细菌耐药性的流行趋势及控制措施胡云建PPT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,*,*,细菌耐药性的流行趋势及控制措施,卫生部北京医院 胡云建,细菌耐药性的流行趋势,卫生部要求：开展细菌耐药监测工作，定期发布细菌耐药信息，建立细菌耐药预警机制，针对不同的细菌耐药水平采取相应应对措施,2011,年,CHINET,参加单位,上海华山医院,上海瑞金医院,北京协和医院,卫生部北京医院,浙医一附院,上海儿科医院,湖北同济医院,广州医学院一附院,上海市儿童医院,重庆医大一附院,甘肃省人民医院,新疆医大一附院,安徽医科大学一附院,昆明医学院一附院,浙江邵逸夫医院,临床分离细菌,年,月收集各医院临床分离菌共株。,其中革兰阳性菌株，占,.,革兰阴性菌株，占,.,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,11860,27.96,摩根菌属,198,0.47,克雷伯菌属,6981,16.46,产碱杆菌,128,0.30,不动杆菌属,6723,15.85,少动鞘氨醇单胞菌,120,0.28,铜绿假单胞菌,6012,14.17,金杆菌属,208,0.49,肠杆菌属,2519,5.94,罗尔斯顿菌属,109,0.26,嗜麦芽窄食单胞菌,1889,4.45,气单胞菌属,106,0.25,变形杆菌属,1271,3.00,多源菌属,45,0.11,流感嗜血杆菌,830,1.96,普罗威登菌属,34,0.08,沙雷菌属,598,1.41,志贺菌属,154,0.36,其他假单胞菌,322,0.76,丛毛单胞菌,25,0.06,其他嗜血杆菌,211,0.50,奈瑟菌属,23,0.05,沙门菌属,655,1.54,博特菌属,37,0.09,柠檬酸杆菌属,424,1.00,黄杆菌属,23,0.05,伯克霍尔德菌属,455,1.07,其他,327,0.77,莫拉菌属,128,0.30,合计,42415,100.0,菌种分布：不动杆菌属铜绿假单胞菌；沙门菌属,；伯克霍尔德菌；,人们最关注哪些多药耐药革兰阴性杆菌？,产,ESBL,-,的肠杆菌科菌,(2010,年以前）,碳青霉烯耐药,的革兰阴性杆菌,Enterobacteriaceae,肠杆菌科,(CRE),P. aeruginosa,绿脓杆菌,Acinetobacter baumannii,鲍曼不动杆菌,其它对所有或几乎所有常规药物,均耐药,的革兰阴性杆菌。,2011,年,CHINET,监测网各医院产,ESBL,菌株检出率,医院,大肠埃希菌,肺克和产酸,奇异变形杆菌,产,ESBLs,株数,/,总株数,（,%,）,产,ESBLs,株数,/,总株数,（,%,）,产,ESBLs,株数,/,总株数,（,%,）,华山医院,376/637,59.0,232/629,36.9,45/87,51.7,协和医院,537/1026,52.3,202/701,28.8,29/115,25.2,同济医院,769/1029,74.7,358/643,55.7,10/64,15.6,浙医一附院,580/999,58.1,311/665,46.8,0/120,0.0,广州一附院,278/596,46.6,120/380,31.6,0/103,0.0,北京医院,190/314,60.5,42/145,29.0,8/22,36.4,上海儿科医院,664/1242,53.5,217/373,58.2,9/77,11.7,上海儿童医院,384/622,61.7,202/312,64.7,4/49,8.2,重庆医大一附院,256/383,66.8,120/319,37.6,5/58,8.6,甘肃省人民医院,246/400,61.5,92/353,26.1,4/26,15.4,新疆医大一附院,236/607,38.9,227/615,36.9,10/47,21.3,安徽医大一附院,652/994,65.6,192/365,52.6,18/53,34.0,云南医大一附院,440/904,48.7,249/502,49.6,5/29,17.2,浙大邵逸夫医院,407/792,51.4,104/377,27.6,0/122,0.0,合计,6015/11860,50.7,2668/6937,38.5,147/1066,13.8,头孢菌素折点,旧折点,新折点,所有产,ESBL,菌株当检测出对超广谱头孢菌素* “敏感”时，报告为以下药物“耐药”,:,头孢噻肟,头孢他啶,头孢曲松,头孢吡肟,产,ESBL,菌株可能不会检测出对所有超广谱头孢菌素* “耐药”,产,ESBL,菌株会检测出对至少一种超广谱头孢菌素* “耐药”,对于产,ESBL,菌株的预期结果,20010,年版,CLSI,的判断标准有变化,Courtesy of Dr. Jean Patel CDC,*头孢噻肟，头孢他啶，头孢曲松，头孢吡肟,肠杆菌科细菌,-,碳青霉烯酶的检测,(,KPC,、,NDM-1,的检测,),2011,年,15,家医院,11860,株大肠埃希菌耐药率（,%,）,对亚胺培南和美罗培南的耐药率上升,对哌拉西林、氟喹诺酮类、庆大霉素和头孢噻肟的耐药率高（,50%,以上）,对碳青霉烯类、两种酶抑制剂复方、磷霉素和阿米卡星的耐药率低,2011,年,15,家医院,6981,株克雷伯菌属耐药率（,%,）,对亚胺培南和美罗培南的耐药率上升,2011,年,15,家医院,1271,株变形杆菌属耐药率（,%,）,2011,年,15,家医院,2519,株肠杆菌属细菌耐药率（,%,）,对,3,种碳青霉烯类的耐药率上升,对阿米卡星、两种酶抑制剂复方、头孢吡肟和环丙沙星的耐药率,20%,2011,年,15,家医院,24829,株肠杆菌科细菌耐药率（,%,）,抗菌药物,耐药,敏感,亚胺培南,4.8,92.3,美罗培南,4.1,94.5,厄他培南,6.1,85.0,阿米卡星,8.3,89.0,哌拉西林,/,他唑巴坦,9.6,81.1,头孢哌酮,/,舒巴坦,10.3,73.1,头孢他啶,30.7,63.8,头孢吡肟,22.7,69.8,庆大霉素,38.7,59.3,对碳青霉烯类的耐药率为,4-6%,；,对阿米卡星、磷霉素和两种酶抑制剂复方的耐药率,10%,铜绿假单胞菌和不动杆菌,临床最常见的两类非发酵菌,铜绿假单胞菌：革兰阴性杆菌宽,0.51.0,m,，长,1.53.0m,。无芽孢，有单鞭毛。临床分离的菌株常有菌毛和微荚膜。,贾文祥主编,.,医学微生物学,.,人民卫生出版社,2005.,不动杆菌为革兰氏染色阴性、无芽孢、两端钝圆、散在或个别成双排列、,大小,(0.6,1.0),m(1.0,1.6),m,的杆状,(,球杆状,),细菌。,图中显示的是鲍曼不动杆菌。,陈翠珍等,.,海洋水产研究,2 0 0 5,年,8,月第,26,卷 第,4,期,2011,年,15,家医院,6012,株铜绿假单胞菌耐药率（,%,）,2011,年,15,家医院,6723,株不动杆菌属,(,鲍曼不动,88.6%),细菌的耐药率（,%,）,对多黏菌素的耐药率低,对亚胺培南、美罗培南的耐药率,60%,（,）,对两种舒巴坦合剂的耐药率,（,40%-60%,）,对多数抗菌药的耐药率,60%,2011,年,15,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（,1889,株）,抗菌药物,伯克霍尔德菌属（,363,株）,耐药,敏感,耐药,敏感,头孢哌酮,/,舒巴坦,19.0,58.5,哌拉西林,/,他唑巴坦,12.6,79.3,左氧氟沙星,10.0,87.2,头孢他啶,18.0,76.8,复方磺胺甲噁唑,16.6,81.8,美罗培南,13.5,77.4,米诺环素,1.8,84.8,复方磺胺甲噁唑,41.0,52.1,米诺环素,5.0,85.9,CHINET,各医院铜绿假单胞菌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,118,13.8,86.2,15.7,83.5,广州医大一附院,486,28.6,71.4,17.6,80.9,重庆医大一附院,258,18.9,76.4,10.5,81.3,上海儿科医院,159,9.1,86.4,7.1,91.6,卫生部北京医院,431,46.5*,50.5,42.5 *,54.5,上海华山医院,642,40.7 *,56.8,33.4,60.8,北京协和医院,686,20.3,77.8,15.5,81.8,甘肃省人民医院,115,5.2,93.9,4.4,94.7,上海瑞金医院,433,34.4,63.0,28.5,69.9,湖北同济医院,613,19.1,78.9,18.9,78.9,浙医一附院,630,28.7,69.3,21.8,75.8,新疆医大一附院,408,27.2,68.8,25.6,69.7,安徽医大一附院,454,27.3,67.8,28.7,66.7,昆明医大一附院,255,58.0 *,35.3,52.3 *,39.5,浙江邵逸夫医院,324,27.3,67.7,26.5,71.7,对碳青霉烯类的耐药率,40%,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,205,35.6*,64.4,36.6*,63.4,广州医大一附院,468,50.0,50.0,77.3,22.7,重庆医大一附院,389,57.0,42.5,57.2,42.5,上海儿科医院,359,69.6,28.2,72.3,27.5,卫生部北京医院,129,53.5,46.5,53.5,45.7,上海华山医院,586,69.0,30.3,69.6,29.9,北京协和医院,753,61.0,38.5,61.9,37.3,甘肃省人民医院,222,23.6*,75.5,23.6*,75.0,上海瑞金医院,447,62.6,36.3,62.9,36.7,湖北同济医院,773,54.5,44.6,55.6,44.0,浙医一附院,717,72.6,27.1,73.7,26.1,新疆医大一附院,386,46.6*,51.3,49.5*,47.9,安徽医大一附院,466,54.3,42.2,55.6,41.8,昆明医大一附院,374,68.5,31.2,69.9,29.1,浙江邵逸夫医院,449,74.8,24.8,77.9,21.8,对碳青霉烯类的耐药率,50%,2011,年,15,家医院,16233,株非发酵菌耐药率（,%,）,抗菌药物,耐药,敏感,头孢哌酮,/,舒巴坦,28.5,52.7,美罗培南,45.2,52.2,阿米卡星,35.3,60.9,头孢他啶,39.6,51.2,头孢吡肟,41.9,51.5,哌拉西林,/,他唑巴坦,41.4,54.5,亚胺培南,48.6,49.0,环丙沙星,43.7,50.7,什么是多重耐药菌株（,MDRO,）？,目前没有标准定义!,国际上正努力对以下定义进行标化：,MDR,多药耐药,(如对, 3,类药物耐药),XDR, extensively drug-R,广泛药物耐药,如 对几乎所有药物耐药但对至少一类药物敏感,PDR,pandrug-R,所有药物耐药,(如，对所有类型药物耐药),这些定义用于”获得性“（相对于”天然“）耐药以及可能治疗这些菌株感染用到的药物,泛耐药,泛耐药,(PDR),：铜绿假单胞菌,鲍曼不动杆菌,G-b,第三、四代头孢菌素、酶抑制剂复方制剂、碳青霉烯类、氨基糖苷类和氟喹诺酮类,(Clinical infectious Diseases,2006,43(suppl2):s41-121),具体指：头孢他啶、头孢吡肟、亚胺培南、美罗培南、哌拉西林,-,三唑巴坦、,头孢哌酮,/,舒巴坦、,环丙沙星、左氧氟沙星、庆大霉素、阿米卡星、,2011,年各医院泛耐药株数,医院,肺炎克雷伯菌,肠杆菌科细菌*,PDR,株数总株数,PDR,（）,PDR,株数总株数,PDR,（）,华山医院,97/616,15.7,106/1731,6.1,瑞金医院,13/514,2.5,16/2235,0.7,协和医院,2/599,0.3,4/2399,0.2,同济医院,0/597,0.0,4/2072,0.2,浙医一附院,10/637,1.6,11/2201,0.5,广州一附院,0/365,0.0,0/1271,0.0,重医一附院,0/285,0.0,0/942,0.0,北京医院,5/138,3.6,5/615,0.8,儿科医院,0/368,0.0,5/2418,0.2,儿童医院,0/292,0.0,2/1321,0.2,甘肃省人民医院,0/284,0.0,0/1067,0.0,新疆医大一附院,0/544,0.0,0/1572,0.0,安徽医大一附院,7/329,2.1,10/1719,0.6,昆明医大一附院,0/452,0.0,2/1751,0.1,浙江邵逸夫医院,16/370,4.3,20/1515,1.3,合计,150/6390,2.3,185/24829,0.7,2010,189/5032,3.8,224/19289,1.2,*：包括肺炎克雷伯菌、大肠埃希菌、阴沟肠杆菌、产气肠杆菌、柠檬酸杆菌属、黏质沙雷菌等,THANK YOU,SUCCESS,2024/10/4,27,可编辑,2011,年各医院泛耐药株数,医院,铜绿假单胞菌,鲍曼不动杆菌,PDR,株数总株数,（）,PDR,株数,总株数,（）,华山医院,18/642,2.8,232/560,41.4,瑞金医院,11/433,2.5,118/421,28.0,协和医院,3/686,0.4,295/700,42.1,同济医院,7/613,1.1,85/374,22.7,浙医一附院,5/630,0.8,158/659,24.0,广州一附院,0/486,0.0,0/438,0.0,重医一附院,3/258,1.2,115/362,31.8,北京医院,20/431,4.6,26/117,22.2,儿科医院,0/159,0.0,121/340,35.6,儿童医院,0/118,0.0,45/184,24.5,甘肃人民医院,0/115,0.0,7/182,3.8,新疆医大一附院,1/408,0.2,0/376,0.0,安徽医大一附院,17/454,3.7,76/448,17.0,昆明医大一附院,24/255,9.4,13/365,3.6,浙江邵逸夫医院,0/324,0.0,1/432,0.2,合计,109/6012,1.8,1292/5958,21.7,2010,86/5080,1.7,1058/4949,21.4,各种革兰阴性杆菌中泛耐药菌株所占比例,铜绿假单胞菌,鲍曼不动杆菌,弗劳地柠檬酸杆菌,肺炎克雷伯菌,大肠埃希菌,肠杆菌属,2008 CHINET,2.1,10.9,5.9,0.3,0,0,2009 CHINET,1.7,17.0,2.7,1.8,0.06,0.35,2010 CHINET,1.7,21.4,5.2,3.8,0.07,0.56,2011 CHINET,1.8,21.7,/,2.3,/,/,对多重耐药阴性菌感染的治疗方案,在未来几年中，不会有新药上市,耐药情况只会越来越严峻,1.,肺炎链球菌,及溶血性,链球菌,自,1967,年第一株,PRSP,（耐青霉素的肺炎链球菌）发现以来，在世界范围内有关青霉素不敏感肺炎链球菌流行的报道在不断增多。,A lexander,研究,表明其发生率在非洲、美洲超过,30% ,亚洲地区病原监测网（,ANSORP,）,4,的研究报道显示，同时期韩国为,85%,、台湾为,91.3%,、香港为,59%,、日本为,65%,、越南为,61%,、泰国为,58%,。,肺炎链球菌,青霉素,(,g/ml),敏感,中介,耐药,青霉素注射,(,非脑膜炎,),2,4,8,青霉素注射,(,脑膜炎,),0.06,-,0.1,2,青霉素,(,口服青霉素,V),0.06,0.12-1,2,CLSI M100-S19. Table 2G.,表,2G,对每个类型均提供了治疗建议。,标本：血诊断：肺炎,肺炎链球菌,头孢曲松,(,脑膜炎,) 0.5 S,头孢曲松,(,非脑膜炎,) 0.5 S,红霉素,1 R,左氧氟沙星,1 S,美罗培南 ,0.25 S,青霉素,(,脑膜炎,) 1 R,青霉素,(,非脑膜炎,) 1 S,青霉素,(,口服青霉素,V,) 1 I,万古霉素,0.5 S,MIC (g/ml),Final Report,终报告,肺炎链球菌的分布,儿童,2008,2009,2010,2011,PSSP,79.1,68.9,70.3,73.6,PISP,9.7,17.4,15.9,13.5,PRSP,11.2,13.7,13.8,12.9,成人,2008,2009,）,2010,2011,PSSP,94.3,95.0,92.2,93.1,PISP,2.3,3.8,3.3,4.8,PRSP,3.4,1.3,4.4,2.1,儿童和成人患者肺炎链球菌的耐药率（%）,抗菌药物,2008,2009,2010,2011,儿童,成人,儿童,成人,儿童,成人,儿童,成人,红霉素,90.8,74.4,93.9,79.6,79.0,80.2,97.1,91.1,克林霉素,92.2,68.8,93.6,75.7,79.8,79.8,94.1,85.4,莫西沙星,1.0,0,0.2,2.5,3.7,0,0.2,1.3,左氧氟沙星,10.0,0,0.6,2.5,7.4,0.9,0.5,3.8,2.,金黄色葡萄球菌,:,MSSA,MRSA,MSSA,对主要抗菌药物的耐药性统计,2008,2009,2010,2011,抗生素名称,%R,%R,%R,%R,青霉素,G,92.5,90.9,92.1,90.7,氨苄西林,/,舒巴坦,1.1,1.1,1.5,1.1,头孢唑啉,1.3,0.8,1.7,2.9,头孢呋辛钠,2.0,1.2,2.4,1.4,头孢西丁,0,0,0,0,庆大霉素,12.2,12.4,11.9,14.3,利福平,2.9,3.2,3.2,2.6,左旋氧氟沙星,7.0,7.0,6.7,7.6,复方新诺明,7.4,6.5,10.7,16.6,红霉素,50.8,50.9,50.4,48.7,利奈唑胺,0,0,0,0,万古霉素,0,0,0,0,金黄色葡萄球菌的主要耐药问题是对甲氧西林耐药株（,MRSA,）的检出率,:,不同医院检出率有较大的不同。,2008,2009,2010,2011,CHINET,55.9,52.7,51.7,50.6,北京医院,78.2,78.3,77.6,85.3,万古霉素和金葡菌,VSSA, vancomycin-susceptible,S. aureus,VSSA-,万古霉素敏感的金葡菌,VISA, vancomycin-intermediate,S. aureus,VISA-,万古霉素中介的金葡菌,VRSA, vancomycin-resistant,S. aureus,VRSA-,万古霉素耐药的金葡菌,hVISA, heteroresistant VISA,h,VISA-,异质性耐药的,VISA,Case,State,Year,Age,Source,Diagnosis,Underlying Conditions,1,MI,2002,40,Plantar ulcers & Catheter tip,Plantar soft tissue infection,Diabetes, dialysis,2,PA,2002,70,Plantar ulcer,Osteomyelitis,Obesity,3,NY,2004,63,Urine from a nephrostomy tube,No infection,Multiple sclerosis, Diabetes, kidney stones,4,MI,2005,78,Toe wound,Gangrene,Diabetes, vascular disease,5,MI,2005,58,Surgical site wound after panniculectomy,Surgical site infection,Obesity,6,MI,2005,48,Plantar ulcer,Osteomyelitis,MVA, chronic ulcers,7,MI,2006,43,Triceps wound,Necrotizing fasciitis,Diabetes, dialysis, chronic ulcers,8,MI,2007,48,Toe wound,Osteomyelitis,Diabetes, obesity, chronic ulcers,9,MI,2007,54,Surgical site wound after foot amputation,Osteomyelitis,Diabetes, hepatic encephalopathy,10,MI,2009,53,Plantar foot wound,Plantar soft tissue infection,Diabetes, obesity, lupus, rheumatoid arthritis,11,DE,2010,64,Wound drainage,Prosthetic joint infection,Diabetes, end-stage renal disease, dialysis,什么是,VRE (,耐万古霉素肠球菌,),肠球菌是人类肠道和女性生殖道的常见菌，并且广泛存在于自然界。这些细菌有时也会引起感染。,万古霉素是一种常用于治疗肠球菌感染的抗生素。在部分病例中，肠球菌已经开始产生对万古霉素的耐药性，被称为耐万古霉素肠球菌或,VRE,。,大部份,VRE,感染发生在住院病人中。,vanA,从,VRE,转至金葡菌,Ferber, D. 2003. Science 302:1488.,van,A,预防传播,合理应用抗菌药物,有效的诊断和治疗,预防感染,12,遏制医务工作者传播,11,隔离定植患者患者,9,严格掌握万古霉素应用指证,1,接种疫苗,2,拔除导管,6,专家会诊,7,治疗感染，而非污染,3,针对性病原治疗,8,治疗感染，而非定植,4,控制抗菌药物应用,5,参考当地流行病学资料,10,及时停用抗菌药物,综合医院住院患者,抗菌药物使用率,不超过,60%,三级综合医院,抗菌药物品种,原则上,不超过,50,种,实现抗菌药物临床应用,动态监测、评估和预警,接受,限制使用级,抗菌药物治疗的住院患者抗菌药物使用前微生物检验,样本送检率,不低于,50%,；接受,特殊使用级,抗菌药物治疗的住院患者抗菌药物使用前微生物送检率不低,于,80%,医疗机构组织感染、药学等相关专业技术人员,对抗菌药物处方、医嘱实施专项点评,对目标细菌耐药率超过某耐药水平的，要采取相应措施,成立抗菌药物临床应用管理小组,加大信息化建设力度,国家,筛查种类,颁布时间,英国,MRSA,2002,法国,MRSA,2006,比利时,MRSA,1992,丹麦,MRSA,1996,挪威,MRSA,-,德国,多重耐药菌,2001,瑞典,MRSA,，,VRE,2000,THANK YOU,SUCCESS,2024/10/4,52,可编辑,