제 6장. 비뇨기계 항생제 사용법
항생제 사용법 요약
급성 단순방광염의 경험적 항생제 요법
(2016 단순요로감염가이드라인.대한요로생식기감염학회.)
| 항생제 | 용법 (경구) | 기간 |
|---|---|---|
| Fosfomycin trometamol | 3g qd | 1 day |
| Pivmecillinam* | 400mg tid | 3 days |
| Nitrofurantoin macrocrystal* | 100mg bid | 5 to 7 days |
| Beta-Lactams | ||
| Amoxicillin-clavulanate | 250/125mg tid
500/125mg bid |
7 days |
| Cefaclor | 250mg tid | 7 days |
| Cefdinir | 100mg tid | 5 to 7 days |
| Cefcapene pivoxil | 100mg tid | 5 to 7 days |
| Cefpodoxime prexetil | 100mg tid | 5 to 7 days |
| Fluoroquinolones | ||
| Ciprofloxacin** | 500mg bid
500mg 서방정 qd |
3 days |
| Tosufloxacin** | 150mg bid | 3 days |
* ; 현재, 국내 사용불가
** ; 임신부 사용불가
폐경전 여성에서 단순 급성신우신염의 초기 경험요법
(2016 단순요로감염가이드라인.대한요로생식기감염학회.)
경구요법: 경도 및 중등도 단순 급성 신우신염
| 항생제 | 용량 | 치료기간 |
|---|---|---|
| Ciprofloxacin1) | 500-750mg bid | 7-10일 |
| Levofloxacin1) | 250-500mg qd | 7-10일 |
| Levofloxacin | 750mg qd | 5일 |
| 대체약제 (임상적으로 fluoroquinolone 과 동등한 효과를 보이지만, 세균학적 효과 동등성은 입증되지 못함) | ||
| Cefpodoxime proxetil | 200mg bid | 10일 |
| Ceftibuten | 400mg bid | 10일 |
| 항생제 감수성 검사가 시행된 경우 (일차 치료로는 적절하지 않음) | ||
| Trimethoprimsulphamethoxazole | 160/800mg bid | 14일 |
| Co-amoxiclav2),3) | 0.5/0.125g tid | 14일 |
| * 1) 저용량은 연구되었으나 고용량은 전문가의 견해, 2) 단순 급성 신우신염의 치료로서 단독사용 연구는 없음, 3) 그람양성균 에서 주로 사용 | ||
비경구요법: 중증 단순급성 신우신염
• 증상이 호전된 후 경구요법으로 전환할 수 있으며 1-2주간 치료를 지속한다. 본 표에서는 용량만 표기
| 항생제 | 용량 |
|---|---|
| Ciprofloxacin | 400mg bid |
| Levofloxacin1) | 250-500mg qd |
| Levofloxacin | 750mg qd |
| 대체약제 | |
| Cefotaxime2) | 2g tid |
| Ceftriaxone1),4) | 1-2g qd |
| Ceftazidime2) | 1-2g tid |
| Cefepime1),4) | 1-2g bid |
| Co-amoxiclav2),3) | 1.5g tid |
| Piperacillin/tazobactam1),4) | 2.5-4.5g tid |
| Gentamicin2) | 5mg/kg qd |
| Amikacin2) | 15mg/kg qd |
| Ertapenem4) | 1g qd |
| Imipenem/cilastatin4) | 0.5/0.5g tid |
| Meropenem4) | 1g tid |
| Doripenem4) | 0.5g tid |
| 1) 저용량은 연구되었으나 고용량은 전문가의 견해
2) 단순 급성 신우신염의 치료로서 단독사용 연구는 없음 3) 그람양성 균에서 주로 사용 4) 단순 급성 신우신염 및 복잡성 요로감염 동일 권고안 | |
항생제 사용 용량
(Ref> 2012 Stanford guide to antimicrobial therapy 42nd ed.)
| Class, Agent, Name | Usual adult dosage | Preg risk |
|---|---|---|
| Natural penicillins
Benzathine penicillin G Penicillin G |
-
600,000-1.2 million units IM q2-4wks Low: 600,000-1.2 million units IM per day |
B
B |
| -
Penicillin V |
High: ≥20 million units IV q 24hrs
500 mg p.o bid, tid |
B |
| Aminopenicillins
amoxicillin amoxicillin-ER amoxicillin-clavulanate Ampicillin - ampicillin-sulbactam |
-
250mg-1g po tid One 775mg tab po q D 500/125, 875/125 1tab po bid 250mg-500mg po q 6hr 50-200mg/kg IV/day 1.5-3g IV q 6hr |
B
B B B B |
| Extended spectrum
penicillins piperacillin - |
-
3-4g IV q 4-6hr (max 24g/day) for urinary tract infection: 2g IV q 6hr |
B |
| Antipseudomonal penicillins
piperacillin-tazobactam - - - |
-
standard dose (no pseudomonas) 3.375g IV q 6hr or 4.5g IV q 8hr standard dose (pseudomonas) 3.375g IV q 4hr or 4.5g IV q 6hr |
B |
| Carbapenems
Doripenem - Ertapenem Imipenem+cilastatin Meropenem |
-
intra abdominal, complicated UTI 500mg IV q 8hr (1hr infusion) 1g IV/IM q 24hr 0.5g IV q 6hr 0.5-1g IV q 8hr |
B
B C B |
| Cephalosporins
1세대 Cefazolin Cefadroxil Cephalexin 2세대 cefotetan cefoxitin cefuroxime cefaclor cefprozil |
- - 1-1.5g IV/IM q 8hr (max 12g/day) 0.5-1g po q 12hr 0.25-1g po q 6hr (max 4g/day) - 1-3g IV/IM q 12hr 1g q 8hr-2g IV/IM q 6-8hr 0.75-1.5g IV/IM q 8hr 0.25-0.5 g po q 8hr 0.25-0.5 g po q 12hr |
B B B B B B B B |
| cefuroxime axetil
3세대 cefoperazone-sulbactam cefotaxime ceftazidime ceftizoxime ceftriaxone cefdinir cefditoren pivoxil cefixime cefpodoxime proxetil ceftibuten |
0.125-0.5 g po q 12hr
- 1-2g IV q 12hr 1g q8-12hr to 2g IV q 4hr 1-2g IV/IM q 8-12hr 1-2g IV q 8-12hr 1-2g once daily 300mg po q 12hr or 600 mg q2 4hr 400mg po bid 400mg po bid 0.1-0.2g po q 12hr 0.4g po q 24hr |
B
B B B B B B B B B B |
| Macrolide
Azithromycin Clarithromycin |
- 0.5g IV per day (oral 제제는 질병에 따라 변동) 0.5g po q 12hr |
B
C |
| Tetracyclines
Doxycycline |
-
0.1 g po/IV q 12hr |
B |
| Fluoroquinolones
ciprofloxacin gemifloxacin levofloxacin moxifloxacin ofloxacin |
-
250mg po bid/400mg IV q 12hr 320mg po q 24hr 250, 500, 750mg po/IV q 24hr 400mg po/IV 24hr 200-400mg po bid |
C
C C C C |
| Amnioglycoside
Amikacin Gentamycin |
-
15mg/kg/day IV 3mg/kg q 8hr IV |
D
D |
| 기타
fosfomycin metronidazole - |
-
3g with water po times 1 dose Anaerobic infection: IV 7.5mg/kg q 6hr oral dose 1g qd |
B
B |
Preg risk: 임신시 사용가능여부 FDA category
12세 이하 UTI 항생제 사용법
(Ref> 2013 EAU guideline, 요로생식기감염)
| Class, Agent, Name | total dosage per day |
|---|---|
| Cephalosporins
cefotaxime ceftazidime ceftibuten cefixime cefuroxime axetil cefpodoxime proxetil cefaclor Cephalexin Ceftriaxone |
-
100-200mg/kg (청소년3-6g) IV 100-150mg/kg (청소년2-6g) IV 9mg/kg (청소년 0.4g) po 8-12mg/kg (청소년 0.4g) po 20-30mg/kg (청소년 0.5-1g) po 8-10mg/kg (청소년 0.4g) po 50-100mg/kg (청소년 1.5-4g) po 50-100mg/kg 50-100mg/kg |
| Aminopenicillins
ampicillin amoxicillin amoxicillin-clavulanate - |
-
100-200mg/kg (청소년 3-6g) IV 50-100mg/kg (청소년 1.5-6g) po 60-100mg/kg (청소년3.6-6.6g) IV 45-60mg/kg (청소년 1500+375mg) po |
| Aminoglycosides
tobramycin Gentamycin |
-
5mg/kg (청소년3-5mg/kg, 최대 0.4g) IV 5mg/kg (청소년3-5mg/kg, 최대 0.4g) IV |
| 기타
Trimethoprim |
-
6mg/kg po |
신기능에 따른 용량 조정 (Ref> 2013 EAU guideline)
| Antibiotic | GFR (mL/min) | Comments | ||
|---|---|---|---|---|
| Mild
50-20 |
Moderate
20-10 |
Severe
< 10 |
||
| *Aciclovir | Normal dose every 12h | normal dose every 24h | 50% of normal dose every 24h | Give postHD |
| Aciclovir po | normal | Herpes simplex: normal Herpes zoster: 800mg Total Dissolved Solids tds | Herpes simplex: 200mg bid Herpes zoster: 800 mg bd | Give postHD |
| Amikacin | 5-6mg/kg 12h | 3-4mg/ kg 24h HD: 5mg/ kg post HD and monitor levels | 2mg/kg 24-48h | Give post-HD Monitor preand 1h postdose levels after 3rd dose and adjust dose as required |
| Amoxicillin po | normal | normal | 250mg 8h (normal) | Give postHD |
| Amphotericin | normal | normal | normal | |
| (Liposonal+ lipid complex) | Amphotericin is highly NEPHROTOXIC. Consider using liposomal/lipid complex amphotericin. Daily monitoring of renal function (GFR) essential. | |||
| Ampicillin IV | normal | 250-500mg 6h | 250mg 6h (500mg 6h) | Give postHD |
| Benzylpenicillin | Normal | 75% | 0-50% Max. 3.6g/ day (1.2g qds) | Give postHD Refer to microbiology for dosing in SBE |
| Caspofungin | normal | normal | normal | |
| Cefotaxime | normal | normal | 1g stat then 50% | Give postHD |
| Cefradine | normal | normal | 250mg 6h | Give postHD |
| Ceftazidime | 1g 12h | 1g 24h | 500mg 24h (1g 24h) | Give postHD |
| Ceftriaxone | normal | normal | normal Max. 2g/day | |
| Cefuroxime IV | normal | 750mg-1.5g 12h | 750mg 24h (750mg 12h) | Give postHD |
| Ciproflazin IV+po | normal | 50% | 50% | |
| Clarithromycin IV+po | normal | normal | 50% | Give postHD |
| Clindamycin IV+po | normal | normal | normal | |
| Coamoxiclav IV (Augmentin) | normal | 1.2 stat then 50% 12h (1.2g 12h) | 1.2 stat then 50% 24h (1.2g stat then 600mg 12h) | Give postHD |
| Coamoxiclav po (Augmentin) | normal | 375-625mg 12h (375mg 8h) | 375mg 12h (375mg 8h) | Give postHD |
| Cotrimoxazole IV | normal | Normal for 3/7 then 50% | 50% | Give postHD |
| Doxycycline contraindicated | normal | normal | normal | All other tetracyclines contraindicated in renal impairment |
| Erythromycin IV+po | normal | normal | normal Max. 1.5g/ day (500mg qds) * | |
| *Ethambutol | normal | 24-36h | 48h | Give postHD |
| Monitor levels if GFR < 30mL/min (contact Mirco) | ||||
| Flucloxacillin IV+po | normal | normal | normal Max. 4g/day | |
| Fluconazole | normal | normal | 50% | Give post-HD No adjustments in single-dose therapy required |
| *Flucytosine | 50mg/kg 12h | 50mg/kg 24h | 50mg/kg stat thendose according to levels | Give post-HD Levels should be monitored predialysis. |
| Fusidic acid | normal | normal | normal | |
| 1) Gentamicin ONCE DAILY | GFR 10-40mL/min
3mg/kg stat (max. 300mg) Check pre-dose levels 18- 24h after first dose Redose only when level < 1mg/L |
GFR < 10mL/ min
2mg/kg (max. 200mg) redose according to levels |
BOTH METHODS Give postHD
Monitor blood levels: | |
| 2) Gentamicin CONVENTIONAL | 80mg 12h 80mg 48h | 80mg 24h HD: 1-2mg/ kg
Post-HD: redose according to levels |
Once daily: pre only
Conventional: pre and 1 h post level required. | |
| Imipenem | 500mg 8-12h | 250-500mg bid | Risk of convulsions - use Meropenem: see below | Give postHD |
| Isoniazid | normal | normal | 200-300mg 24h | Give postHD |
| Itraconazole | normal | normal | normal | |
| Levoflaxacin | 500mg stat then 250mg bid** | 500mg stat then 125mg bid** | 500mg stat then 125mg od | **Applies if full dose is 500 mg bid If full dose is 500 mg od, five reduced doses daily |
| Linezolid | normal | normal | normal | Give postHD |
| Meropenem | 12h | 50% 12h | 50% 24h | Give postHD |
| Metronidazole | normal | normal | 12h (normal) | Give postHD |
| Nitrofurantoin | Do NOT use in renal impairment | |||
| Penicillin V | normal | normal | normal | Give postHD |
| Piperacillin/ Tazobactam (Tazocin) | 4.5g 8h | 4.5g 12h | 4.5g 12h | Give postHD |
| Pyrazinamide | normal | normal | normal | |
| Rifampicin | normal | normal | 50-100% | |
| *Teicoplanin | 100% 48h | 100% 72h | 100% 72h | Dose reduction after day 3 of therapy |