MRSA肺炎诊治

单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,单击以编辑母版标题样式,单击以编辑母版文本样式,第二级,第三级,第四级,第五级,06-23-00,朱戌冬,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,斯沃与万古霉素 替考拉林的比较,*,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,二级,三级,四级,五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,MRSA肺炎诊治,南京军区南京总医院呼吸与危重症医学科,201,2,.0,5,.,12,杭州,MRSA肺炎的抗感染治疗,MRSA-,全球性公共卫生问题,Hajo Grundmann, et al.,Lancet 2006;368:874-85,美国：,MRSA,感染死亡人数超过,AIDS,DeLeo and Chambers,JCI,2009,adapted from Klevens et al.,JAMA I2007,5,The Burden of MRSA,Increased hospitalization,MRSA infections increase the median length of hospital stay for nosocomial infections (median: 12 days for MRSA versus 4 days for methicillin-susceptible,S aureus,MSSA) and surgical site infections (SSIs) (median: 23 days for MRSA versus 14 days for MSSA),Increased cost,MRSA infections increase per-patient hospital costs in New York City hospitals by approximately $2500 to $3700 (expressed in 1995 dollars) compared with MSSA,Direct hospital cost from nosocomial MRSA bacteremia is 2.8 times greater than that for MSSA bacteremia,MRSA SSIs increase median hospital cost by approximately $40,000 compared with MSSA infections,Increased mortality,Nosocomial MRSA infections are associated with higher mortality compared with MSSA (21% versus 8%),MRSA SSIs are associated with a higher 90-day mortality rate (20.7% for MRSA versus 6.7% MSSA),Abramson MA, Sexton DJ.,Infect Control Hosp Epidemiol,. 1999;20:408-411.,Engemann JJ et al.,Clin Infect Dis.,2003;36:592-598.,Rubin RJ et al.,Emerg Infect Dis.,1999;5:9-17.,ICU,医院感染的主要致病原,EPIC II study,：,75,个国家,1265,个,ICU,参加,JAMA. 2009;302(21):2323-2329,HAP,致病原：,SENTRY 2004-2008,N=31,436,Clinical Infectious Diseases 2010; 51(S1):S81S87,MRSA,在欧洲的蔓延,Rates of hospital Staphylococcus aureus isolates that are methicillin-resistant, based on samples from inpatient, outpatient, and ICU patients.,Adapted from European Antimicrobial Resistance Surveillance System EARSS interactive database results (2),ANSORP,：,MRSA,是亚洲地区,HAP,的主要致病菌,Asian HAP Working Group. Am J Infect Control 2008;36:S83-92.,2.,胡必杰等,.,中华结核和呼吸杂志,.2005;28(2):112-116,院内肺炎分离菌株构成比,(%),一项自，对,562,例院内肺炎患者分离,918,株致病菌的监测结果显示,金黄色葡萄球菌占院内肺炎分离菌株第二位,n=171,n=148,n=148,n=132,n=81,中国,16,家大型教学医院呼吸科,HAP,致病原分离情况,(599,例分离到,694,株菌,2008-2010),其中,8%,为,ORSA,MRSA,是亚洲（及中国）,HAP,主要致病菌,Asian HAP Working Group. Am J Infect Control 2008;36:S83-92.,MRSA是导致院内肺炎患者死亡的危险因素之一,1997-2003年间，德国202家ICU病房共8432例院内肺炎患者,多重对数,回归,分析患者死亡危险因素,耐药是导致死亡(更为严重疾病的替代指标)抑或不适当或延误治疗的因素么？,Gastmeier P, et al. ICHE 2007; 28: 466-72,死亡率,(%),18/32,22/54,8/32,8/54,31.3%,Carmen Gonazalez et al. Clinical Infectious Diseases. 1999;29:1171-1177.,与,MSSA,组相比，,MRSA,组的死亡率增加,31,MRSA,感染死亡率明显高于,MSSA,两个,Meta,分析比较了,MRSA,和,MSSA,菌血症的病死率,MRSA=methicillin-resistant,Staphylococcus,aureus,; MSSA=methicillin-susceptible,S.,aureus,; RR=relative risk.,Cosgrove SE, Sakoulas G, Perencevich EN, et al. Comparison of mortality associated with methicillin-resistant and methicillin-susceptible,Staphylococcus aureus,bacteremia: a meta-analysis.,Clin Infect Dis,. 2003;36:53-59; Whitby M, McLaws ML, Berry G. Risk of death from methicillin-resistant,Staphylococcus aureus,bacteremia.,Med J Aust,. 2001;175:264-267.,Mortality (%),19802000N=3963,19902000N=2209,0,10,20,30,40,50,12,29,23,36,MRSA,MSSA,RR=1.42,P,.001,RR=2.12,P,.001,延误正确的抗菌治疗导致病死率上升,延误治疗,早期治疗,Lodise TP et al, Clin Infect Dis 2003; 36:1418-1423.,Iregui MI et al, Chest 2002; 122:262-268.,p=0.05,病死率,(%),0,5,10,15,20,25,30,35,40,45,呼吸机相关肺炎,2,金葡菌菌血症,1,p2,周的患者,入住,ICU,或烧伤病房,脑血管病后遗症,昏迷患者,外科伤口感染或烧伤患者,I,型糖尿病患者,长期腹膜透析,/,血液透析患者,接触MRSA感染或定植者的患者,日间看护中心的工作人员或被看护者,运动员及其密切接触者,军人或退伍军人,囚犯,无家可归者,男性同性恋患者,静脉注射毒品者,美洲原住民,Healthcare,Associated MRSA,Community,Acquired MRSA,流感样前驱症状；,严重的呼吸症状，如迅速进展的肺炎并发展为急性呼吸窘迫综合征（ARDS）；,高热，体温39；,咯血；低血压；白细胞减少；,胸片显示多叶浸润并可有空洞；,已知有CA-MRSA寄植或近期曾去流行区的历史（如北美旅行），近期与CA-MRSA感染或寄植者有接触；,属于CA-MRSA寄植率增加相关的人群；,以前有反复发生的疖或皮肤脓肿病史或家族史（在过去6个月内发生2次）,CA-MRSA,引起,CAP,的线索,MRSA,定植导致感染风险增加,Crit Care Med 2010 Vol. 38, No. 1,，,109,MRSA in Dialysis patients,5,287 cases of invasive MRSA cases reported by the Active Bacterial Core Surveillance in 2005,813 in dialysis patients with 45.2 cases per 1000 patients,70%,of infections in those age 50 or greater,86%,Bloodstream infections,17%,mortality rate,多种危险因素同时存在进一步增加,MRSA,感染风险,INT: intubation;,OW: open wound;,TA: treatment with ATB;,ST: steroid administration.,BMC Infectious Diseases 2011, 11:303,有助于早期识别,MRSA,感染的临床线索,皮肤软组织或骨关节的化脓性感染,菌血症样症状或局部脓肿形成,金葡菌感染的特殊临床表现,Scalded Skin Syndrome (SSS)、皮肤烫伤样改变,Rash、extremely Sensitive,Toxic Shock Syndrome (TSS),Fever, rash, nausea,休克和心动过速,与胸部影像改变不相符的呼吸困难和紫绀,迅速出现的突破性感染,Clinical Infectious Diseases 2010;51(S2):S183S197,Curr Opin Pulm Med 15:218222,International Journal of Antimicrobial Agents 30 (2007) 289296,Classical presentation of PVL-associated MRSA pneumonia,a previously fit young patient,with an flu-like illness (pyrexia, myalgia, chills) diarrhea and vomiting toxic shock:,Toxic shock:,fever 39 C,tachycardia 140 bpm,hemoptysis,hypotension,marked leukopenia (may be normal early on),multilobar infiltrates on CXR, accompanied by effusions and often cavitation,very high CRP level (often 200350 g/L),Sputum smear reveals sheets of staphylococci,International Journal of Antimicrobial Agents 30 (2007) 289296,考虑,CA-MRSA,肺炎的临床表现：,（,WHEN TO SUSPECT CA-MRSA PNEUMONIA,）,Clin Pulm Med 2010;17: 260265,MRSA,肺炎的影像特点,Primary MRSA pneumonia：,necrotizing airspace disease,multilobular, often bilateral involvement,cavitating alveolar consolidation,”bubbly,” consolidations,NOT air-bronchograms,CDR,，,2010,；,33,：,1-6,MRSA,肺炎的影像特点,ground- glass opacities,nodules,Irregular,not round,可同时分布于内带及外带,CDR,，,2010,；,33,：,1-6,多发斑片影、结节影和“,bubbly” consolidations,“,CDR,，,2010,；,33,：,1-6,MRSA,肺炎的影像特点,Metastatic MRSA pneumonia,multiple nodules with peripheral and basal predominance,cavitating or noncavitating,less round,likely to have a surrounding “ground-glass” halo,CDR,，,2010,；,33,：,1-6,MRSA,肺炎的影像特点,Complications of MRSA pneumonia,Abscess,Empyema,Bronchopleural fistula,Acute respiratory distress syndrome,（,ARDS,）,.,CDR,，,2010,；,33,：,1-6,MRSA,肺炎的确诊,:,最大问题是时间,肺炎的确诊：CAP or HAP?,致病原的确认：定植 or 感染？,侵入性检查：BAL、PBS,定量培养,革兰染色涂片,致病原耐药性的确认,MSSA or MRSA?,MRSA来源的分析：HA-MRSA or CA-MRSA,我们目前对MRSA认识的现状,初始经验性治疗主要针对,G-,杆菌，极少覆盖,MRSA,。,原因：,*,认识不足；,*,在万古霉素时代认为只有分离到,MRSA,时才能用药；,*,认为,违反抗生素政策,基本认识,降阶梯治疗策略同样适用于,G+,球菌（,MRSA,）肺炎，即早覆盖。,一旦证明无,MRSA,时即停药。,短疗程不适用。,意大利,udine,教学医院：,VAP,经验性抗,MRSA,治疗,2,项：加入抗,MRSA,经验性治疗,痰涂片革兰染色，报告？,培养阴性？,以下情况高度提示革兰阳性球菌感染,血流感染,：,包括导管相关的血流感染，菌血症，脓毒症，细菌性心内膜炎,皮肤软组织感染,：,包括伤口和创面感染,手术部位感染,：,包括植入物感染,骨和关节感染,：,骨髓炎,培养阴性？,以下情况有可能革兰阳性球菌感染,HAP,（,MRSA,）,VAP,（,MRSA,）,复杂,UTI,（,MRSA,，,肠球菌,）,非呼吸机相关肺炎需要覆盖,MRSA,的 其他危险因素,流感、糖尿病、颅脑外伤、肾衰、昏迷并发肺炎,已接受长疗程,SCs,、,FQs,治疗,已接受多种抗,GNB,治疗不效,所在社区流行,MRSA,吸毒。,MRSA,肺炎的抗菌治疗,CAP,（,2007 ATS,）,经验性抗菌治疗的推荐方案,住院,ICU,患者,头孢噻肟，头孢曲松或阿莫西林,/,舒巴坦 加上 阿奇霉素 （证据等级,level II,）或氟喹诺酮类（强烈推荐）,对哌拉西林过敏患者：呼吸氟喹诺酮类及阿奇霉素，强烈推荐,特殊考虑,如怀疑铜绿假单胞菌,抗肺炎链球菌或抗铜绿假单胞菌（哌拉西林,/,他唑巴坦，头孢吡肟，亚胺培南或美罗培南 加上任一环丙沙星或左氧氟沙星 （,750mg,） 或上述任一内酰胺酶类药,如怀疑,CA-MRSA,添加万古霉素或利奈唑胺（中等推荐）,HAP,（,2005 ATS,）,晚发、,MDR,危险因素和所有重症肺炎经验治疗,AJRCCM 2005,；,171,：,388,欧洲指南, ERS, ESCMID, ESICM: Torres,et al. Int Care Med,2009;35:9-29,金葡菌感染的抗生素推荐治疗,（英国指南）,2006年亚洲HAP工作组,抗生素选择策略,特殊耐药菌感染的抗生素方案,Jae-Hoon Song, and the Asian HAP Working Group. Am J Infect Control 2008;36:S83-92,.,MRSA,感染临床实践指南,（,20,11,IDSA,）,严重,CAP的住院患者,如何治疗？,Clin Infec Dis,20,11；52(3)：285-292,MRSA,感染临床实践指南,（,20,11,IDSA,）,MRSA,肺炎,（,HCA-，HA-，CA-MRSA,）,如何治疗？,Clin Infec Dis,20,11；52(3)：285-292,MRSA,感染,如何治疗？,MRSA,的治疗选择,Sanford Guide 20,10,-201,1,万古霉素,18岁以上成人肺炎明确病原菌的,治疗推,荐,Sanford Guide 20,10,-201,1,MRSA肺炎的,治疗推,荐,Sanford Guide 20,1,0-201,1,MRSA,治疗药物,肺穿透,性比较,ZEPHyR,研究及编者述评,58,编者述评,谢,谢,Thank You !,不尽之处，恳请指正！,