《復(fù)雜腹腔感染》課件

復(fù)雜腹腔感染浙江省嘉興市第二醫(yī)院ICU蔡繼明IAI相關(guān)指南theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,2002IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；ClinicalInfectiousDiseases2021;50:133–64InfectiousDiseasesSocietyofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.2021;41:279-281腹腔感染(IAI)概述過去一個世紀(jì)IAI治療取得巨大進步，死亡率顯著下降90%in1900to23%in2002IAI不同來源感染的死亡率

appendix(0.25%)stomach/duodenum(21%)pancreas(33%)smallbowel(38%)largebowel(45%)biliarytract(50%)JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74?supplement4august2007IAI定義分類f.M.pieracci,p.S.barie,ManageMentofSevereSepSiSofabdoMinalorigin,ScandinavianJournalofSurgery96:184–196,2007單純腹腔感染復(fù)雜腹腔感染Intra-abdominalinfectionsalsocanbecategorizedasuncomplicatedversuscomplicated,althoughthedistinctionisnotalwaysclearJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007UncomplicatedIAI單純性腹腔感染僅累及1個器官,而且沒有解剖結(jié)構(gòu)的破壞通常病灶可完全切除，僅需預(yù)防性使用抗菌藥物BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Drugs.2005;65(12):1611-20

復(fù)雜腹腔感染(cIAI)復(fù)雜腹腔感染(cIAI)通常定義為空腔臟器的內(nèi)容穿入腹腔導(dǎo)致局限性腹膜炎(包括膿腫)、彌漫性腹膜炎感染源經(jīng)外科處理后，仍殘留細(xì)菌，需使用抗感染藥物cIAI更多地與不良預(yù)后相關(guān)，其最大挑戰(zhàn)是早期識別JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Drugs.2005;65(12):1611-20

細(xì)菌性腹膜炎分類原發(fā)性腹膜炎繼發(fā)性腹膜炎第三型腹膜炎JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007Primarybacterialperitonitis指腹腔沒有破口的自發(fā)性腹膜炎更多見于嬰幼兒、肝硬化及免疫抑制的病人Secondarybacterialperitonitis繼發(fā)性腹膜炎是腸源細(xì)菌通過胃腸道穿孔泄漏入腹腔導(dǎo)致的感染炎癥Itmaybecommunity-acquiredorhealthcare–associated.Tertiaryperitonitis原發(fā)、繼發(fā)性腹膜炎經(jīng)治療后病癥仍持續(xù)或48小時后病癥復(fù)蘇常見于有嚴(yán)重合并癥或免疫抑制的病人特點:醫(yī)院獲得性感染多為耐藥菌可能為腸道菌群易位社區(qū)獲得性腹腔感染感染發(fā)生于社區(qū)，如化膿性闌尾炎，結(jié)腸憩室穿孔多為革蘭氏陰性菌、厭氧菌，較少耐藥多為輕中度腹腔感染如有臟器功能不全、免疫抑制的病人那么歸為重度腹腔感染醫(yī)院獲得性腹腔感染IDSAcIAI指南的定義該指南排除了肝脾實質(zhì)的膿瘍、泌尿生殖系統(tǒng)來源的感染、后腹膜感染(但除外胰腺感染)2003版指南不擬適用于小于18歲兒童及原發(fā)性腹膜炎，2021版作了擴展

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005腹腔感染常見致病菌胃、十二指腸、近端小腸與膽道：革蘭陰性或陽性需氧菌或兼性需氧菌遠(yuǎn)端小腸：不同密度的革蘭陰性需氧菌或兼性需氧菌、厭氧菌如脆弱擬桿菌結(jié)腸：兼性需氧〔大腸桿菌〕或純厭氧菌，鏈球菌、腸球菌亦常見PathogensassociatedwithperitonitisJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74?supplement4august2007cIAI綜合治療策略液體復(fù)蘇、感染源控制(ie,surgicaldebridement,drainage,andrepair)、適當(dāng)系統(tǒng)地抗感染是cIAI治療成功的主要局部沒有感染源的控制，抗生素治療繼發(fā)或第三型腹膜炎不可能成功首要的是感染源的控制JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007cIAI如何選擇抗生素單藥還是聯(lián)合治療病人根底狀況藥物開始治療時機及療程給藥劑量、頻率抗菌譜、相互作用、耐藥性之前抗生素的使用情況防止藥物毒副作用及誘導(dǎo)耐藥社區(qū)獲得性腹腔感染JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005cIAI危險分層JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007High-severityIAIAdvancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppressionIDSofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.2021;41:279-281氨基糖苷類氨基糖苷類不推薦作為社區(qū)獲得性腹腔感染的常規(guī)治療(A-1)氨基糖苷類根據(jù)局域菌種別離藥敏結(jié)果,可以是院內(nèi)獲得性腹腔感染的首選.腹腔感染氨基糖苷類的治療應(yīng)該個體化(A-1)抗厭氧菌藥物藥物敏感試驗提示Bacteroidesfragilis對以下藥物普遍耐藥clindamycin,cefotetan,cefoxitin,andquinolones上述藥物不能單藥治療B.fragilis第三型及醫(yī)院獲得性腹腔感染耐藥菌感染更常見病原體類似于其他院內(nèi)感染治療基于局部常見院感菌種及耐藥情況院內(nèi)感染考慮覆蓋腸球菌是適宜的抗真菌治療基于先前抗生素使用情況及根底危險因素JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74?supplement4august2007MAZUSKIJE,Antimicrobialtreatmentforintra-abdominalinfections.ExpertOpinPharmacother.2007Dec;8(17):2933-45抗腸球菌治療指征常規(guī)抗腸球菌治療對社區(qū)獲得性腹腔感染沒有必要(A-1)醫(yī)院獲得性腹腔感染需考慮給予覆蓋腸球菌的藥物(B-3).

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005抗真菌治療指征

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005何時開始抗感染治療應(yīng)當(dāng)在確診感染和獲得培養(yǎng)結(jié)果前疑心IAI的診斷時即開始抗生素治療抗感染的目標(biāo)是去除感染病原體、減少復(fù)發(fā)、縮短感染病癥體征消除時間抗生素應(yīng)該在液體復(fù)蘇開始后給藥，恢復(fù)充分的血流灌注使良好的藥物分布成為可能。尤其是氨基糖苷類，其腎毒性會因腎灌注缺乏而加重哪些病人需要抗感染治療創(chuàng)傷或醫(yī)源性腸損傷致腹腔污染12h內(nèi)修補的病人(Level1)以及胃腸穿孔24h內(nèi)修補的病人(Level3)不認(rèn)為已經(jīng)合并IAI，僅需給予24h或更短的預(yù)防用藥炎癥病灶能夠完全移除的病人如沒有穿孔的急性或壞疽性闌尾炎或膽囊炎，或者沒有發(fā)生穿孔或腹膜炎的腸梗阻或腸壞死，也僅需給予24h或更短的預(yù)防用藥(Level2)已經(jīng)合并廣泛IAI的上述病人應(yīng)該給予超過24h的抗感染治療(Level3).theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,200281.Theadministrationofprophylacticantibioticstopatientswithseverenecrotizingpancreatitispriortothediagnosisofinfectionisnotrecommended(A-I).DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；ClinicalInfectiousDiseases2021;50:133–64抗感染療程theTherapeuticAgentsCommitteeoftheSurgicalInfection