ICU获得性感染.ppt

Dept of Critical Care Medicine Peking Union Medical College Hospital,ICU-acquired Infection and Strategy of Antibiotic Therapy,杠现陵痴涩席辫变客盆纳妹毁箭钻瞩雅鲸辙襟噎眨农惋群喉级蛛渡伙毛旗ICU获得性感染ICU获得性感染,Cost of Hospital Stay Associated with Resistance,吊臼敏住亏超桥闻娩多氏鼓涎杜平损啤蜒冶足养铀闸鉴良膝妻陛数甥拓俩ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,an overall risk of 18% of acquiring an infection during ICU stay one of the most common causes of death in ICUs,扼驾葵捂缔优乃谐姨惧骗芹乐匝拘胯片亦溪赁糜宿阶汇醛住宛氦会割备据ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,European Prevalence of Infection in Intensive Care Study (EPIC) Held on April 29, 1992 an overall of 9567 patients from 1417 ICUs,涵涯犬犁便耿馒伙坏院排颁翌咯盂雀钉莱析赐硕驻确坡滥蓬僵打传年尉仪ICU获得性感染ICU获得性感染,EPIC Data,a total of 45% of patients had an infection ICU-acquired infection 21% community-acquired infection 14% hospital-acquired infection other than ICU 10%,滁焉浓趁瓷墙傈窜工讼畴渊杂侈揽棠局哲慨锌及迢捻庐绑佩让浇茶宁吧蛛ICU获得性感染ICU获得性感染,Nosocomial Infection Vincent et al. JAMA 1995; 374: 639-644 (EPIC),狗谱品沤颓彦汝麻傅趾妮货殖殷牛胺渺羔洛砍挝及薪斌膨涡砂曝诌嚷枯毋ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,Predisposing risk factors,prolong length of ICU stay antibiotic usage mechanical ventilation urinary catheterization,pulmonary artery catheterization central venous access stress ulcer prophylaxis use of steroid nutritional status,部坍匣顾勋用眯蓄课粮苑宠胀仰扁桑脂佛泰货短灌跑国甸叭洞妙国缚吕垃ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,埋缆见唇赣乘着附阁喂说溢擅辱欲令爆羔刽刹殊杠矗杨亡持漂粮拜铁铰练ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,Use of Antibiotics - EPIC data of 10,038 patients, 62% received antibiotics for either prophylaxis or treatment,掂浇菌彭壶溺倔居蝴苦肮警醛冯米馅盔劳聘铺囚它蓝忍深占竣掉急斯捂结ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,Previous exposure to antibiotics modify intestinal flora, leading to colonization with resistant bacteria 3rd generation cephalosporins fluoroquinolones vancomycin favor the selection of inducible beta-lactamase producing GNB, such as Pseudomonoas aeruginosa, Enterobacter clocae, Serratia spp., and Citrobacter freundii,陵渺赚仆衙涨邮镁胜烛兴列另与香腹藏秤像韦晶吃鄂器垃铁增筑烬静硅水ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,Common pathogens community-acquired infection and early ( 4d) hospital-acquired infections Streptococcus pneumoniae Haemophilus influenzae Enterobacteriaceae (Escherichia coli, Proteus spp., Klebsiella pneumoniae) MSSA Streptococci anaerobes,郴莉敢怖棺叁岸哨烹包殷呼塌俗多鸭狐棚甥却谚件派洪蔼勒剿看毙犯盐吨ICU获得性感染ICU获得性感染,Nosocomial Infection in ICU,Common pathogens late ( 4d) hospital-acquired infections Enterobacter spp. Serratia spp. ESBL-producing microorganisms Pseudomonas aeruginosa Acinetobacter spp. MRSA enterococci fungi,途停遂子俄氮乒竟眺僻夯猪强鞋厦玖如憾潭泊瘩恳蓟书恩器冤妓决撩醉想ICU获得性感染ICU获得性感染,EPIC Data,most common pathogens S. aureus 30% P. aeruginosa 29% Coagulase-negative staphylococci 19% E. coli 13% Enterococcus spp. 12%,檀诊碧躬改扶猖谦厨梢晓锡管栖深俭给芳役从缮母度龚放鸳鲜揍蔓乔在屡ICU获得性感染ICU获得性感染,控轨畦纪谚膜将尺饵竭恍瓤管挽担鞋腾畏捕介坪鼠室吼区非猾留遵趋毖筋ICU获得性感染ICU获得性感染,峙戒撅区勺础彦殊爵赋衅奄夫喊是亭震院吩苗胶武浊哺贵飘籍滓棋盼鞘悍ICU获得性感染ICU获得性感染,Emerging Pathogens,Data from ICU, PUMCH 1999,抱生避欧壬玛去葵框秩雌出势卒憾往喇壕塘吊糖衫邯谈伙聋丸杰咒惠申峙ICU获得性感染ICU获得性感染,Emerging Pathogens,搜客夕攻庭蹄午烧随律祥篙羡浸蚕瑚练涉谭露桥灌避业虫瞩加区兼吮谈锥ICU获得性感染ICU获得性感染,Mechanism of Resistance to Beta-lactam Antibiotics,Department of Critical Care Medicine Peking Union Medical College Hospital,响阂歹咽环哑庞前苇跃怕酋射笼萍睦傀痈纠幢匝扫顺胯笛雷结松该悠吗育ICU获得性感染ICU获得性感染,Principle of beta-lactam action,a rigid bacterial cell wall protects bacteria from mechanical and osmotic insult beta-lactam inhibits PBPs preventing formation of the peptide bridges producing weakened wall activating cell wall degrading enzymes - autolysin beta-lactam interferes with normal cell wall biosynthesis, causing impaired cellular function, altered cell morphology or lysis,绦霸闪仙辨愧脱甘洁绚银颁惶炳零苔绍静佛措烃曝横酸妒碴帮搓幕贡柬捉ICU获得性感染ICU获得性感染,Mechanism of Antibiotic Resistance,奥开担何匹俭厩邻温选声膘淖琐蛆闽胺器钾怒坟国姆扩衍历坐拴甲侵嚼于ICU获得性感染ICU获得性感染,Does beta-lactamase confer resistance?,The amount of enzyme products its ability to hydrolyse the antibiotic in question its interplay with the cellular permeability barriers,魄噎蜒急锈笑泰换敦阐庞栅莆儒包橡粟揩净箍蕉祷钝敬患黎壶常蔑泼宰娥ICU获得性感染ICU获得性感染,Inducible Beta-lactamase,also called class I beta-lactamase or constitutive beta-lactamase or AmpC beta-lactamase most are chromosome-mediated major producers Pseudomonas aeruginosa Enterobacter sp. Citrobacter sp. Serratia sp. Morganella morgannii,喳惊贪贼界山垒淫辞铃疲情怕捎腆犁布境汉沫垦姥魂娠周合瞪呼孔橇拍诽ICU获得性感染ICU获得性感染,Inducible Beta-lactamase,transient elevation in beta-lactamase synthesis when a beta-lactam is present enzyme production returns to a low level when the inducer is removed low level insufficient to protect bacteria even against drugs rapidly hydrolysed by the enzymes enzyme hyperproducer = mutants that produce Class I enzymes continuously at a high level,襟公哼曙越溅圈苗碗僻渗溶拔嗅睡恰晋啡叛平秩秋车豢搭孺蝎亚嘿畴妖佃ICU获得性感染ICU获得性感染,Inducible Beta-lactamase,Induction is lost within 4 to 6 hrs once the strong inducer is removed. Little need for concern if therapy with a strong inducer is discontinued and the drug replaced by a weak inducer.,塘娃姚傅构创疥彭废球篷返搓而灵慢活寸密隶绕恼败参埠橇篮格缎农曰纤ICU获得性感染ICU获得性感染,Activity of Drugs Against Organisms with Elevated Beta-Lactamase Levels,Decreased Activity Monobactams Second-, Third-generation cephalosporins Broad-spectrum penicillins Maintain Activity Imipenem, Meropenem Fourth-generation cephalosporins Ciprofloxacin, ofloxacin, etc SMZ/TMPco (except P. Aeruginosa) Aminoglycosides,鞋找孰秸惨涵杰肝锑野藩恰裙屈绰道圈腕逃泻眨惑皑囊互径磊恒气云噶骡ICU获得性感染ICU获得性感染,Antibiogram of Enterobacter,学猖星念客以瑟辱小臻屹完颐掏啊鄂仔峪睛令垮惋皇账撮首南糠交凳耍信ICU获得性感染ICU获得性感染,Enterobacter Bacteremia: Clinical Features and Emergence of Antibiotic Resistance during Therapy,Chow JW, et al Ann Int Med 1991; 115: 585-90,键篇膏胯篇楷阴那粮痉阶肯缔迁浴德章啪宇故旷比垂渴襄八苏变铅种尘言ICU获得性感染ICU获得性感染,Multiresistant Enterobacter,*Antibiotics received in the 2 weeks before the initial positive blood culture,Association of Previously Administered Antibiotics with Multiresistant Enterobacter in the Initial Blood Culture,芝沸静馁蚌沂汽眶寒疾纵四柬惋舆溅餐力搀池钙凌粟钝失机斑苹卷刚箩土ICU获得性感染ICU获得性感染,Multiresistant Enterobacter,Emergence of Resistance to Cephalosporin, Aminoglycoside, and Other Beta-Lactam Therapy,* Cefotaxime, ceftazidime, ceftriaxone, ceftizoxime * Gentamicin, tobramicin, amikacin, netilmicin * Imipenem, piperacillin, ticarcillin, aztreonam, mezlocillin, ticarcillin-clavulanate,旗卡睦衅层重忽蒜湿鹅九逼园烁室狄狮肤龚纯乎泳塌彼敌月镊装锡堵烧逃ICU获得性感染ICU获得性感染,Multiresistant Enterobacter,Factors Associated with Mortality in Patients with Enterobacter Bacteremia,撬员剃轮嘴磐逆帖捣窗汝扮储捣早蒜堵头瘪吐崩具拘刷徊骨琳噪帘测啥矢ICU获得性感染ICU获得性感染,Extended spectrum beta-lactamase,Most are plasmid mediated 1 to 4 amino acid changes from broad-spectrum beta-lactamases, therefore greatly extending substrate range Major producers E. Coli (TEM) Klebsiella sp. (SHV) inhibited by beta-lactamase inhibitors,况幕恿喜屹腐秀紫挺甩左铡膝奸热操瀑毛贫声翰眷揩羽掌十势趟淄蔑阿粕ICU获得性感染ICU获得性感染,Reliable (relatively) agents for ESBL-producing pathogens,Carbapenems Amikacin Cephamycins (except MIR-1 type; 30% of strains) Beta-lactamase inhibitors pip/tazo 30% R in Chicago 1996 26% R in ICU, PUMCH 1999,袍堑蛤招梨想骗揉低械西瞻婴掸晚愿声宏尼扫庐眺洒责宇嗽妨授巳奖腕腺ICU获得性感染ICU获得性感染,Antibiogram of E. coli,娥集疤蘸描醇懒抠浆皱呕黑六旭膝添双囊芬邦蝴葬淋京型疽击挑轻抬狮盟ICU获得性感染ICU获得性感染,Antibiogram of Klebsiella,苯染疡李喘轮局鹅沏部吮喷扣招喧侗盟森唉胡灿廉炉模啮涅隘悟务盏怎隘ICU获得性感染ICU获得性感染,Prevalence of CAZ-R Klebsiella,From Itokazu G, et al. Nationwide Study of Multiresistance Among Gram-Negative Bacilli from ICU patients Clinical Infectious Diseases 1996; 23: 779-85,旨橱栅闲芦函纹挤傣遵碌犊碎警单北幕动操澄逮闽淤茨柒储垣绥佃赴受壳ICU获得性感染ICU获得性感染,Cross-Resistance in CAZ-R Klebsiella,From Itokazu G, et al. Nationwide Study of Multiresistance Among Gram-Negative Bacilli from ICU patients Clinical Infectious Diseases 1996; 23: 779-85,畅赏巩堆行咸谭俩绳仁闸喝乔熬诀形醛秧州登呢菲椒滨江尼冰搂械禹瘩吊ICU获得性感染ICU获得性感染,Prevalence of ESBL,Data from Intensive Care Unit, Peking Union Medical College Hospital, 1999,思臆累础巡月旭忱楷锥垃逻设足涂贿陆蹋科勉把佯鲍蝴嫡痢吁弥巡拜擅貉ICU获得性感染ICU获得性感染,Cross-Resistance in CAZ-R Klebsiella,Data from Intensive Care Unit, Peking Union Medical College Hospital, 1995-1999,痈匝鼎正珊隔慧裳模炔踊显协反筐齿壕贞告效人举速坏畔第围融侣刷益顷ICU获得性感染ICU获得性感染,Effect of ESBL on Mortality,Analysis of mortality in 216 bacteremic patients caused by Klebsiella pneumoniae,Patterson et al. 37th ICAAC, 1997, Abstr J-210,纷牲笋奸冈鞘圆业妖术掏硬死拣彪蛤邑廓志赔访砍帽撕梦扼斥蹭怂毫盘倘ICU获得性感染ICU获得性感染,Effect of ESBL on Mortality,Patterson et al. 37th ICAAC, 1997, Abstr J-210,Empiric antibiotic therapy in 32 bacteremic patients caused by ESBL-positive Klebsiella pneumoniae,戒强翔阂聋塘斥萄丧菊壤席尼姥背朵牲议悄缅馆连揍绳丸涛窗息帐些芥酶ICU获得性感染ICU获得性感染,Molecular Epidemiology of CAZ-R E. Coli and K. Pneumoniae Blood Isolates,Schiappa D, et al Rush University and University of Illinois, Chicago IL Journal of infectious Diseases 1996; 174: 529-37,小酞养崭栖箭赞冯比位绵韧佛询乔啃侗键庇俄烟仗秧椿骸摈执苇慷政搓水ICU获得性感染ICU获得性感染,Risk Factors for CAZ-R Klebsiella Bacteremia,喉唁匠涡蝴拢童擅驮又舅批啦庆劝胎想福酌咋乖省顽慷钦赫荧想霍籍塞营ICU获得性感染ICU获得性感染,CAZ-R Klebsiella Bacteremia,* p = 0.02,Outcome of Patients with CAZ-R Bacteremia Who Received Appropriate vs. Inappropriate Therapy Within 72 Hours of Bacteremic Event,呵国召坷秋碱嫌皋新甫盈哆叭酮踌粱收屠纳箕辐枝消足宿礁物斧怪昭一红ICU获得性感染ICU获得性感染,Ceftazidime - emergence of resistance,Emergence of Antibiotic-Resistant Pseudomonas aeruginosa: Comparison of Risks Associated with Different Antipseudomonal Agents by Carmeli Y, et al. Antimicrobial Agents and Chemotherapy 1999; 43 (6): 1379-82,骏斗向的驳饮藩鹰馈廊鲁念捷躇藐吊石淑翔诸柠吩址援缩仇绎讲爬盈未踊ICU获得性感染ICU获得性感染,Ceftazidime - emergence of resistance,a 320-bed urban tertiary-care teaching hospital in Boston, Mass. 11,000 admissions per year 4 study agents with antipseudomonal activity ceftazidime, ciprofloxacin, imipenem, piperacillin a total of 271 patients (followed for 3,810 days) with infections due to P. Aeruginosa were treated with the study agents resistance emergence in 28 patients (10.2%), with an incidence of 7.4 per 1,000 patient-days,滁护镰惯藏韵包耀贴棺思憋形柑异奔馋慢阵陶缮虾责氛玛溜志顷仗跟躁懈ICU获得性感染ICU获得性感染,Ceftazidime - emergence of resistance,Table. Multivariable Cox hazard models for the emergence of resistance to any of the four study drugs,袍阔聂娥贯崭描渣歼皑镜借坚蔽疏沈捎图璃敝茸然苛槐鸥筛武涌贿蓄燕诽ICU获得性感染ICU获得性感染,Classification of Antibiotic Therapy,Prophylactic Use Therapeutic Use Empiric therapy Definitive therapy,耸体卸绊核派擎唁抖滴哀镑钮肉榔抛豺询柄胖靛燃腔安享年跨钨岭烽煽莉ICU获得性感染ICU获得性感染,Empiric Antibiotic Therapy,Department of Critical Care Medicine Peking Union Medical College Hospital,姓囤翌锻焰污涪弃导扶疵不惠唱教局粳偿谓支实趟扦肋夷鄙舔盟敏级挺茨ICU获得性感染ICU获得性感染,Empiric Antibiotic Therapy,When treating seriously ill patients who are at risk of developing septic shock when pathogens are unknown or not confirmed antibiotic selection according to epidemiology of NI in the ward resistance profile of most common pathogens,喳惧遭说陶胶落礁鄙载予附扯谭舞枕肩寇曰花导愁老点馒统理之桅舌质蛮ICU获得性感染ICU获得性感染,Empiric Antibiotic Therapy,Searching for infection focus collecting samples for culture starting empiric antibiotic therapy as soon as possible referring to definitive antibiotic therapy as soon as possible,扔咒结界碉沦四再尝项辨佬畏玉寿瘁旬阁派块驱仓灸屡叮曲受则邓诈形吃ICU获得性感染ICU获得性感染,Antibiotic Therapy and Prognosis,Objective: To evaluate the relationship between the adequacy of antibiotic treatment for BSI and clinical outcomes among ICU pts Design: Prospective cohort study Setting: A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teaching hospital Patients: 492 pts from July 1997 to July 1999 Intervention: None,砍憨匝革极滚授谈股果厉倚奢乞足劫忱才峡屠反簇茸萧阀谆携痔界粱掷易ICU获得性感染ICU获得性感染,Antibiotic Therapy and Prognosis,147 (29.9%) pts received inadequate antimicrobial treatment for their BSI The most commonly identified bloodstream pathogens and their associated rates of inadequate antimicrobial treatment included vancomycin-resistant enterococci (n = 17; 100%) Candida species (n = 41; 95.1%) MRSA (n = 46; 32.6%) SCoN (n = 96; 21.9%) Pseudomonas aeruginosa (n = 22; 10.0%),陷锌啪脉缩系泻应疫琐韦嚣口菠油筐居悬翁掘权洒炬圣遗两戍墟因狰荷贝ICU获得性感染ICU获得性感染,Antibiotic Therapy and Prognosis,Hospital mortality rate pts with a BSI receiving inadequate antimicrobial tx (61.9%) pts with a BSI receiving adequate antimicrobial tx (28.4%) (RR, 2.18; 95% CI, 1.77 to 2.69; p 0.001) Independent determinant of hospital mortality by multiple logistic regression analysis administration of inadequate antimicrobial tx (OR, 6.86; 95% CI, 5.09 to 9.24; p 0.001),霹液瞒慌柬歼莉禽帧肺报非台歹娜缺睬咳幽区长纂莎箭唤指河端嗡颇衅音ICU获得性感染ICU获得性感染,Antibiotic Therapy and Prognosis,Independent predictor of the administration of inadequate antimicrobial tx by multiple logistic regression analysis BSI attributed to Candida species (OR, 51.86; 95% CI, 24.57 to 109.49; p 0.001) prior administration of antibiotics during the same hospitalization (OR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008) decreasing serum albumin concentrations (1-g/dL decrements) (OR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014) increasing central catheter duration (1-day increments) (OR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008),腑取冒巫栏俊陈沃维鹊侣匝葫噬械粹丢尚趴沫排选弹酒塔柔陷榴釜斡美尾ICU获得性感染ICU获得性感染,Inappropriate empiric antibiotic therapy,Objective: to assess the incidence, risk, and prognosis factors of NP acquired during mechanical ventilation (MV) Settings a 1,000-bed teaching hospital April 1987 through May 1988 Patients 78 (24%) episodes of NP in 322 consecutive mechanically ventilated patients,碘瑶秃鄙任甩啮惊枪物巧砸书簧汽纱赊邮济是植簿帜浇娃址区氢辖禁字疫ICU获得性感染ICU获得性感染,Inappropriate empiric antibiotic therapy,From: Torres et al. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990 Sep;142(3):523-8,椅榴摈洗橇仪举腔傈索酌茹膊省便撩记绿瘴活溢煞脖匠庭拧扎侍义旭洪遏ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,Objective: To assess the frequency of and the reasons for changing empiric antibiotics during the treatment of pneumonia acquired in ICU Design: A prospective multicenter study of 1 years duration Setting: Medical and surgical ICUs in 30 hospitals all over Spain. Patients: Of a total of 16,872 patients initially enrolled into the study, 530 patients developed 565 episodes of pneumonia after admission to the ICU.,孕雏但靳舔狈闻审阉积度履汀鹊巳篇晴荚趁槽藤讥匀掏谗绊貌涛蹭腑墨夯ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,Empiric antibiotics in 490 (86.7%) of the 565 episodes of pneumonia The most frequently used antibiotics amikacin 120 cases tobramycin 110 ceftazidime 96 cefotaxime 96 Monotherapy in 135 (27.6%) of the 490 episodes Combination of 2 antibiotics in 306 episodes (62.4%) Combination of 3 antibiotics in 49 episodes (10%),践漱勃衔哭褐辞驴画佃犁绕憋媚恩促剑望毋傈狄里援巨刽涯中艺焦侄惹教ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,The empiric tx modified in 214 (43.7%) cases isolation of a microorganism not covered by treatment 133 (62.1%) cases lack of clinical response 77 (36%) development of resistance 14 (6.6%) Individual factors associated with modification of empiric treatment identified in the multivariate analysis microorganism not covered (RR 22.02; 95%CI 11.54 to 42.60; p 0.0001) administration of more than one antibiotic (RR 1.29; 95% CI 1.02 to 1.65; p = 0.021) previous use of antibiotics (RR 1.22; 95% CI 1.08 to 1.39; p = 0.0018),培躬市曝瘫弱艰敏吗倒虫娠侗认捅惧氟环院租脊孰欲棺唯舞害快逼障缨言ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,Compared with appropriate empiric therapy, inappropriate therapy was associated with higher mortality (p=0.0385) more complications (p0.001) higher incidence of shock (p0.005) more GIB (p=0.003),From: Alvarez-Lerma F. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired Pneumonia Study Group. Intensive Care Med 1996 May;22(5):387-94,恤堂鹿殖移疹仇沾栅瓦磊颅菩沸较迅阔座候葱粗芋凑坛落岂奖党林消蔡颐ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,Objective To define the impact of BAL data on the selection of antibiotics and the outcomes of patients with VAP Design: Prospective observation and bronchoscopy with BAL, performed within 24 h of dx of a new episode of hospital-acquired VAP or progression of a prior episode of NP Setting: A 15-bed medical and surgical ICU,柒例淫支盏起套阿晓槽政苑蛛柒伯萝逃既靛窖挝袁然灭抨鼎蓝勒习唉竟祖ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,Patients: 132 pts hospitalized for more than 72 h mechanically ventilated a new or progressive lung infiltrate plus at least two of the following three clinical criteria for VAP abnormal temperature ( 38 C or 10,000 or 3,000) purulent bronchial secretions Interventions: Bronchoscopy with BAL within 24 h of clinical dx of VAP or progression of an infiltrate due to prior VAP or NP All patients received antibiotics, 107 prior to bronchoscopy and 25 immediately after bronchoscopy.,硒当嘿姚视姨碴舍煎祷峙竿磋牲毯敌卯结到蛆垣矿钧谩啪屋淬心踢残尊脚ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,From: Luna CM, Vujacich P, Niederman MS, Vay C, Gherardi C, Matera J, Jolly EC. Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia. Chest 1997 Mar;111(3):676-85,缆著龙拧荡抉桌串痕疗奈块近姿龚郑微垄子谱捂悯晋柯器孤蛮吟殖翘拽惜ICU获得性感染ICU获得性感染,Difficulty in empiric antibiotic therapy,From: Kollef MH, Ward S The influence of mini-BAL cultures on patient outcomes: implications for the antibiotic management of ventilator-associated pneumonia. Chest 1998 Feb;113(2):412-20,毫滁萤躲柴申滋僚芹跃奄秋墩彪知茹稚绳仪猛我钾绩晕未勇短罐胃锌泵旺ICU获得性感染ICU获得性感染,Hospital Infection Control,Department of Critical Care Medicine Peking Union Medical College Hospital,锅姓焉谋凳凭积抹烧拌腹判羹冠钳琅狭侥郝衫算搞增娟玩宋军威烤撅各渠ICU获得性感染ICU获得性感染,Scheduled Changes of Empiric Antibiotic Therapy,Objective: To determine the impact of a scheduled change of abx classes, used for the empiric tx of suspected gram-negative bacterial infections, on the incidence of VAP and nosocomial bacteremia Patients: 680 patients undergoing cardiac surgery were evaluated Intervention: During a 6-mo period (i.e., the before-period), our traditional practice of prescribing a 3rd generation cephalosporin (ceftazidime) for the empiric tx of suspected gram-negative bacterial infections was continued This was followed by a 6-mo period (i.e., the after-period) during which a quinolone (ciprofloxacin) was used in place of the third-generation cephalosporin.,鞍批僧泻葬承诧羌墒羽蛮表嚷谤阻佃荡绥科敦陨七佣沼艇疯卞浓翠交掉韩ICU获得性感染ICU获得性感染,Scheduled Changes of Empiric Antibiotic Therapy,From: Kollef MH, Vlasnik J, Sharpless L, Pasque C, Murphy D, Fraser V Scheduled change of antibiotic classes: a strategy to decrease the incidence of ventilator-associated pneumonia. Am J Respir Crit Care Med 1997 Oct;156(4 Pt 1):1040-8,凭筐碉愿患眨灸漳捞给饶推授蛇豺沥短粗要眶儿骆涎嚏消亦柿帽驱酚父飞ICU获得性感染ICU获得性感染,Nosocomial Infection Control,Scheduled changes of antibiotic class