医院获得性肺炎杜斌课件

医院获得性肺炎(杜斌)加强医疗科医院获得性肺炎(杜斌)HAP-概况 定义 住院48小时后发生的肺炎 接受机械通气患者的7%至40%收治ICU的患者较普通病房患者明显增高 气管插管进行机械通气的患者发生肺炎危险性增加数倍医院获得性肺炎(杜斌)HAP-概况 常见医院获得性感染的第一位 罹患率及病死率最高 40%to 80%住院死亡患者中约15%直接与医院获得性肺炎有关 1/3 to 1/2=归因死亡率医院获得性肺炎(杜斌)ICU中HAP的患病率3,668名MICU&SICU患者420(11.5%)发生HAP56%为早期发病(96 hours)44%为晚期发病(96 hours)Ibrahim,et al.Chest 2000;117:1434-1442.医院获得性肺炎(杜斌)HAP-流行病学患病率 NNIS-所有住院患者医院获得性下呼吸道感染 0.6 例/100 住院患者 ICU患者8%至20%EPIC-医院获得性肺炎 10038名ICU患者中967名=9.6%欧洲医院获得性肺炎协作组 肺炎粗患病率8.9%医院获得性肺炎(杜斌)HAP-流行病学 接受机械通气的ICU患者发生肺炎的危险明显增加作者比数比Cross10SENIC21Celis 7EPIC?Chevret 3医院获得性肺炎(杜斌)ReferencesStudy YearsNo.of PtsStudiedIncidence ofVAP,%DiagnosticCriteriaMortalityRate,%Salata1981-19825141Clinical,autopsy76Craven1983-198423321Clinical55Langer1983-198472423Clinical44Fagon1981-19855679PSB71Kerver19863947Clinical30Jimenez19867727PSB38Driks1986-198713018Clinical56Torres1987-198832224Clinical,PSB33Baker1989-19935145.4PSB,BAL24Kollef1992-199322715.5Clinical37Fagon1989-1994111827.5PSB,BAL53HAP-流行病学医院获得性肺炎(杜斌)HAP-流行病学 23个意大利ICU进行的前瞻性研究 长期接受机械通气治疗(72 hrs)的724名患者 VAP平均患病率=23%5%5%68.8%68.8%0%0%20%20%40%40%60%60%80%80%MV 1dMV 1dMV 30dMV 30d医院获得性肺炎(杜斌)HAP-流行病学0.0%10.0%20.0%30.0%40.0%051015202530days of ventilationcumulative hazard of pneumonia,%肺炎患病危险每日增加肺炎患病危险每日增加1%医院获得性肺炎(杜斌)HAP-流行病学 气管插管时间=发生HAP非常重要的危险因素医院获得性肺炎(杜斌)HAP-病死率医院获得性肺炎(杜斌)HAP-病死率致病菌也是影响病死率的危险因素 革兰氏阴性杆菌肺炎较革兰氏阳性球菌病死率更高 56%vs 24%(Graybill)50%vs 5%(Stevens)绿脓杆菌Pseudomonas aeruginosa 70%to 80%医院获得性肺炎(杜斌)HAP-病死率细菌耐药性-死亡的危险因素 迟发性肺炎(Kollef)高危致病菌(P.aeruginosa,Acinetobacter spp.,and S.maltophilia)65%vs 31%MRSA vs MSSA(Rello)85.7%vs 11.9%(RR=20.72)医院获得性肺炎(杜斌)HAP-死亡的危险因素多因素回归分析 呼吸功能衰竭的恶化 存在最终致命性基础疾病 存在迅速致命性基础疾病 出现休克 不适当的抗生素治疗 ICU的种类-by Torres et al医院获得性肺炎(杜斌)HAP-死亡的危险因素VariablesOR(95%CI)in1978 ICUpatientsOR(95%CI)in1118 mechanicallyventilated patientsAPACHE II score1.08(1.06-1.10)1.06(1.04-1.09)Number of dysfunction organs1.54(1.36-1.74)1.36(1.19-1.56)Nosocomial bacteremia2.51(1.78-3.55)2.12(1.49-3.02)Nosocomial pneumonia2.08(1.55-2.80)1.51(1.17-2.03)Fatal underlying disease1.76(1.38-2.25)1.60(1.23-2.09)Admission from other ICU1.30(1.01-1.68)NS死亡的独立危险因素死亡的独立危险因素-多因素分析的结果多因素分析的结果医院获得性肺炎(杜斌)HAP-死亡的危险因素ReferencesYearDiagnosticCriteriaType ofPatientsCrudeMortality inCases,%CrudeMortality inControls,%AttributableMortality,%RiskRatioCraig andConnely1978-1979ClinicalNon-ICU andICU20.45.614.83.6Leu et al1982-1983ClinicalNon-ICU20.313.56.81.5Fagon et al1988-1990PSB,BALVentilated54.227.127.12.0Cunnion et al1987-1991ClinicalSICU(95%ventilated)5555011.6MICU(95%ventilated)557.547.57.3Baker et al1989-1993PSB,BALTrauma,ventilated242401医院获得性肺炎的粗病死率与归因死亡率医院获得性肺炎的粗病死率与归因死亡率-5项对照队列研究的结果项对照队列研究的结果医院获得性肺炎(杜斌)HAP-预后AuthorpopulationendpointVAP groupctrl groupP valueJimenz-duration of MV32 d10 dCraig&Connelly-ICU stay3 xLeu-hospital stay+9.2 dFagon-ICU stay21 d15 d 0.02Bakertraumaduration of MV12.0 d8.0 d 0.001ICU stay20.5 d15.0 d 0.001hospital stay43.0 d34.0 d24 h)再次气管插管 既往应用抗生素?可证实的误吸 应用肌松剂 气管插管套囊压力过低 仰卧位医院获得性肺炎(杜斌)HAP-危险因素HAP的独立危险因素逻辑回归分析结果 既往应用抗生素 器官功能衰竭 年龄超过60岁 平卧位-by Kollef医院获得性肺炎(杜斌)HAP-危险因素应激性溃疡的预防-荟粹分析的结果 sucralfate vs H2 blockers9 studies sucralfate vs antacids 10 studies 应激性溃疡的预防sucralfate=antacids H2 blockers 医院获得性肺炎发生率sucralfate 35%oxygento maintain an arterial oxygen saturation 90%Rapid radiographic progression,multilobarpneumonia,or cavitation of a lung infiltrate Evidence of severe sepsis with hypotension and/orend-organ dysfunction:Shock(systolic blood pressure 90 mmHg,ordiastolic blood pressure 60 mmHg)Requirement for vasopressors for more than 4 h Urine output 20 ml/h or total urine output 80 ml in4 h(unless another explanation is available)Acute renal failure requiring dialysis医院获得性肺炎(杜斌)不正确的经验性抗生素治疗 目的:评价机械通气过程中医院获得性肺炎的发生率，危险和预后因素 背景 1,000张床位的教学医院 1987年4月至1988年5月 患者人群 322名连续收治的机械通气患者中78(24%)例医院获得性肺炎医院获得性肺炎(杜斌)不适当的经验性抗生素治疗OR95%CIP valueThe presence of an ultimately orrapidly fatal underlying disease8.843.5222.20.0018worsening of acute respiratoryfailure caused by pneumonia11.944.75300.0096the presence of septic shock2.831.415.780.016an inappropriate antibiotic tx5.812.70-12.480.02the type of ICU hospitalization(noncardiac surgerical and non-surgical ICU compared withpost-cardiac surgery ICU)3.381.705.710.06From:Torres et al.Incidence,risk,and prognosis factors of nosocomial pneumonia in mechanically ventilated patients.Am Rev Respir Dis 1990 Sep;142(3):523-8医院获得性肺炎(杜斌)不适当的经验性抗生素治疗1.01 年龄较小年龄较小1.04 APACHE II1.88 血行性感染血行性感染3.39 既往抗生素治疗既往抗生素治疗比数比比数比危险因素危险因素医院获得性肺炎(杜斌)不适当的经验性抗生素治疗医院获得性肺炎(杜斌)HAP-经验性治疗6342114Rello et al,1997823865Luna et al,1997573160Kollef and Ward,19989230118Celis et al,19883532430Alvarez-Lema,1996Inappropriatedly treated patientsAppropriately treated patientsPatients,no.StudyMortality,%抗生素治疗的正确性对抗生素治疗的正确性对VAP患者病死率的影响患者病死率的影响医院获得性肺炎(杜斌)经验性抗生素治疗与正确的经验性抗生素治疗相比较，不适当的抗生素治疗可导致：病死率增加(p=0.0385)并发症增加(p0.001)休克发生率增加(p 38 C or 10,000 or 3,000)脓性气管分泌物干预措施 在临床诊断VAP后或原有VAP侵润影进展后24小时内进行纤维支气管镜下BAL 所有患者均应用抗生素，其中107在纤维支气管镜见检查前，25名在纤维支气管镜检查后立即应用抗生素医院获得性肺炎(杜斌)经验性抗生素治疗医院获得性肺炎(杜斌)HAP-经验性治疗Algorithm for classifying patients with ventilator-acquired pneumoniaTable 1Onset any timeNoTable 2Onset any timeYesRisk FactorsMild-to ModerateTable 1Early OnsetTable 3Late OnsetNoTable 3Onset any timeYesRisk FactorsSevereSeverity of Illness医院获得性肺炎(杜斌)Core OrganismsCore AntibioticsEnteric gram-negative bacilli(Non-pseudomonal)Enterobacter peciesCephalosporinSecond generationEscherichia colior Nonpseudomonal third generationKlebsiella SpeciesBeta-lactam/beta-lactamase inhibitorcombinationProteus speciesSerratia marcescensIf allergic to penicillinFluoroquinoloneHemophilus influenzaeMethicillin-sensitive Staphylococcusaureusor Clindamycin+aztreonamStreptococcus pneumoniae*Excludes patients with immunosuppression.Patients with mild-to-moderate HAP,no unusual risk factors,onset any time or patients with severe hospital-acquired pneumonia with early onset*HAP-经验性治疗医院获得性肺炎(杜斌)Core Organisms Plus:Core Antibiotics Plus:Anaerobes(recent abdominal surgery,witnessedaspiration)Clidamycinor beta-lactam/beta-lactamase inhibitor(alone)Staphylococcus aureus(coma,head trauma,diabetes mellitus,renal failure)+/-Vancomycin(until methicillin-resistant Staphylococcusaureus is ruled out)Legionella(high-dose steroids)Erythromycin+/-rifampin*Pseudomonas aeruginosa(prolonged ICU stay,steroids,antibiotics,structural lung disease)Treat as severe hospital-acquired pneumonia*Excludes patients with immunosuppression.*Rifampin may be added if Legionella species is documented.Patients with mild-to-moderate hospital-acquired pneumonia with risk factors,onset any time*HAP-经验性治疗医院获得性肺炎(杜斌)Core Organisms Plus:Core Antibiotics Plus:Pseudomonas aeruginosaAcinetobacter speciesAminoglycoside or ciprofloxacinConsider MRSAplus one of the followingAntipseudomonal penicillinBeta-lactam/beta-lactamase inhibitorCeftazidime or cefoperazoneImipenemAztreonam*+/-Vancomycin*Excludes patients with immunosuppression.*Aztreonam efficacy is limited to enteric gram-negative bacilli and should not be used in combination with an aminoglycoside if gram-positive or Hemophilus influenzae infection is of concern.Patients with severe hospital-acquired pneumonia with risk factors,early onset or patients with severe HAP,late onset*HAP-经验性治疗医院获得性肺炎(杜斌)HAP-经验性治疗从下列抗生素中选择1种2代或3代头孢菌素内酰胺类/内酰胺酶抑制剂氟喹诺酮类抗生素没有危险因素具有危险因素在MRSA流行的医院中考虑加用万古霉素从下表中选择2种抗生素抗绿脓杆菌的内酰胺类抗生素氟喹诺酮类抗生素氨基糖甙类抗生素住院时间或气管插管时间少于5天住院时间或气管插管时间超过5天诊断肺炎医院获得性肺炎(杜斌)HAP-预防Mortality benefit unprovenASelective digestive tract decontaminationHypothetically beneficial,no supportive dataCPostpyloric position for enteral feeding tubeLess aspiration shown in intubated patients;however,raised head of bed might be a risk for pneumonia in extubated patients requiring reintubationCElevated head of bedRecent multicenter trial showed no differenceBNon-pH-altered peptic ulcer prophylaxisRecommendation based on 1 study with trend toward benefitBOral position of endotracheal tube instead of intranasal positionOf 5 randomized trials,only 1 demonstrated reduced pneumonia;the other 4 had favorable trending dataBKinetic bed therapyReports of increased frequency of endotracheal tube occlusion with heat and moisture exchangersBHeat and moisture exchangers instead of heated humidifiersRequires specific endotracheal tube suction systemAModified endotracheal tube allowing subglottic suctioning of secretionsMore frequent changes of no benefitAVentilator circuit changes no more than every 7 dCommentStrength of Evidence,GradeIntervention医院获得性肺炎(杜斌)HAP-预防传统的感染控制措施 University of Washington,Seattle 6张床位的开放式ICU，仅有2个洗手池 14张床位，独立隔离房间，有单独的洗手池 对细菌定植或感染总体发生率无影响医院获得性肺炎(杜斌)HAP-预防传统的感染控制措施 24%的医务人员接触患者后洗手 单纯改善环境不能有效降低感染率 医务人员的态度和行为更为重要医院获得性肺炎(杜斌)HAP-预防Wash HandsUse GlovesFrom:Khatib M,et al.Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU.Chest 1999;116:172-5医院获得性肺炎(杜斌)HAP-预防Phase IPhase IIWeek 1Week 4Week 1Week 4Patient contact537543Handwashing46%92%Before contact78%29%94%92%After contact92%Use of gloves56%43%结论结论 简单的标志可以有效提醒医务人员进行洗手简单的标志可以有效提醒医务人员进行洗手 降低医院获得性肺炎的发病率？降低医院获得性肺炎的发病率？医院获得性肺炎(杜斌)HAP-预防教育课程的效果 肺炎发病率 4.0%1.6%by Britt et al PICU中使用简单的隔离措施(disposable,nonwoven polypropylene gowns,nonsterile latex gloves)每日感染率减半 首次感染发生延迟 8 20天by Klein et al医院获得性肺炎(杜斌)HAP-预防Medical Devices Agency one report of MRSA being detected on the internal components of an ICU ventilator staff unaware that air filters inside the equipment need to be cleaned or replaced on a regular basis UK hospitals alerted to MRSA contaminationSept.27,2001医院获得性肺炎(杜斌)HAP-预防振动及旋转床 minimize complete immobilizationsNo.ofIncidence of Nosocomial PneumoniaAuthorsYearsptsStandard bedCLRTP valueKelley19874352%28%NSGentilello19886534%19%NSSummer19898616%9%NSFink19909940%14%0.006De Boisblanc199312422%9%0.05医院获得性肺炎(杜斌)HAP-预防持续或间断吸引口咽部分泌物 气管插管具有单独的管腔，供每小时清除套囊上方潴留的分泌物 145例机械通气患者 肺炎 12.8%vs 29.1%(p0.05)肺炎发生延迟 16.2 vs 8.3 d医院获得性肺炎(杜斌)HAP-预防AuthorsNo.OfptsRegimensResultsSystemic AntibioticsLepper51Chl,Ery,Pcn,StrNo benefitPetersdorf102Pcn,Str,Tetra No benefitPetersdorf150ChlNo benefitMandelli570Pcn,Cefoxitin No benefitTopical AntibioticsKlick751Poly BReducedpneumonia rateFeeley292Poly BKlastersky85GentaReducedP.aeruginosapneumonia rateKlastersky47Poly B,Kana,GentaUnchangedmortality rateRouby598ColiDevelopedcolonization withresistant GNB抗生素预防的效果抗生素预防的效果医院获得性肺炎(杜斌)HAP-预防结论 降低VAP发生率及严重程度的有效抗生素 需要包括 静脉(PCN G)以及 局部(genta/polymyxin B)医院获得性肺炎(杜斌)HAP-预防选择性胃肠道去污染,SDD 全身性抗生素 头孢曲松/TMP/喹诺酮 不被吸收局部抗生素预防 氨基糖甙类/多粘菌素 B/两性霉素 B 口咽部应用软膏 通过经口胃管或经鼻胃管医院获得性肺炎(杜斌)HAP-预防选择性胃肠道去污染 预防GNB及念珠菌属在口咽部及胃内定植 不影响厌氧菌落 对革兰氏阳性球菌作用有限医院获得性肺炎(杜斌)HAP-预防Pneumonia RatesAuthorsSDDControlCommentsVandenbroucke7%28%OR=0.21(0.15-0.29),historic controls8%45%OR=0.12(0.08-0.19),concurrent controlsSDD trialists14%29%OR=0.37(0.31-0.43)Kollef7%22%Risk difference=0.145(0.116-0.174)Heyland-RR=0.46(0.39-0.56)Hurley6%28%OR=0.18(0.14-0.23),historic controls14%31%OR=0.35(0.30-0.42),concurrent controlsEffect of SDD on Pneumonia Rates医院获得性肺炎(杜斌)HAP-预防Mortality RatesAuthorsSDDControlCommentsVandenbroucke25%26%OR=0.91(0.67-1.23)historic controls21%26%OR=0.70(0.45-1.09),concurrent controlsSDD trialists28%30%OR=0.90(0.79-1.04)Kollef24%26%Risk difference=0.019(-0.016-0.054)Heyland-RR=0.87(0.79-0.97)Hurley24%27%OR=0.77(0.61-0.97,historic controls26%29%OR=0.86(0.74-0.99),concurrent controlsEffect of SDD on Mortality Rates医院获得性肺炎(杜斌)HAP-预防评论(1)SDD组医院获得性肺炎的减少=GNB肺炎 在盲法研究中并非总观察到肺炎发生率的下降医院获得性肺炎(杜斌)HAP-预防评论(2)对病死率的影响=存在争议 医院获得性肺炎患病率10-15%GNB60-70%归因死亡率50%of 40-50%预防GNB肺炎导致的死亡 所有ICU患者的1.5-3.5%医院获得性肺炎(杜斌)HAP-预防评论(3)耐药性的出现 耐药性GNB的诱导性选择 高水平耐药肠球菌或MRSA发生率增加 对机械通气时间，ICU住院时间及总住院时间的影响 增加抗生素的花费及微生物学监测费用