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革兰阴性菌的主要耐药表型课件

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革兰阴性菌的主要耐药表型 革兰阴性菌的主要耐药表型PPT 耐药革兰阴性菌 革兰阴性杆菌
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lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 主要的革兰阴性菌的耐药表型 ü b-内酰胺类抗生素 ü 氨基糖苷类抗生素 ü 喹诺酮类抗生素 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 本章目的本章目的 l l 能解释什么是能解释什么是JarlierJarlier分类分类 l l 了解主要的肠杆菌科细菌的获得性耐药表型了解主要的肠杆菌科细菌的获得性耐药表型 l l 了解铜绿假单孢菌的获得性耐药表型了解铜绿假单孢菌的获得性耐药表型 l l 了解不动杆菌属耐药表型了解不动杆菌属耐药表型 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 天然耐药 抗生素原因 青霉素 G / M无法进入 MLSK无法进入 糖肽类无法进入 夫西地酸无法进入 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 对β类酰胺类抗生素的耐药机理 无进入通道 外排 PBP 修改 产酶(400种以上) Ø 青霉素酶 Ø 广谱青霉素酶 Ø Extended Spectrum Beta-Lactamase (ESBL) Ø 抑制剂酶TEM Ø 头孢呋辛酶 Ø 低水平/高水平头孢菌素酶 Ø 碳青霉烯酶 3.1 The Enterobacteriaceae GCS - TM - 0210 – 2008/09/19- chap 3.1 - p.5 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process beta-lactamase 类型 » 非常普遍 » 大于 400 种 质粒 广谱青霉素酶 ESBL 抑制剂耐药TEM 头霉素酶 头孢菌素酶 高水平 高水平 天然 获得性 染色体 头孢菌素酶 ** 持续性 诱导 青霉素酶* 持续性 * : Pase (group 2, 4), ESBL (group 6) ** : Case constitutive (group 1, 4), Inducible (group 3) Cefuroximase (group 5) 3.1 The Enterobacteriaceae GCS - TM - 0210 – 2008/09/19- chap 3.1 - p.6 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process Group 2 天然PASE b-内酰胺类的天然耐药表型 (*: 大多数属该组) amox inhib ticar C1G SSSS Group 1 无天然耐药存在,除大肠埃希菌和志贺 菌属产底水平CASE amoxamox inhib ticarticar C1G R R S R R S amox amox inhibinhib ticar C1G C1G R R R*R*S R R amox amox inhibinhib ticarticar C1G C1G R R R R R R R R Group 4 CASE + PASE Group 3 天然CASE CASE:头孢菌素酶 PASE:青霉素酶 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 肠杆菌科的天然耐药 阿莫西林 AMC 替卡西林 1代 3代 Escherichia coliSSSSS I IShigella/SalmonellaSSSSS Proteus mirabilisSSSSS II II K. pneumoniae / oxytoca RSRSS Citrobacter diversus RSRSS E. cloacae / aerogenes RRSRR Citrobacter freundiiRRSRR Proteus vulgarisRSSRS IIIIIISerratia marcescens RRSRS/in Morganella morganiiRRSRS/in Hafnia alveiRRSRS Providencia rettgeriRRSRS Providencia stuartiiRRSRS IVIVYersinia enterocolitica RRRRS/r r = 低水平耐药, in = 可诱导 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 10 b内酰胺类的获得性耐药 肠杆菌科 Group 3 Natural cephalosporinase Group 4 : CASE + PASE HLCHLC 染色体头孢菌素酶染色体头孢菌素酶 Amp CAmp C Group 1 野生株 Group 2 Natural penicillinase HLCHLC((突变)突变) 获得性青霉素酶 IRT ESBLESBL 获得性青霉素酶 ESBL ESBL 碳青酶烯酶 获得性青霉素酶 ESBL ESBL ESBLESBL IRT AmpCAmpC ApmCApmC HLPHLP((突变)突变) Group 1 Enterobacteriaceae and b-lactams E. coli, Shigella spp, Salmonella spp, P. mirabilis(P48) * *Rare – New – ESBL plus impermeabilityRare – New – ESBL plus impermeability Group 2 Enterobacteriaceae and b-lactams Klebsiella spp, Citrobacter koseri, E. hermanii, C. amalonaticus(P49) lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 13 Group 3 b-lactams(P49表6-3) Enterobacter spp, Serratia spp, Providencia spp, Citrobacter freundii, P. vulgaris, P. penneri, Morganella spp lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 14 Group 4 b-lactams Yersinia spp lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 15 肠杆菌科 氨曲南酶( hyper K1 ) New EnzymeNew Enzyme l注:该酶引起的耐药其3代头孢的MIC值低于ESBL。 并可用敏感的3代头孢治疗。 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 对碳青霉烯类的耐药 u 通透障碍(显示交叉耐药) – 膜孔蛋白丢失. (奇异变形 杆菌, 阴沟肠杆菌,假单孢菌) 通透障碍 + HLC (阴沟, 产气, 雷氏普罗威登菌) v 碳青霉烯酶(MERO强于IMI) • 青霉素酶类 (A类,丝氨酸酶类,IMI-1,KPC…)S. marcescens, E.cloacae – 对3代头孢保持活性 (except with E.cloacae)- 氨曲南 R • 金属酶类(B类,IMP-1,NDM-1…) :  E.coli, C.freundii, E.aerogenes… 水解3代头孢 – 氨曲南 S. 肠杆菌科 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process MHT: Classification of Carbapenemases ClassCarbapenemaseFound inNotes A KPCEnterobacteriaceaeHydrolyze all β-lactams. Inhibited by clavulanic acid. SMES. marcescens BMetallo beta- lactamases (IMP, VIM, GIM, SPM, NDM) P. aeruginosa Enterobacteriaceae Acinetobacter S. Maltophilia Hydrolyze all β-lactams except aztreonam. Somewhat inhibited by clavulanic acid. Require zinc for enzymatic activity; inhibited by EDTA. 17 Reference: Queenan MIC 2 Mero 16-21; MIC 2-4 Imi MIC 2-4 If using 2012 Current Breakpoints & MHT test requested for epidemiology Perform MHT Perform MHT When should we perform MHT? lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 20 b-内酰胺类的耐药表型 b-内酰胺酶: • 野生型 (天然头孢菌素酶) • 青霉素酶 • HLC • • ESBLESBL • • 碳青霉烯酶碳青霉烯酶 对b-内酰胺抗生素的通透障碍 • 泵出机制 • Porine D2丢失(碳青霉烯类) 铜绿假单孢菌 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 21 P.aeruginosa / b-lactamases (P53表6-8) lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 22 碳青霉烯酶: • 金属酶(IMP-1, MET-1, VIM-1) : 产生于铜绿假单孢 ,但是嗜麦芽寡养单胞菌 ,恶臭假单胞菌 ,荧光假单 胞菌 ,鲍氏不动杆菌 …中也发现 氨曲南 S P.aeruginosa / b-lactamases lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 23 P.aeruginosa / b-lactams 通透障碍(主要机制) EFFLUXD2 抗生素OprMOprJOprN TICRSSS TIC/CLAVRSSS PIPsSSS PIP/TAZsSSS CAZsSSS C4GsRSS ATMRSSS IMISSRR lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 24 氨基糖苷类的耐药表型 肠杆菌科和铜绿 修饰酶 通透障碍 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 25 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 肠杆菌科 和氨基糖苷类(P51表6-6) 注:对斯氏普罗威登斯菌 外的肠杆菌科细菌常常敏感 AAC6’常常伴随ESBL ISEPA=AMIKACIN lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 铜绿假单孢菌和氨基糖苷类 P54表6-9 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 喹诺酮类的耐药表型 肠杆菌科细菌和铜绿假单孢菌 p靶位的修改 p泵出 p通透障碍 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 29 喹诺酮类,肠杆菌科 (P52表6-7) DNA旋转酶由亚单位gyrA、gyrB组成 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 30 喹诺酮类,铜绿(P54表6-10) 注: ü 对1代全耐 ü VT2 C 上面仅有1、4型 ü 获得性耐药源于靶位修改、通透障碍或兼而有之 GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.31 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 鲍曼不动杆菌 –Β类酰胺酶:上世纪70年代前仅对青霉素耐药。 当前如果对氨基青霉素,氨基青霉素+克拉维酸,1,2代 头孢耐药,依然考虑为野生型。 –氨基糖苷类 都敏感 –甲氧苄啶 天然耐药 野生型 GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.32 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 不动杆菌属 » Beta-lactams 耐药机制 –产酶 • 青霉素酶 • 苯唑西林酶 (carbapenemase class D) • 头孢菌素酶 –无法进入Impermeability –靶位修改 GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.33 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 不定杆菌属 Beta-lactams 表型IIIIIIIVVVI 产酶« Wild »*PaseCasePase+Ca se CARBAPEN EMASE (METALLO- OR OXA) RESISTANT CARBAPENE MS (IMPERMEABI LITY) AminopenicillinRRRRRR Aminopenicillin + Clav. acRRRRRR CarboxypenicillinSRSRRS Cephalosporin 1st genRRRRRR Cephalosporin 2nd genRRRRRR Cephalosporin 3rd genSSRRRS AztreonamSSRRRS CarbapenemsSSSSRR * 染色体头孢菌素酶(低产) GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.34 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 不动杆菌属 氨基糖苷类的耐药机制: 产酶 酶类表型Phenotype频率 AAC(3) IG 30% AAC(3) IIGTN0-10% AAC(6’)TNA10-30% AAC(6’) IIGTN0-10% ANT(2’’) I GT0-10% APH(3’) IA30% RESISTANT (GEN NET AMI TOB) RESISTANT (GEN NET AMI) RESISTANT (GEN NET) RESISTANT (GEN TOB AMI) RESISTANT (GEN) RESISTANT (TOB GEN NET) RESISTANT (TOB NET AMI) RESISTANT (TOB NET) WILD AES GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.35 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 不动杆菌属 » 鲍曼不动对以下抗生素天然敏感: –利福平 –多粘菌素 –氟喹诺酮类 » 但是 –当前70%的菌株已对氟喹诺酮类 耐药 (靶位修改) GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.36 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 嗜麦芽窄嗜单胞菌 » 对大量抗生素天然耐药 –Beta-lactams (aminopenicillin, cephalosporin, carbapenems) –氨基糖甙类 (Kana, Tobra, Genta, Netil, Amika) –四环素 –喹诺酮类(1st generation, 2nd generation) –磷霉素 野生型 GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.37 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 嗜血杆菌属 » 天然耐药: –林可霉素 –其它的大环类脂类及环酮内酯类活性也降低 » 已知的获得性耐药 –B类酰胺酶 • 法国40-60% 菌株产酶,我国:30% • 不能很好的表达 = 使用头报销噻吩检测 –PBP 修改 • 影响所有的b-lactams • 主要是无荚膜的菌株 –亚胺培南耐药 • 原理不清 –其它抗生素 (罕见) • Chloramphenicol, Tetracyclin, Rifampicin, Cotrimoxazole and quinolones GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.38 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 脑膜炎奈瑟菌,淋病奈瑟菌 »天然耐药: –林可霉素 –糖肽类 –甲氧苄啶 –多粘菌素类 »已知的获得性耐药机理 –Beta-Lactams •B类酰胺酶: – N. meningidis很少, – N. gonorrhoeae常见 – 氨基青霉素失活,3代头孢不受影响 •PBP修改 •不能进入Impermeability –四环素 • N. gonorrhoeae 常见 – 质粒耐药= 高耐, – 染色体= 低耐. –喹诺酮类 •N. gonorrhoeae耐药增加 GCS - TM - 0210 – 2008/09/19- chap 3.4 - p.39 3.4 The Non Fermenters lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process 卡他莫拉菌 » 天然耐药: –林可霉素 –糖肽类 –甲氧苄啶 » 已知获得性耐药机理 b-lactamase • 广泛存在 • 可能是染色体介导 • 体外弱表达 = 使用头报销噻吩 lAsymptomatic ulcerative colitis patients on an ProDepression A Risk Factor for Infant Mental HealthMammography Benchmarks Angoff Process The A to Z of Susceptibility Testing GCS - TM - 0210 Version 3 - Revision 2004/01/06p. 7 - 40 革兰阴性菌的主要耐药表型 B内酰胺类 氨基糖苷类 喹诺酮类 复习复习
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