ICU感染的治疗.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,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,ICU,感染,:,患病率,医院获得性感染的患病率为,5 30%,ICU,患者感染的患病率约为,18 50%,较普通患者高,3 18,倍,ICU,床位,=,医院总床位数的,5%,医院获得性感染,=25%,Spencer RC.Epidemiology of infection in ICUs.Intensive Care Med 1994;20:S2-6.,Bates DW,Miller EB,Cullen DJ,et al.Patient risk factors for adverse drug events in hospitalized patients.ADE Prevention Study Group.Arch Intern Med 1999;159:2553-60.,Singh N,Yu VL.Rational empiric antibiotic prescription in the ICU.Chest 2000;117:1496-9.,ICU危重病患者的感染,European Prevalence of Infection,in Intensive Care Study(EPIC),1992,年,4,月,29,日进行,1417,个,ICU,参加,总计,9567,名,ICU,患者,ICU危重病患者的感染,ICU感染的组成,EPIC,内科,外科,ICU,NNIS,PUMC,下呼吸道感染,24,18,65,27,53,泌尿系感染,43,31,18,20,5,手术部位感染,11,12,9,16,血行性感染,15,10,2,21,12,其他,18,30,13,20,14,感染对患者预后的影响,增加住院日,额外医疗费用,手术部位感染,7.3,3,152,肺炎,5.9,5,683,血行性感染,7.4,3,517,泌尿系感染,1.0,680,总计,4.0,2,100,ICU血行性感染:致病菌,ICU获得性肺炎:致病菌,NNIS,PUMCH,ICU感染的致病菌,耐药菌,NNIS(1996 2000),北京协和医院,ICU,(1995 2000),平均耐药率,(%),10%,百分,位数,90%,百分,位数,MRSA,46.5,15.4,66.7,87,MRSE,74.9,56.9,86.7,95,亚胺培南耐药的铜绿假单胞菌,16.7,0.0,31.3,27,头孢他啶耐药的铜绿假单胞菌,11.7,0.0,25.0,28,哌拉西林耐药的铜绿假单胞菌,15.0,0.0,31.6,38,三代头孢菌素耐药的肠杆菌,25.9,10.0,50.9,54,亚胺培南耐药的肠杆菌,0.9,0.0,4.0,5,三代头孢菌素耐药的肺炎克氏菌,5.4,0.0,18.5,22,三代头孢菌素耐药的大肠杆菌,0.9,0.0,6.5,17,氟喹诺酮耐药的大肠杆菌,4.2,0.0,11.1,67,Du B,Chen DC,Liu DW,Xu YC,Xie XL,Chen MJ.Natl Med J China 1996;76:262-6.,Li Y,Du B,Chen DC,Liu DW.Beijing Med J 2002;24:3-5,Du B.Natl Med J China 2001;81:1278-80,0%,20%,40%,60%,80%,100,%,Luna,1997,Ibrahim,2000,Kollef,1998,Kollef,1999,Rello,1997,Alvarez-Lerma,1996,最初充分治疗,最初不充分治疗,*,病死率指总病死率或感染相关病死率,Alvarez-Lerma F et al.,Intensive Care Med,1996;22:387-394.,Rello J et al.,Am J Respir Crit Care Med,1997;156:196-200.,Kollef MH et al.,Chest,1999;115:462-474,Kollef MH et al.,Chest,1998;113:412-420.,Ibrahim EH at al.,Chest,2000;118:146-155.,Luna CM et al.,Chest,1997;111:676-685.,病死率*,ICU,中重度感染的危重病患者最初不充分抗生素治疗的病死率,*,ESBL阳性菌感染不适当抗生素治疗与病死率,OR=4.701,P=0.016,Bin Du,Yun Long,Hongzhong Liu,Dechang Chen,Dawei Liu,Yingchun Xu,Xiuli Xie.Extended-spectrum beta-lactamase-producing-,Escherichia coli,and,Klebsiella pneumoniae,bloodstream infection:risk factors and clinical outcome.Intensive Care Med 2002;28(12):1718-23,7/14,14/71,ICU感染的抗生素治疗:指征,经验性抗生素治疗,致病菌未知,广谱抗生素,针对性抗生素治疗,(,降阶梯治疗,),根据致病菌及药敏结果,结合临床疗效,换用窄谱抗生素,ICU感染的抗生素治疗:意义,经验性抗生素治疗,覆盖可能的致病菌,降低病死率,针对性抗生素治疗,(,降阶梯治疗,),减少广谱抗生素的使用,避免耐药发生,抗生素治疗前后血培养的阳性率,139,名患者,抗生素治疗前,抗生素治疗过程中,开始抗生素治疗,83,名患者,(60%),血培养阴性或分离出污染菌,0/83(0%),分离到致病菌,56,名患者,(40%),分离到致病菌,26/56(45%),分离到致病菌,25,名患者,(45%),分离到致病的葡萄球菌,19/25(76%),分离到葡萄球菌,14,名患者,(25%),分离到致病的链球菌,5/14(36%),分离到链球菌,17,名患者,(30%),分离到革兰阴性杆菌,2/17(12%),分离到革兰阴性杆菌,1/139(0.72%),分离到新的致病菌,Grace CJ,Lieberman J,Pierce K,et al.Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy.Clin Infect Dis 2001;32:1651-5,临床意义,应用抗生素前进行血培养分离到致病菌的可能性增加,2.2,倍,在开始抗生素治疗最初,72,小时内,连续进行血培养的结果,可以根据应用抗生素前血培养的结果预测,极少分离到新的致病菌,医生可以等待应用抗生素前的血培养结果回报后,再进行新的血培养,Grace CJ,Lieberman J,Pierce K,et al.Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy.Clin Infect Dis 2001;32:1651-5,医院获得性肺炎的抗生素治疗,目的,:,评价频繁更换抗生素对,VAP,患者预后的影响,方法,:,回顾性分析,56,名,VAP,患者的临床资料,根据更换抗生素的频率分为,4,组,第,1,组,(n=19),最初抗生素治疗无更改,第,2,组,(n=8),最初抗生素治疗更改,1,次,第,3,组,(n=19),最初抗生素治疗更改,2,次,第,4,组,(n=10),最初抗生素治疗更改,3,次,降阶梯治疗及简化治疗除外,Kawabata M,Corla-Souza A,Niederman M,et al.The impact of changes in antimicrobial therapy on patients with ventilator-associated pneumonia.Chest 2003;124(Suppl 4):79S,医院获得性肺炎的抗生素治疗,Kawabata M,Corla-Souza A,Niederman M,et al.The impact of changes in antimicrobial therapy on patients with ventilator-associated pneumonia.Chest 2003;124(Suppl 4):79S,医院获得性肺炎的抗生素治疗,Kawabata M,Corla-Souza A,Niederman M,et al.The impact of changes in antimicrobial therapy on patients with ventilator-associated pneumonia.Chest 2003;124(Suppl 4):79S,医院获得性肺炎的抗生素治疗,P=0.004,P=0.04,Kawabata M,Corla-Souza A,Niederman M,et al.The impact of changes in antimicrobial therapy on patients with ventilator-associated pneumonia.Chest 2003;124(Suppl 4):79S,如何鉴别真正的致病菌和污染菌,常见致病菌,(95%),金黄色葡萄球菌,大肠杆菌,肠杆菌,铜绿假单胞菌,肺炎链球菌,白色念珠菌,常见污染菌,(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,TA培养结果与医院获得性肺炎,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%,TA培养结果与医院获得性肺炎,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,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,2,名患者,(8%),明确肺部念珠菌病,25,名患者,375,份肺活检标本,280,份,(77%),培养阳性,共分离,470,株细菌,10,名患者,(40%),分离出念珠菌属,(n=40,9%),10,名患者,(40%),1,份肺组织活检标本分离念珠菌属,至少其他一种采样方法也分离到相同的念珠菌,不同采样方法进行念珠菌定量培养,相关性很好,不能鉴别念珠菌肺炎,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,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,ICU感染的诊断,微生物学检查结果不能取代临床诊断,VAP:,下呼吸道标本的培养结果用于,调整抗生素治疗,非诊断肺炎,ICU患者的抗生素治疗,意大利,43,个,ICU,共,979,名危重病患者,(14,岁,),99%,全身性感染患者应用抗生素,经验性广谱抗生素,93%,抗生素药敏结果,93%,经验性抗生素治疗错误,37.6%,更换或加用抗生素,降阶梯治疗,(n=16),Malacarne P,Rossi C,Bertolini G,et al.Antibiotic usage in intensive care units:a pharmaco-epidemiological multicentre study.Antimicrob Chemother.2004 Jul;54(1):221-4,感染性休克的抗生素治疗,107,名感染性休克患者,细菌学证实,78(72%),经验性抗生素治疗,-,内酰胺,+,氨基糖甙,n=59,-,内酰胺,+,氟喹诺酮,n=21,加用万古霉素,n=14,正确的经验性抗生素治疗,89%(69/78),Leone M,Bourgoin A,Cambon S,et al.Empirical antimicrobial therapy of septic shock patients:adequacy and impact on the outcome.Crit Care Med.2003 Feb;31(2):462-7,感染性休克的抗生素治疗,抗生素治疗的改变,(,第,3 4,天,),患者数,(n=81),%,改变最初的经验性抗生素,56(80),换用窄谱,-,内酰胺抗生素,18(22),停止联合抗生素治疗,34(42),升阶梯,13(16),根据微生物学检查结果,6(7),得到检查结果前临床恶化,7(8.6),Leone M,Bourgoin A,Cambon S,et al.Empirical antimicrobial therapy of septic shock patients:adequacy and impact on the outcome.Crit Care Med.2003 Feb;31(2):462-7,VAP的经验性抗生素治疗,2001 2003,年,78,名疑似,VAP,患者,铜绿假单胞菌,14.8%,改用窄谱抗生素,(%),致病菌已知,35%,革兰阳性菌,46%,革兰阴性菌,54%,致病菌未知,10%,CAP的经验性抗生素治疗,204,名住,ICU,的重症,CAP,患者,致病菌已知,117(57.3%),更换抗生素,85(41.6%),换用窄谱抗生素,65(31.9%),换用正确抗生素,11(5.4%),联合应用抗生素,5(2.4%),铜绿假单胞菌,Rello J,Bodi M,Mariscal D,et al.Microbiological testing and outcome of patients with severe community acquired pneumonia.Chest 2003;123:174-80,经验性抗生素:下呼吸道培养阴性,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 128(4):2706-2713,经验性抗生素:下呼吸道培养阴性,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 128(4):2706-2713,经验性抗生素:下呼吸道标本阴性,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 128(4):2706-2713,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,PaO,2,/FiO,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,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,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,抗生素指南对临床治疗感染的指导,西洛杉矶医院,HAP,抗生素指南,轻中度,HAP,哌拉西林,/,他唑巴坦,头孢曲松或左旋氧氟沙星,(,青霉素过敏,),重度,HAP,亚胺培南,+,阿米卡星,(95%),亚胺培南,+,环丙沙星,(,或左旋氧氟沙星,)(,肾毒性,),MRSA:,万古霉素,非典型病原体,:,阿奇霉素,Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,抗生素指南对临床治疗感染的指导,NNIS(n=48),GUIDE(n=58),HAP,次数,56,61,年龄,岁,67.7,9.6,68.0,11.5,基础疾病,充血性心力衰竭,17(35),10(16)*,手术后,20(42),10(17)*,诊断,HAP,时,SAPS,评分,12.9,3.9,12.6,3.1,发生,HAP,前,住院日,20.4,16.6,19.7,28.0,ICU,住院日,15.6,14.9,6.2,13.2*,机械通气天数,10.4,11.7,5.4,13.2*,Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,抗生素指南对临床治疗感染的指导,Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,抗生素指南对临床治疗感染的指导,NNIS(n=56),GUIDE(n=61),亚胺培南,10(18),61(100),万古霉素,25(45),28(46),环丙沙星,3(5),23(38),阿米卡星,8(14),22(36),头孢噻肟,22(39),0(0),甲硝唑,21(38),6(10),头孢他啶,11(20),0(0),哌拉西林,11(20),0(0),庆大霉素,11(20),2(3),氟康唑,8(14),3(5),克林霉素,7(13),1(2),Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,抗生素指南对临床治疗感染的指导,Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,抗生素指南对临床治疗感染的指导,NNIS(n=56),GUIDE(n=61),正确的经验性抗生素治疗,26(46),52(81)*,不正确的经验性抗生素治疗,30,9,耐药革兰阳性菌,15,8,耐药革兰阴性菌,15,1,预后,14,天病死率,13(23),5(8)*,30,天病死率,21(38),14(23),住院病死率,25(45),18(30),Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,抗生素指南对临床治疗感染的指导,Cox,风险比例模型,30,天病死率,(HR),GUIDE0.46(p=.041),住院病死率,(HR),GUIDE0.44(p=.018),Soo Hoo GW,Wen YE,Nguyen TV,Goetz MB.Impact of Clinical Guidelines in the Management of Severe Hospital-Acquired Pneumonia.Chest 2005;128:2778-2787.,总结,ICU患者为感染的高危人群,适当的经验性抗生素治疗能够改善预后,正确理解微生物学检查结果,及时调整针对性抗生素治疗,