醫(yī)院獲得性肺炎-如何理解培養(yǎng)結(jié)果

1、The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006; 355: 2619-26302531篩選患者篩選患者1387不合格患者不合格患者1144合格患者合格患者740入選患者入選患者404未入選患者未入選患者不同意無家屬在場(chǎng)未找到患者原因未知已開始針對(duì)VAP的其他抗生素治療18 患者需要進(jìn)行纖維支氣管鏡檢查其他原因醫(yī)生拒絕入選1812 無人行纖維支氣管鏡檢查375 ETA

2、365 BALThe Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006; 355: 2619-2630The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 200

3、6; 355: 2619-2630The Canadian Critical Care Trials Group. A randomized trial of diagnostic techniques for ventilator-associated pneumonia. N Engl J Med 2006; 355: 2619-2630Kollef MH. Diagnosis of ventilator-associated pneumonia. N Engl J Med 2006; 355: 2691-2693滿足臨床診斷標(biāo)準(zhǔn)(n = 50)發(fā)熱病因明確(n = 45)感染性(n =

4、37)非感染性(n = 8)肺炎(n = 19)鼻竇炎，導(dǎo)管感染泌尿系感染(n = 14)念珠菌血癥膽囊炎膿胸，腹膜炎肺動(dòng)脈栓塞(n = 6)肺外(n = 2)合并感染(n = 14)合并感染(n = 11)合并感染 (n = 0)纖維增殖(n = 5)化學(xué)吸入(n = 1)胰腺炎(n = 1)藥物熱(n = 1)Meduri GU, et al. Chest 1994; 106: 221Baram D, Hulse G, Palmer LB. Stable Patients Receiving Prolonged Mechanical Ventilation Have a High Alve

5、olar Burden of Bacteria. Chest 2005; 127: 1353-1357Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.el Ebiary M, Torres A, Fabregas N, et al. Significance of the isolation of Ca

6、ndida species from respiratory samples in critically ill, non-neutropenic patients: an immediate postmortem histologic study. Am J Respir Crit Care Med 1997; 156: 583-590el Ebiary M, Torres A, Fabregas N, et al. Significance of the isolation of Candida species from respiratory samples in critically

7、ill, non-neutropenic patients: an immediate postmortem histologic study. Am J Respir Crit Care Med 1997; 156: 583-590肺組織病理檢查l念珠菌病8% (2/25)呼吸道標(biāo)本培養(yǎng)l念珠菌40% (10/25)VS.el Ebiary M, Torres A, Fabregas N, et al. Significance of the isolation of Candida species from respiratory samples in critically ill, no

8、n-neutropenic patients: an immediate postmortem histologic study. Am J Respir Crit Care Med 1997; 156: 583-590Rello J, Esandi ME, Diaz E, et al. The role of Candida sp isolated from bronchoscopic samples in nonneutropenic patients. Chest 1998; 114: 146-149Rello J, Esandi ME, Diaz E, et al. The role

9、of Candida sp isolated from bronchoscopic samples in nonneutropenic patients. Chest 1998; 114: 146-149致病菌定植菌=Kollef MH, Kollef K. Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results. Chest 2005; 128(

10、4): 2706-2713Kollef MH, Kollef K. Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results. Chest 2005; 128(4): 2706-2713Kollef MH, Kollef K. Antibiotic Utilization and Outcomes for Patients With Clinical

11、ly Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results. Chest 2005; 128(4): 2706-2713Croce M, Faban T, Mueller EW, et al. The appropriate diagnostic threshold for ventilator-associated pneumonia using quantitative cultures. J Trauma 2004; 56:931-936Timsit JF, Ceva

12、l G, Gachot B, et al. Usefulness of a strategy based on bronchoscopy with direct examination of bronchoalveolar lavage fluid in the initial antibiotic therapy of suspected ventilator-associated pneumonia. Intensive Care Med 2001; 27: 640-647Raghavendran K, Wang J, Belber C, MD. Predictive Value of S

13、putum Gram Stain for the Determination of Appropriate Antibiotic Therapy in Ventilator-Associated Pneumonia. J Trauma 2007; 62: 1377-1383Raghavendran K, Wang J, Belber C, MD. Predictive Value of Sputum Gram Stain for the Determination of Appropriate Antibiotic Therapy in Ventilator-Associated Pneumo

14、nia. J Trauma 2007; 62: 1377-1383Raghavendran K, Wang J, Belber C, MD. Predictive Value of Sputum Gram Stain for the Determination of Appropriate Antibiotic Therapy in Ventilator-Associated Pneumonia. J Trauma 2007; 62: 1377-1383Micek ST, Ward S, Fraser VJ, Kollef MH. A Randomized Controlled Trial o

15、f an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia. Chest 2004; 125:17911799Micek ST, Ward S, Fraser VJ, Kollef MH. A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia. Chest 2004;

16、 125:17911799Micek ST, Ward S, Fraser VJ, Kollef MH. A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia. Chest 2004; 125:17911799Ewig S, Torres A, El-Ebiary M, Fbregas N, Hernndez C, Gonzlez J, Nicols JM, Soto L. Bacterial c

17、olonization patterns in mechanically ventilated patients with traumatic and medical head injury: incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 188-198Ewig S, Torres A, El-Ebiary M, Fbregas N, Hernndez C, Gonzlez J, Nicols JM, Soto

18、 L. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury: incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 188-198Ewig S, Torres A, El-Ebiary M, Fbregas N, Hernndez C, Gonzlez J,

19、Nicols JM, Soto L. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury: incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 188-198Ewig S, Torres A, El-Ebiary M, Fbregas N, Hernndez

20、 C, Gonzlez J, Nicols JM, Soto L. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury: incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 188-198Ewig S, Torres A, El-Ebiary M, Fbre

21、gas N, Hernndez C, Gonzlez J, Nicols JM, Soto L. Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury: incidence, risk factors, and association with ventilator-associated pneumonia. Am J Respir Crit Care Med 1999; 159: 188-19804896144192240288Hou

22、rs of mechanical ventilation0.00.20.40.60.8Probability of early-onset pneumoniaPts not colonized with Group I pathogensPts colonized with Group I pathogensP = 0.02Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance

23、. Crit Care Med 2003; 31:1964 1970.Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospe

24、ctive analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.3939301701020304050All VAP-causative bacteria iso

25、lated beforeAt least one but not all VAP-causativebacteria isolated beforeAll bacteria isolated before misleadingPrior specimens sterileNo. of episodesHayon J, Figliolini C, Combes A, Trouillet JL, Kassis N, Dombret MC, Gibert C, Chastre J. Role of Serial Routine Microbiologic Culture Results in the

26、 Initial Management of Ventilator-associated Pneumonia. Am J Respir Crit Care Med 2002; 165: 41-461010123991061794305101520All VAP-causative bacteria isolatedbeforeAt least one but not all VAP-causativebacteria isolated beforeAll bacteria isolated before misleadingPrior specimens sterileNo. of episo

27、des 7 dHayon J, Figliolini C, Combes A, Trouillet JL, Kassis N, Dombret MC, Gibert C, Chastre J. Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia. Am J Respir Crit Care Med 2002; 165: 41-46Hayon J, Figliolini C, Combes A, Trouillet JL, Kassis N, Dombret MC, Gibert C, Chastre J. Role of Se