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Старый 14.01.2010, 23:04
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По гайдам: Vancomycin 30 mg/kg per 24 h IV in 2 doses for 6-8 wks + Rifampin 900 mg/24 h IV in 3 divided doses for 6-8 wks + Gentamicin 3 mg/kg per 24 h IV (maximum 240 mg/d), divided in 3 doses for 6-8 wks.

Цитата:

Methicillin susceptibility*—*Vancomycin is the critical drug for isolates resistant to methicillin, while a semisynthetic penicillinase-resistant penicillin (nafcillin, oxacillin) is the mainstay of therapy for isolates susceptible to methicillin. In patients with penicillin allergy that does not involve anaphylaxis, swelling, or hives, the AHA recommends that a first generation cephalosporin can substitute for nafcillin or oxacillin. We agree with this recommendation.

If the organism is susceptible to gentamicin by routine testing, this should be the second agent, with rifampin as the third agent. (See "Rifampin" below). The aminoglycoside should be administered for the initial two weeks of treatment, after which it can be discontinued and the other two agents continued for at least four additional weeks. If the organism is resistant to gentamicin, an alternative aminoglycoside should be sought based upon antibiotic susceptibilities.

If the isolate is resistant to all available aminoglycosides, a fluoroquinolone to which the strain is highly susceptible should be used [11-13] . If a fluoroquinolone is used in lieu of an aminoglycoside, we prefer to continue the three-drug regimen for the entire course of treatment. When the isolate is resistant to all aminoglycosides and fluoroquinolones, daptomycin [14] , linezolid [15] , or trimethoprim-sulfamethoxazole could be considered as a third drug for the initial two weeks of therapy. If breakthrough bacteremia or microbiologic failure occurs in patients receiving daptomycin, the isolate recovered from the breakthrough bacteremia should be tested for the development of daptomycin resistance [16] .

Optimal therapy of PVE caused by methicillin-resistant S. aureus with reduced vancomycin susceptibility, has not been established. Although linezolid and daptomycin are often active against these organisms, clinical experience in the treatment of PVE is limited [14,17] .

Rifampin*—*Rifampin appears to have the unique ability to kill staphylococci that are adherent to foreign material, based upon in vitro data, evidence from animal model experiments, and clinical observations [4,8-13,18] . This drug is an essential component of regimens used to treat staphylococcal PVE. However, bacterial cells have a relatively high intrinsic mutation rate for the gene controlling the rifampin site of action. These mutations allow the selection of a rifampin-resistant subpopulation when large numbers of staphylococci are exposed to ineffective rifampin-containing regimens [4,11] .

To protect against the emergence of resistance, the recommended regimens for staphylococcal PVE (see "Staphylococci" above) ideally contain two additional antimicrobials, which should be identified prior to the initiation of rifampin, if at all possible. Thus, a regimen with two other drugs to which the staphylococci are susceptible should be in place at the time rifampin is begun. If the isolate is not sensitive to two additional antimicrobials, therapy with a single antistaphylococcal agent should be administered for three to five days before beginning rifampin. This strategy may reduce the total number of staphylococci at the site of infection and thus diminish the probability that a rifampin-resistant subpopulation will emerge. Nevertheless, susceptibility to rifampin should be reassessed when regimens containing rifampin fail [8]