ICU获得性感染.ppt

DeptofCriticalCareMedicinePekingUnionMedicalCollegeHospital,ICU-acquiredInfectionandStrategyofAntibioticTherapy,CostofHospitalStayAssociatedwithResistance,NosocomialInfectioninICU,anoverallriskof18%ofacquiringaninfectionduringICUstayoneofthemostcommoncausesofdeathinICUs,NosocomialInfectioninICU,EuropeanPrevalenceofInfectioninIntensiveCareStudy(EPIC)HeldonApril29,1992anoverallof9567patientsfrom1417ICUs,EPICData,atotalof45%ofpatientshadaninfectionICU-acquiredinfection21%community-acquiredinfection14%hospital-acquiredinfectionotherthanICU10%,NosocomialInfectionVincentetal.JAMA2019;374:639-644(EPIC),NosocomialInfectioninICU,Predisposingriskfactors,prolonglengthofICUstayantibioticusagemechanicalventilationurinarycatheterization,pulmonaryarterycatheterizationcentralvenousaccessstressulcerprophylaxisuseofsteroidnutritionalstatus,NosocomialInfectioninICU,NosocomialInfectioninICU,UseofAntibiotics-EPICdataof10,038patients,62%receivedantibioticsforeitherprophylaxisortreatment,NosocomialInfectioninICU,Previousexposuretoantibioticsmodifyintestinalflora,leadingtocolonizationwithresistantbacteria3rdgenerationcephalosporinsfluoroquinolonesvancomycinfavortheselectionofinduciblebeta-lactamaseproducingGNB,suchasPseudomonoasaeruginosa,Enterobacterclocae,Serratiaspp.,andCitrobacterfreundii,NosocomialInfectioninICU,Commonpathogenscommunity-acquiredinfectionandearly(4d)hospital-acquiredinfectionsEnterobacterspp.Serratiaspp.ESBL-producingmicroorganismsPseudomonasaeruginosaAcinetobacterspp.MRSAenterococcifungi,EPICData,mostcommonpathogensS.aureus30%P.aeruginosa29%Coagulase-negativestaphylococci19%E.coli13%Enterococcusspp.12%,EmergingPathogens,DatafromICU,PUMCH2019,EmergingPathogens,MechanismofResistancetoBeta-lactamAntibiotics,DepartmentofCriticalCareMedicinePekingUnionMedicalCollegeHospital,Principleofbeta-lactamaction,arigidbacterialcellwallprotectsbacteriafrommechanicalandosmoticinsultbeta-lactaminhibitsPBPspreventingformationofthepeptidebridgesproducingweakenedwallactivatingcellwalldegradingenzymes-autolysinbeta-lactaminterfereswithnormalcellwallbiosynthesis,causingimpairedcellularfunction,alteredcellmorphologyorlysis,MechanismofAntibioticResistance,Doesbeta-lactamaseconferresistance?,Theamountofenzymeproductsitsabilitytohydrolysetheantibioticinquestionitsinterplaywiththecellularpermeabilitybarriers,InducibleBeta-lactamase,alsocalledclassIbeta-lactamaseorconstitutivebeta-lactamaseorAmpCbeta-lactamasemostarechromosome-mediatedmajorproducersPseudomonasaeruginosaEnterobactersp.Citrobactersp.Serratiasp.Morganellamorgannii,InducibleBeta-lactamase,transientelevationinbeta-lactamasesynthesiswhenabeta-lactamispresentenzymeproductionreturnstoalowlevelwhentheinducerisremovedlowlevelinsufficienttoprotectbacteriaevenagainstdrugsrapidlyhydrolysedbytheenzymesenzymehyperproducer=mutantsthatproduceClassIenzymescontinuouslyatahighlevel,InducibleBeta-lactamase,Inductionislostwithin4to6hrsoncethestronginducerisremoved.Littleneedforconcerniftherapywithastronginducerisdiscontinuedandthedrugreplacedbyaweakinducer.,ActivityofDrugsAgainstOrganismswithElevatedBeta-LactamaseLevels,DecreasedActivityMonobactamsSecond-,Third-generationcephalosporinsBroad-spectrumpenicillinsMaintainActivityImipenem,MeropenemFourth-generationcephalosporinsCiprofloxacin,ofloxacin,etcSMZ/TMPco(exceptP.Aeruginosa)Aminoglycosides,AntibiogramofEnterobacter,EnterobacterBacteremia:ClinicalFeaturesandEmergenceofAntibioticResistanceduringTherapy,ChowJW,etalAnnIntMed1991;115:585-90,MultiresistantEnterobacter,*Antibioticsreceivedinthe2weeksbeforetheinitialpositivebloodculture,AssociationofPreviouslyAdministeredAntibioticswithMultiresistantEnterobacterintheInitialBloodCulture,MultiresistantEnterobacter,EmergenceofResistancetoCephalosporin,Aminoglycoside,andOtherBeta-LactamTherapy,*Cefotaxime,ceftazidime,ceftriaxone,ceftizoxime*Gentamicin,tobramicin,amikacin,netilmicin*Imipenem,piperacillin,ticarcillin,aztreonam,mezlocillin,ticarcillin-clavulanate,MultiresistantEnterobacter,FactorsAssociatedwithMortalityinPatientswithEnterobacterBacteremia,Extendedspectrumbeta-lactamase,Mostareplasmidmediated1to4aminoacidchangesfrombroad-spectrumbeta-lactamases,thereforegreatlyextendingsubstraterangeMajorproducersE.Coli(TEM)Klebsiellasp.(SHV)inhibitedbybeta-lactamaseinhibitors,Reliable(relatively)agentsforESBL-producingpathogens,CarbapenemsAmikacinCephamycins(exceptMIR-1type;30%ofstrains)Beta-lactamaseinhibitorspip/tazo30%RinChicago201926%RinICU,PUMCH2019,AntibiogramofE.coli,AntibiogramofKlebsiella,PrevalenceofCAZ-RKlebsiella,FromItokazuG,etal.NationwideStudyofMultiresistanceAmongGram-NegativeBacillifromICUpatientsClinicalInfectiousDiseases2019;23:779-85,Cross-ResistanceinCAZ-RKlebsiella,FromItokazuG,etal.NationwideStudyofMultiresistanceAmongGram-NegativeBacillifromICUpatientsClinicalInfectiousDiseases2019;23:779-85,PrevalenceofESBL,DatafromIntensiveCareUnit,PekingUnionMedicalCollegeHospital,2019,Cross-ResistanceinCAZ-RKlebsiella,DatafromIntensiveCareUnit,PekingUnionMedicalCollegeHospital,2019-2019,EffectofESBLonMortality,Analysisofmortalityin216bacteremicpatientscausedbyKlebsiellapneumoniae,Pattersonetal.37thICAAC,2019,AbstrJ-210,EffectofESBLonMortality,Pattersonetal.37thICAAC,2019,AbstrJ-210,Empiricantibiotictherapyin32bacteremicpatientscausedbyESBL-positiveKlebsiellapneumoniae,MolecularEpidemiologyofCAZ-RE.ColiandK.PneumoniaeBloodIsolates,SchiappaD,etalRushUniversityandUniversityofIllinois,ChicagoILJournalofinfectiousDiseases2019;174:529-37,RiskFactorsforCAZ-RKlebsiellaBacteremia,CAZ-RKlebsiellaBacteremia,*p=0.02,OutcomeofPatientswithCAZ-RBacteremiaWhoReceivedAppropriatevs.InappropriateTherapyWithin72HoursofBacteremicEvent,Ceftazidime-emergenceofresistance,EmergenceofAntibiotic-ResistantPseudomonasaeruginosa:ComparisonofRisksAssociatedwithDifferentAntipseudomonalAgentsbyCarmeliY,etal.AntimicrobialAgentsandChemotherapy2019;43(6):1379-82,Ceftazidime-emergenceofresistance,a320-bedurbantertiary-careteachinghospitalinBoston,Mass.11,000admissionsperyear4studyagentswithantipseudomonalactivityceftazidime,ciprofloxacin,imipenem,piperacillinatotalof271patients(followedfor3,810days)withinfectionsduetoP.Aeruginosaweretreatedwiththestudyagentsresistanceemergencein28patients(10.2%),withanincidenceof7.4per1,000patient-days,Ceftazidime-emergenceofresistance,Table.MultivariableCoxhazardmodelsfortheemergenceofresistancetoanyofthefourstudydrugs,ClassificationofAntibioticTherapy,ProphylacticUseTherapeuticUseEmpirictherapyDefinitivetherapy,EmpiricAntibioticTherapy,DepartmentofCriticalCareMedicinePekingUnionMedicalCollegeHospital,EmpiricAntibioticTherapy,WhentreatingseriouslyillpatientswhoareatriskofdevelopingsepticshockwhenpathogensareunknownornotconfirmedantibioticselectionaccordingtoepidemiologyofNIinthewardresistanceprofileofmostcommonpathogens,EmpiricAntibioticTherapy,Searchingforinfectionfocuscollectingsamplesforculturestartingempiricantibiotictherapyassoonaspossiblereferringtodefinitiveantibiotictherapyassoonaspossible,AntibioticTherapyandPrognosis,Objective:ToevaluatetherelationshipbetweentheadequacyofantibiotictreatmentforBSIandclinicaloutcomesamongICUptsDesign:ProspectivecohortstudySetting:AmedicalICU(19beds)andasurgicalICU(18beds)fromauniversity-affiliatedurbanteachinghospitalPatients:492ptsfromJuly2019toJuly2019Intervention:None,AntibioticTherapyandPrognosis,147(29.9%)ptsreceivedinadequateantimicrobialtreatmentfortheirBSIThemostcommonlyidentifiedbloodstreampathogensandtheirassociatedratesofinadequateantimicrobialtreatmentincludedvancomycin-resistantenterococci(n=17;100%)Candidaspecies(n=41;95.1%)MRSA(n=46;32.6%)SCoN(n=96;21.9%)Pseudomonasaeruginosa(n=22;10.0%),AntibioticTherapyandPrognosis,HospitalmortalityrateptswithaBSIreceivinginadequateantimicrobialtx(61.9%)ptswithaBSIreceivingadequateantimicrobialtx(28.4%)(RR,2.18;95%CI,1.77to2.69;p0.001)Independentdeterminantofhospitalmortalitybymultiplelogisticregressionanalysisadministrationofinadequateantimicrobialtx(OR,6.86;95%CI,5.09to9.24;p0.001),AntibioticTherapyandPrognosis,IndependentpredictoroftheadministrationofinadequateantimicrobialtxbymultiplelogisticregressionanalysisBSIattributedtoCandidaspecies(OR,51.86;95%CI,24.57to109.49;p0.001)prioradministrationofantibioticsduringthesamehospitalization(OR,2.08;95%CI,1.58to2.74;p=0.008)decreasingserumalbuminconcentrations(1-g/dLdecrements)(OR,1.37;95%CI,1.21to1.56;p=0.014)increasingcentralcatheterduration(1-dayincrements)(OR,1.03;95%CI,1.02to1.04;p=0.008),Inappropriateempiricantibiotictherapy,Objective:toassesstheincidence,risk,andprognosisfactorsofNPacquiredduringmechanicalventilation(MV)Settingsa1,000-bedteachinghospitalApril1987throughMay1988Patients78(24%)episodesofNPin322consecutivemechanicallyventilatedpatients,Inappropriateempiricantibiotictherapy,From:Torresetal.Incidence,risk,andprognosisfactorsofnosocomialpneumoniainmechanicallyventilatedpatients.AmRevRespirDis1990Sep;142(3):523-8,Difficultyinempiricantibiotictherapy,Objective:ToassessthefrequencyofandthereasonsforchangingempiricantibioticsduringthetreatmentofpneumoniaacquiredinICUDesign:Aprospectivemulticenterstudyof1yearsdurationSetting:MedicalandsurgicalICUsin30hospitalsalloverSpain.Patients:Ofatotalof16,872patientsinitiallyenrolledintothestudy,530patientsdeveloped565episodesofpneumoniaafteradmissiontotheICU.,Difficultyinempiricantibiotictherapy,Empiricantibioticsin490(86.7%)ofthe565episodesofpneumoniaThemostfrequentlyusedantibioticsamikacin120casestobramycin110ceftazidime96cefotaxime96Monotherapyin135(27.6%)ofthe490episodesCombinationof2antibioticsin306episodes(62.4%)Combinationof3antibioticsin49episodes(10%),Difficultyinempiricantibiotictherapy,Theempirictxmodifiedin214(43.7%)casesisolationofamicroorganismnotcoveredbytreatment133(62.1%)caseslackofclinicalresponse77(36%)developmentofresistance14(6.6%)Individualfactorsassociatedwithmodificationofempirictreatmentidentifiedinthemultivariateanalysismicroorganismnotcovered(RR22.02;95%CI11.54to42.60;p0.0001)administrationofmorethanoneantibiotic(RR1.29;95%CI1.02to1.65;p=0.021)previoususeofantibiotics(RR1.22;95%CI1.08to1.39;p=0.0018),Difficultyinempiricantibiotictherapy,Comparedwithappropriateempirictherapy,inappropriatetherapywasassociatedwithhighermortality(p=0.0385)morecomplications(p0.001)higherincidenceofshock(p38Cor10,000or3,000)purulentbronchialsecretionsInterventions:BronchoscopywithBALwithin24hofclinicaldxofVAPorprogressionofaninfiltrateduetopriorVAPorNPAllpatientsreceivedantibiotics,107priortobronchoscopyand25immediatelyafterbronchoscopy.,Difficultyinempiricantibiotictherapy,From:LunaCM,VujacichP,NiedermanMS,VayC,GherardiC,MateraJ,JollyEC.ImpactofBALdataonthetherapyandoutcomeofventilator-associatedpneumonia.Chest2019Mar;111(3):676-85,Difficultyinempiricantibiotictherapy,From:KollefMH,WardSTheinfluenceofmini-BALculturesonpatientoutcomes:implicationsfortheantibioticmanagementofventilator-associatedpneumonia.Chest2019Feb;113(2):412-20,HospitalInfectionControl,DepartmentofCriticalCareMedicinePekingUnionMedicalCollegeHospital,ScheduledChangesofEmpiricAntibioticTherapy,Objective:Todeterminetheimpactofascheduledchangeofabxclasses,usedfortheempirictxofsuspectedgram-negativebacterialinfections,ontheincidenceofVAPandnosocomialbacteremiaPatients:680patientsundergoingcardiacsurgerywereevaluatedIntervention:Duringa6-moperiod(i.e.,thebefore-period),ourtraditionalpracticeofprescribinga3rdgenerationcephalosporin(ceftazidime)fortheempirictxofsuspectedgram-negativebacterialinfectionswascontinuedThiswasfollowedbya6-moperiod(i.e.,theafter-period)duringwhichaquinolone(ciprofloxacin)wasusedinplaceofthethird-generationcephalosporin.,ScheduledChangesofEmpiricAntibioticTherapy,From:KollefMH,VlasnikJ,SharplessL,PasqueC,MurphyD,FraserVScheduledchangeofantibioticclasses:astrategytodecreasetheincidenceofventilator-associatedpneumonia.AmJRespirCritCareMed2019Oct;156(4Pt1):1040-8,NosocomialInfectionControl,ScheduledchangesofantibioticclassesforempirictreatmentofsuspectedordocumentedGNBinfectionsTimeperiod1(n=1323)ceftazidimeTimeperiod2(n=1243)ciprofloxacinTimeperiod3(n=1102)cefepime,NosocomialInfectionControl,Scheduledchangesofantibioticclassestargetedattheempirictreatmentofgram-negativebacterialinfectionscanreducetheoccurrenceofinadequateantimicrobialtreatmentofnosocomialinfectionsreducingtheadministrationofinadequateantimicrobialtreatmentforpatientswithanAPACHEII15canimprovehospitalsurvival,FromKollefMH.Theclini