严重感染治疗策略-邱海波2

1、李家泰李家泰 中华检验医学杂志中华检验医学杂志, 2005, 28(1): 25lProspective cohort study.Dec 1996 to Sep 2000 Inpatient surgical wards at a university hospN=924 pats with GNR infectionslOutcomes were compared between GNR infections with and without antibiotic reslrGNRs: resistant to one or more of the followingall aminogl

2、ycosides, including amikacinall cephalosporinsall carbapenemsall fluoroquinolonesCrit Care Med 2003; 31:10351041rGNR:病死率u ESBL和和AmpC是是ICU重症感染致病菌耐药的重重症感染致病菌耐药的重要原因要原因u 三代头胞大量使用是导致三代头胞大量使用是导致G-菌出现菌出现ESBL和和AmpC 的的 主要原因主要原因u ESBL和和AmpC使使ICU重症感染患者的病死率明重症感染患者的病死率明显增加显增加u 近近3年年, ICU非发酵糖细菌的比例从非发酵糖细菌的比例从41.2

3、%升高升高到到47.9%铜绿假单胞菌、不动杆菌属、嗜麦芽铜绿假单胞菌、不动杆菌属、嗜麦芽窄食单胞菌分别位居窄食单胞菌分别位居1、4、7位位u 碳青霉烯类抗生素、酶抑制剂制剂等敏感性较碳青霉烯类抗生素、酶抑制剂制剂等敏感性较高高 ICU重症感染的重要性重症感染的重要性 细菌耐药机制及细菌耐药机制及ICUICU细菌流行情况细菌流行情况 重症感染的治疗策略重症感染的治疗策略 感染灶的充分引流感染灶的充分引流 早期经验性治疗与降阶梯策略早期经验性治疗与降阶梯策略 正确的目标性治疗正确的目标性治疗非抗生素治疗策略非抗生素治疗策略l气管插管与机械通气气管插管与机械通气n插管路径插管路径nNIV/IVNIV

4、/IVn声门下的积液声门下的积液n气囊的管理气囊的管理n湿化与雾化湿化与雾化n管路与冷凝水管路与冷凝水nMVMV时间时间nICUICU的医疗强度的医疗强度l误吸误吸/ /体位体位n体位体位/ /胃肠道返流胃肠道返流n营养途径营养途径l口鼻咽腔口鼻咽腔/ /肠道定植肠道定植l溃疡预防溃疡预防/ /血糖控制血糖控制Every pats presenting with severe sepsis should be evaluated for the presence of a focus of infection amenable to source control measuresDrainag

5、e of an abscess or local focus of infectionRemoval of a potientially infected deviceGuidelines for sepsis. Intensive Care Med 2004, 30: 536-555 重症感染的重要性重症感染的重要性 细菌耐药机制及细菌耐药机制及ICUICU细菌流行情况细菌流行情况 重症感染的治疗策略重症感染的治疗策略感染灶的充分引流感染灶的充分引流早期经验性治疗与降阶梯策略早期经验性治疗与降阶梯策略正确的目标性治疗正确的目标性治疗对有急性而危及生命的全身性感染患者对有急性而危及生命的全身性

6、感染患者无法及时得到细菌学资料无法及时得到细菌学资料应根据本病房的细菌流行病学调查结果应根据本病房的细菌流行病学调查结果选择对常见致病菌有效的广谱抗生素选择对常见致病菌有效的广谱抗生素k经验性治疗推理性治疗经验性治疗推理性治疗提高患者的生存率提高患者的生存率降低细菌产生耐药性降低细菌产生耐药性Dr. Jordi RelloProfessor of Critical Care ,University Rovira & virgili Tarragona, Spain死亡：死亡： 绝对危险度下降绝对危险度下降6.1%6.1%死亡：死亡： 绝对危险度下降绝对危险度下降9 9死亡：死亡： 绝对

7、危险度下降绝对危险度下降4%4%ICU经验性抗生素治疗经验性抗生素治疗VAP:22-73%为抗生素起始治疗不为抗生素起始治疗不当当0%0%20%20%40%40%60%60%80%80%100%100%AdequateNot-adequate/no-ANTLuna CM et al.Chest 1997Adequate38%(6/16)Not-adequate/not-ANT81.6%(40/49) 132 pats with suspected NPBAL in 55 pats Leibovici et alAdequate vs inadequate initial antibiotic:

8、 Mortality: 20% vs 34% From J Intern Med, 1998, 244: 379 14lIn a retrospective cohort study of pneumonia in 18,209 patientsAdministering antibiotics within 4 h of hospital arrival was associated with improved survival.Houck PM et al. Arch Intern Med. 2004, 164: 6376441. Grade EIntravenous antibiotic

9、 therapy should be started within 1st h of recognition of severe sepsis, after appropriate cultures have been obtainedGuidelines for sepsis. Intensive Care Med 2004, 30: 536-5552. Grade DbInitial empiric anti-infective therapy should include one or more drugs that have activity against the likely pa

10、thogensbThe choice of drug should be guided by the susceptibility patterns of microorganisms in the community and the hospitalGuidelines for sepsis. Intensive Care Med 2004, 30: 536-555早期经验性治疗早期经验性治疗是抗感染的经验性治疗方案，具有如下是抗感染的经验性治疗方案，具有如下两个特性：两个特性： 开始即使用广谱抗生素以覆盖所有可开始即使用广谱抗生素以覆盖所有可能的致病菌能的致病菌 随后随后(48-72h)(

11、48-72h)根据微生物学检查结果根据微生物学检查结果调整抗生素的使用，使之更有针对性调整抗生素的使用，使之更有针对性Dr. Luciano GattinoniProfessor of Anesthesiology,Institute of Emergency Surgery,University of Milan, ItalylTreatment protocols and guidelines-important tool for optimal therapyl Establishing local susceptibility profiles that can be used to

12、develop therapy protocolsl“Not only we did want to treat with the initial therapy that was appropriate, but we wanted to minimize the emergence of resistance” l“Not only we did want to treat with the initial therapy that was appropriate, but we wanted to minimize the emergence of resistance” lIt is

13、essential to be able to recognize those pats who are treatment failure0 05 51010151520202525303035354040Percentage occurrence (%)Percentage occurrence (%)PAPASASAASASotherotherKPKPESESSPSPPA: Pseuso aeruginosa; SA:Staphylococcus aureus; AS: Acinetobacter species; KP: Klebsiella pneumoniae; ES: Enter

14、obacter species; SP: Strep pneumoniaeOther: E coli, Haemophilus influ, SerratiaKollef MH Clinical Inf Dis 2000, 31 (S4):131-8多重耐药致病菌多重耐药致病菌N=22MV 7天天抗生素：否抗生素：否N=12MV7 d of MV and prior antibiotic useTrouillet JL. Am J Respir Crit Care Med 1998, 157: 531539% susceptibilityVAP病原菌耐药的危险因素病原菌耐药的危险因素:最重要的

15、是最近接受过抗生素治疗最重要的是最近接受过抗生素治疗(最近最近15天天)其次是机械通气至少其次是机械通气至少7天天VAP的的致病菌致病菌敏感性最高敏感性最高IMPAmikacinVanco Value PointsTemperature C 36.5 and 38.5 and 39 or 4,000 and 11,000 :0 11,000 1 Tracheal secretions Few0 Moderate1 Large2 PaO2/FiO2, mmHg 240 or present ARDS1 5 days) or risk factors forMDR PathogensNoYesLi

16、mited Spectrum TherapyBroad SpectrumTherapy for MDR PathogensAlgorithm for Initiating Empiric Antibiotic TherapyATS. Am J Respir Crit Care Med 2005;171:388-416Potential PathogenStreptococcus pneumoniaeHaemophilus influenzaeMethicillin-sensitive Staphylococcus aureusEnteric gram-negative bacilli(Anti

17、biotic sensitive) Enterobacter species Escherichia coli Klebsiella species Proteus species Serratia marcescensRecommended AntibioticCeftriaxoneorLevofloxacin, moxifloxacin, or ciprofloxacinorAmpicillin/sulbactamorErtapenemATS. Am J Respir Crit Care Med 2005;171:388-416Potential PathogensP. aeruginos

18、aESBL (+) K. pneumoniaeAcinetobacter speciesMRSAL. pneumophilaTherapyAntipseudomonal cephalosporin(cefepime, ceftazidime) orAntipseudomonal carbapenem(İmipenem, meropenem) orPiperacillin-tazobactamplusCiprofloxacin or levofloxacin orAminoglycosideLinezolid or vancomycinATS. Am J Respir Crit Care Med

19、 2005;171:388-416 ICU重症感染的重要性重症感染的重要性 细菌耐药机制及细菌耐药机制及ICUICU细菌流行情况细菌流行情况 重症感染的治疗策略重症感染的治疗策略 感染灶的充分引流感染灶的充分引流 早期经验性治疗早期经验性治疗 正确的目标性治疗正确的目标性治疗3. Grade EThe antimicrobial regimen should always be reassessed after 4872h on the basis of using a narrow-antibiotic to prevent the development of resistance, to reduce toxicity, and costsGuidelines for sepsis. Intensive Care Med 2004, 30: 536-555l初始经验性治疗之前，应采集呼吸道标本初始经验性治疗之前，应采集呼吸道标本l呼吸道标本的病原学检查结果并不总是可靠的呼吸道标本的病原学检查结果并不总是可靠的细菌耐药性试验细菌耐药性试验( (药敏药敏) )及时、正确