院内获得性感染的诊治课件

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,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,内 容,医院内感染的病原菌及其药敏情况,耐药菌产生的因素,耐药菌感染的治疗,内 容医院内感染的病原菌及其药敏情况,今天不采取行动,明天将无药可用,细菌耐药性,今天不采取行动细菌耐药性,Bad Bugs:ESKAPE,E,nterococcus faecium;,S,taphylococcus aureus;,K,lebsiella;,A,cinetobacter;,P,seudomonas;,E,nterobacter,Bad Bugs:ESKAPEEnterococcus f,中国,:ESBL,的发生率,year,中国:ESBL 的发生率 year,2010,年,CHINET,耐药监测革兰阴性菌菌种分布,细菌,株数,细菌,株数,大肠埃希菌,9225,26.91,摩根菌属,195,0.57,克雷伯菌属,5529,16.13,产碱杆菌,107,0.31,不动杆菌属,5523,16.11,少动鞘氨醇单胞菌,94,0.27,铜绿假单胞菌,5080,14.82,金杆菌属,92,0.27,肠杆菌属,1961,5.72,罗尔斯顿菌属,74,0.22,嗜麦芽窄食单胞菌,1661,4.85,气单胞菌属,76,0.22,变形杆菌属,907,2.65,多源菌属,53,0.15,流感嗜血杆菌,734,2.14,普罗威登菌属,46,0.13,沙雷菌属,437,1.27,志贺菌属,149,0.43,其他假单胞菌,420,1.23,丛毛单胞菌,14,0.04,其他嗜血杆菌,395,1.15,奈瑟菌属,11,0.03,沙门菌属,355,1.04,博特菌属,13,0.04,柠檬酸杆菌属,350,1.02,黄杆菌属,16,0.05,伯克霍尔德菌属,320,0.93,其他,218,0.64,莫拉菌属,227,0.66,合计,34282,100.0,2010年CHINET耐药监测革兰阴性菌菌种分布 细菌株数,院内常见,G,-,菌耐药率排名,2010 CHINET,头孢哌酮,/,舒巴坦,亚胺培南,美罗培南,哌拉西林,/,他唑巴坦,头孢吡肟,头孢他啶,大肠埃希菌属,6.5,1.6,1.4,5.9,25.7,30.7,克雷伯克菌属,14.8,8.8,8.9,16.6,23.8,35.4,柠檬杆菌属,16.7,8.7,7,20.6,17.2,42,变形杆菌属,1.9,5.2,1.6,4.3,4.3,5.7,铜绿假单胞菌,17.9,3,0,.,8,25.8,24.1,19.3,21.6,不动杆菌,30.7,57.1,58.3,64.6,64.1,64.2,嗜麦芽窄食单胞菌,13.8,无抗菌谱,无抗菌谱,无抗菌谱,无抗菌谱,无抗菌谱,肠杆菌科,9.1,4.6,4.2,10.4,22.0,31.0,非发酵菌,23.5,48.7,45.6,42.9,41.6,42.6,绿色表示耐药率,30%,院内常见G-菌耐药率排名2010 CHINET头孢哌酮/,2010,年,14,家医院,9225,株大肠埃希菌耐药率（,%,）,2010年14家医院9225株大肠埃希菌耐药率（%）,2010,年,14,家医院,5529,株克雷伯菌属耐药率（,%,）,2010年14家医院5529株克雷伯菌属耐药率（%）,2010,年,14,家医院,13751,株非发酵菌耐药率,（,%,）,抗菌药物,耐药,敏感,头孢哌酮,/,舒巴坦,23.5,54.4,美罗培南,45.6,51.7,阿米卡星,38.1,58.4,头孢他啶,42.6,52.6,头孢吡肟,41.6,52.5,哌拉西林,/,他唑巴坦,42.9,52.8,亚胺培南,48.7,48.4,环丙沙星,43.4,50.5,2010年14家医院13751株非发酵菌耐药率（%）抗菌药物,2010,年,14,家医院,5080,株铜绿假单胞菌耐药率（,%,）,2010年14家医院5080株铜绿假单胞菌耐药率（%）,2010,年,14,家医院,5523,株不动杆菌属,(,鲍曼不动,89.6%),细菌的耐药率（,%,）,除头孢哌酮,/,舒巴坦、米诺环素外，其余抗菌药的耐药率均,50%,亚胺培南和美罗培南的耐药率接近,60%,2010年14家医院5523株不动杆菌属(鲍曼不动89.6%,2010,年,14,家医院嗜麦芽窄食单胞菌和伯克霍尔德菌属的耐药率（,%,）,抗菌药物,嗜麦芽窄食单胞菌（,1661,株）,抗菌药物,伯克霍尔德菌属（,320,株）,耐药,敏感,耐药,敏感,头孢哌酮,/,舒巴坦,13.8,65.2,哌拉西林,/,他唑巴坦,22.1,70.4,左氧氟沙星,10.7,86.1,头孢他啶,21.8,72.8,复方磺胺甲噁唑,11.2,86.7,美罗培南,19.7,70.3,米诺环素,3.4,82.1,复方磺胺甲噁唑,27.6,64.0,米诺环素,17.6,68.1,2010年14家医院嗜麦芽窄食单胞菌和伯克霍尔德菌属的耐药率,CHINET,各医院不动杆菌属对亚胺培南和美罗培南的耐药率,医院,株数,亚胺培南,美罗培南,耐药,敏感,耐药,敏感,上海儿童医院,100,50.0,48.0,48.0,52.0,广州医大一附院,243,33.3,62.9,39.5,58.9,重庆医大一附院,377,63.1,35.8,63.3,35.5,上海儿科医院,186,47.0,43.8,58.9,37.8,卫生部北京医院,247,61.9,38.1,61.5,37.7,上海华山医院,532,62.7,36.7,63.8,36.0,北京协和医院,706,67.5,32.1,68.0,31.7,甘肃省人民医院,244,12.3,87.7,13.2,86.4,上海瑞金医院,503,46.8,53.0,46.1,53.3,湖北同济医院,595,54.8,43.4,57.6,42.1,浙医一附院,782,74.6,24.6,75.7,23.8,新疆医大一附院,294,35.8,61.8,32.2,65.3,安徽医大一附院,422,54.0,43.6,58.4,40.4,昆明医大一附院,292,72.4,24.0,70.4,29.6,CHINET各医院不动杆菌属对亚胺培南和美罗培南的耐药率医院,ESBLs,（,+,）和,ESBLs,（,-,）肠杆菌科细菌对抗菌药物敏感率和耐药率（上海,2008,）,ESBLs（+）和ESBLs（-）肠杆菌科细菌对抗菌药物敏感,不发酵革兰阴性杆菌对抗菌药物的敏感率和耐药率（上海,2008,）,不发酵革兰阴性杆菌对抗菌药物的敏感率和耐药率（上海2008）,肠杆菌科细菌和不发酵革兰阴性杆菌对,9,种抗菌药物的敏感率和耐药率（上海,2008,）,肠杆菌科细菌和不发酵革兰阴性杆菌对9种抗菌药物的敏感率和耐药,各医院分离的泛耐药革兰阴性杆菌的检出率（上海,2008,）,各医院分离的泛耐药革兰阴性杆菌的检出率（上海2008）,18,上海地区不动杆菌属的耐药性变迁,耐药率,%,18上海地区不动杆菌属的耐药性变迁耐药率%,嗜麦芽窄食单胞菌临床分离率逐年上升,(,上海,),Wang F,et al.Chin J Infect Chemother.2008.3(2):65-70,嗜麦芽窄食单胞菌临床分离率逐年上升(上海)Wang F,MDR,：通常把对常用的,7,种抗假单胞菌的抗生素（包括抗假单胞菌的青霉素类、头孢菌素类、氨基糖苷类、喹诺酮类、碳青霉烯类、四环素类、磺胺类）中的至少,3,类耐药的,AB,菌株称之为多重耐药菌,PDR,：对上述,7,类抗生素全耐药的细菌菌株称之为泛耐药菌。,MDR：通常把对常用的7种抗假单胞菌的抗生素（包括抗假单胞菌,MDR,或,PDR,引起医院感染影响因素,抗生素压力,携带耐药菌患者的流动,长期住院,机械通气,近期手术,入住,ICU,疾病严重程度,感染控制措施不到位,MDR或PDR引起医院感染影响因素抗生素压力,产,ESBL,的危险因素,Risk factor,OR,95%CI OR,P value,机械通气天数,1.1,1.06-1.15,0.001,三代头孢菌素,7.17,2.59-19.8,0.001,氨基糖苷类,2.65,1.15-6.09,0.02,SXT,8.84,3.07-25.5,0.001,ARDS,3.1,1.0-9.7,0.05,22,Journal of Antimicrobial Chemotherapy 2005 56(1):139-145,产ESBL的危险因素 Risk factorOR95%C,Figure 1.,Annual consumption(g/patient-day x 1,000)of carbapenems,extended-spectrum cephalosporins,ciprofloxacin,aminoglycosides and%of isolates of imipenem-resistant and PDRAB at the National Taiwan University Hospital,19932000.,Hsueh PR,et al.Emerg Infect Dis.2002 8(8):827-832.,Figure 1.Annual consumption(,产,ESBLs,菌株,产生,与,三代头孢,相关,三代头孢菌素与,ESBLs,菌株产生增加具有明显相关性,，在中国绝大多是为,CTX-M,型，主要以头孢曲松以及头孢噻肟的过度使用有关,Paterson DL,et al.Ann Intern Med.2004 Jan 6;140(1):26-32.,三代,头孢菌素,产,ESBLs菌株,(n=78),非产,ESBLs菌株,(n=175),风险率,头孢噻肟,33.3,66.7,1.1,头孢曲松,85.7,14.3,3.31,头孢他啶,66.7,33.3,2.26,任何三代头孢,75.2,25.8,2.99,产ESBLs菌株产生与三代头孢相关三代头孢菌素与ESBLs菌,亚胺培南与,MDR,铜绿假单胞菌（,MDRP,）的相关性,P,值,OR,值,OR,的,95%,可信区间,年龄（岁）,0.374,1.010,0.981.05,ICU/RCU,0.56,0.657,0.162.70,COPD/,支扩,0.182,2.96,0.60214.56,APACHE II,0.977,1.001,0.9161.095,机械通气,0.010,8.19,1.6540.7,HAP,0.731,1.292,0.35.56,混合感染,0.306,2.035,0.5222.936,氟喹喏酮,0.188,2.749,0.6112.4,亚胺培南,/,美罗培南,0.0001,44,8,9,16219,曹彬 王辉 朱元珏 陈民钧,.,中华呼吸结核杂志，,2004,年,1,月底,27,卷第,1,期，,P31-35.,采用病例对照研究方法，收集北京协和医院,1999,年,1,月,-2002,年,12,月,MDRP,引起的院内感染,44,例，并随机选择同时期敏感铜绿假单胞菌院内感染,68,例作为对照，采用单因素及多因素,logistic,回归进行分析,独立危险因素,亚胺培南与MDR铜绿假单胞菌（MDRP）的相关性P值OR值O,亚胺培南消耗量与铜绿假单胞菌耐药的相关性,Lepper PM,et al.,Antimicrob Agents Chemother,.2002;46:2920-2925.,在头孢他啶，哌拉西林,/,他唑巴坦与亚胺培南三种药物中，唯有亚胺培南的使用与铜绿假单胞菌的耐药呈显著相关。,铜绿假单胞菌对亚胺培南耐药显著相关，同时与铜绿假单胞菌对头孢他啶和哌拉西林,/,他唑巴坦耐药呈显著相关。,结论：,亚胺培南消耗量与铜绿假单胞菌耐药的相关性 Lepper PM,-,内酰胺酶复合制剂替换三代头孢菌素和亚胺培南,可降低产,ESBLs