快樂小藥師 Im pharmacist nichts glücklich

前幾天本來要寫的，不過一忙就已經在朋友的部落格看到了，所以我就不多寫了

可以直接去他的部落格看看：

http://jerryljw.blogspot.com/2009/08/leptospirosis.html

那我總是要寫一點東西，所以我就Abx Guide裡面的內容擷取給大家看看好了

懶得看英文的人，就直接拉到下方紅字吧

Clinical：

Consider dx with fever, elevated bilirubin, elevated creatinine, transaminases ~5-7-fold above normal.

Risk factors include farming, slaughterhouse work, walking in alleys, swimming in fresh water (triathletes, kayaking), flood victims.

In U.S., Hawaii endemic for leptospirosis.

Hx: abrupt onset fever, severe leg muscle aches, in appropriate epidemiological context.

May be biphasic illness: septicemic phase then immune phase (fever, meningitis).

Complications: renal failure,hemorrhage, myocarditis; mortality can be as high as 25% if untreated.

Transmitted in inner cities, suburban and rural areas.

Diagnosis uncommon, depends on serology or culture in specialized laboratory.

Diagnosis: two FDA-approved commercially available kits available, an indirect hemagglutination (MRL) and a dipstick test (PanBio). Dipstick test is better performer.

In U.S., definitive testing (culture and microagglutination test (MAT) only available at CDC through state health labs, and at Vinetz lab at the U. of Cal San Diego (joseph_vinetz@hotmail.com). Blood should be inoculated into Fletcher's media immediately for subsequent transport to specialized lab for culture.

SITES OF INFECTION

Systemic illness with protean manifestations; multi-organ involvement possible.

Liver: jaundice, transaminases can be normal or elevated typically no more than 5-7-fold above normal.

Renal: acute renal failure usually resolves, but may require dialysis; ATN, interstitial nephritis; RBCs, WBCs, protein seen in urine; IV fluids may obviate need for dialysis.

Pulmonary: hemorrhage; atypical pneumonia, scattered patchy infiltrates, or ARDS.

Cardiac: EKG abnormalities common; myocarditis; heart failure.

CNS: aseptic meningitis (CSF WBCs 10-1000); hyporeflexia and axonal motor weakness.

GI: intestinal hemorrhage (rare); elevated lipase, amylase mimicking pancreatitis; mimics cholecystitis leading to surgery.

Eye: conjunctival suffusion (dilated small vessels), hypopyon, uveitis.

Derm: non-specific rash can occur, not typical.

TREATMENT

Penicillin

1.5 million units IV q6 hr for hospitalized patients x 5-7 d.

Doxycycline

100 mg bid IV or PO x 5-7 d.

Ceftriaxone

1 g IV q day x 5-7 d.

Prophylaxis

Doxycycline 200 mg PO once per week when unavoidable exposure to environments at high risk for leptospirosis (e.g., swimming through jungle waters, kayaking in developing countries).

Should be part of pre-travel medicine advice.

除了藥物的選擇以外，還有使用上的建議：

Amoxicillin

Would likely be effective.

Cefotaxime

Would likely be effective.

 Ceftriaxone

Shown to be as effective as penicillin in an open labeled trial in Thailand.

Ciprofloxacin 

Of unknown efficacy in the clinical setting.

 Doxycycline

Drug of choice, usually when oral therapy chosen.

 Penicillin

Drug of choice. Jarisch-Herxheimer reaction can occur.

Azithromycin  

Very likely to be effective .

OTHER INFORMATION

Cultures should be obtained prior to abx (inoculated into Fletcher's media); some commercial blood culture systems do not kill leptospires, and such specimens should be sent expeditiously to CDC or UCSD for specific lepto cultures.

Epidemiology: leptospirosis can be transmitted to humans from vaccinated animals (e.g., cattle or dogs)--the vaccine may prevent animal illness but not the chronic carrier/transmission state.