《复杂腹腔感染》课件

复杂腹腔感染浙江省嘉兴市第二医院ICU蔡继明IAI相关指南theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,2002IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；ClinicalInfectiousDiseases2021;50:133–64InfectiousDiseasesSocietyofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.2021;41:279-281腹腔感染(IAI)概述过去一个世纪IAI治疗取得巨大进步，死亡率显著下降90%in1900to23%in2002IAI不同来源感染的死亡率

appendix(0.25%)stomach/duodenum(21%)pancreas(33%)smallbowel(38%)largebowel(45%)biliarytract(50%)JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007IAI定义分类f.M.pieracci,p.S.barie,ManageMentofSevereSepSiSofabdoMinalorigin,ScandinavianJournalofSurgery96:184–196,2007单纯腹腔感染复杂腹腔感染Intra-abdominalinfectionsalsocanbecategorizedasuncomplicatedversuscomplicated,althoughthedistinctionisnotalwaysclearJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007UncomplicatedIAI单纯性腹腔感染仅累及1个器官,而且没有解剖结构的破坏通常病灶可完全切除，仅需预防性使用抗菌药物BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Drugs.2005;65(12):1611-20

复杂腹腔感染(cIAI)复杂腹腔感染(cIAI)通常定义为空腔脏器的内容穿入腹腔导致局限性腹膜炎(包括脓肿)、弥漫性腹膜炎感染源经外科处理后，仍残留细菌，需使用抗感染药物cIAI更多地与不良预后相关，其最大挑战是早期识别JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Drugs.2005;65(12):1611-20

细菌性腹膜炎分类原发性腹膜炎继发性腹膜炎第三型腹膜炎JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007Primarybacterialperitonitis指腹腔没有破口的自发性腹膜炎更多见于婴幼儿、肝硬化及免疫抑制的病人Secondarybacterialperitonitis继发性腹膜炎是肠源细菌通过胃肠道穿孔泄漏入腹腔导致的感染炎症Itmaybecommunity-acquiredorhealthcare–associated.Tertiaryperitonitis原发、继发性腹膜炎经治疗后病症仍持续或48小时后病症复苏常见于有严重合并症或免疫抑制的病人特点:医院获得性感染多为耐药菌可能为肠道菌群易位社区获得性腹腔感染感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔多为革兰氏阴性菌、厌氧菌，较少耐药多为轻中度腹腔感染如有脏器功能不全、免疫抑制的病人那么归为重度腹腔感染医院获得性腹腔感染IDSAcIAI指南的定义该指南排除了肝脾实质的脓疡、泌尿生殖系统来源的感染、后腹膜感染(但除外胰腺感染)2003版指南不拟适用于小于18岁儿童及原发性腹膜炎，2021版作了扩展

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005腹腔感染常见致病菌胃、十二指肠、近端小肠与胆道：革兰阴性或阳性需氧菌或兼性需氧菌远端小肠：不同密度的革兰阴性需氧菌或兼性需氧菌、厌氧菌如脆弱拟杆菌结肠：兼性需氧〔大肠杆菌〕或纯厌氧菌，链球菌、肠球菌亦常见PathogensassociatedwithperitonitisJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007cIAI综合治疗策略液体复苏、感染源控制(ie,surgicaldebridement,drainage,andrepair)、适当系统地抗感染是cIAI治疗成功的主要局部没有感染源的控制，抗生素治疗继发或第三型腹膜炎不可能成功首要的是感染源的控制JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007cIAI如何选择抗生素单药还是联合治疗病人根底状况药物开始治疗时机及疗程给药剂量、频率抗菌谱、相互作用、耐药性之前抗生素的使用情况防止药物毒副作用及诱导耐药社区获得性腹腔感染JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005cIAI危险分层JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007High-severityIAIAdvancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppressionIDSofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.2021;41:279-281氨基糖苷类氨基糖苷类不推荐作为社区获得性腹腔感染的常规治疗(A-1)氨基糖苷类根据局域菌种别离药敏结果,可以是院内获得性腹腔感染的首选.腹腔感染氨基糖苷类的治疗应该个体化(A-1)抗厌氧菌药物药物敏感试验提示Bacteroidesfragilis对以下药物普遍耐药clindamycin,cefotetan,cefoxitin,andquinolones上述药物不能单药治疗B.fragilis第三型及医院获得性腹腔感染耐药菌感染更常见病原体类似于其他院内感染治疗基于局部常见院感菌种及耐药情况院内感染考虑覆盖肠球菌是适宜的抗真菌治疗基于先前抗生素使用情况及根底危险因素JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007MAZUSKIJE,Antimicrobialtreatmentforintra-abdominalinfections.ExpertOpinPharmacother.2007Dec;8(17):2933-45抗肠球菌治疗指征常规抗肠球菌治疗对社区获得性腹腔感染没有必要(A-1)医院获得性腹腔感染需考虑给予覆盖肠球菌的药物(B-3).

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005抗真菌治疗指征

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005何时开始抗感染治疗应当在确诊感染和获得培养结果前疑心IAI的诊断时即开始抗生素治疗抗感染的目标是去除感染病原体、减少复发、缩短感染病症体征消除时间抗生素应该在液体复苏开始后给药，恢复充分的血流灌注使良好的药物分布成为可能。尤其是氨基糖苷类，其肾毒性会因肾灌注缺乏而加重哪些病人需要抗感染治疗创伤或医源性肠损伤致腹腔污染12h内修补的病人(Level1)以及胃肠穿孔24h内修补的病人(Level3)不认为已经合并IAI，仅需给予24h或更短的预防用药炎症病灶能够完全移除的病人如没有穿孔的急性或坏疽性阑尾炎或胆囊炎，或者没有发生穿孔或腹膜炎的肠梗阻或肠坏死，也仅需给予24h或更短的预防用药(Level2)已经合并广泛IAI的上述病人应该给予超过24h的抗感染治疗(Level3).theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,200281.Theadministrationofprophylacticantibioticstopatientswithseverenecrotizingpancreatitispriortothediagnosisofinfectionisnotrecommended(A-I).DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；ClinicalInfectiousDiseases2021;50:133–64抗感染疗程theTherapeuticAgentsCommitteeoftheSurgicalInfection