严重感染治疗策略-邱海波2

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,非发酵革兰阴性杆菌对三种碳青霉烯的敏感性,李家泰 中华检验医学杂志,2005,28(1):25,G-,杆菌耐药对预后的影响,Prospective cohort study.,Dec 1996 to Sep 2000,Inpatient surgical wards at a university hosp,N=924 pats with GNR infections,Outcomes were compared between GNR infections with and without antibiotic,res,rGNRs,:resistant to one or more of the following,all,aminoglycosides,including,amikacin,all,cephalosporins,all,carbapenems,all,fluoroquinolones,Crit,Care Med 2003;31:10351041,rGNR,:,入住,ICUMVCRRT,抗生素更换住院时间病死率,小 结,ESBL,和,AmpC,是,ICU,重症感染致病菌耐药的重要原因,三代头胞大量使用是导致,G-,菌出现,ESBL,和,AmpC,的 主要原因,ESBL,和,AmpC,使,ICU,重症感染患者的病死率明显增加,近,3,年,ICU,非发酵糖细菌的比例从,41.2%,升高到,47.9%,铜绿假单胞菌、不动杆菌属、嗜麦芽窄食单胞菌分别位居,1,、,4,、,7,位,碳青霉烯类抗生素、酶抑制剂制剂等敏感性较高,ICU,重症感染的重要性,细菌耐药机制及,ICU,细菌流行情况,重症感染的治疗策略,感染灶的充分引流,早期经验性治疗与降阶梯策略,正确的目标性治疗,内 容 提 要,非抗生素治疗策略,气管插管与机械通气,插管路径,NIV/IV,声门下的积液,气囊的管理,湿化与雾化,管路与冷凝水,MV,时间,ICU,的医疗强度,误吸,/,体位,体位,/,胃肠道返流,营养途径,口鼻咽腔,/,肠道定植,溃疡预防,/,血糖控制,Source control-,Grade E,Every pats presenting with severe sepsis should be evaluated for the presence of a focus of infection amenable to source control measures,Drainage of an abscess or local focus of infection,Removal of a,potientially,infected device,Guidelines for sepsis,.Intensive Care Med 2004,30:536-555,重症感染的重要性,细菌耐药机制及,ICU,细菌流行情况,重症感染的治疗策略,感染灶的充分引流,早期经验性治疗与降阶梯策略,正确的目标性治疗,内 容 提 要,早期经验性治疗的对象,对有急性而危及生命的全身性感染患者,无法及时得到细菌学资料,应根据本病房的细菌流行病学调查结果,选择对常见致病菌有效的广谱抗生素,经验性治疗推理性治疗,提高患者的生存率,降低,细菌产生耐药性,早期经验性治疗,的,目标,Dr.,Jordi,Rello,Professor of Critical Care,University,Rovira,&,virgili,Tarragona,Spain,9,死亡：,绝对危险度下降,6.1%,早期有效抗感染治疗的重要性,死亡：,绝对危险度下降,9,死亡：,绝对危险度下降,4%,ICU,严重感染病人起始抗生素治疗覆盖面不足,-,死亡率增加,ICU,经验性抗生素治疗,VAP:,22-73%,为抗生素起始治疗不当,医院获得性肺炎,-,迅速,恰当的抗生素治疗,，明显提高生存率,Luna CM et al.Chest 1997,Adequate38%(6/16),Not-adequate/not-ANT81.6%(40/49),132 pats with suspected NP,BAL in 55 pats,Bloodstream infections,Leibovici,et al,Adequate,vs,inadequate initial antibiotic:Mortality:20%,vs,34%,From J Intern Med,1998,244:379,早期及时,抗生素治疗的重要性,In a retrospective cohort study of pneumonia in 18,209 patients,Administering antibiotics,within 4 h,of hospital arrival was associated with improved survival.,Houck PM et al.,Arch Intern Med.,2004,164:637,644,Antibiotic therapy,1.Grade E,Intravenous antibiotic therapy should be started within,1,st,h,of recognition of severe sepsis,after appropriate cultures have been obtained,Guidelines for sepsis,.Intensive Care Med 2004,30:536-555,Antibiotic therapy,2.Grade D,Initial empiric anti-infective,therapy should include one or more drugs that have activity against the likely pathogens,The choice of drug should be guided by the susceptibility patterns of microorganisms in the community and the hospital,Guidelines for sepsis,.Intensive Care Med 2004,30:536-555,Antibiotic therapy,早期经验性治疗,是抗感染的经验性治疗方案，具有如下两个特性：,开始,即使用广谱抗生素以覆盖所有可能的致病菌,随后,(48-72h),根据微生物学检查结果调整抗生素的使用，使之更,有针对性,Dr.,Luciano,Gattinoni,Professor of Anesthesiology,Institute of Emergency Surgery,University of Milan,Italy,如何保证起始治疗的准确性,Getting it right(A-protocol),Treatment protocols and guidelines-important tool for optimal therapy,Establishing local susceptibility profiles that can be used to develop therapy protocols,“Not only we did want to treat with the initial therapy that was appropriate,but we wanted to minimize the emergence of resistance”,CCM 2001,，,29,：,1109,1115,如何保证起始治疗的准确性,Getting it right(A),CCM 2001,，,29,：,1109,1115,如何保证起始治疗的准确性,Getting it right(A),“Not only we did want to treat with the initial therapy that was appropriate,but we wanted to minimize the emergence of resistance”,CCM 2001,，,29,：,1109,1115,如何保证起始治疗的准确性,Getting it right(B-Bacteria,resis,),It is essential to be able to recognize those pats who are treatment failure,CCM 2003,，,31,：,676,抗生素治疗,3d,VAP,无效,-,tended to be survivors,有效,-tended to be non-S,More importantly,Those pats who had no clinical response within the first 3d were receiving inadequate antimicrobial therapy,Most common pathogens associated with inadequate initial antimicrobial,threapy,PA:,Pseuso,aeruginosa,;,SA:Staphylococcus,aureus,;AS:,Acinetobacter,species;,KP:,Klebsiella,pneumoniae,;ES:,Enterobacter,species;SP:Strep,pneumoniae,Other:E coli,Haemophilus,influ,Serratia,Kollef MH Clinical Inf,Dis,2000,31(S4):131-8,机械通气时间与既往抗生素治疗是多重耐药致病菌,VAP,的独立危险因素,多重耐药致病菌,N=22,MV 7,天,抗生素：否,N=12,MV7 d of MV and prior antibiotic use,Trouillet,JL.Am J,Respir,Crit,Care Med 1998,157:531539,%susceptibility,细菌耐药特点,VAP,病原菌耐药的危险因素,:,最重要的是最近接受过抗生素治疗,(,最近,15,天,),其次是机械通气至少,7,天,经验性治疗,VAP,的致病菌,敏感性最高,IMP,Amikacin,Vanco,简化的,临床诊断标准,Clinical,Pulmonary Infection Score,Value Points,Temperature,C,36.5 and 38.5 and 39 or 4,000 and 240 or,present,ARDS1,5 days)or,risk factors for,MDR Pathogens,No,Yes,Limited Spectrum,Therapy,Broad Spectrum,Therapy for MDR Pathogens,Algorithm for Initiating,Empiric Antibiotic Therapy,ATS.Am J,Respir,Crit,Care Med 2005;171:388-416,Initial Empiric Antibiotic Therapyfor Patients with No Risk Factors,Potential Pathogen,Streptococcus pneumoniae,Haemophilus influenzae,Methicillin-sensitive Staphylococcus aureus,Enteric gra