复杂腹腔感染课件

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,*,*,*,*,*,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,复杂,腹腔感染,IAI,相关指南,the Therapeutic Agents Committee of the Surgical Infection,Society,The,Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal,Infections:An,Executive,Summary,SURGICAL,INFECTIONS Volume 3,Number 3,2002,IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease,Pharmacists,Guidelines,for the Selection of,Antiinfective,Agents for Complicated Intra-abdominal Infections,，,CID2003,37:997,1005,Diagnosis and Management of Complicated,Intra-abdominal Infection in,Adults and,Children:Guidelines,by the Surgical Infection,Societyand,the Infectious Diseases Society of,America,；Clinical,Infectious Diseases 2010;50:133,64,Infectious Diseases Society of Taiwan;Taiwan Surgical Society of,Gastroenterology,etal,Guidelines,for antimicrobial therapy of intra-abdominal infections in adults,J,Microbiol,Immunol,Infect.2008;41:279-281,腹腔感染,(IAI),概述,过去一个世纪,IAI,治疗取得巨大进步，死亡率显著下降,90%in 1900 to 23%in 2002,IAI,不同来源感染的死亡率,appendix(0.25%),stomach/duodenum(21%),pancreas(33%),small bowel(38%),large bowel(45%),biliary,tract(50%),JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections,cleveland,clinic journal of medicine volume 74 supplement 4 august 2007,IAI,定义分类,f.M.,pieracci,p.S.,barie,ManageMent,of Severe,SepSiS,of,abdoMinal,origin,Scandinavian Journal of Surgery 96:184196,2007,单纯腹腔感染,复杂腹腔感染,Intra-abdominal infections also can be categorized as uncomplicated versus complicated,although the distinction is not always clear,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Uncomplicated IAI,单纯性腹腔感染仅累及,1,个器官,而且没有解剖结构的破坏,通常病灶可完全切除，仅需预防性使用抗菌药物,Blot S,De,Waele,JJ,.,Critical issues in the clinical management of complicated intra-abdominal infections.,Drugs.,2005;65(12):1611-20,复杂腹腔感染,(,cIAI,),复杂腹腔感染,(,cIAI,),通常定义为空腔脏器的内容穿入腹腔导致局限性腹膜炎,(,包括脓肿,),、弥漫性腹膜炎,感染源经外科处理后，仍残留细菌，需使用抗感染药物,cIAI,更多地与不良预后相关，其最大挑战是早期识别,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Blot S,De,Waele,JJ,.,Critical issues in the clinical management of complicated intra-abdominal infections.,Drugs.,2005;65(12):1611-20,细菌性腹膜炎分类,原发性腹膜炎,继发性腹膜炎,第三型腹膜炎,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Primary bacterial peritonitis,指腹腔没有破口的自发性腹膜炎,更多见于婴幼儿、肝硬化及免疫抑制的病人,Secondary bacterial peritonitis,继发性腹膜炎是肠源细菌通过胃肠道穿孔泄漏入腹腔导致的感染炎症,It may be community-acquired or healthcareassociated.,Tertiary peritonitis,原发、继发性腹膜炎经治疗后症状仍持续或,48,小时后症状复苏,常见于有严重合并症或免疫抑制的病人,特点,:,医院获得性感染,多为耐药菌,可能为肠道菌群易位,社区获得性腹腔感染,感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔,多为革兰氏阴性菌、厌氧菌，较少耐药,多为轻中度腹腔感染,如有脏器功能不全、免疫抑制的病人则归为重度腹腔感染,医院获得性腹腔感染,多为术后感染，如肠吻合口瘘并腹腔感染,可合并休克、脏器功能损害，多为重度腹腔感染,可为革兰氏阴性杆菌、肠球菌或条件致病菌，多为耐药菌。如产,ESBL,的大肠杆菌，阴沟肠杆菌，铜绿假单胞菌，还有念珠菌,IDSAcIAI,指南的定义,该指南排除了肝脾实质的脓疡、泌尿生殖系统来源的感染、后腹膜感染,(,但除外胰腺感染,),2003,版指南不拟适用于小于,18,岁儿童及原发性腹膜炎，,2010,版作了扩展,IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease,Pharmacists,Guidelines,for the Selection of,Antiinfective,Agents for Complicated Intra-abdominal Infections,，,CID2003,37:9971005,腹腔感染常见致病菌,胃、十二指肠、近端小肠与胆道：革兰阴性或阳性需氧菌或兼性需氧菌,远端小肠：不同密度的革兰阴性需氧菌或兼性需氧菌、厌氧菌如脆弱拟杆菌,结肠：兼性需氧（大肠杆菌）或纯厌氧菌，链球菌、肠球菌亦常见,Pathogens associated with peritonitis,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections,cleveland,clinic journal of medicine volume 74 supplement 4 august 2007,cIAI,综合治疗策略,液体复苏、感染源控制,(,ie,surgical debridement,drainage,and repair),、适当系统地抗感染是,cIAI,治疗成功的主要部分,没有感染源的控制，抗生素治疗继发或第三型腹膜炎不可能成功,首要的是感染源的控制,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,cIAI,如何选择抗生素,单药还是联合治疗,病人基础状况,药物开始治疗时机及疗程,给药剂量、频率,抗菌谱、相互作用、耐药性,之前抗生素的使用情况,避免药物毒副作用及诱导耐药,社区获得性腹腔感染,应选择对肠源性革兰氏阴性专性或兼性需氧菌有效或针对,-,内酰胺类敏感革兰氏阳性球菌,源于远端小肠、结肠、梗阻性的近端胃肠穿孔应包含抗厌氧菌活性,避免应用治疗,ICU,院内感染的药物，除非是高危病人,覆盖肠球菌的药物对社区获得性腹腔感染无益,高危病人选择广谱抗生素,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease,Pharmacists,Guidelines,for the Selection of,Antiinfective,Agents for Complicated Intra-abdominal Infections,，,CID2003,37:9971005,cIAI,危险分层,JOHN A.WEIGELT,MD,Empiric,treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,High-severity IAI,Advanced age;poor nutri