醫(yī)院獲得性肺炎 - 如何理解培養(yǎng)結(jié)果1課件

醫(yī)院獲得性肺炎:BALF定量培養(yǎng)試驗(yàn)設(shè)計(jì):多中心隨機(jī)臨床試驗(yàn)入選標(biāo)準(zhǔn):免疫功能正常的成年患者住ICU超過(guò)4天后懷疑呼吸機(jī)相關(guān)性肺炎排除標(biāo)準(zhǔn):假單胞菌屬或MRSA定植或感染分組:診斷:BALF定量培養(yǎng)vs.ETA的非定量培養(yǎng)治療:美羅培南+環(huán)丙沙星vs.美羅培南TheCanadianCriticalCareTrialsGroup.Arandomizedtrialofdiagnostictechniquesforventilator-associatedpneumonia.NEnglJMed2006;355:2619-2630醫(yī)院獲得性肺炎:BALF定量培養(yǎng)2531篩選患者1387不合格患者1144合格患者740入選患者404未入選患者不同意無(wú)家屬在場(chǎng)未找到患者原因未知已開(kāi)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2無(wú)人行纖維支氣管鏡檢查375ETA365BALTheCanadianCriticalCareTrialsGroup.Arandomizedtrialofdiagnostictechniquesforventilator-associatedpneumonia.NEnglJMed2006;355:2619-2630醫(yī)院獲得性肺炎:BALF定量培養(yǎng)ETABALP值28天病死率18.4%18.9%0.946天時(shí)針對(duì)性治療74.6%74.2%0.90無(wú)抗生素存活天數(shù)10.67.96最高M(jìn)ODS評(píng)分8.64.06TheCanadianCriticalCareTrialsGroup.Arandomizedtrialofdiagnostictechniquesforventilator-associatedpneumonia.NEnglJMed2006;355:2619-2630醫(yī)院獲得性肺炎:BALF定量培養(yǎng)研究的局限性僅29.2%(740/2531)的篩選患者入選40%的篩選患者因存在耐藥細(xì)菌感染或定植而被排除BAL有助于降階梯治療或停用抗生素治療(對(duì)耐藥細(xì)菌感染或定植的高?；颊咭饬x更為顯著)KollefMH.Diagnosisofventilator-associatedpneumonia.NEnglJMed2006;355:2691-2693醫(yī)院獲得性肺炎最常見(jiàn)的ICU獲得性感染罹患率及病死率最高40–80%住院死亡患者中約15%直接與醫(yī)院獲得性肺炎有關(guān)1/3–1/2=歸因死亡率醫(yī)院獲得性肺炎定義住院48小時(shí)后發(fā)生的肺炎ICU患者>普通病房患者機(jī)械通氣患者肺炎危險(xiǎn)性接受機(jī)械通氣患者的7–40%醫(yī)院獲得性肺炎–臨床診斷發(fā)熱白細(xì)胞升高膿性分泌物胸片新出現(xiàn)的浸潤(rùn)影氣管內(nèi)吸取物定量培養(yǎng)的診斷價(jià)值閾值(cfu/mL)敏感性,%特異性,%準(zhǔn)確率,%103865261104715761105718875106718682107439582臨床醫(yī)師如何理解培養(yǎng)結(jié)果痰培養(yǎng)陽(yáng)性是否均為致病菌痰培養(yǎng)陰性是否提示無(wú)感染革蘭染色是否有助于鑒定致病菌痰培養(yǎng)陰性是否可以停用抗生素平時(shí)培養(yǎng)結(jié)果是否有助于抗生素的選擇假設(shè)1接受機(jī)械通氣患者下呼吸道標(biāo)本培養(yǎng)出的細(xì)菌即為致病菌長(zhǎng)期機(jī)械通氣患者下呼吸道的細(xì)菌定植目的:檢查接受長(zhǎng)期機(jī)械通氣患者肺泡內(nèi)細(xì)菌負(fù)荷背景:大學(xué)醫(yī)院及長(zhǎng)期護(hù)理院的呼吸監(jiān)護(hù)病房患者:接受長(zhǎng)期機(jī)械通氣且沒(méi)有肺炎臨床表現(xiàn)的14名患者指標(biāo):右中葉及舌葉BALF的定量培養(yǎng)結(jié)果:在進(jìn)行檢查的32個(gè)肺葉中的29個(gè),至少有一種微生物定量培養(yǎng)>104cfu/mL.多數(shù)肺葉有多種微生物生長(zhǎng)BaramD,HulseG,PalmerLB.StablePatientsReceivingProlongedMechanicalVentilationHaveaHighAlveolarBurdenofBacteria.Chest2005;127:1353-1357機(jī)械通氣患者的細(xì)菌定植(n=356)BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.氣管支氣管炎的提示臨床表現(xiàn)發(fā)熱膿性氣管分泌物氣管分泌物培養(yǎng)大量致病菌肺部浸潤(rùn)影肺炎本身，而非上述臨床表現(xiàn)與患者預(yù)后不良相關(guān)下呼吸道分離出念珠菌的意義25名非粒細(xì)胞缺乏的機(jī)械通氣患者(>72h)去世后立即進(jìn)行尸體解剖,并采取下呼吸道標(biāo)本elEbiaryM,TorresA,FabregasN,etal.SignificanceoftheisolationofCandidaspeciesfromrespiratorysamplesincriticallyill,non-neutropenicpatients:animmediatepostmortemhistologicstudy.AmJRespirCritCareMed1997;156:583-590肺組織病理檢查念珠菌病 8%(2/25)呼吸道標(biāo)本培養(yǎng)念珠菌

40%(10/25)VS.下呼吸道分離出念珠菌的意義結(jié) 論在接受機(jī)械通氣的非粒細(xì)胞缺乏的危重病患者肺組織活檢分離到念珠菌的比例高達(dá)40%明確的念珠菌肺炎僅為8%肺組織的不同區(qū)域普遍存在念珠菌定植呼吸道標(biāo)本中分離到念珠菌,不能準(zhǔn)確預(yù)測(cè)是否存在念珠菌肺炎無(wú)論是否進(jìn)行定量培養(yǎng)elEbiaryM,TorresA,FabregasN,etal.SignificanceoftheisolationofCandidaspeciesfromrespiratorysamplesincriticallyill,non-neutropenicpatients:animmediatepostmortemhistologicstudy.AmJRespirCritCareMed1997;156:583-590下呼吸道分離出念珠菌的意義結(jié) 論非粒細(xì)胞缺乏患者如果經(jīng)纖維支氣管鏡采樣分離到念珠菌屬,即使?jié)舛群芨?也可能沒(méi)有深部念珠菌病應(yīng)當(dāng)根據(jù)組織學(xué)證據(jù)或無(wú)菌標(biāo)本的培養(yǎng)結(jié)果確定是否開(kāi)始抗真菌治療RelloJ,EsandiME,DiazE,etal.TheroleofCandidaspisolatedfrombronchoscopicsamplesinnonneutropenicpatients.Chest1998;114:146-149如何應(yīng)對(duì)下呼吸道分離的念珠菌InternationalConsensusConferenceonVAPManagement12名VAP專家有關(guān)VAP診斷和治療的21個(gè)問(wèn)題非粒細(xì)胞缺乏患者下呼吸道分離出念珠菌時(shí),是否需要加用抗真菌藥物?答案–No(12/12)即使經(jīng)纖維支氣管鏡采樣評(píng)價(jià)診斷標(biāo)準(zhǔn)優(yōu)劣的方法敏感性,特異性,陽(yáng)性預(yù)期值(PPV)和陰性預(yù)期值(NPV)的四格表檢查結(jié)果患病無(wú)病總計(jì)+aba+b–cdc+d合計(jì)a+cb+da+b+c+d敏感性=a/(a+c)PPV=a/(a+b)特異性=d/(b+d)NPV=d/(c+d)LR=敏感性/(1–特異性)醫(yī)院獲得性肺炎的診斷:痰培養(yǎng)的準(zhǔn)確性敏感性=82%肺炎患者培養(yǎng)陽(yáng)性比例82%肺炎患者培養(yǎng)陰性比例18%特異性=0–33%非肺炎患者培養(yǎng)陰性比例0–33%非肺炎患者培養(yǎng)陽(yáng)性比例67–100%醫(yī)院獲得性肺炎的診斷:痰培養(yǎng)的準(zhǔn)確性陽(yáng)性預(yù)期值(PPV)=痰培養(yǎng)陽(yáng)性者中肺炎比例陰性預(yù)期值(NPV)=痰培養(yǎng)陰性者非肺炎比例PPV/NPV的局限性不同患病率情況下PPV的比較(敏感性和特異性=90%)患病率=10%患病率=1%檢查結(jié)果患病無(wú)病總計(jì)檢查結(jié)果患病無(wú)病總計(jì)+90090018,00+909901,080–1008,1008,200–108,9108,920合計(jì)1,0009,00010,000合計(jì)1009,90010,000PPV=900/1,800=50%PPV=90/1,080=8%LR=(900/1,000)/[1–(81,00/9,000)]=9.0LR=(90/100)/[1–(8,910/9,900)]=9.0評(píng)價(jià)診斷標(biāo)準(zhǔn)優(yōu)劣的方法似然比(LR) =敏感性/(1–特異性) 肺炎患者中痰培養(yǎng)陽(yáng)性比例 非肺炎患者中痰培養(yǎng)陽(yáng)性比例LR1.5=醫(yī)院獲得性肺炎的診斷:痰培養(yǎng)的準(zhǔn)確性陽(yáng)性似然比(+veLR) =敏感性/(1–特異性) 肺炎患者中痰培養(yǎng)陽(yáng)性比例 非肺炎患者中痰培養(yǎng)陽(yáng)性比例 =0.82/(1–0or0.33) =0.82–1.22=痰培養(yǎng)陽(yáng)性:臨床意義對(duì)于細(xì)菌感染患者不容易遺漏致病菌無(wú)法區(qū)分致病菌與定植菌對(duì)于明確VAP患者有助于確定抗生素的選擇假設(shè)2如果懷疑VAP的患者下呼吸道標(biāo)本培養(yǎng)為陰性,應(yīng)當(dāng)停用抗生素經(jīng)驗(yàn)性抗生素:下呼吸道標(biāo)本培養(yǎng)陰性臨床懷疑VAP但BAL培養(yǎng)結(jié)果陰性的101名患者19名患者(18.8%)BAL前應(yīng)用抗生素平均年齡60.417.9歲平均APACHEII評(píng)分23.28.7臨床懷疑VAP前機(jī)械通氣時(shí)間2.91.9天KollefMH,KollefK.AntibioticUtilizationandOutcomesforPatientsWithClinicallySuspectedVentilator-AssociatedPneumoniaandNegativeQuantitativeBALCultureResults.Chest2005;128(4):2706-2713經(jīng)驗(yàn)性抗生素:下呼吸道標(biāo)本培養(yǎng)陰性BAL后65名患者(64.4%)應(yīng)用經(jīng)驗(yàn)性抗生素療程2.10.8天(1–3天)沒(méi)有人應(yīng)用經(jīng)驗(yàn)性抗生素>3天6例患者(5.9%)因繼發(fā)VAP應(yīng)用經(jīng)驗(yàn)性抗生素距離最初BAL及停用經(jīng)驗(yàn)性抗生素>72h住院死亡35例(34.7%)包括2例繼發(fā)VAP患者死亡與VAP無(wú)關(guān)KollefMH,KollefK.AntibioticUtilizationandOutcomesforPatientsWithClinicallySuspectedVentilator-AssociatedPneumoniaandNegativeQuantitativeBALCultureResults.Chest2005;128(4):2706-2713經(jīng)驗(yàn)性抗生素:下呼吸道標(biāo)本培養(yǎng)陰性對(duì)于臨床懷疑VAP但BAL培養(yǎng)陰性患者72小時(shí)內(nèi)停用經(jīng)驗(yàn)性抗生素甚至不應(yīng)用經(jīng)驗(yàn)性抗生素KollefMH,KollefK.AntibioticUtilizationandOutcomesforPatientsWithClinicallySuspectedVentilator-AssociatedPneumoniaandNegativeQuantitativeBALCultureResults.Chest2005;128(4):2706-2713經(jīng)驗(yàn)性抗生素:下呼吸道標(biāo)本培養(yǎng)陰性滿足VAP臨床診斷標(biāo)準(zhǔn),且BALF定量培養(yǎng)<105cfu/ml的嚴(yán)重創(chuàng)傷患者立即停用抗生素是安全的假陰性率為3%主要由銅綠假單胞菌或不動(dòng)桿菌屬引起B(yǎng)ALF的革蘭染色有助于鑒別非VAP患者避免不必要的抗生素使用CroceM,FabanT,MuellerEW,etal.Theappropriatediagnosticthresholdforventilator-associatedpneumoniausingquantitativecultures.JTrauma2004;56:931-936TimsitJF,CevalG,GachotB,etal.Usefulnessofastrategybasedonbronchoscopywithdirectexaminationofbronchoalveolarlavagefluidintheinitialantibiotictherapyofsuspectedventilator-associatedpneumonia.IntensiveCareMed2001;27:640-647氣管內(nèi)吸取物常規(guī)培養(yǎng)的診斷價(jià)值痰培養(yǎng)陰性致病菌=其他菌?(如綠膿桿菌)致病菌=綠膿桿菌=1-敏感性 =100%-82%=18%連續(xù)三次未培養(yǎng)出致病菌的概率 =18%x18%x18%=0.6%痰培養(yǎng)陰性:臨床意義除外常見(jiàn)致病菌!!!不能除外無(wú)法常規(guī)培養(yǎng)的致病菌非典型病原體真菌卡氏肺囊蟲(Pneumocystisjirovecii)病毒厭氧菌結(jié)核…假設(shè)3痰標(biāo)本的革蘭染色能夠預(yù)測(cè)培養(yǎng)結(jié)果痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果目的:分析痰標(biāo)本革蘭染色的準(zhǔn)確性方法:2002年12月至2006年6月連續(xù)收治的124名ICU患者,共186例次VAP回顧性分析VAP定義:BALF定量培養(yǎng)>104CFU/mLCPIS>6RaghavendranK,WangJ,BelberC,MD.PredictiveValueofSputumGramStainfortheDeterminationofAppropriateAntibioticTherapyinVentilator-AssociatedPneumonia.JTrauma2007;62:1377-1383痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果BALF結(jié)果革蘭染色結(jié)果GNB+GPCGNBGPC-veGNB+GPC15461GNB142616GPC133143-ve1818935RaghavendranK,WangJ,BelberC,MD.PredictiveValueofSputumGramStainfortheDeterminationofAppropriateAntibioticTherapyinVentilator-AssociatedPneumonia.JTrauma2007;62:1377-1383痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果陽(yáng)性預(yù)期值(PPV)GNB+GPC 0.25GNB 0.52GPC 0.47陰性預(yù)期值(NPV) 0.78革蘭染色陰性時(shí),仍有10/45培養(yǎng)結(jié)果陽(yáng)性Kappa值 0.314RaghavendranK,WangJ,BelberC,MD.PredictiveValueofSputumGramStainfortheDeterminationofAppropriateAntibioticTherapyinVentilator-AssociatedPneumonia.JTrauma2007;62:1377-1383痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果作者患者數(shù)診斷標(biāo)準(zhǔn)肺炎比例Allaouchiche118(146)PSB>10351/146Mimoz134(186)PSB10381/186Duflo104(116)miniBALF>10367/116Davis155BAL>105Kopelman223(227)BALF>104Raghavendran124(186)BALF>104痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果作者分組敏感性特異性PPVNPVAllaouchiche90746593MimozPSB54867274PTC69897884Duflo7610010075DavisGPC87596883GNB73497842KopelmanGPC80664889GNB67746972Raghavendran91446878痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果作者完全符合部分符合不符合KappaAllaouchiche26/5120/515/510.586Duflo26/6719/6722/670.730Davis71/15554/15530/155Raghavendran90/18637/18650/1860.314Total213/459130/459107/459痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果740名懷疑VAP患者入選35名患者沒(méi)有革蘭染色結(jié)果705名患者資料供分析350名BAL355名ETAAlbertM,FriedrichJO,AdhikariNKJ,etal.UtilityofGramstainintheclinicalmanagementofsuspectedventilator-associatedpneumonia:secondaryanalysisofamulticenterrandomizedtrial.JCritCare2008;23:74-81痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果AlbertM,FriedrichJO,AdhikariNKJ,etal.UtilityofGramstainintheclinicalmanagementofsuspectedventilator-associatedpneumonia:secondaryanalysisofamulticenterrandomizedtrial.JCritCare2008;23:74-81革蘭染色結(jié)果培養(yǎng)結(jié)果-veGPCGNBGNB+GPC-ve232(32.9)25(3.6)60(8.5)14(2.0)GPC43(6.1)39(5.5)16(2.3)23(3.3)GNB7(1.0)16(2.3)84(12.0)5(0.7)GNB+GPC42(6.0)81(11.5)64(9.1)34(4.8)痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果AlbertM,FriedrichJO,AdhikariNKJ,etal.UtilityofGramstainintheclinicalmanagementofsuspectedventilator-associatedpneumonia:secondaryanalysisofamulticenterrandomizedtrial.JCritCare2008;23:74-81痰標(biāo)本:革蘭染色vs.培養(yǎng)結(jié)果革蘭染色未見(jiàn)細(xì)菌,培養(yǎng)有致病菌生長(zhǎng)99/331(30%)革蘭染色未見(jiàn)GNB,培養(yǎng)有GNB生長(zhǎng)113/452(25%)革蘭染色未見(jiàn)GPC,培養(yǎng)有GPC生長(zhǎng)45/428(11%)AlbertM,FriedrichJO,AdhikariNKJ,etal.UtilityofGramstainintheclinicalmanagementofsuspectedventilator-associatedpneumonia:secondaryanalysisofamulticenterrandomizedtrial.JCritCare2008;23:74-81痰標(biāo)本革蘭染色:臨床意義與培養(yǎng)相比,能夠更快得到結(jié)果指導(dǎo)經(jīng)驗(yàn)性抗生素治療?對(duì)確定致病菌不一定有幫助僅不足1/2的病例完全符合假設(shè)4停用抗生素?zé)o須痰培養(yǎng)陰性VAP停用抗生素的臨床指標(biāo)確認(rèn)引起肺部浸潤(rùn)影的非感染性因素(如肺不張,肺水腫)從而無(wú)需抗生素治療癥狀及體征提示感染得到控制體溫

38.3C白細(xì)胞計(jì)數(shù)<10,000/L[10x109/L]或較最高值下降>25%胸片表現(xiàn)改善或無(wú)進(jìn)展膿性痰消失PaO2/FiO2>

250(停用抗生素時(shí)須滿足所有上述標(biāo)準(zhǔn))MicekST,WardS,FraserVJ,KollefMH.ARandomizedControlledTrialofanAntibioticDiscontinuationPolicyforClinicallySuspectedVentilator-AssociatedPneumonia.Chest2004;125:1791–1799VAP停用抗生素的策略MicekST,WardS,FraserVJ,KollefMH.ARandomizedControlledTrialofanAntibioticDiscontinuationPolicyforClinicallySuspectedVentilator-AssociatedPneumonia.Chest2004;125:1791–1799VAP停用抗生素的策略MicekST,WardS,FraserVJ,KollefMH.ARandomizedControlledTrialofanAntibioticDiscontinuationPolicyforClinicallySuspectedVentilator-AssociatedPneumonia.Chest2004;125:1791–1799預(yù)后停用抗生素組(n=150)對(duì)照組(n=140)P值住院病死率48(32.0)52(37.1)0.357住院日(天)15.718.215.415.90.865ICU住院日(天)7.30.798機(jī)械通氣天數(shù)7.10.649繼發(fā)感染56(37.3)46(32.9)0.425痰培養(yǎng)與停用抗生素指征停用抗生素指征臨床治愈而非細(xì)菌學(xué)清除假設(shè)5在ICU患者發(fā)生呼吸機(jī)相關(guān)性肺炎(VAP)前常規(guī)進(jìn)行下呼吸道標(biāo)本的微生物培養(yǎng)鑒別VAP致病菌經(jīng)驗(yàn)性抗生素治療危重病患者的細(xì)菌定植收入ICU時(shí)細(xì)菌定植的比例為83%(39/47)鼻咽拭子,支氣管吸取物,胃液,PSBI組細(xì)菌肺炎鏈球菌金黃色葡萄球菌流感嗜血桿菌II組細(xì)菌革蘭陰性腸道桿菌假單胞菌屬EwigS,TorresA,El-EbiaryM,FàbregasN,HernándezC,GonzálezJ,NicolásJM,SotoL.Bacterialcolonizationpatternsinmechanicallyventilatedpatientswithtraumaticandmedicalheadinjury:incidence,riskfactors,andassociationwithventilator-associatedpneumonia.AmJRespirCritCareMed1999;159:188-198危重病患者的細(xì)菌定植EwigS,TorresA,El-EbiaryM,FàbregasN,HernándezC,GonzálezJ,NicolásJM,SotoL.Bacterialcolonizationpatternsinmechanicallyventilatedpatientswithtraumaticandmedicalheadinjury:incidence,riskfactors,andassociationwithventilator-associatedpneumonia.AmJRespirCritCareMed1999;159:188-198危重病患者的細(xì)菌定植EwigS,TorresA,El-EbiaryM,FàbregasN,HernándezC,GonzálezJ,NicolásJM,SotoL.Bacterialcolonizationpatternsinmechanicallyventilatedpatientswithtraumaticandmedicalheadinjury:incidence,riskfactors,andassociationwithventilator-associatedpneumonia.AmJRespirCritCareMed1999;159:188-198危重病患者的細(xì)菌定植細(xì)菌在上呼吸道的定植是下呼吸道細(xì)菌定植的獨(dú)立危險(xiǎn)因素入ICU時(shí)I組細(xì)菌定植 OR9.9(1.8–56.3)隨訪時(shí)II組細(xì)菌定植 OR23.9(3.8–153.3)既往應(yīng)用抗生素I組細(xì)菌在下呼吸道定植 OR0.2(0.05–0.86)II組細(xì)菌在下呼吸道定植 OR6.1(1.3–29)EwigS,TorresA,El-EbiaryM,FàbregasN,HernándezC,GonzálezJ,NicolásJM,SotoL.Bacterialcolonizationpatternsinmechanicallyventilatedpatientswithtraumaticandmedicalheadinjury:incidence,riskfactors,andassociationwithventilator-associatedpneumonia.AmJRespirCritCareMed1999;159:188-198危重病患者的細(xì)菌定植EwigS,TorresA,El-EbiaryM,FàbregasN,HernándezC,GonzálezJ,NicolásJM,SotoL.Bacterialcolonizationpatternsinmechanicallyventilatedpatientswithtraumaticandmedicalheadinjury:incidence,riskfactors,andassociationwithventilator-associatedpneumonia.AmJRespirCritCareMed1999;159:188-19804896144192240288Hoursofmechanicalventilation0.00.8Probabilityofearly-onsetpneumoniaPtsnotcolonizedwithGroupIpathogensPtscolonizedwithGroupIpathogensP=0.02VAP發(fā)生前的微生物學(xué)檢查目的:確定微生物學(xué)監(jiān)測(cè)對(duì)于診斷呼吸機(jī)相關(guān)肺炎(VAP)及化膿性氣管支氣管炎(TBX)的價(jià)值患者:356名心臟手術(shù)患者微生物學(xué)監(jiān)測(cè)方法:PSB+ETA頻率:心臟手術(shù)結(jié)束后,拔除氣管插管前,手術(shù)后3天,以及每周一次終止時(shí)間:拔除氣管插管,發(fā)生VAP或TBX,死亡BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學(xué)檢查VAP診斷標(biāo)準(zhǔn)CXR出現(xiàn)新發(fā)浸潤(rùn)影或原有浸潤(rùn)影加重下列標(biāo)準(zhǔn)中2條或2條以上:發(fā)熱(38.5C)或低體溫(<36C)白細(xì)胞升高(12x109/L)膿性氣管分泌物過(guò)去48小時(shí)內(nèi)PaO2/FIO2下降15%或CPIS>6TBX診斷標(biāo)準(zhǔn)膿性氣管分泌物CXR沒(méi)有肺炎導(dǎo)致的浸潤(rùn)影下列標(biāo)準(zhǔn)中2條或2條以上:發(fā)熱(38.5C)或低體溫(<36C)白細(xì)胞升高(12x109/L)呼吸道分泌物細(xì)菌計(jì)數(shù)明顯升高BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學(xué)檢查VAP患病率 7.87%(28/356)發(fā)病率 34.5例/1,000機(jī)械通氣日TBX患病率 8.15%(29/356)發(fā)病率 31.13例/1,000機(jī)械通氣日BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學(xué)檢查微生物學(xué)監(jiān)測(cè)1626個(gè)標(biāo)本平均每名患者4.562.8個(gè)標(biāo)本[2–30]預(yù)測(cè)準(zhǔn)確性VAP 1/28TBX 1/29BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前微生物培養(yǎng)結(jié)果(n=125)HayonJ,FiglioliniC,CombesA,TrouilletJL,KassisN,DombretMC,GibertC,ChastreJ.RoleofSerialRoutineMicrobiologicCultureResultsintheInitialManagementofVentilator-associatedPneumonia.AmJRespirCritCareMed2002;165:41-46VAP發(fā)生前微生物培養(yǎng)結(jié)果(n=102)HayonJ,FiglioliniC,CombesA,TrouilletJL,KassisN,DombretMC,GibertC,ChastreJ.RoleofSerialRoutineMicrobiologicCultureResultsintheInitialManagementofVentilator-associatedPneumonia.AmJRespirCritCareMed2002;165:41-46VAP發(fā)生前的微生物學(xué)檢查HayonJ,FiglioliniC,CombesA,TrouilletJL,KassisN,DombretMC,GibertC,ChastreJ.RoleofSerialRoutineMicrobiologicCultureResultsintheInitialManagementofVentilator-associatedPneumonia.AmJRespirCritCareMed2002;165:41-46VAP發(fā)生前分離的細(xì)菌敏感性特異性PPVNPVMRSA23/35(66)[50–81]76/90(84)[76–91]23/37(62)[46–77]76/88(86)[78–92]銅綠假單胞菌15/32(47)[30–64]79/93(85)[77–91]15/29(52)[34–70]79/96(82)[74–89]鮑曼不動(dòng)桿菌7/20(35)[16–57]83/105(79)[71–86]7/29(24)[10–41]83/96(87)[78–92]VAP發(fā)生前的微生物學(xué)檢查致病菌僅能發(fā)現(xiàn)33%(73/220)的致病菌呼吸道分離細(xì)菌的陽(yáng)性預(yù)期值<72h:56%72h:13%患者對(duì)38%(47/125)的病例完全沒(méi)有幫助僅31%(39/125)的病例致病菌完全吻合HayonJ,FiglioliniC,CombesA,TrouilletJL,KassisN,DombretMC,GibertC,ChastreJ.RoleofSerialRoutineMicrobiologicCultureResultsintheInitialManagementofVentilator-associatedPneumonia.AmJRespirCritCareMed2002;165:41-46VAP發(fā)生前的微生物學(xué)檢查結(jié)論VAP發(fā)生前常規(guī)進(jìn)行微生物檢查僅能發(fā)現(xiàn)少量致病菌由于分離的多數(shù)細(xì)菌并不參與其后的VAP發(fā)病,因此培養(yǎng)結(jié)果常常引起誤導(dǎo)耐藥細(xì)菌在引發(fā)感染前能夠分離到敏感性<70%不能作為經(jīng)驗(yàn)性抗生素選擇的唯一依據(jù)經(jīng)驗(yàn)性抗生素治療應(yīng)當(dāng)覆蓋VAP發(fā)生前72小時(shí)內(nèi)呼吸道分離出的細(xì)菌HayonJ,FiglioliniC,CombesA,TrouilletJL,KassisN,DombretMC,GibertC,ChastreJ.RoleofSerialRoutineMicrobiologicCultureResultsintheInitialManagementofVentilator-associatedPneumonia.AmJRespirCritCareMed2002;165:41-46VAP發(fā)生前的微生物學(xué)檢查41名VAP患者(BAL培養(yǎng)確診)既往下呼吸道標(biāo)本分離出相同的致病菌(n=34)經(jīng)驗(yàn)性抗生素治療充分(n=34)既往下呼吸道標(biāo)本分離出不同的致病菌(n=6)經(jīng)驗(yàn)性抗生素治療充分(n=4)既往沒(méi)有下呼吸道標(biāo)本(n=1)經(jīng)驗(yàn)性抗生素治療充分(n=1)經(jīng)驗(yàn)性抗生素治療充分38/40(95%)MichelF,Franceschini