ICU常见的易发感染的疾病及其诊疗思路-M3-课件

ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料单击此处添加副标题ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料单击此处添加副标题ICU常见的易发感染的疾病及其

诊疗思路JianguoTangTrauma-Emergency-CriticalCareMedicineCenter(T-E-CCMC)你好ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料单击此1ICU常见的易发感染的疾病及其

诊疗思路JianguoTang

Trauma-Emergency-CriticalCareMedicineCenter(T-E-CCMC)ICU常见的易发感染的疾病及其

诊疗思路JianguoTa2内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病3内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病4ICU感染患者感染性疾病诊治感染的预防与控制重症感染入住ICUICU获得感染（ICU-acquiredinfections）ICU内获得性感染的预防与控制感染相关问题是ICU永恒主题ICU工作要点之一是感染ICU感染患者感染性疾病诊治重症感染入住ICUICU内获得575countries1265ICUS13796patients7087(51.4%)infectedpatients9084(71%)receivingantibioticsICUmortalityrate25%(infected)&11%(non-infected)(P<.001)Infectionaccountedfor40%oftotalICUexpenditures75countries6SiteofinfectionSiteofinfection7DistributionofNosocomialInfectionsbySiteinMedical-SurgicalICUinUSInfectControlHospEpidemiol2000;21:510-515.

83%ofepisodesofnosocomialpneumoniawereassociatedwithMV25%VAP27%VAPDistributionofNosocomialInf8ICU常见的易发感染的疾病Pneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)SkinandwoundinfectionSinusitisGastrointestinalinfection(oftenwithClostridiumdifficile)ICU常见的易发感染的疾病Pneumonia(often9内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病10ICU感染的病原学细菌(G+;G-;厌氧菌)不典型细菌真菌病毒etc…ICU感染的病原学细菌(G+;G-;厌氧菌)11Mohnarin2019ICU&Non-ICU非ICUICU病原菌%病原菌%大肠埃希菌19.4鲍氏不动杆菌20.7肺炎克雷伯菌11.9铜绿假单胞菌

13.3铜绿假单胞菌

11.8肺炎克雷伯菌11.2金黄色葡萄球菌9.7金黄色葡萄球菌9.8鲍氏不动杆菌8.8大肠埃希菌7.8阴沟肠杆菌3.6嗜麦芽寡养单胞菌5表皮葡萄球菌3.3屎肠球菌4屎肠球菌3.1表皮葡萄球菌3粪肠球菌2.8洋葱伯克霍尔德菌2.8嗜麦芽寡养单胞菌2.4阴沟肠杆菌2.2Mohnarin2019ICU&Non-ICU非IC12ICU常见的易发感染的疾病及其诊疗思路-M3-课件1318ICUs18-monthstudy105episodesIFIsoccurredin5,561PatientsCandida:16.5cases/1,000admissionsFilamentousfungi:2.3cases/1,000admissionsFilamentousfungi:mainlyinvasivepulmonaryaspergillosis18ICUsFilamentousfungi:main14SEMINARSINRESPIRATORYANDCRITICALCAREMEDICINE.2019.31(1):79-86SEMINARSINRESPIRATORYANDCR15JournalofIntensiveCareMedicine.2019,25(2):78-92JournalofIntensiveCareMedi16ClinicalInfectiousDiseases.2019,45:205-216ClinicalInfectiousDiseases.217MainpathogensinICUEEnterococcusfaeciumE

E.coliSStaphylococcusaureusKKlebsiellapneumoniaeAAcinetobacterbaumaniiPPseudomonasaeruginosaEEnterobacterspeciesS

StenotrophomonasmaltophiliaACandidaalbican;AspergillosisESKAPESEAESKAPE2球菌+2真菌+3肠杆菌科+3非发酵菌Badbugs，NoDrugsNoESKAPEMainpathogensinICUEEnter18

大肠埃希菌ESBL+肺炎克雷伯菌ESBL+

非ICUICU非ICUICU200965.573.84564.1201968.668.541.979201971.9/48.2/

MRSAMRSCoN

非ICUICU非ICUICU200954.372.48095.4201948.979.464.273.9201947.978.982.290.4Mohnarin2009-2019ICU&Non-ICU大肠埃希菌ESBL+肺炎克雷伯菌ESBL+非ICU19Mohnarin2019ICU&Non-ICU

铜绿假单胞菌体外药敏比较Mohnarin2019ICU&Non-ICU

铜绿20Mohnarin2019ICU&Non-ICU

鲍氏不动杆菌体外药敏比较Mohnarin2019ICU&Non-ICU

鲍氏21ICU获得性感染病原特征G-60-65%;G+35-40%;Fungal15-25%SEAESKAPEICU:non-fermentingAntimicrobial-ResistanceorganismsinICUICU获得性感染病原特征G-60-65%;G+22内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病23ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne24CausesofVAPRespirCare.2019,50(6):742–763CausesofVAPRespirCare.2019,25中国16家大型教学医院HAP临床调查(599例分离到694株菌)病原菌菌株数%病例数Sort鲍曼不动杆菌17529.221铜绿假单胞菌12520.872金黄色葡萄球菌7712.853肺炎克雷伯杆菌589.684白色念珠菌355.845嗜麦芽窄食单胞菌274.516大肠埃希菌203.347阴沟肠杆菌132.178醋酸钙不动杆菌40.6720其他不动杆菌属81.3412不动杆菌属占所有病例数31.23%；占总GNB的38.56%中国16家大型教学医院HAP临床调查(599例分离到694株26致病原分离情况

早发性HAPvs迟发性HAP致病原分离情况

早发性HAPvs迟发性HAP27ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne28KoreanJUrol.2019;54:59-65KoreanJUrol.2019;54:59-6529ESBL53.1%ESBL37.5%ESBL53.1%ESBL37.5%30ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne31ClinicalInfectiousDiseases2019;39:309–172019-2019Nosocomialbloodstreamisolates(SCOPEStudy)ClinicalInfectiousDiseases232ClinicalInfectiousDiseases2019;39:309–17NosocomialBloodstreamIsolates(SCOPEStudy)9.8%23.2%67.0%ClinicalInfectiousDiseases233ICU常见的易发感染的疾病及其诊疗思路-M3-课件34ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne35MicrobiologyofPeritonitis1.LarocheM,HardingG.EurJClinMicrobiolInfectDis.2019;17:542-550.2.BariePS.JChemother.2019;11:464-477.B.fragilisgroupClostridiumspp.EnterococciS.EpidermidisMRSAPseudomonas+A.baumanniiCandidaB.fragilisgroupClostridiumspp.

E.coliKlebsiellaspp.StreptococcusEnterococcusspp.CandidaE.coliKlebsiellaspp.Streptococcusspp.Tertiary(Polymicrobial)2Secondary(Polymicrobial)1,2Primary(Monomicrobial)1S.anginosus©Copyright2019gbf.de/AllrightsreservedE.coli©Copyright2019cmsp/AllrightsreservedB.fragilis©Copyright2019cmsp/AllrightsreservedS.epidermidis©Copyright2019cmsp/AllrightsreservedMicrobiologyofPeritonitis1.36最初1-4周病原特征最初1-4周病原特征37MicrobiologyofCA&HCA-IAI1.LarocheM,HardingG.EurJClinMicrobiolInfectDis.2019;17:542-550.2.BariePS.JChemother.2019;11:464-477.Enterobacterspp.Pseudomonas+A.baumanniiEnterococcusspp.MRSACandidaE.coliStreptococcusHCA/HA-IAICA-IAIS.anginosus©Copyright2019gbf.de/AllrightsreservedE.coli©Copyright2019cmsp/AllrightsreservedB.fragilis©Copyright2019cmsp/AllrightsreservedS.epidermidis©Copyright2019cmsp/AllrightsreservedMicrobiologyofCA&HCA-IAI38ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)

非发酵菌、金葡菌、肠杆菌科Catheter-associatedurinarytractinfection(UTI)

ESBL+肠杆菌科、肠球菌、念珠菌Bloodstreaminfection(BSI)

G+、G-、念珠菌Intra-abdominalinfection(IAI)

继发/第三类型/院内：非发酵/肠杆菌科、肠球菌、念珠菌ThepathogensofcommonHAIPne39内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病40ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略不同耐药菌抗生素选择策略ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略41MDR(多)-XDR(泛)-PDR(全)MDR

isdefinedasnon-susceptibilitytoatleastoneagentin3ormoreantimicrobialcategories[allpenicillinsandcephalosporins(includinginhibitorcombinations),fluroquinolones,andaminoglycosidesXDRisdefinedasnon-susceptibilitytoatleast1agentinallbut2orfewerantimicrobialcategories(i.e.bacterialisolatesremainsusceptibletoonlyoneortwocategories).PDRisdefinedasnon-susceptibilitytoallagentsinallantimicrobialcategories(i.e.noagentstestedassusceptibleforthatorganism)JGlobInfectDis.2019Sep–Dec;2(3):291–304MDR(多)-XDR(泛)-PDR(全)MDRisdef42耐药机制酶：水解酶或钝化酶或修饰酶靶位改变(如核糖体和核蛋白)(Targetalteration)：点发生突变使抗生素无法结合发挥作用或被修饰使之与抗生素的结合不紧密主动外排泵机制(Effluxpumps)

细菌细胞膜膜孔蛋白发生改变(Outermembraneporins:OMP)

细菌菌膜(Biofilm)的形成，使抗生素无法进入胞内的耐药机制耐药机制酶：水解酶或钝化酶或修饰酶43水解酶或钝化酶

NEnglJMed.2019;362:1804-13水解酶或钝化酶

NEnglJMed.2019;344膜孔蛋白

NEnglJMed.2019;362:1804-13膜孔蛋白

NEnglJMed.2019;362:45靶位改变

NEnglJMed.2019;362:1804-13PBP靶位改变

NEnglJMed.2019;362:46外排泵

NEnglJMed.2019;362:1804-13外排泵

NEnglJMed.2019;362:1471940s2000sPenicillinsNarrow-spectrumcephemsExpanded-spectrumcephemsCarbapenemsAmpC-typeβ-lactamasesExtended-spectrumβ-lactamases(ESBLs)CarbapenemasesPenicillinasesBroad-spectrumβ-lactamases水解酶或钝化酶b-lactamase1940s2000sPenicillinsNarrow-sp48β-LactamasesandantibioticsKoreanjinternmed.2019,27:128-242A类B类D类?β-LactamasesandantibioticsKo49β-Lactamasesandantibioticsβ-LactamasesOptionsESBLß-lactam/ß-lactamaseinhibitorCarbapenemsColistin

Tigecyclline

Amikacin？

Fosfomycin？CefamycinsAmpC4-generationcephalosporinsCarbapenemasesCeftazidime(Dcategories)？

Aztreonam(BcategoriesOXA)？β-Lactamasesandantibioticsβ-50ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略不同耐药菌抗生素选择策略ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略51感染？病原菌G+orG-orFungalG+G-肠杆菌科非发酵菌耐药评估、危险因素评估严重程度感染部位？FungalCandidaAspergillosisStaphyl-ococcusEntero-coccusLocalecology感染？病原菌G+orG-orFung52感染？病原菌G+orG-orFungalG+G-肠杆菌科非发酵菌耐药评估、危险因素评估严重程度感染部位？FungalCandidaAspergillosisStaphyl-ococcusEntero-coccus感染？病原菌G+orG-orFung53Makeyourempiricalantibioticsmoreappropriated

-肠杆菌科头霉素、磷霉素、阿米卡星、替加环素、多粘菌素？Makeyourempiricalantibiotic54NEnglJMed.2019,362;1804-13NEnglJMed.2019,362;1804-155碳青霉烯不敏感肠杆菌科体外药敏实验MarianaC,etal.AAC.2019:570-573碳青霉烯不敏感肠杆菌科MarianaC,etal.56Makeyourempiricalantibioticsmoreappropriated

-

PDR-肺克/大肠多粘菌素替加环素亚胺培南/美洛培南剂量/输注时间磷霉素利福平氟喹诺酮氨基糖苷米诺环素、多西环素

联合用药替加环素+多粘菌素替加环素+磷霉素替加环素+氨基糖苷类碳青霉烯类+氨基糖苷类碳青霉烯类+多粘菌素碳青霉烯类+喹诺酮类Makeyourempiricalantibiotic57感染？病原菌G+orG-orFungalG+G-肠杆菌科非发酵菌耐药评估、危险因素评估严重程度感染部位？FungalCandidaAspergillosisStaphyl-ococcusEntero-coccusMDR/XDR/PDR?CRPA?CRAB?感染？病原菌G+orG-orFung58Makeyourempiricalantibioticsmoreappropriated

-非发酵菌MDR/XDR/PDR?CRPA?CRAB?Makeyourempiricalantibiotic59Makeyourempiricalantibioticsmoreappropriated

-非发酵菌-铜绿假单胞菌抗假单胞菌青霉素类哌拉西林/他唑巴坦、哌拉西林、替卡西林/克拉维酸抗假单胞菌头孢菌素类头孢哌酮/舒巴坦、头孢他啶、头孢吡肟、头孢哌酮、氨曲南碳青霉烯类美罗培南、亚胺培南氨基糖苷类阿米卡星、妥布霉素、庆大霉素氟喹诺酮类环丙沙星、左氧氟沙星

-磷霉素

-其他抗生素：多粘菌素B\E多为联合或上述药过敏而选用厄他培南：对非发酵菌无效；替加环素：对铜绿无效Makeyourempiricalantibiotic60Makeyourempiricalantibioticsmoreappropriated

-非发酵菌-鲍曼不动杆菌CurrentOpinioninInfectiousDiseases2019,23:332–339Makeyourempiricalantibiotic61NEnglJMed.2019,362;1804-13CRAB:ColistinSulbactam6g/dayIncreaseto9g/dayTigecyclineMeropenam1-2g3hq8hImipenam.5-1g3hq8h+rifampin/minocycline/doxycycline/azithromycinNEnglJMed.2019,362;1804-162药物方案剂量（菌株及严重程度）舒巴坦单用/联合4g/d，可增至6~8g，分3~4次（国外）头胞哌酮/舒巴坦单用/联合3g（2:1）q8h或q6h碳青霉烯类单用/联合IMP或MP1gq8h或q6hCNS中MP可加至2gq8h多西环素联合100mgq12h静脉或口服氨基糖苷类（丁卡）联合15~20mg/kg/d（国外）0.6/d（国内）严重感染且肾功能正常加至0.8/d多粘菌素E联合2.5~5mg/kg/d或200~400万u，分2~4次替加环素联合100mg首剂，以后50mgq12h2019年《中国鲍曼不动杆菌感染诊治与防控专家共识》Makeyourempiricalantibioticsmoreappropriated

-非发酵菌-鲍曼不动杆菌药物方案剂量（菌株及严重程63Makeyourempiricalantibioticsmoreappropriated

-非发酵菌-鲍曼不动杆菌Makeyourempiricalantibiotic64感染？病原菌G+orG-orFungalG+G-肠杆菌科非发酵菌耐药评估、危险因素评估严重程度感染部位？FungalCandidaAspergillosisStaphyl-ococcusEntero-coccus感染？病原菌G+orG-orFung65Expandedoff-labelindicationsofnewestantimicrobialagentsforresistantGPCDrugSSTIUTIBSIHAP/CAPIEB/JIEye/CNSIAANotesLinezolid√√E.F√

NotCR-BSIDaptomycin√⊙√X√XNotPneu↓CSFTigecycline√?⊙X√CAP⊙X√NotHAP(esp.VAP)Serumcon?CSF?TeicoplaninX↓CSFVancomycin√√√√√√√IDSA√VREMICCreepExpandedoff-labelindications66感染？病原菌G+orG-orFungalG+G-肠杆菌科非发酵菌耐药评估、危险因素评估严重程度感染部位？FungalCandidaAspergillosisStaphyl-ococcusEntero-coccus感染？病原菌G+orG-orFung67MayoClinProc.2019;86(8):805-817MayoClinProc.2019;86(8):80568InvasiveCandidiasisInvasiveCandidiasis69ICU常见的易发感染的疾病及其诊疗思路-M3-课件70ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略

ESBL/AmpC/Carbapenemases不同耐药菌抗生素选择策略肠杆菌科非发酵菌：铜绿/鲍曼

G+FungalCandida/aspergillosisICU常见感染抗生素选择策略细菌耐药与抗生素选择策略71内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病72AntimicrobialtherapyforsevereHAIGetitrightthefirsttimeHithardupfrontBroad-spectrumantibiotics(appropriatespectrum)Shortperiod/durationDe-escalationorstoppedPk-PdindividualizationAntimicrobialtherapyforseve73IndicationsandbesttimingforstartingantibiotictherapyEmergentUrgentDelayedIndicationsandbesttimingfo74AntimicrobialtherapyforsevereHAIGetitrightthefirsttimeHithardupfrontBroad-spectrumantibiotics(appropriatespectrum)Shortperiod/durationDe-escalationorstoppedPk-PdindividualizationAntimicrobialtherapyforseve75MakeyourempiricalantibioticsmoreappropriatedHostcharacteristicsThesiteofinfectionKnowledgeoflocalecologyTheseverityofthediseaseMakeyourempiricalantibiotic76MDR?Severity?CoverG+?Antifungal?De-escalation?Fungal?MDR?Severity?CoverG+?De-escal77AntimicrobialtherapyforsevereHAIGetitrightthefirsttimeHithardupfrontBroad-spectrumantibiotics(appropriatespectrum)

Shortperiod/duration

（8d&15d）

De-escalationorstoppedPk-PdindividualizationAntimicrobialtherapyforseve78PredetermineddurationofantibiotictherapybyIDSAguidelinesPredetermineddurationofanti79AntimicrobialtherapyforsevereHAIGetitrightthefirsttimeHithardupfrontBroad-spectrumantibiotics(appropriatespectrum)

Shortperiod/durationDe-escalationorstoppedPk-PdindividualizationAntimicrobialtherapyforseve80Algorithmforde-escalationdecision-makingatday3inanimprovingpatientCritCareClin.2019,27:149-162Algorithmforde-escalationde81CritCareClin.2019,27:149-162CritCareClin.2019,27:14982AntimicrobialtherapyforsevereHAIGetitrightthefirsttimeHithardupfrontBroad-spectrumantibiotics(appropriatespectrum)

Shortperiod/durationDe-escalationorstoppedPk-PdindividualizationAntimicrobialtherapyforseve83InterrelationshipamongPk-PdVargheseJM,etal.CritCareClin.2019,27:19-34InterrelationshipamongPk-PdV84Pk&PdparametersofantibioticsonaC-TcurveRobertsJA,etal.Pharmacokineticissuesforantibioticsinthecriticallyillpatient.CritCareMed.2009,37:840-851.Pk&Pdparametersofantibio85Pharmacodynamic

propertiesRobertsJA,etal.Pharmacokineticissuesforantibioticsinthecriticallyillpatient.CritCareMed.2009,37:840-851.KillcharacteristicsT-DT-D(moderate-prolongedT1/2orPAE)C-DC-D(moderate-prolongedT1/2orPAE)Antibioticsβ-lactamsCarbapenemsAztrecnamErythromycinClarithromycinLincosamidesClindamycinLinezolidTigecyclineLinezolidQuinupristin/dalfopristinAzithromycinTetracyclinesGlycopeptidesTigecyclineAminoglycosideMetronidazoleTelithromycinDaptomycinColistinFluoroquinolonDaptomycinPk-PdT>MICAUC/MICCmax/MICAUC/MICT-D:Time-dependent;C-D:Concentration-dependentPharmacodynamicpropertiesRobe86Pk-PdofnewestantimicrobialagentsforresistantGPCDrugClassDosageEliminationDoseadjustmentProteinbindingT1/2VdLinezolidOxazolidinone600mg12hH65%Non-enzyme30%(R)NDoseafterDialysis31%4-6h0.8L/kg(40-50L)TigecyclineGlycylcyclines100mgIV,50mgq12hBiliary60%R20-40%(Unchanged)H-Y71-89%36h10L/kgDaptomycin

Lipopeptide4–6mg,-10mg/kgqdR78%R-Y92%8-9h0.1L/kgVancomycinGlycopeptide15-20mg/kgIVq8-12hR80-90%R-Y10-55%(30%)4-8h0.3L/kgTeicoplaninGlycopeptide4-6mg/kgIVq12h*34-6mg/kgqdR80%R-Y90-95%70-100h0.6L/kgPk-Pdofnewestantimicrobial87Pk-PdofnewestantimicrobialagentsforresistantGPCDrugT1/2PAETime/ConcentrationPK/PDPK/PDPK/PDLinezolid4-6hProlongedTAUICT>MICAUIC:80-120T>MIC40%:Pneumococci85%:Severeinfection1Tigecycline36hProlongedTAUICT>MICAUIC>17.9:cSSTIAUIC>6.96:cIAIT>MIC>50%Daptomycin8-9hProlongedCAUICCmax/MICAUIC189(Free)Cmax/MIC:2-4bacteriocidalVancomycin4-8hProlongedTAUICAUIC400Troughlevel:15-20mg/LTeicoplanin70-100hProlongedTAUICAUIC125:Troughlevel>10mg/LAUIC350:Troughlevel>20mg/L1.Bacteraemia,LRTI,skinandskinstructureinfectionPk-Pdofnewestantimicrobial88抗真菌药物的Pk-PdMayoClinProc.2019;86(8):805-817抗真菌药物的Pk-PdMayoClinProc.20189抗真菌药物的Pk-PdM.sinnollareddy,etal.IntJAntimicrobAgents(2019),doi:10.1016抗真菌药物的Pk-PdM.sinnollareddy,e90Pk-PdofAntifungalAgentsPk-PdofAntifungalAgents91ICU常见的易发感染的疾病及其诊疗思路-M3-课件92β-lactams;Carbapenems增加单次给药量、给药频率、延长输注时间（Extended/prolongedinfusion）；持续输注（continuousinfusion）能够使抗生素血清浓度更大限度保持于MIC值之上，更有利于发挥抗生素的抗菌活性，保证临床疗效。β-lactams;Carbapenems增加单次给药量、93ICU常见的易发感染的疾病及其诊疗思路-M3-课件94ICU常见的易发感染的疾病及其诊疗思路-M3-课件95ICU常见的易发感染的疾病及其诊疗思路-M3-课件96PkchangesincriticallyillpatientsPkchangesincriticallyillp97ICU常见感染抗生素应用要点GetitrightthefirsttimeHithardupfrontBroad-spectrumantibiotics(appropriatespectrum)Shortperiod/durationDe-escalationorstoppedPk-PdindividualizationICU常见感染抗生素应用要点Getitrightthe98内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病99谢谢观看共同学习相互提高谢谢观看共同学习相互提高100ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料单击此处添加副标题ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料单击此处添加副标题ICU常见的易发感染的疾病及其

诊疗思路JianguoTangTrauma-Emergency-CriticalCareMedicineCenter(T-E-CCMC)你好ICU常见的易发感染的疾病及其诊疗思路-M3-文档资料单击此101ICU常见的易发感染的疾病及其

诊疗思路JianguoTang

Trauma-Emergency-CriticalCareMedicineCenter(T-E-CCMC)ICU常见的易发感染的疾病及其

诊疗思路JianguoTa102内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病103内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病104ICU感染患者感染性疾病诊治感染的预防与控制重症感染入住ICUICU获得感染（ICU-acquiredinfections）ICU内获得性感染的预防与控制感染相关问题是ICU永恒主题ICU工作要点之一是感染ICU感染患者感染性疾病诊治重症感染入住ICUICU内获得10575countries1265ICUS13796patients7087(51.4%)infectedpatients9084(71%)receivingantibioticsICUmortalityrate25%(infected)&11%(non-infected)(P<.001)Infectionaccountedfor40%oftotalICUexpenditures75countries106SiteofinfectionSiteofinfection107DistributionofNosocomialInfectionsbySiteinMedical-SurgicalICUinUSInfectControlHospEpidemiol2000;21:510-515.

83%ofepisodesofnosocomialpneumoniawereassociatedwithMV25%VAP27%VAPDistributionofNosocomialInf108ICU常见的易发感染的疾病Pneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)SkinandwoundinfectionSinusitisGastrointestinalinfection(oftenwithClostridiumdifficile)ICU常见的易发感染的疾病Pneumonia(often109内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病110ICU感染的病原学细菌(G+;G-;厌氧菌)不典型细菌真菌病毒etc…ICU感染的病原学细菌(G+;G-;厌氧菌)111Mohnarin2019ICU&Non-ICU非ICUICU病原菌%病原菌%大肠埃希菌19.4鲍氏不动杆菌20.7肺炎克雷伯菌11.9铜绿假单胞菌

13.3铜绿假单胞菌

11.8肺炎克雷伯菌11.2金黄色葡萄球菌9.7金黄色葡萄球菌9.8鲍氏不动杆菌8.8大肠埃希菌7.8阴沟肠杆菌3.6嗜麦芽寡养单胞菌5表皮葡萄球菌3.3屎肠球菌4屎肠球菌3.1表皮葡萄球菌3粪肠球菌2.8洋葱伯克霍尔德菌2.8嗜麦芽寡养单胞菌2.4阴沟肠杆菌2.2Mohnarin2019ICU&Non-ICU非IC112ICU常见的易发感染的疾病及其诊疗思路-M3-课件11318ICUs18-monthstudy105episodesIFIsoccurredin5,561PatientsCandida:16.5cases/1,000admissionsFilamentousfungi:2.3cases/1,000admissionsFilamentousfungi:mainlyinvasivepulmonaryaspergillosis18ICUsFilamentousfungi:main114SEMINARSINRESPIRATORYANDCRITICALCAREMEDICINE.2019.31(1):79-86SEMINARSINRESPIRATORYANDCR115JournalofIntensiveCareMedicine.2019,25(2):78-92JournalofIntensiveCareMedi116ClinicalInfectiousDiseases.2019,45:205-216ClinicalInfectiousDiseases.2117MainpathogensinICUEEnterococcusfaeciumE

E.coliSStaphylococcusaureusKKlebsiellapneumoniaeAAcinetobacterbaumaniiPPseudomonasaeruginosaEEnterobacterspeciesS

StenotrophomonasmaltophiliaACandidaalbican;AspergillosisESKAPESEAESKAPE2球菌+2真菌+3肠杆菌科+3非发酵菌Badbugs，NoDrugsNoESKAPEMainpathogensinICUEEnter118

大肠埃希菌ESBL+肺炎克雷伯菌ESBL+

非ICUICU非ICUICU200965.573.84564.1201968.668.541.979201971.9/48.2/

MRSAMRSCoN

非ICUICU非ICUICU200954.372.48095.4201948.979.464.273.9201947.978.982.290.4Mohnarin2009-2019ICU&Non-ICU大肠埃希菌ESBL+肺炎克雷伯菌ESBL+非ICU119Mohnarin2019ICU&Non-ICU

铜绿假单胞菌体外药敏比较Mohnarin2019ICU&Non-ICU

铜绿120Mohnarin2019ICU&Non-ICU

鲍氏不动杆菌体外药敏比较Mohnarin2019ICU&Non-ICU

鲍氏121ICU获得性感染病原特征G-60-65%;G+35-40%;Fungal15-25%SEAESKAPEICU:non-fermentingAntimicrobial-ResistanceorganismsinICUICU获得性感染病原特征G-60-65%;G+122内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病123ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne124CausesofVAPRespirCare.2019,50(6):742–763CausesofVAPRespirCare.2019,125中国16家大型教学医院HAP临床调查(599例分离到694株菌)病原菌菌株数%病例数Sort鲍曼不动杆菌17529.221铜绿假单胞菌12520.872金黄色葡萄球菌7712.853肺炎克雷伯杆菌589.684白色念珠菌355.845嗜麦芽窄食单胞菌274.516大肠埃希菌203.347阴沟肠杆菌132.178醋酸钙不动杆菌40.6720其他不动杆菌属81.3412不动杆菌属占所有病例数31.23%；占总GNB的38.56%中国16家大型教学医院HAP临床调查(599例分离到694株126致病原分离情况

早发性HAPvs迟发性HAP致病原分离情况

早发性HAPvs迟发性HAP127ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne128KoreanJUrol.2019;54:59-65KoreanJUrol.2019;54:59-65129ESBL53.1%ESBL37.5%ESBL53.1%ESBL37.5%130ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne131ClinicalInfectiousDiseases2019;39:309–172019-2019Nosocomialbloodstreamisolates(SCOPEStudy)ClinicalInfectiousDiseases2132ClinicalInfectiousDiseases2019;39:309–17NosocomialBloodstreamIsolates(SCOPEStudy)9.8%23.2%67.0%ClinicalInfectiousDiseases2133ICU常见的易发感染的疾病及其诊疗思路-M3-课件134ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)Catheter-associatedurinarytractinfection(UTI)Bloodstreaminfection(BSI)Intra-abdominalinfection(IAI)ThepathogensofcommonHAIPne135MicrobiologyofPeritonitis1.LarocheM,HardingG.EurJClinMicrobiolInfectDis.2019;17:542-550.2.BariePS.JChemother.2019;11:464-477.B.fragilisgroupClostridiumspp.EnterococciS.EpidermidisMRSAPseudomonas+A.baumanniiCandidaB.fragilisgroupClostridiumspp.

E.coliKlebsiellaspp.StreptococcusEnterococcusspp.CandidaE.coliKlebsiellaspp.Streptococcusspp.Tertiary(Polymicrobial)2Secondary(Polymicrobial)1,2Primary(Monomicrobial)1S.anginosus©Copyright2019gbf.de/AllrightsreservedE.coli©Copyright2019cmsp/AllrightsreservedB.fragilis©Copyright2019cmsp/AllrightsreservedS.epidermidis©Copyright2019cmsp/AllrightsreservedMicrobiologyofPeritonitis1.136最初1-4周病原特征最初1-4周病原特征137MicrobiologyofCA&HCA-IAI1.LarocheM,HardingG.EurJClinMicrobiolInfectDis.2019;17:542-550.2.BariePS.JChemother.2019;11:464-477.Enterobacterspp.Pseudomonas+A.baumanniiEnterococcusspp.MRSACandidaE.coliStreptococcusHCA/HA-IAICA-IAIS.anginosus©Copyright2019gbf.de/AllrightsreservedE.coli©Copyright2019cmsp/AllrightsreservedB.fragilis©Copyright2019cmsp/AllrightsreservedS.epidermidis©Copyright2019cmsp/AllrightsreservedMicrobiologyofCA&HCA-IAI138ThepathogensofcommonHAIPneumonia(oftenventilator-associatedpneumonia,VAP)

非发酵菌、金葡菌、肠杆菌科Catheter-associatedurinarytractinfection(UTI)

ESBL+肠杆菌科、肠球菌、念珠菌Bloodstreaminfection(BSI)

G+、G-、念珠菌Intra-abdominalinfection(IAI)

继发/第三类型/院内：非发酵/肠杆菌科、肠球菌、念珠菌ThepathogensofcommonHAIPne139内容提要ICU常见的易发感染的疾病ICU获得性感染病原特征ICU常见的易发感染病原学ICU常见感染抗生素选择策略ICU常见感染抗生素应用要点内容提要ICU常见的易发感染的疾病140ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略不同耐药菌抗生素选择策略ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略141MDR(多)-XDR(泛)-PDR(全)MDR

isdefinedasnon-susceptibilitytoatleastoneagentin3ormoreantimicrobialcategories[allpenicillinsandcephalosporins(includinginhibitorcombinations),fluroquinolones,andaminoglycosidesXDRisdefinedasnon-susceptibilitytoatleast1agentinallbut2orfewerantimicrobialcategories(i.e.bacterialisolatesremainsusceptibletoonlyoneortwocategories).PDRisdefinedasnon-susceptibilitytoallagentsinallantimicrobialcategories(i.e.noagentstestedassusceptibleforthatorganism)JGlobInfectDis.2019Sep–Dec;2(3):291–304MDR(多)-XDR(泛)-PDR(全)MDRisdef142耐药机制酶：水解酶或钝化酶或修饰酶靶位改变(如核糖体和核蛋白)(Targetalteration)：点发生突变使抗生素无法结合发挥作用或被修饰使之与抗生素的结合不紧密主动外排泵机制(Effluxpumps)

细菌细胞膜膜孔蛋白发生改变(Outermembraneporins:OMP)

细菌菌膜(Biofilm)的形成，使抗生素无法进入胞内的耐药机制耐药机制酶：水解酶或钝化酶或修饰酶143水解酶或钝化酶

NEnglJMed.2019;362:1804-13水解酶或钝化酶

NEnglJMed.2019;3144膜孔蛋白

NEnglJMed.2019;362:1804-13膜孔蛋白

NEnglJMed.2019;362:145靶位改变

NEnglJMed.2019;362:1804-13PBP靶位改变

NEnglJMed.2019;362:146外排泵

NEnglJMed.2019;362:1804-13外排泵

NEnglJMed.2019;362:11471940s2000sPenicillinsNarrow-spectrumcephemsExpanded-spectrumcephemsCarbapenemsAmpC-typeβ-lactamasesExtended-spectrumβ-lactamases(ESBLs)CarbapenemasesPenicillinasesBroad-spectrumβ-lactamases水解酶或钝化酶b-lactamase1940s2000sPenicillinsNarrow-sp148β-Lactamasesandantibioti