神经科重症监护室感染的控制王宁

1、会计学1神经科重症监护室感染的控制王宁神经科重症监护室感染的控制王宁B. Indredavik, F. Bakke,; S.A. Slrdahl, et al.Stroke,1998,29(5):895899一项随机、对照研究，220例患者分为NICU组及普通病房组神经重症监护室普通病房NHP评分B. Indredavik, F. Bakke,; S.A. Slrdahl, et al.Stroke,1998,29(5):895899TABLE 1. The Mean/Median Scores and Proportion of Patients With a Score of 30 on

2、FAI for Stroke Unit and General Wards Patients Assessed 5 Years After Stroke*Percentages were calculated from patients alive after 5 years: in the stroke unit (SU) group, 45 patients; in the general wards (GW) group, 32 patients.B. Indredavik, F. Bakke,; S.A. Slrdahl, et al.Stroke,1998,29(5):895899B

3、ruce Ovbiagele,MD,et al. Journal of Stroke and Cerebrovascular Diseases, 2006;5(15):209-21311家医院，663例缺血性脑卒中患者，住院期感染发生率感染率%11家医院间感染率不同，变化范围为肺炎：0-27%；泌尿系感染：5-22%Langhorne P，et al. Stroke 2000; 31:1223-9.1.Ruediger Hilker.MD,et al. Stroke,2003;34:975-9812. Uwe Walter,et al. J Neurol (2007) 254:13231329

4、236例NICU急性缺血性脑卒中患者SAP的发生率为21%21.6%2Infection typeNo. of infection（%）No. ofper 100 patientsNo. ofper 1000 patient daysUTI70（42.9）40.937.5Pneumonia44（27.0）25.723.6PBSI31（19.0）18.116.6Clinical sepsis10（ 6.1）5.85.4STI4（ 2.5）2.32.1Venous catheter 4（ 2.5）2.32.1Total163（100.0）95.387.3The types and rates of

5、 ICU acquired infections per 100 patients admitted and per 1000 patient daysUTI: Urinary tract infection; PBSI: primary bloodstream infection; STI: soft tissue infection J. Infect.Dis. 2007；60：8791显著增加脑卒中相关性肺炎（SAP）发生RR值的危险因素Ruediger Hilker.MD,et al. Stroke,2003;34:975-981*P0.05, *P 0.001.相对危险度（RR）机械

6、通气*吞咽困难*正常胸片*脊椎基底动脉卒中*大脑多部位卒中*脊椎基底动脉多部位卒中*ORP值意识7.4 (2.918.4)0.001面瘫3.1 (1.09.3)0.05轻度偏瘫0.6 (0.41.1)0.08失语2.1 (0.76.1)0.18发音困难1.4 (0.63.4)0.47疏忽1.2 (0.43.8)0.72R Dziewas,et al. J Neurol Neurosurg Psychiatry 2004;75:852856.钱树星,龙军,等.中华神经医学杂志, 2006,10(5):1050-1052总的感染发生率%Infection and Risk of Ischemic

7、Stroke Differences Among Stroke Subtypes A. Paganini-Hill, E. Lozano, G. Fischberg，et al. ResultsInfections, either total or specific, were not found more frequently in cases than controls. However, patients with a recent respiratory tract infection suffered more often from large-vessel atherothromb

8、oembolic or cardioembolic stroke than did patients without infection (48% vs 24%, P0.07). ConclusionsOur results suggest that respiratory tract infection may act as a trigger and increase the risk of large-vessel and/or cardioembolic ischemic stroke, especially in those without vascular risk factors

9、. Stroke. 2003;34:452-457S. Aslanyana, C. J. Weir,et al. European Journal of Neurology, 2004, 11: 4953脑卒中感染患者第7天时亚组Kaplan-Meier生存曲线吸入性肺炎泌尿系感染 吸入性肺炎泌尿系感染无感染 死亡率%P0.05，RR:3.3Ruediger Hilker.MD,et al. Stroke,2003;34:975-981124例NICU急性脑卒中患者住院期间死亡率P0.05，RR:2.595%CI:1.0-5.9死亡率%Ruediger Hilker.MD,et al. Str

10、oke,2003;34:975-981124例NICU急性脑卒中患者随访期间死亡率余霞,翟云霞.中国老年学杂志2003,23:466P0.01P0.01死亡率%钱树星,龙军,等.中华神经医学杂志, 2006,10(5):1050-10522004年9月一2006年5月珠江医院神经外科重症监护病房(ICU）临床痰标本中共分离出102株致病菌G-菌：71.6%G+菌：28.4%王宁,陈文进,等.中国现代神经疾病杂志,2006,6(1):40-43G+菌：31.25%G-菌：68.75%神经外科重症监护病房合并感染患者85例，收集致病菌256株Ali A. El-Solh et al. Am J R

11、espir Crit Care Med Vol 167. pp 16501654, 2003病原菌比例病原菌比例 (%)抗菌药物%鲍曼不动杆菌大肠埃希菌铜绿假单胞菌肺炎克雷伯菌哌拉西林88.287.557.171.4亚胺培南5.912.542.90氨曲南88.287.5100.085.7头孢吡肟100.0100.071.435.7钱树星,龙军,等.中华神经医学杂志, 2006,10(5):1050-1052抗菌药物%金黄色葡萄球菌粪肠球菌凝固酶阴性葡萄球菌克林霉素88.287.557.1头孢哌酮/舒巴坦5.912.542.9万古霉素050.00头孢西丁63.6100.033.3G-菌G+菌20

12、04年9月一2006年5月，102株致病菌抗菌药物铜绿假单胞菌肺炎克雷伯菌鲍曼不动杆菌大肠埃希菌氨苄西林/舒巴坦1009891100头孢曲松44294241亚胺培南1121413左氧氟沙星8482100-抗菌药物金黄色葡萄球菌凝固酶阴性葡萄球菌粪肠球菌克林霉素8991-氨苄西林/舒巴坦98100-左氧氟沙星917467青霉素100100-G-G+王宁,陈文进,等.中国现代神经疾病杂志,2006,6(1):40-432003年1月-2004年12， 256株致病菌ATS/IDSA. Guidelines for the management of adults with hospital-acq

13、uired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med, 2005，171:388-416.ATS/IDSA. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med, 2005，171:388-416.开始应用抗菌药物经验治疗的

14、指征ATS/IDSA. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med, 2005，171:388-416. 卒中后发热应考虑是否有肺炎发生，且应给予合适的抗菌素治疗Harold P,et al.AHA/ASA Guidelines for stroke.Circulation 2007;115;e478-e534ATS/IDSA. Guideli

15、nes for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.Am J Respir Crit Care Med, 2005，171:388-416.怀疑怀疑HAP, VAP 或或HCAP取得取得LRTLRT标本培养标本培养( (定量或者半定量定量或者半定量) &) &显微镜检查显微镜检查48 -72 48 -72 小时临床改善小时临床改善 降阶梯治疗，降阶梯治疗，如果可能如果可能. 治疗治疗7- 8天和再评估

16、天和再评估寻找其它病原体寻找其它病原体,并发症并发症, 其它诊断或者感染部位其它诊断或者感染部位2 &3天天:培养结果培养结果& 临床反应评估临床反应评估: (体温体温, WBC,胸部胸部X线片线片,氧合，脓痰氧合，脓痰,血液动力学改变以及器官功能）血液动力学改变以及器官功能）是是无无除非临床怀疑程度低或者除非临床怀疑程度低或者LRT标本显微镜检查阴性，应开始经验性抗标本显微镜检查阴性，应开始经验性抗感染治疗感染治疗: ATS分组和当地微生物学资料分组和当地微生物学资料培养培养- -考虑停药考虑停药调整抗感染方案调整抗感染方案, 寻找其它病原体寻找其它病原体,并发症并发症, 其

17、它诊断或者感染部位其它诊断或者感染部位培养培养+ +培养培养+ +培养培养- -1、刘长庭，张进川.现代纤维支气管镜诊断治疗学. 北京：人民军医出版社,(997.24)2、赖国祥,陈学香,赖红兵,等. 解放军医学杂志,2002,27:7303、林航,赖国祥等.临床神经病学杂志,2003,16(6):372-373林航,赖国祥等.临床神经病学杂志,2003,16(6):372-373患者比例%Hendrik Harms,et al. .PLoS ONE 3(5): e2158.P=0.032脑卒中后感染率%Hendrik Harms,et al. www.ploso

18、. PLoS ONE 3(5): e2158.TABLE 1. The Mean/Median Scores and Proportion of Patients With a Score of 30 on FAI for Stroke Unit and General Wards Patients Assessed 5 Years After Stroke*Percentages were calculated from patients alive after 5 years: in the stroke unit (SU) group, 45 patients; in the g