds 2005, Churchill Livingstone USA.
256
12/10/07 1:00:34 PM
16

: .
: .

.
.
.
.
.
.
.
.

.

.
12/10/07 1:00:34 PM
16

.
, .
14%-17%, .
,
38% .

. , , 77%
. , ,
10 , .
1980,
. ,
.
1.
:
()
.
: .
: .
258
12/10/07 1:00:34 PM

: ( ).
:
1.
,
2. ,
6-12 ,
3. ,
4. ,
5.
.

- .
.
, , , .
1

.
1. .
1. : ,
, ,
, ,
. ( )
1-3% .
2. :
,
, , .
7-8%
.
3. :
, ..
,
(.. , ..).
15-20%
.
4. :

(.. ).
40-50% ,
.
259
12/10/07 1:00:34 PM
16

. ,
2.
,
>4 .
2. .
>70

(. , ,
, )
(, ,
)
>3

3.
3.
.

: , ,
,

, , ,
,
()
260
12/10/07 1:00:34 PM

3
(
),

ERCP
Stent

/

/

, AV fistula
Stent
1
1
261
12/10/07 1:00:34 PM
16
4. .
: 1,5 g
: 2 g
: 2 g
: 2 g
:
600 mg
/: 3 g
: 500 mg
/ : 1,2 g
/: 4,5 g
/: 5,2g
:
1. ( ,
48).

.
2. , , , Bilow
.
3. :

.
4.
.
5. O . , ,
, .
6. .
.
7. :
,
.
,
(MRSA) (>15%),
( )

262
12/10/07 1:00:34 PM

1 g .
8.
.
2.
2.1.

.
,
.

, .

, .
,
, .
.
1.
,
.

. .
.
.
.

( 2
24 ).
5.
2.
. ,
.
3. Candida albicans 20%
263
12/10/07 1:00:35 PM
16
. , ,
. ,
( ). C. lbicans, .
,
B, .
4. .
, .

, ,
.
5. 5-7 ,
, ( , )

, .
6.
.
2.1.1.
1.
. 12
pH,
24 . , 12,
.
HCl ,
Helicobacter pylori.
2.
.
24 ,
.
, 5
.
264
12/10/07 1:00:35 PM

5. .
/
3 g IV 6
/
5,2 g IV 6
/
4,5g IV 6
:
1 g IV 24
/:
1 g IV 8
:
2 g IV 8

: 1,5 IV 8
: 2 g IV 6
:
2 g IV 12
: 2 g IV 6
+ 500 mg IV
12
:
: 2 g IV 8
: 2 g IV 8
: 2 g IV 24
: 2 g IV 8
+ : 500 mg IV
8
:
2 g IV 8
+ :
500 mg IV 8
:
400 mg IV 8
+ :
500 mg IV 8
1 100 mg
50 mg x 2 IV

, .
. , /.
265
12/10/07 1:00:35 PM
16
3.
.
.
75% ,
.
,
30%
. , ,
,

.
4.

, (, ).
(),
15-70%
.
:
- SIRS, ,
- .

:
- ,
, , ,
.
- RSA, .
- .
5.
. Gram-
(, , ,
).
. 70% .

.

. 2-3
266
12/10/07 1:00:35 PM

, .
5
.
4-6 6-8 .
. .
(750 mg x 3 p.o.) 10 .
4-5 .
.
6.

.
, :
) : .
) : ( 2-3 ).
) (): .
. ,
+ .
7.
.
.
5, .
3-6
10 . .

, . , ,

24,
. , ,
.
8.
.
, . +
.
9.
.
+ / /
.
267
12/10/07 1:00:35 PM
16
2.1.2.
A.
. .
:
/
+
+
, 8-10 .
B.
.
,
.
.
5
. 8 .
, /
,
.
.
.
,
, . ,

( 6).

.
.
.

. ( ) , Pseudomonas aeruginosa, S. epidermidis,
Candida albicans.
. ( CT U/S) .
. ,
24.
268
12/10/07 1:00:35 PM

6.
.
/:
1g IV 8
: 2 g IV 8
/
4,5 g IV 6
1 g IV 12
600 mg 12
10-12 mg/kg
400 mg IV 12
400 mg IV 8
: 15 mg/kg IV
24
: 5 mg/kg IV
24
: 5 mg/kg IV
24
: 4-6 mg/kg IV
24

3-5 mg/kg IV 24

(500 mg IV x3)
2.2.
,
.
, . (
)
( ).

, ,
, , ,
, .
, .
:
269
12/10/07 1:00:35 PM
16
1.
2.
3.
4.
5.
6.
7.
8. .
7. .

/
3 g IV 6
400 mg IV 8
+ 500 mg IV 12
/ 5,2g IV 8
1 g IV 24
+ 600 mg IV 6

2 g IV 6
2 g IV 6
2 g IV 12
2 g IV 8
600 mg IV 6
+
500 mg IV 12

Streptococcus pyogenes S. aureus
Clostridrium sp.
5 x 106 iu IV 4
600 mg IV 6

/
4,5 g IV 6
/
1 g IV 8
2 g IV 8
+ 600 mg IV 6
1 g IV 12
800 mg IV 24
(10 mg/kg)
600 mg IV 12
270
12/10/07 1:00:35 PM

.
Gram , , . .
, , , ( 7).
7 Gram +
.
7-14
.
-.
2.2.1.
, , . 2-3
.
.
. .
2.3.

20% .
(, )
, , . , .
shock
. , :
(1-3 )
.
2.3.1.

271
12/10/07 1:00:35 PM
16

.
(, )
,
,
<10 ,
24 ,
10,
.
2.3.2.
1,5% ,
, 40%. Streptococcus pneumonie Haemophilus influenzae Staphylococcus aureus.
( 8).
8. .
()
0-2
2-5
5-18
>18
1
1
2
2
5 3
5 3
1,5 per os 12 ( ) .
7 ( 1 7 23).
3
23 .
2
9. .

, ,

, ,

18
2

/
5
/
5
272
12/10/07 1:00:36 PM

2.3.3.
, , ,
.
( 9).
3.
0,5-5% :
1.
: 3 .
: Staphylococcus aureus (5080%), Escherichia coli, Proteus sp., Pseudomonas aeruginosa, Klebsiella sp.,
Enterobacter sp.
2.
: >3 . :
Staphylococcus epidermidis, Propionibacterium acnes, Corynebacterium sp.,
Bacteroides fragilis, Candida sp., Mycobacterium sp.
Szilagyi:
:
: Scarpa
: (, )
.
. , , .

, , , .
,
.

+
+
/
+
/.
6
3-6 .
X

273
12/10/07 1:00:36 PM
16
:
.
3.1.
,

.
.
-
, .
,
, gram (+) , Staphylococcus
ureus. , ,
gram (-) , , .

,
.
, ,
( 10) , :
) ,
) ,
) ,
)
) .
,
.

,
.

.
274
12/10/07 1:00:36 PM

10. .
1
2

>2 (
, ,
, )
/ 2 cm

,

( )
,

:
2 cm
, ,
, ,
,

(,
, , , , ,
, ,
)
11. .
/
/
+
/
+
/
+ +
+ +
+
275
12/10/07 1:00:36 PM
16

,
gram + .
,
gram + , gram - ,
MRSA ( 11).

, . , ,
.
. :
- , 1-2
.
- ,
2 4
,
.
- ,
12
.
, ,
,
.
, , ,
, , .
,
, .
276
12/10/07 1:00:36 PM

,
,
, .
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Solomkin JS., Umanskiy K. Intraabdominal sepsis: newer interventional and antimicrobial therapies for infected necrotizing pancreatitis. Curr Opin Crit Care, 2003; 9:424-7.
Malangoni MA. Contributions to the management of intraabdominal infections. Am J Surg, 2005;
190:255-9.
Krobot K., Yin D., Zhang Q., Sen S., Altendorf-Hofmann A., Scheele J., Sendt W. Effect of inappropriate initial empiric antibiotic therapy on outcome of patients with community-acquired intraabdominal infections requiring surgery. Eur J Clin Microbiol Infect Dis, 2004 23:682-7.
Solomkin JS., Bjornson HS., Cainzos M., Dellinger EP., Dominioni L., Eidus R., Faist E., Leaper D., Lee JT.,
Lipsett PA., Napolitano L., Nelson CL., Sawyer RG., Weigelt J., Wilson SE. A consensus statement on empiric therapy for suspected gram-positive infections in surgical patients. Am J Surg, 2004; 187:134-45.
Clancy TE., Benoit EP., Ashley SW. Current management of acute pancreatitis. J Gastrointest Surg,
2005; 9:440-52.
Cavanagh PR., Lipsky BA., Bradbury AW., Botek G. Treatment for diabetic foot ulcers. Lancet, 2005;
366:1725-35.
Sheppard SJ. Antibiotic treatment of infected diabetic foot ulcers. J Wound Care, 2005;14:260-3.
Lee SY., Kuti JL., Nicolau DP. Antimicrobial management of complicated skin and skin structure
infections in the era of emerging resistance. Surg Infect 2005; 6:283-95.
Dellinger EP. Antibiotic prophylaxis in trauma: Penetrating abdominal injuries and open fractures.
Rev Infect Dis 1991; 13S:847-57
Sims EH., Thadepalli H., Ganesan K., Mandal AK. How many antibiotics are necessary to treat abdominal trauma victims? Am Surg, 1997;63:525-35.
The EAST Practice Management Guidelines Work Group. Practice management guidelines for prophylactic antibiotic use in penetrating abdominal trauma. http://www.east.org/tpg.asp.
Standards, Practice Guidelines and Statements Developed and/or Endorsed by Infectious Diseases
Society of America. http://www.idsociety.org/
Lipsky BA., Berendt AR., Deery HG. et al. Diagnosis and Treatment of Diabetic Foot Infections. Clin
Infect Dis, 2004;39:885-910.
277
12/10/07 1:00:36 PM
12/10/07 1:00:36 PM
17

: .
: .

.
.
.
.
.
.
.
12/10/07 1:00:36 PM
17
I.
A.

( 1). -
1530% 5-10%
. 5-15 ,
.

. (15-30%) .
,

.

2-5 . , . , ,
, , .
,

. , , .

, . .
280
12/10/07 1:00:36 PM

1. .

C G

Arcanobacterium haemolyticum
Flancisella tularensis
, ,
,
Vincent
,
,
,

Coronavirus

Coxsackie virus
Epstein-Barr virus
1 2

,
Herpangina, -

,
HIV

psittaci
, ,
,
,
, , , , ,
, , .

,
, 2-3 .

,
90-95% .

.
(Strep test)
(<30).
281
12/10/07 1:00:36 PM
17
(Kit)
.
80-90% >95%, . Strep test, ,
, , ,
, .

( ,
, ,
(Pediatric Autoimmune Neuropsychiatric Disorders Associated
with Streptococcal Infection-PANDAS), ,

.
1.
.
) .
.
Strep test
- .
Strep test,
,
,

,
Strep test.
, ,
-
.
) .
Strep test .
282
12/10/07 1:00:36 PM

, .
(Penicillin 50.000-100.000 IU/kg 2-3 x 10 ) . , 2.
15-20%.
1. .
.

( )
Strep Test
( 2)
2. .

V 50.000 -100.000 IU/kg/24 (2-3 ) x 10 , po
Benzathine Penicillin G 6 x105 IU x 7-10 IM
50-90 mg/kg (2-3 ) x 7-10 po

40 mg/kg/24 (2-3) x 10
25 mg/kg/24 (2 ) x 7-10
20 mg/kg/24 (1 ) x 3
- :
1. 20-30 mg/kg/24 (3 ) x 10
2. V (50.000 IU/kg/24) x 10
+ (20 mg/kg/24) x 4
3. / (80-90 mg/kg/24) x 10
4.
283
12/10/07 1:00:36 PM
17
B.
()
,
6-18 .
:
. (25-50%),
. (15-30%),
. (3-20%),
. (2-3%).
H :

( )

.

.
1.
1. .
2. ( 3 4).
3. 48-72
( 5).
2.
:
1. .
2. .
3. - (TMP/SMX) , (
>3 6 ). 40-80%.
4. 3 (
) ,
.
284
12/10/07 1:00:36 PM

3. . .
<6
6-2
>2
(
)

(-)
:
= 82%
= 72%
4. .
- 80-90 mg/kg/24 (2 ) x 7-10
- / 90 mg/kg/24 (2 ) x 7-10
( - , 39C)
- 2 3 x 5-10
- 25 mg/kg/24 (2 ) x 7-10
- 10 mg/kg/24 (1 ) x 3 30 mg/kg/24
5.
48-72 .
- / 80-90 mg/kg/24
- IM 50 mg/kg (1 ) x 3
-
- 10 mg/kg/24 (1 ) x 3 30 mg/kg/24
25 mg/kg/24 (2 ) x 7-10
. 5-10% .
: , , , . 3-5%.
.
:

>10-14
()
.
285
12/10/07 1:00:37 PM
17
<6 .
.
1.
.
/
/ .
10 3-6 .
4-6 ( 6).
, , , -,
, , .
6. .

:

.

( 1).
14-35% . 20-60% , 8-40%
.
:
1.
, ,
. (WHO).
2.
5 ,
(=>39C), (>20.000/mm3)
.
286
12/10/07 1:00:37 PM

3. ,
.
4. , 1/3
. . , .
5. ,
. , .
, ,
.
6. CRP (C- )
. ,
.
7.
2.
8.

: <4 , SaO2<92%, >70 /min >50
/min , , ,
(), , ,
.
9.
,
( ) 2-3 24.
10. (
SaO2>92% FiO2>0,6) ( , ), shock
.
11.

. 10%
.
12. <5 >5
3.
287
12/10/07 1:00:37 PM
17
1. .
3 3

Bordetella pertussis
H. influenzae

(RSV)
, ,
1,2,3
(CMV)
4 5

H. influenzae

Moxarella catarhallis
(RSV)
,
1,2,3
(HMPV)
,

(VZV)
5 18

Legionell sp.

EBV, ,
, ..
2. .
/
( <18 )
(1 2 )
(PCR)
( )

10-15%
(RSV,
..) /
, ,
, ,
Gram , /,

288
12/10/07 1:00:37 PM

3. .
<5
>5
. :
(90-100 mg/kg/24)
/
(90 mg/kg/24)
2
( 30 mg/kg/24)

10mg/kg 24
(1 ) 3-5
15-30 mg/kg/24

(100,000 IU/kg/24)
2
+/-
. : IV

/
(90-100 mg/kg/24)
(100-200,000 IU/kg/24)
*
3
+/-
( )
3
150 mg/kg/24
+/- 40 mg/kg/24
10 mg/kg/24
+
*

**
: 7-10 .
: 6 ( IV
).
**
24 2-3 24 (+/-) .
289
12/10/07 1:00:37 PM
17
.

1 2.
:

.
,
, 30% . ,
.

. , , . , (US) ()
. ,
.
,
80%. Proteus mirabilis , ,

.
290
12/10/07 1:00:37 PM

1. .

(0-2 )

/ :
(2 -2
>10 cfu/ml
>103-104 cfu/ml,

>10 cfu/ml
>103-104 cfu/ml,

(2-5 )
>104-105 cfu/ml

(5 )
>104-105 cfu/ml

:
US,
:
: US
: US

:
US, KO
>104-105 cfu/ml

US: .
: o .
: .
291
12/10/07 1:00:37 PM
17
2.
.
(0-2 )
US /
2-3
x 1
,

KO

/ :
(2 -2
+
)
US /

24-48

(2-5 )
Tmp/Smx
,
US /
10 14

:
+
US /
:
Tmp/Smx,
,
,
10 14
+
(5
)
:
Tmp/Smx,
,
US /

24-48

10-14

24-48

10-14
Tmp/Smx
Tmp/Smx
,
10 14
292
12/10/07 1:00:37 PM
:
+
US
Tmp/Smx
/
24-48

10-14
:
Tmp/Smx,
,
3
IV.
.
1.
:
H. influenzae type b
S. pneumoniae.
:
Group B streptococcus ()
Listeria monocytogenes ()
Escherichia coli ()
Salmonella sp.
. influenzae .
, .
2.

293
12/10/07 1:00:37 PM
17
3.

0-4
(200 mg/kg/24 :4) +
(150 mg/kg/24 :3)
+ (5 mg/kg/24 :2)
4-12
(300 mg/kg/24 :4) + (200mg/kg/24 :4) (100
mg/kg/24 :2)
3 -18
(100 mg/kg/24 :2 1 )
(

)

0,6 mg/kg /24 V
24.

(40 mg/kg/24) +
(300 mg/kg/24) +
(150 mg/kg/24)

Shunt +

100 mg/kg/24
H. influenzae type b
( ), IV
S. pneumoniae
( 4 g/24)
, (,
) .
,
( ) 1-2 ,
.
Group B streptococcus

Listeria
Salmonella
E. coli

294
12/10/07 1:00:37 PM

7 - /
10 -
21 -
14-21 - group B
6 -
: .
: 0,5-2 g/kg IV 30 /
:

5-10 mg/kg IV, 1-2 ()

5 mg/kg/24 2

0,02 mg/kg/ ()

= : 4-5

: -

>48-72 h =
shock:
shock.

()
(): <300 , <25%,
<100 mg/dl, >30 mg/dl.
:
/

( )

.
4.
24 .
5.
:
( ).
: 10 mg/kg x 2 x 2 p.o. ()
20 mg/kg x 1 x 4 ().
295
12/10/07 1:00:38 PM
17
: 600 mg x 2 x 2
500 mg x 1 p.o. () 600 mg x 1 x 4 ().
: 250 mg x 1 .
5 7
,
(, , , , .., --).
(2 30 ).
(2 5 ).
.
1.

S. aureus
Gram (-)
Toxoplasma gondii
().
2.

3.

,
+ (+/- )
/:
: +
: >6 .
296
12/10/07 1:00:38 PM

.
1.

.
2.

Y /

()
().
3.

+ + .
.
1.
:
Herpes Simplex Virus
Enteroviruses
Varicella Zoster Virus
Epstein-Barr Virus.
:
(M. tuberculosis, Bartonella sp.)
(T. gondii).
2.
.
: , , .
: .
297
12/10/07 1:00:38 PM
17
3.

5-10 mg/kg IV, 1-2 ()
5 mg/kg/24 2
0,02 mg/kg/

0,5-2 g/kg IV 30 (1-3 ) /
0,6 mg/kg/24 4 x 4-5
.

, (: 60 mg/kg/24 3 21 , : 1500
mg/m2 3 14-21 ).
V.
: -
Ecsherichia coli. , Listeria monocytogenes, Staphylococcus aureus, Gram
( Klebsiella pneumoniae)
, b.

(), , (Pseudomonas aeruginosa, Enterobacter
cloacae, Citrobacter freudii, Acinetobacter sp.), Staphylococcus epidermidis
Candida sp.
- : , ()
.
: (, ), .
: 14-21 .
: (, ) , :
4-6 .
298
12/10/07 1:00:38 PM

(MRSA): . :

. .
: ( ).
: -, : 6
.

.
.
: S. aureus ( MRSA), -
, Gram ( E. coli), -
.
.
. , ,
.
,
, () .
: E ( ) .
: 4-6 , 3-4
, >4 .
.

,
, .
.
- : .
(E. coli, K. pneumoniae, Enterobacter sp.,
Salmonella sp., Clostridium difficile, ..) .
.
299
12/10/07 1:00:38 PM
17
: , .

( ). , .
: , , , ( ),
. ,
.
.

.
10% .
: (50 mg/kg/24 x 4 x 14 ).
(10 mg/kg/24 x 1 x 4 ).
.

: (
) . , , , , ,
.
: Gram , (PCR)
. Gram ,

( ).
: .
:
,
.
: (50 mg/kg)
. .

HIV.
.

: Toxoplasma gondii, , (CMV), (), , - (VZ).
: ,
300
12/10/07 1:00:38 PM

(
) -
.

,
, (, , , , , ,
, , , ) / (, , , , , ).
.
1.
: IgG IgM , PCR. , ,

().
: (1 mg/kg/24 x 1) (100
mg/kg/24 x 2) (5-10 mg/kg x 3 ), 1 . , (1 mg/kg/24 x 2).
2.
,
IgG IgM ( IgG ,
, ). , IgG
IgM . , .
-- (MMR) .
: .
: , ,
, IgG IgM
PCR. .
: .
301
12/10/07 1:00:38 PM
17
3.
2 , IgG IgM
, ().
: (12 mg/kg/24 .. x 2
x 6 ).
4.
: ,
VDRL RPR ( )
FTA , () .
: G (150.000 U/kg/24 .. x 2 x 10
). , .
.
5.
, 2
: IgG IgM
( ) PCR .
: (60 mg/kg/24 .. x 3 x 21 ).
6.
,
- (VZIG) (. ).
90%
, , 2% .

. :
5
2 ,

30% .
302
12/10/07 1:00:38 PM

: . :
, IgG IgM, PCR.
: (30 mg/kg/24 .. x 3 x 7 ) VZIG (0,2-1 ml/kg .. / ,
.: 210-6603501-2).
VI.
1.
1.
.
2. , , .
3.
.
4. <500 l .
.
5.
,

(.. G-CSF) .
6.
4-7 .
303
12/10/07 1:00:38 PM
17
1.
.
(.. ,
, ),
(C5b-C9) . meningitidis

,
(.. , AIDS, (, ) ,
,
)
(
(,
)
), ,
, ,

(,
)
2.
(
, , , ), (.. , , / , /
, / ). .
3 4 (, , )
(, )
+
- (/)
+ (,
, , )
- / shock
-
gram (-)
+ (,
)
:
- / shock
-
- gram
(+) (.. MSRA,
)
304
12/10/07 1:00:38 PM

:
, , Hickman,
Broviac, .., . (.. ,
, , ), , .
: ,
, ,
.
/-.
/
/ .
.
( ).
.
3.
. ,
.
3.1.

(, ,
, )
-
o, , ,
, ,
,
, CMV, influenza
305
12/10/07 1:00:39 PM
17

: , ,
, ,
:
: RSV, , influenza, parainfluenza
: ,
, ,
: RSV, , influenza, parainfluenza,
CMV, VZV, HSV
: , ,
,
: ,

Gram (+) (-) ,
,
: , ,
,
: RSV, , influenza, parainfluenza
Gram (+) (-) , ,

, , ,
: ,
: RSV, , influenza, parainfluenza,
CMV, VZV, HSV
: , ,
,
. ,
.
/ / /
B ( , , ). CMV
( ,
, ) .
306
12/10/07 1:00:39 PM

4.
CMV
-
( /
)
VZV
HIV
(,
)

(
)

1. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH, Infectious Diseases Society of
America. Practice guidelines for the diagnosis and management of group A streptococcal
pharyngitis. Infectious Diseases of America. Clin Infect dis. 2002;35:113-25
-
1. American Academy of Pediatrics. Subcommittee on management of Acute Otitis Media. Diagnosis
and management of acute otitis media. Pediatrics 2004; 113:1451-65. Review
2. American Academy of Pediatrics. Subcommittee on management of Sinusitis and Committee
on Quality Improvement Clinical practice guideline: management of sinusitis. Pediatrics 2001;
108:789-808.

1. Kumar P, McKean MC. Evidence based paediatrics: Review of BTS guidelines for the management
of community acquired pneumonia in children. J Infect 2004;48:134-8.
2. Ostapchuk M, Roberts D, Haddy R. Community-Acquired Pneumonia in infants and children. Am
Fam Physician 2004;70:899-908.
3. British Thoracic Society. Guidelines for the Management of Community Acquired Pneumonia in
Childhood. Thorax 2002 (Suppl):1-24
4. Black S, Shninefield H, Baxter R, et al. Postlisensure Surveillance for Pneumococcal Invasive Disease
After Use of Heptavalent Pneumococcal conjugate Vaccine i Northen California Kaiser Permanente.
Pediatr Infect Dis J 2004;23:485-9.

1. Schlager TA. Urinary tract infections in infants and children. Infect Dis Clin North Am 2003;17:353-65.
307
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17

1. Chavez-Bueno S, McCracken GH. Bacterial Meningitis in children. Pediatr Clin N Am 2005;52:795-810.
- -
1. Pediatric Septic shock and multiple organ failure. Crit Care Clin. 2003 July;19:413-40, viii. Review.
PMID: 12848313 [PubMed - indexed for MEDLINE]
2. TORCH Infections. Toxoplasmosis, Other (syphilis, varicella-zoster, parvovirus B19), Rubella,
Cytomegalovirus (CMV), and Herpes infections. Curr Womens Health Rep. 2002 Aug;2:253-8.
Review. PMID: 12150751 [PubMed - indexed for MEDLINE]

1. Paul M, Yahav D, Fracer A, Leibovici L. Empirical antibiotic monotherapy for febrile neutropenia:
systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother.
2006 Feb;57:176-89.Equb 2005 Dec 12. Review.
2. Donowitz GR, Maki DG, Crnich CJ, Pappas PG, Rolston KV. Infections in the neutropenic patient-new
views of an old problem. Hematology Am Soc Hematol Educ Program. 2001; 114-39. Review.
308
12/10/07 1:00:39 PM

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47, 191
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135, 161, 181
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101, 257
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83, 117, 256
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3, 13, 21, 33, 191
., ...,
, ..
257
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257
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,
.,
, ,
..
., - ,
, ..
3, 13, 21, 33
3, 13, 21, 33, 47,
161, 215, 255,
256
135, 161, 181, 227
309
12/10/07 1:00:39 PM
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ISBN 978-960-88929-2-7

Group A Streptococci (S. pyogenes)

(Strep-test)2,3. 86% 91%, 90% 95%.

Streptococcus pneumoniae (~40%)

- Escherichia coli, Klebsiella pneumoniae

(Hospital Acquired Pneumonia HAP

 (trough) 1 g/ml 4 g/ml.

 , trough 15-20 g/ml.

Singh et al., Am J Resp Crit Care Med, 2000;162:505-11.

70 (10 mg/kg/24 3 ) 1 mg = 12500 IU.

. VAP (late onset)

Norwalk, Rotavirus, C. perfringens,

Campylobacter, Shigella, Salmonella,

E. coli O 157: H7. ,

diarrhea in developed and developing countries. J Clin Gastroenterol, 2005;39:757-73.

625 mg tid/1 g bid

qid: , tid: , bid: , od:

C. trachomatis, N. gonorrhoeae, HSV, - - .

(Syphilis, Treponema pallidum)

: Benzyl benzoate 25% .

: Benzyl benzoate 25% (emulsion)

HPV (HPV DNA TESTING)

HPV DNA testing

HPV DNA test

Kimberlin DW.et al. Genital herpes N Engl J Med,2004;350:1970-77.

: 15 mg/kg, 12, IV,

(MIC>0,12 mg/L 0,5 mg/L)

M (MIC>0,12 mg/L 0,5 mg/L)

G: 18-30x106 iu/24, IV,

: 15 mg/kg, 12, IV, 6

G: 18-30x106 iu/24, IV,

: 15 mg/kg, 12, IV, 6

: 15 mg/kg, 12, IV, 6

G: 30x106 iu/24, IV,

G: 30x106 iu/24, IV,

: 600 mg, 12, IV p.o., 8

-: 7,5 mg/kg, 8, IV,

: 600 mg, 12, IV p.o., 8

: 500 mg, 6, IV, 8

: 600 mg, 12, IV p.o.,

: 15 mg/kg, 12, IV,

: 600 mg, 12, IV p.o.,

*: 15 mg/kg, 12, IV,

*: 15 mg/kg, 12, IV,

: 15 mg/kg, IV, 12,

: 4 00 mg, IV, 12 750

* (antibiotic lock therapy).

* (antibiotic lock therapy ALT).

* Dumont et al.6 , 83%

2. MASCC (Multinational Association for Supportive Care in Cancer)

70 (10 mg/kg/24 3 ) 1 mg = 12500 IU.

200-400 mg - 800 mg (10-12 mg/kg)/24 . 400 mg/24.

50 mg/24, Candida albicans 100

Candida glabrata, krusei

Scedosporium prolificans, Alternaria,

Staphylococcus aureus (95%)

/ 3 g/6 IV +/- 1 mg/

100% 40% 20%

Coagulase negative staphylococci

, TBC (. . 250, 251)

Rx, MRI, Te99 3

(Gram, Ziehl Neelsen, Giemsa)

ALT, AST, GT, ALP,

Staphylococcus aureus (44%)

(trough) 1 g/ml 4 g/ml.

, trough 15-20 g/ml.

: 4 00 mg, IV, 12 750