医院获得性肺炎如何理解培养结果.ppt

,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,医院获得性肺炎,:,如何理解培养结果,医院获得性肺炎,:BALF,定量培养,试验设计,:,多中心随机临床试验,入选标准,:,免疫功能正常的成年患者,住,ICU,超过,4,天后怀疑呼吸机相关性肺炎,排除标准,假单胞菌属或,MRSA,定植或感染,分组,:,诊断,:BALF,定量培养,vs.ETA,的非定量培养,治疗,:,美罗培南,+,环丙沙星,vs.,美罗培南,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,医院获得性肺炎,:BALF,定量培养,2531,筛选患者,1387,不合格患者,1144,合格患者,740,入选患者,404,未入选患者,不同意,无家属在场,未找到患者,原因未知,已开始针对,VAP,的其他抗生素治疗,18,患者需要进行纤维支气管镜检查,其他原因,医生拒绝入选,2,无人行纤维支气管镜检查,375 ETA,365 BAL,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,医院获得性肺炎,:BALF,定量培养,ETA(n=374),BAL(n=365),合计,(n=739),明确,VAP,0,1(0.3),1(0.1),高度可疑,VAP,0,180(49.3),180(24.4),可能,VAP,310(82.9),134(36.7),444(60.1),无,VAP,64(17.1),50(13.7),114(15.4),高度可疑,VAP=,临床诊断,+BALF 10,4,cfu/ml;,可能,VAP=,临床诊断,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,医院获得性肺炎,:BALF,定量培养,ETA,BAL,P,值,28,天病死率,18.4%,18.9%,0.94,6,天时针对性治疗,74.6%,74.2%,0.90,无抗生素存活天数,10.6,7.9,10.4,7.5,0.86,最高,MODS,评分,8.6,4.0,8.3,3.6,0.26,The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630,医院获得性肺炎,:BALF,定量培养,研究的局限性,仅,29.2%(740/2531),的筛选患者入选,40%,的筛选患者因存在耐药细菌感染或定植而被排除,BAL,有助于降阶梯治疗或停用抗生素治疗,(,对耐药细菌感染或定植的高危患者意义更为显著,),Kollef MH.Diagnosis of ventilator-associated pneumonia.N Engl J Med 2006;355:2691-2693,医院获得性肺炎,最常见的,ICU,获得性感染,罹患率及病死率最高,40 80%,住院死亡患者中约,15%,直接与医院获得性肺炎有关,1/3 1/2=,归因死亡率,医院获得性肺炎,定义,住院,48,小时后发生的肺炎,ICU,患者,普通病房患者,机械通气患者肺炎危险性,接受机械通气患者的,7 40%,医院获得性肺炎,患病率,所有住院患者,0.6,例,/100,名住院患者,NNIS,ICU,患者,8 20%,9.6%(967/10038)EPIC,8.9%,欧洲医院获得性肺炎协作组,医院获得性肺炎,临床诊断,发热,白细胞升高,脓性分泌物,胸片新出现的浸润影,呼吸机相关性肺炎,临床诊断,满足临床诊断标准,(n=50),发热病因明确,(n=45),感染性,(n=37),非感染性,(n=8),肺炎,(n=19),鼻窦炎，导管感染,泌尿系感染,(n=14),念珠菌血症,胆囊炎,脓胸，腹膜炎,肺动脉栓塞,(n=6),肺外,(n=2),合并感染,(n=14),合并感染,(n=11),合并感染,(n=0),纤维增殖,(n=5),化学吸入,(n=1),胰腺炎,(n=1),药物热,(n=1),Meduri GU,et al.Chest 1994;106:221,气管内吸取物定量培养的诊断价值,阈值,(cfu/mL),敏感性,%,特异性,%,准确率,%,10,3,86,52,61,10,4,71,57,61,10,5,71,88,75,10,6,71,86,82,10,7,43,95,82,谁在进行下呼吸道标本的定量培养,?,单纯经纤维支气管镜,进行下呼吸道标本采样,没有意义,临床医师如何理解培养结果,痰培养阳性是否均为致病菌,痰培养阴性是否提示无感染,革兰染色是否有助于鉴定致病菌,痰培养阴性是否可以停用抗生素,平时培养结果是否有助于抗生素的选择,假设,1,接受机械通气患者下呼吸道标本培养出的细菌即为致病菌,长期机械通气患者下呼吸道的细菌定植,目的,:,检查接受长期机械通气患者肺泡内细菌负荷,背景,:,大学医院及长期护理院的呼吸监护病房,患者,:,接受长期机械通气且没有肺炎临床表现的,14,名患者,指标,:,右中叶及舌叶,BALF,的定量培养,结果,:,在进行检查的,32,个肺叶中的,29,个,至少有一种微生物定量培养,10,4,cfu/mL.,多数肺叶有多种微生物生长,Baram D,Hulse G,Palmer LB.Stable Patients Receiving Prolonged Mechanical Ventilation Have a High Alveolar Burden of Bacteria.Chest 2005;127:1353-1357,机械通气患者的细菌定植,(n=356),Bouza E,Prez A,Muoz P,et al.Ventilator-associated pneumonia after heart surgery:A prospective analysis and the value of surveillance.Crit Care Med 2003;31:1964 1970.,气管支气管炎的提示,临床表现,发热,脓性气管分泌物,气管分泌物培养大量致病菌,肺部浸润影,肺炎本身，而非上述临床表现与患者预后不良相关,下呼吸道分离出念珠菌的意义,25,名非粒细胞缺乏的机械通气,(72 h),患者,去世后立即进行肺活检,去世后立即进行下呼吸道采样,气道内吸取物,保护性毛刷,PSB,肺泡支气管灌洗,BAL,盲目活检,平均每例患者,14,块组织,双侧纤维支气管镜指导下活检,每例患者,2,块组织,肺组织标本的组织学检查,呼吸道标本区分为念珠菌阳性及其他,el Ebiary M,Torres A,Fabregas N,et al.Significance of the isolation of Candida species from respiratory samples in critically ill,non-neutropenic patients:an immediate postmortem histologic study.Am J Respir Crit Care Med 1997;156:583-590,下呼吸道分离出念珠菌的意义,25,名非粒细胞缺乏的机械通气患者,(72 h),去世后立即进行尸体解剖,并采取下呼吸道标本,el Ebiary M,Torres A,Fabregas N,et al.Significance of the isolation of Candida species from respiratory samples in critically ill,non-neutropenic patients:an immediate postmortem histologic study.Am J Respir Crit Care Med 1997;156:583-590,肺组织病理检查,念珠菌病,8%(2/25),呼吸道标本培养,念珠菌,40%(10/25),VS.,下呼吸道分离出念珠菌的意义,结论,在接受机械通气的非粒细胞缺乏的危重病患者,肺组织活检分离到念珠菌的比例高达,40%,明确的念珠菌肺炎仅为,8%,肺组织的不同区域普遍存在念珠菌定植,呼吸道标本中分离到念珠菌,不能准确预测是否存在念珠菌肺炎,无论是否进行定量培养,el Ebiary M,Torres A,Fabregas N,et al.Significance of the isolation of Candida species from respiratory samples in critically ill,non-neutropenic patients:an immediate postmortem histologic study.Am J Respir Crit Care Med 1997;156:583-590,下呼吸道分离出念珠菌的意义,37,名连续收治的患者,经纤维支气管镜采取的呼吸道标本念珠菌培养阳性,明确污染,3(8.1%),可能污染,30(81.0%),不能明确是否污染,2(5.4%),念珠菌肺炎,0,Rello J,Esandi ME,Diaz E,et al.The role of Candida sp isolated from bronchoscopic samples in nonneutropenic patients.Chest 1998;114:146-149,下呼吸道分离出念珠菌的意义,结论,非粒细胞缺乏患者如果经纤维支气管镜采样分离到念珠菌属,即使浓度很高,也可能没有深部念珠菌病,应当根据组织学证据或无菌标本的培养结果确定是否开始抗真菌治疗,Rello J,Esandi ME,Diaz E,et al.The role of Candida sp isolated from bronchoscopic samples in nonneutropenic patients.Chest 1998;114:146-149,如何应对下呼吸道分离的念珠菌,International Consensus Conference on VAP Management,12,名,VAP,专家,有关,VAP,诊断和治疗的,21,个问题,非粒细胞缺乏患者下呼吸道分离出念珠菌时,是否需要加用抗真菌药物,?,答案,No(12/12),即使经纤维支气管镜采样,评价诊断标准优劣的方法,敏感性,特异性,阳性预期值,(PPV),和阴性预期值,(NPV),的四格表,检查结果,患病,无病,总计,+,a,b,a+b,c,d,c+d,合计,a+c,b+d,a+b+c+d,敏感性,=a/(a+c),PPV=a/(a+b),特异性,=d/(b+d),NPV=d/(c+d),LR=,敏感性,/(1,特异性,),医院获得性肺炎的诊断,:,痰培养的准确性,敏感性,=82%,肺炎患者培养阳性比例,82%,肺炎患者培养阴性比例,18%,特异性,=0 33%,非肺炎患者培养阴性比例,0 33%,非肺炎患者培养阳性比例,67 100%,气管内吸取物常规培养的诊断价值,某些致病菌,(,如铜绿假单胞菌,),培养为阴性时,可以除外其感染,致病菌,定植菌,医院获得性肺炎的诊断,:,痰培养的准确性,阳性预期值,(PPV)=,痰培养阳性者中肺炎比例,阴性预期值,(NPV)=,痰培养阴性者非肺炎比例,PPV/NPV,的局限性,不同患病率情况下,PPV,的比较,(,敏感性和特异性,=90%),患病率,=10%,患病率,=1%,检查结果,患病,无病,总计,检查结果,患病,无病,总计,+,900,900,18,00,+,90,990,1,080,100,8,100,8,200,10,8,910,8,920,合计,1,000,9,000,10,000,合计,100,9,900,10,000,PPV=900/1,800=50%,PPV=90/1,080=8%,LR=(900/1,000)/1 (81,00/9,000)=9.0,LR=(90/100)/1 (8,910/9,900)=9.0,评价诊断标准优劣的方法,似然比,(LR),=,敏感性,/(1,特异性,),肺炎患者中痰培养阳性比例,非肺炎患者中痰培养阳性比例,LR,1.5,=,医院获得性肺炎的诊断,:,痰培养的准确性,阳性似然比,(+ve LR),=,敏感性,/(1,特异性,),肺炎患者中痰培养阳性比例,非肺炎患者中痰培养阳性比例,=0.82/(1 0 or 0.33),=0.82 1.22,=,痰培养阳性,:,临床意义,对于细菌感染患者,不容易遗漏致病菌,无法区分致病菌与定植菌,对于明确,VAP,患者,有助于确定抗生素的选择,假设,2,如果怀疑,VAP,的患者下呼吸道标本培养为阴性,应当停用抗生素,经验性抗生素,:,下呼吸道标本培养阴性,临床怀疑,VAP,但,BAL,培养结果阴性的,101,名患者,19,名患者,(18.8%)BAL,前应用抗生素,平均年龄,60.4,17.9,岁,平均,APACHE II,评分,23.2,8.7,临床怀疑,VAP,前机械通气时间,2.9,1.9,天,Kollef MH,Kollef K.Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results.Chest 2005;128(4):2706-2713,经验性抗生素,:,下呼吸道标本培养阴性,BAL,后,65,名患者,(64.4%),应用经验性抗生素,疗程,2.1,0.8,天,(1 3,天,),没有人应用经验性抗生素,3,天,6,例患者,(5.9%),因继发,VAP,应用经验性抗生素,距离最初,BAL,及停用经验性抗生素,72 h,住院死亡,35,例,(34.7%),包括,2,例继发,VAP,患者,死亡与,VAP,无关,Kollef MH,Kollef K.Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results.Chest 2005;128(4):2706-2713,经验性抗生素,:,下呼吸道标本培养阴性,对于临床怀疑,VAP,但,BAL,培养阴性患者,72,小时内停用经验性抗生素,甚至不应用经验性抗生素,Kollef MH,Kollef K.Antibiotic Utilization and Outcomes for Patients With Clinically Suspected Ventilator-Associated Pneumonia and Negative Quantitative BAL Culture Results.Chest 2005;128(4):2706-2713,经验性抗生素,:,下呼吸道标本培养阴性,满足,VAP,临床诊断标准,且,BALF,定量培养,10,4,CFU/mL,CPIS 6,Raghavendran K,Wang J,Belber C,MD.Predictive Value of Sputum Gram Stain for the Determination of Appropriate Antibiotic Therapy in Ventilator-Associated Pneumonia.J Trauma 2007;62:1377-1383,痰标本,:,革兰染色,vs.,培养结果,BALF,结果,革兰染色结果,GNB+GPC,GNB,GPC,-ve,GNB+GPC,15,4,6,1,GNB,14,26,1,6,GPC,13,3,14,3,-ve,18,18,9,35,Raghavendran K,Wang J,Belber C,MD.Predictive Value of Sputum Gram Stain for the Determination of Appropriate Antibiotic Therapy in Ventilator-Associated Pneumonia.J Trauma 2007;62:1377-1383,痰标本,:,革兰染色,vs.,培养结果,阳性预期值,(PPV),GNB+GPC0.25,GNB0.52,GPC0.47,阴性预期值,(NPV)0.78,革兰染色阴性时,仍有,10/45,培养结果阳性,Kappa,值,0.314,Raghavendran K,Wang J,Belber C,MD.Predictive Value of Sputum Gram Stain for the Determination of Appropriate Antibiotic Therapy in Ventilator-Associated Pneumonia.J Trauma 2007;62:1377-1383,痰标本,:,革兰染色,vs.,培养结果,作者,患者数,诊断标准,肺炎比例,Allaouchiche,118(146),PSB 10,3,51/146,Mimoz,134(186),PSB,10,3,81/186,Duflo,104(116),miniBALF 10,3,67/116,Davis,155,BAL 10,5,Kopelman,223(227),BALF 10,4,Raghavendran,124(186),BALF 10,4,痰标本,:,革兰染色,vs.,培养结果,作者,分组,敏感性,特异性,PPV,NPV,Allaouchiche,90,74,65,93,Mimoz,PSB,54,86,72,74,PTC,69,89,78,84,Duflo,76,100,100,75,Davis,GPC,87,59,68,83,GNB,73,49,78,42,Kopelman,GPC,80,66,48,89,GNB,67,74,69,72,Raghavendran,91,44,68,78,痰标本,:,革兰染色,vs.,培养结果,作者,完全符合,部分符合,不符合,Kappa,Allaouchiche,26/51,20/51,5/51,0.586,Duflo,26/67,19/67,22/67,0.730,Davis,71/155,54/155,30/155,Raghavendran,90/186,37/186,50/186,0.314,Total,213/459,130/459,107/459,痰标本革兰染色,:,临床意义,与培养相比,能够更快得到结果,指导经验性抗生素治疗,?,对确定致病菌不一定有帮助,仅不足,1/2,的病例完全符合,假设,4,停用抗生素无须痰培养阴性,VAP,停用抗生素的临床指标,确认引起肺部浸润影的非感染性因素,(,如肺不张,肺水肿,),从而无需抗生素治疗,症状及体征提示感染得到控制,体温,38.3,C,白细胞计数,25%,胸片表现改善或无进展,脓性痰消失,Pa,O,2,/F,iO,2,250,(,停用抗生素时须满足所有上述标准,),Micek ST,Ward S,Fraser VJ,Kollef MH.A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia.Chest 2004;125:17911799,VAP,停用抗生素的策略,Micek ST,Ward S,Fraser VJ,Kollef MH.A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia.Chest 2004;125:17911799,VAP,停用抗生素的策略,Micek ST,Ward S,Fraser VJ,Kollef MH.A Randomized Controlled Trial of an Antibiotic Discontinuation Policy for Clinically Suspected Ventilator-Associated Pneumonia.Chest 2004;125:17911799,预后,停用抗生素组,(n=150),对照组,(n=140),P,值,住院病死率,48(32.0),52(37.1),0.357,住院日,(,天,),15.7,18.2,15.4,15.9,0.865,ICU,住院日,(,天,),6.8,6.1,7.0,7.3,0.798,机械通气天数,5.4,5.7,5.7,7.1,0.649,继发感染,56(37.3),46(32.9),0.425,痰培养与停用抗生素指征,停用抗生素指征,临床治愈,而非细菌学清除,假设,5,在,ICU,患者发生呼吸机相关性肺炎,(VAP),前常规进行下呼吸道标本的微生物培养,鉴别,VAP,致病菌,经验性抗生素治疗,危重病患者的细菌定植,收入,ICU,时细菌定植的比例为,83%(39/47),鼻咽拭子,支气管吸取物,胃液,PSB,I,组细菌,肺炎链球菌,金黄色葡萄球菌,流感嗜血杆菌,II,组细菌,革兰阴性肠道杆菌,假单胞菌属,Ewig S,Torres A,El-Ebiary M,Fbregas N,Hernndez C,Gonzlez J,Nicols JM,Soto L.Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury:incidence,risk factors,and association with ventilator-associated pneumonia.Am J Respir Crit Care Med 1999;159:188-198,危重病患者的细菌定植,Ewig S,Torres A,El-Ebiary M,Fbregas N,Hernndez C,Gonzlez J,Nicols JM,Soto L.Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury:incidence,risk factors,and association with ventilator-associated pneumonia.Am J Respir Crit Care Med 1999;159:188-198,危重病患者的细菌定植,Ewig S,Torres A,El-Ebiary M,Fbregas N,Hernndez C,Gonzlez J,Nicols JM,Soto L.Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury:incidence,risk factors,and association with ventilator-associated pneumonia.Am J Respir Crit Care Med 1999;159:188-198,危重病患者的细菌定植,细菌在上呼吸道的定植是下呼吸道细菌定植的独立危险因素,入,ICU,时,I,组细菌定植,OR 9.9(1.8 56.3),随访时,II,组细菌定植,OR 23.9(3.8 153.3),既往应用抗生素,I,组细菌在下呼吸道定植,OR 0.2(0.05 0.86),II,组细菌在下呼吸道定植,OR 6.1(1.3 29),Ewig S,Torres A,El-Ebiary M,Fbregas N,Hernndez C,Gonzlez J,Nicols JM,Soto L.Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury:incidence,risk factors,and association with ventilator-associated pneumonia.Am J Respir Crit Care Med 1999;159:188-198,危重病患者的细菌定植,Ewig S,Torres A,El-Ebiary M,Fbregas N,Hernndez C,Gonzlez J,Nicols JM,Soto L.Bacterial colonization patterns in mechanically ventilated patients with traumatic and medical head injury:incidence,risk factors,and association with ventilator-associated pneumonia.Am J Respir Crit Care Med 1999;159:188-198,0,48,96,144,192,240,288,Hours of mechanical ventilation,0.0,0.2,0.4,0.6,0.8,Probability of early-onset pneumonia,Pts not colonized with Group I pathogens,Pts colonized with Group I pathogens,P=0.02,VAP,发生前的微生物学检查,目的,:,确定微生物学监测对于诊断呼吸机相关肺炎,(VAP),及化脓性气管支气管炎,(TBX),的价值,患者,:356,名心脏手术患者,微生物学监测,方法,:PSB+ETA,频率,:,心脏手术结束后,拔除气管插管前,手术后,3,天,以及每周一次,终止时间,:,拔除气管插管,发生,VAP,或,TBX,死亡,Bouza E,Prez A,Muoz P,et al.Ventilator-associated pneumonia after heart surgery:A prospective analysis and the value of surveillance.Crit Care Med 2003;31:1964 1970.,VAP,发生前的微生物学检查,VAP,诊断标准,CXR,出现新发浸润影或原有浸润影加重,下列标准中,2,条或,2,条以上,:,发热,(,38.5,C),或低体温,(6,TBX,诊断标准,脓性气管分泌物,CXR,没有肺炎导致的浸润影,下列标准中,2,条或,2,条以上,:,发热,(,38.5,C),或低体温,(36,C),白细胞升高,(,12 x 10,9,/L),呼吸道分泌物细菌计数明显升高,Bouza E,Prez A,Muoz P,et al.Ventilator-associated pneumonia after heart surgery:A prospective analysis and the value of surveillance.Crit Care Med 2003;31:1964 1970.,VAP,发生前的微生物学检查,VAP,患病率,7.87%(28/356),发病率,34.5,例,/1,000,机械通气日,TBX,患病率,8.15%(29/356),发病率,31.13,例,/1,000,机械通气日,Bouza E,Prez A,Muoz P,et al.Ventilator-associated pneumonia after heart surgery:A prospective analysis and the value of surveillance.Crit Care Med 2003;31:1964 1970.,VAP,发生前的微生物学检查,微生物学监测,1626,个标本,平均每名患者,4.56,2.8,个标本,2 30,预测准确性,VAP1/28,TBX1/29,Bouza E,Prez A,Muoz P,et al.Ventilator-associated pneumonia after heart surgery:A prospective analysis and the value of surveillance.Crit Care Med 2003;31:1964 1970.,VAP,发生前微生物培养结果,(n=125),Hayon J,Figliolini C,Combes A,Trouillet JL,Kassis N,Dombret MC,Gibert C,Chastre J.Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia.Am J Respir Crit Care Med 2002;165:41-46,VAP,发生前微生物培养结果,(n=102),Hayon J,Figliolini C,Combes A,Trouillet JL,Kassis N,Dombret MC,Gibert C,Chastre J.Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia.Am J Respir Crit Care Med 2002;165:41-46,VAP,发生前的微生物学检查,Hayon J,Figliolini C,Combes A,Trouillet JL,Kassis N,Dombret MC,Gibert C,Chastre J.Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia.Am J Respir Crit Care Med 2002;165:41-46,VAP,发生前分离的细菌,敏感性,特异性,PPV,NPV,MRSA,23/35(66),50 81,76/90(84),76 91,23/37(62),46 77,76/88(86),78 92,铜绿假单胞菌,15/32(47),30 64,79/93(85),77 91,15/29(52),34 70,79/96(82),74 89,鲍曼不动杆菌,7/20(35),16 57,83/105(79),71 86,7/29(24),10 41,83/96(87),78 92,VAP,发生前的微生物学检查,致病菌,仅能发现,33%(73/220),的致病菌,呼吸道分离细菌的阳性预期值,72 h:56%,72 h:,13%,患者,对,38%(47/125),的病例完全没有帮助,仅,31%(39/125),的病例致病菌完全吻合,Hayon J,Figliolini C,Combes A,Trouillet JL,Kassis N,Dombret MC,Gibert C,Chastre J.Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia.Am J Respir Crit Care Med 2002;165:41-46,VAP,发生前的微生物学检查,结论,VAP,发生前常规进行微生物检查仅能发现少量致病菌,由于分离的多数细菌并不参与其后的,VAP,发病,因此培养结果常常引起误导,耐药细菌在引发感染前能够分离到,敏感性,70%,不能作为经验性抗生素选择的唯一依据,经验性抗生素治疗应当覆盖,VAP,发生前,72,小时内呼吸道分离出的细菌,Hayon J,Figliolini C,Combes A,Trouillet JL,Kassis N,Dombret MC,Gibert C,Chastre J.Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia.Am J Respir Crit Care Med 2002;165:41-46,VAP,发生前的微生物学检查,41,名,VAP,患者,(BAL,培养确诊,),既往下呼吸道标本分离出相同的致病菌,(n=34),经验性抗生素治疗充分,(n=34),既往下呼吸道标本分离出不同的致病菌,(n=6),经验性抗生素治疗充分,(n=4),既往没有下呼吸道标本,(n=1),经验性抗生素治疗充分,(n=1),经验性抗生素治疗充分,38/40(95%),Michel F,Franceschini B,Berger P,Arnal JM,Gainnier M,Sainty JM,Papazian L.Early Antibiotic Treatment for BAL-Confirmed Ventilator-Associated Pneumonia,:,A Role for Routine Endotracheal Aspirate Cultures.Chest 2005:127:589-597,医院获得性肺炎,:,痰标本培养的临床意义,阳性结果提示意义有限,阴性结果除外常见细菌,停用抗生素不依赖培养,革兰染色结果谨慎对待,既往培养结果并不可靠,欢迎参加首届中法危重病医学研讨会,主办,:,中国病理生理学会危重病医学专业委员会,(CSCCM),法语系危重病学会,(SRLF),北京医学会危重病医学专业委员会,(SCCM-BMA),时间,:2007,年,11,月,8,日及,9,日,地点,:,北京宣武区中环假日酒店,(Holiday