68.承上題，王先生入院後因呼吸窘迫須插管治療，感染狀況逐漸控制住。但插管7天後又出現新的下呼吸道感染症狀，此時最可 能造成肺炎的致病菌是下列何者？
(A)Streptococcus pneumoniae
(B)Pseudomonas aeruginosa
(C)methicillin-susceptible Staphylococcus aureus
(D)Mycoplasma pneumoniae

入院四十八小時後才發生的肺炎稱之為院內感染型肺炎(hospital-acquired pneumonia, HAP)

與社區型肺炎不同的是院內感染型肺炎之致病菌往往是多重抗性的細菌，如：綠膿桿菌(Pseumonas aeruginosa)、抗藥性金黃色葡萄球菌(MRSA)、Acinectobacter baumannii等。 

CAP社區肺炎（Community-acquired pneumonia常見細菌抗生素治療

       Streptococcus pneumoniae

                                 若penicilin MIC < 2 ug/ml 建議使用Penicillin , Ampicllin or Amoxicillin

                                 若penicilin MIC >4 ug/ml則考慮3° , 4° cephalosporins  ,  Vancomycin or Teicoplanin

                                 替代：New fluoroquinolones (Moxifloxacin, Levofloxacin 750mg/day,Gemifloxacin)

       Haemophilus influenzae     

              β-lactamase (-)  ： Ampicillin or amoxicillin

              β-lactamase (+) ： Ampicillin/sulbactam , Amoxicillin/clavulanate ,2°cephalosporins

                                替代：New macrolides(Azithromycin) , TMP/SMX , 3° cephalosporins ,fluoroquinolones

     Moraxella catarrhalis

                首選：2° cephalosporins ,Ampicillin/sulbactam , Amoxicillin/clavulanate

                替代：Erythromycin or new macrolidesc , 3° cephalosporins ,Fluoroquinolones

(Atypical CAP)    Legionella spp. , Mycoplasma pneumoniae , Chlamydia pneumoniae

                首選：Erythromycin or new macrolidesc , (Chlamydia可用Tetracyclines)

                替代：Tetracyclines , Fluoroquinolones

HAP院內肺炎（Hospital-acquired pneumonia)常見細菌抗生素治療

   考慮：GNB  K. pneumoniae,  P. aeruginosa ,  Acinetobacter spp.

            首選：3° cephalosporinse(抗綠膿Ceftazidine) or Ureidopenicillins ±Aminoglycosidesf ±Erythromycin or new macrolide

            替代：Timentin or Tazocin or 4°cephalosporins ±Aminoglycosidesf ±Erythromycin or new macrolide ,Fluoroquinolones

  考慮：GPC  MRSA

           首選：Vancomycin Teicoplanin or Linezolid

其他

 (for MDRAB)   ±Sulbactam

(for MDRPA or MDRAB)  ±Colistin

Ref:http://taxol76.pixnet.net/blog/post/26726162-%E8%82%BA%E7%82%8E%E6%8A%97%E7%94%9F%E7%B4%A0%E6%B2%BB%E7%99%82

最佳解多了一個c: Acinectobacter baumannii 鮑氏不動桿菌(AB菌)，為G(-)桿菌