e5吸科耐藥革蘭陰性桿菌與治療策略課件

1、呼吸科耐藥革蘭陰性桿菌與治療策略 株洲市二醫(yī)院劉和平副主任醫(yī)師e5吸科耐藥革蘭陰性桿菌與治療策略呼吸科耐藥革蘭陰性桿菌與治療策略 株洲市二醫(yī)院e5吸科耐藥CAP: OutpatientPreviously HealthyNo recent antibiotic therapy: A macrolidea or doxycyclineRecent antibiotic therapy: A respiratory fluoroquinolone (RFQ) alone, an advanced macrolide (AM) plus high-dose amoxicillin or AM plu

2、s high-dose amoxicillin-clavulanateComorbidities (COPD, Diabetes, Renal or Congestive Heart Failure, or Malignancy)No recent antibiotic therapy: AM or RFQRecent antibiotic therapy: RFQ alone or AM plus a B-lactamSuspected aspiration with infection: Amoxicillin-clavulanate or clindamycinInfluenza wit

3、h bacterial superinfection: B-lactam or a RFQe5吸科耐藥革蘭陰性桿菌與治療策略CAP: OutpatientPreviously HealCAP: InpatientMedical WardNo recent antibiotic therapy: RFQ alone or AM plus B-lactamRecent antibiotic therapy: AM plus B-lactam or RF alone (regimen selected will depend on nature of recent antibiotic therap

4、y)Intensive Care Unit (ICU)Pseudomonas infection is not an issue: B-lactam plus either AM or RFQPseudomonas infection is not an issue but patient has B-lactam allergy: RFQ, with or without clindamycinPseudomonas infection is an issue: Either (1) an antipseudomonal agent plus ciprofluoxacin, or (2) a

5、n antipseudomonal agent plus an aminoglycoside plus RFQ or a macrolidePseudomonas infection is an issue but patient has a -lactam allergy: the Either (1) aztreonam plus levofluoxacin or (2) aztreonam plus moxifluoxacin or gatifluoxacin, with or without an aminoglycoside Nursing HomeReceiving treatme

6、nt in nursing home: RFQ alone or amoxicillin-clavulanate plus AMHospitalized: Same as for medical ward and ICUe5吸科耐藥革蘭陰性桿菌與治療策略CAP: InpatientMedical Warde5吸科NNIS報(bào)告的醫(yī)院內(nèi)肺炎病原體檢出率排位8082(15331)9096(13433)80829096枸櫞酸菌111111腸桿菌91143大腸桿菌8456肺炎桿菌10834其他克雷伯41811奇異變形桿菌5268其他變形桿菌001413粘質(zhì)沙雷菌4377其他沙雷菌101213腸桿菌科合計(jì)

7、4230綠膿桿菌131722金葡菌131911CoNS12138腸球菌22108念珠菌3595其他2625e5吸科耐藥革蘭陰性桿菌與治療策略NNIS報(bào)告的醫(yī)院內(nèi)肺炎病原體檢出率排位8082(153銅綠假單胞菌、肺炎克雷伯菌和鮑曼不動(dòng)桿菌是HAP常見(jiàn)的革蘭陰性桿菌Antimicrob Agents Chemother. 2003 Nov;47(11):3442-7e5吸科耐藥革蘭陰性桿菌與治療策略銅綠假單胞菌、肺炎克雷伯菌和鮑曼不動(dòng)桿菌是HAP常見(jiàn)的革蘭Nosocomial tracheobronchitis in MV patients:incidence, aetiology and out

8、comeSurgical Medical Patients n 36 165 Gram-negative microorganisms 34 (77.2) 162 (78.7) Pseudomonas aeruginosa 14 (31.8) 58 (28) Acinetobacter baumannii 6 (13.6) 55 (26.5) Klebsiella spp. 4 (9.0) 6 (2.8) Enterobacter aerogenes 3 (6.8) 4 (1.9) Serratia spp. 2 (4.5) 11 (5.3) Stenotrophomonas maltophi

9、lia 2 (4.5) 7 (3.3) Escherichia coli 1 (2.2) 8 (3.8) Haemophilus influenzae 0 4 (1.9) Other 2 (4.5) 9 (4.3) Gram-positive microorganisms 10 (22.7) 45 (21.7) MRSA 7 (15.9) 31 (14.9) MSSA 2 (4.5) 6 (2.8) Streptococcus pneumoniae 1 (2.2) 8 (3.8) Eur Respir J 2002; 20: 14831489.e5吸科耐藥革蘭陰性桿菌與治療策略Nosocomi

10、al tracheobronchitis i 醫(yī)院內(nèi)肺炎病原菌（Meta分析，全國(guó)19901998年，6062株菌） 病原體菌株構(gòu)成綠膿桿菌124120.6克雷伯菌60810.1大腸桿菌3565.9腸桿菌屬2784.6不動(dòng)桿菌2754.6嗜麥芽窄食單胞1001.7流感嗜血桿菌500.8金黃色葡萄球菌3585.9腸球菌831.4肺炎鏈球菌611.0e5吸科耐藥革蘭陰性桿菌與治療策略 醫(yī)院內(nèi)肺炎病原菌（Meta分析，全國(guó)19901998年病原菌發(fā)生類型株數(shù)%早發(fā)性晚發(fā)性鮑曼不動(dòng)桿菌1121318.6銅綠假單胞菌1101115.7金黃色葡萄球菌36912.9大腸埃希菌0557.1陰溝腸桿菌1457.

11、1肺炎克雷伯菌1345.7粘質(zhì)沙雷菌0445.7念珠菌1345.7嗜麥芽窄食單胞0334.3變形桿菌0334.3表皮葡萄球菌1122.9腸球菌1122.9產(chǎn)堿桿菌0222.9肺炎鏈球菌1011.4洛菲不動(dòng)桿菌0111.4黃桿菌0111.4合計(jì)115970100.0 52例VAP病原分布(9901) e5吸科耐藥革蘭陰性桿菌與治療策略病原菌發(fā)生類型株數(shù)%早發(fā)性晚發(fā)性鮑曼不動(dòng)桿菌1121318.NLRTI前五位病原菌在6個(gè)常見(jiàn)科室的比較 謝紅梅，胡必杰，何禮賢，等. 2819例醫(yī)院下呼吸道感染病原和預(yù)后分析.上海醫(yī)學(xué)2003；26：880-885e5吸科耐藥革蘭陰性桿菌與治療策略NLRTI前五位病

12、原菌在6個(gè)常見(jiàn)科室的比較 謝紅梅，胡必杰，醫(yī)院內(nèi)肺炎病原早期中期晚期1 3 5 10 15 20鏈球菌流感桿菌金葡菌 MRSA腸桿菌肺克，大腸綠膿桿菌不動(dòng)桿菌嗜麥芽窄食單胞菌入院天數(shù)e5吸科耐藥革蘭陰性桿菌與治療策略醫(yī)院內(nèi)肺炎病原早期中期晚期1 3 呼吸科常見(jiàn)耐藥革蘭陰性桿菌肺炎克雷伯桿菌，大腸埃希菌腸桿菌屬，沙雷菌，枸櫞酸菌，變形桿菌銅綠假單胞菌，其他假單胞菌鮑曼不動(dòng)桿菌，其他不動(dòng)桿菌嗜麥芽窄食單胞菌屬伯克霍爾德菌屬產(chǎn)堿桿菌屬，黃桿菌屬NPRS結(jié)果顯示，銅綠和鮑曼作為MDR問(wèn)題正在凸現(xiàn)e5吸科耐藥革蘭陰性桿菌與治療策略呼吸科常見(jiàn)耐藥革蘭陰性桿菌肺炎克雷伯桿菌，大腸埃希菌e5吸科細(xì)菌耐藥是否會(huì)

13、影響病死率 ?治療肺炎桿菌ESBL菌株血液感染 (n=31)合適治療 (n=19) 病死率 5%不恰當(dāng)治療(n=12)病死率 42% P=0.02Source:Schiappa et al JID 1996; 74:529-36e5吸科耐藥革蘭陰性桿菌與治療策略細(xì)菌耐藥是否會(huì)影響病死率 ?治療肺炎桿菌ESBL菌株血液感染e5吸科耐藥革蘭陰性桿菌與治療策略e5吸科耐藥革蘭陰性桿菌與治療策略在ICU中肺部感染耐藥菌問(wèn)題尤為突出e5吸科耐藥革蘭陰性桿菌與治療策略在ICU中肺部感染耐藥菌問(wèn)題尤為突出e5吸科耐藥革蘭陰性桿菌MDR引起肺炎的防治策略預(yù)防醫(yī)院內(nèi)肺炎（HAP、VAP、HCAP）早期、準(zhǔn)確的病

14、原學(xué)診斷，不要治療定植菌和污染菌停止無(wú)效、耐藥的抗生素，避免更嚴(yán)重的后果加大劑量：從藥敏單中尋找中介（低敏）的藥物聯(lián)合使用，在安全范圍內(nèi)的最大劑量，時(shí)間依賴性的藥在允許范圍縮短用藥間隔，甚至24h連續(xù)點(diǎn)滴舊藥新用：多粘菌素E，舒巴坦對(duì)不動(dòng)桿菌等聯(lián)合用藥：MIC為16ug/ml的頭孢他啶和16ug/ml的阿米卡星合用可能有效；特門汀與氨曲南聯(lián)合治不發(fā)酵糖菌效果有時(shí)很好；氨曲南可耐受金屬酶e5吸科耐藥革蘭陰性桿菌與治療策略MDR引起肺炎的防治策略預(yù)防醫(yī)院內(nèi)肺炎（HAP、VAP、HCManaging Infection In The Critical Care Unit: How Can Infec

15、tion Control Make The ICU Safe?Crit Care Clin. 2005 Jan;21(1):111-28 Shulman L, Ost DDivision of Pulmonary and Critical Care Medicine, North Shore University Hospital, Manhasset, NY 11030, USAe5吸科耐藥革蘭陰性桿菌與治療策略Managing Infection In The CritVAP預(yù)防方法的有效性評(píng)價(jià)Route of intubationSearch for sinusitisCircuit c

16、hangesHumidifierHumidifier changesEndotracheal suctioningSubglottic secretion drainageChest physiotherapyTracheostomyKinetic bedsSemi-recumbent positionProne positionStress ulcer prophylaxisProphylactic antibioticse5吸科耐藥革蘭陰性桿菌與治療策略VAP預(yù)防方法的有效性評(píng)價(jià)Route of intubatie5吸科耐藥革蘭陰性桿菌與治療策略e5吸科耐藥革蘭陰性桿菌與治療策略Antis

17、eptic impregnated endotracheal tubes for the prevention of bacterial colonization在實(shí)驗(yàn)室氣道模型中建立不同對(duì)MRSA, PA, AB 和產(chǎn)氣腸桿菌有抗菌作用的氣管插管(ETTs) ，包裹有洗必泰和碳酸銀抗菌ETT和對(duì)照 ETT (未包裹）用濃度108cfu/ml的菌液污染，5天孵育，管腔的遠(yuǎn)端和近端分別采樣細(xì)菌培養(yǎng)抗菌ETT細(xì)菌定植量為1-100 cfu/管，而對(duì)照ETT達(dá)106cfu/管(P 24 hrs. INTERVENTIONS: Patients were randomized into two gro

18、ups; one group was suctioned with CS and another group with the OS. MEASUREMENTS: Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous and exogenous. MAIN RESULTS: A total of 443 pts (210 with CS, 233 with OS) were included. There were no signific

19、ant differences between groups of patients in age, sex, diagnosis groups, mortality, number of aspirations per day, and APCHE II score. No significant differences: in percentage of pts who developed VAP (20.47% vs. 18.02%); in the number of VAP cases per 1000 MVDs (17.59 vs. 15.84); in the VAP incid

20、ence by MV duration; in the incidence of exogenous VAP; in the microorganisms responsible for pneumonia. Patient cost per day for the CS was more expensive than the OS (11.11 US dollars +/- 2.25 US dollars vs. 2.50 US dollars +/- 1.12 US dollars, p .001). 結(jié)論:閉合痰液吸引系統(tǒng)不能降低VAP發(fā)病率，包括外源性肺炎Crit Care Med.

21、2005 Jan;33(1):115-9e5吸科耐藥革蘭陰性桿菌與治療策略Ventilator-associated pneumoniEarly antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures方法：299需要機(jī)械通氣至少48 h的病例，每周兩次采集氣管內(nèi)吸引物（EA）定量培養(yǎng)。發(fā)生VAP后用 BAL培養(yǎng)確定病原體，并與EA結(jié)果進(jìn)行比較。 最后有75例診斷VAP，41例BAL培養(yǎng)陽(yáng)性，先前常規(guī)EA培養(yǎng)中

22、有34例 (83%)陽(yáng)性，1例早發(fā)肺炎發(fā)生VAP時(shí)還沒(méi)有采集EA；4例結(jié)果不一致但抗菌藥物選用合適，2例選用藥物有延遲結(jié)論：每周兩次常規(guī)EA培養(yǎng)對(duì)早期正確選用VAP治療抗菌藥物是合適的Chest. 2005 Feb;127(2):589-97e5吸科耐藥革蘭陰性桿菌與治療策略Early antibiotic treatment forBlind and bronchoscopic sampling methods in suspected VAP- A multicentre prospective study.OBJECTIVE: To compare 4 sampling methods:

23、 blind tracheal aspirate (blind TA), blind protected telescoping catheter (blind PTC), bronchoscopic PTC and bronchoscopic BAL, for diagnosis of VAP. DESIGN & SETTING : Prospective multicentre study. Five ICU in France. PATIENTS: 63 pts with MV for more than 48 h, no recent antibiotic change (72 h)

24、and suspected nosocomial pneumonia. INTERVENTIONS: All patients underwent the four sampling methods. Direct examination and quantitative cultures of the four specimens were performed. MEASUREMENTS AND RESULTS: Visible secretions expelled from the catheter were present 40 times (63%) for blind PTC an

25、d 45 times (71%) for bronchoscopic PTC. After exclusion of 11 uncertain cases, 34 VAP were diagnosed. Direct examination of PTC (either blind or bronchoscopic) did not differ from direct examination of bronchoscopic BAL in predicting VAP diagnosis and in guiding initial antibiotic treatment correctl

26、y. Compared to that of bronchoscopic BAL (0.98), the area under receiver operating characteristics (ROC) curve was smaller for blind TA (0.78, p=0.002), blind PTC (0.83, p=0.009) and bronchoscopic PTC (0.85, p=0.01). When samples with visible secretions expelled from the catheter were considered, bl

27、ind and bronchoscopic PTC had areas under ROC curve close to that of bronchoscopic BAL (0.90, p=0.22 and 0.91, p=0.27, respectively). CONCLUSIONS: Blind PTC appears to be a good alternative to bronchoscopic sampling for VAP diagnosis, provided that the sample contains visible secretions expelled fro

28、m the catheter.Intensive Care Med. 2004 Jul;30(7):1319-26e5吸科耐藥革蘭陰性桿菌與治療策略Blind and bronchoscopic sampliCombination therapy with polymyxin B for the treatment of multidrug-resistant Gram-negative respiratory tract infectionsBACKGROUND: The treatment of infections caused by multidrug-resistant (MDR)

29、Gram-negative organisms poses a therapeutic challenge. The use of polymyxin B has been resurrected specifically for this purpose. PATIENTS AND METHODS: We retrospectively reviewed the clinical and microbiological efficacy, and safety pro polymyxin B in the treatment of MDR Gram-negative bacterial in

30、fections of the respiratory tract. Twenty-five critically ill patients received a total of 29 courses of polymyxin B administered in combination with another antimicrobial agent. RESULTS: Patients were treated with intravenous, and/or aerosolized polymyxin B. Mean duration of polymyxin B therapy was

31、 19 days (range 2-57 days). End of treatment mortality was 21%, and overall mortality at discharge was 48%. Nephrotoxicity was observed in three patients (10%) and did not result in discontinuation of therapy. CONCLUSIONS: Polymyxin B in combination with other antimicrobials can be considered a reas

32、onable and safe treatment option for MDR Gram-negative respiratory tract infections in the setting of limited therapeutic options.J Antimicrob Chemother. 2004 Aug;54(2):566-9e5吸科耐藥革蘭陰性桿菌與治療策略Combination therapy with polym銅綠假單胞菌Pseudomonas aeruginosae5吸科耐藥革蘭陰性桿菌與治療策略銅綠假單胞菌e5吸科耐藥革蘭陰性桿菌與治療策略A 7-year st

33、udy of severe hospital-acquired pneumonia requiring ICU admission在16張和20張內(nèi)科-外科ICU中，連續(xù)觀察需要入住ICU的重癥HAP，共7年。96次重癥HAP中，GNB占51，PA最常見(jiàn)（24）。51例（53）死亡，曲菌和PA引起的肺炎病死率最高。感染性休克(OR: 14.27)和COPD (OR: 6.11) 是影響預(yù)后的獨(dú)立危險(xiǎn)因素。Intensive Care Med. 2003 Nov;29(11):1981-8e5吸科耐藥革蘭陰性桿菌與治療策略A 7-year study of severe hospi鮑曼不動(dòng)桿菌A

34、cinetobacter baumanniie5吸科耐藥革蘭陰性桿菌與治療策略鮑曼不動(dòng)桿菌e5吸科耐藥革蘭陰性桿菌與治療策略Effect from multiple episodes of inadequate empiric antibiotic therapy for ventilator-associated pneumonia on morbidity and mortality among critically ill trauma patientsBACKGROUND: The purpose of this retrospective study was to determine

35、 the effect of inadequate empiric antibiotic therapy (IEAT) on the outcome for adult trauma patients with VAP. METHODS: This study enrolled 82 patients with multiple VAP episodes (200 VAP episodes; mean 2.4; range 2-5). An episode of IEAT was a VAP episode with empiric therapy having no in vitro act

36、ivity against causative bacteria. There were 78 (39%) IEAT episodes involving 54 patients. Most often, IEAT was attributable to the presence of Acinetobacter spp, Stenotrophomonas maltophilia, or Alcaligenes xylosoxidans. All the patients received appropriate definitive therapy according to the fina

37、l culture. The patients were classified by number of IEAT episodes: 0 (n = 28), 1 (n = 34), and more than 1 (n = 20). RESULTS: Demographics and injury severity were similar among the groups. The mortality rate was 3.6% for no episodes, 8.8% for one episode, and 45% for more than one episode (p 0.001

38、). On the basis of multiple logistic regression, experiencing multiple IEAT episodes was independently associated with the risk of death (odds ratio, 4.28; 95% confidence interval, 1.44-12.71). Additionally, experiencing multiple IEAT episodes was associated with prolonged intensive care unit stay (p = 0.007) and prolonged mechanical ventilation (p = 0.005). CONCLUSIONS: Cr