神經(jīng)科重癥監(jiān)護(hù)室感染的控制王寧

1、會(huì)計(jì)學(xué)1神經(jīng)科重癥監(jiān)護(hù)室感染的控制王寧神經(jīng)科重癥監(jiān)護(hù)室感染的控制王寧B. Indredavik, F. Bakke,; S.A. Slrdahl, et al.Stroke,1998,29(5):895899一項(xiàng)隨機(jī)、對(duì)照研究，220例患者分為NICU組及普通病房組神經(jīng)重癥監(jiān)護(hù)室普通病房NHP評(píng)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家醫(yī)院，663例缺血性腦卒中患者，住院期感染發(fā)生率感染率%11家醫(yī)院間感染率不同，變化范圍為肺炎：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急性缺血性腦卒中患者SAP的發(fā)生率為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顯著增加腦卒中相關(guān)性肺炎（SAP）發(fā)生RR值的危險(xiǎn)因素Ruediger Hilker.MD,et al. Stroke,2003;34:975-981*P0.05, *P 0.001.相對(duì)危險(xiǎn)度（RR）機(jī)械

6、通氣*吞咽困難*正常胸片*脊椎基底動(dòng)脈卒中*大腦多部位卒中*脊椎基底動(dòng)脈多部位卒中*ORP值意識(shí)7.4 (2.918.4)0.001面癱3.1 (1.09.3)0.05輕度偏癱0.6 (0.41.1)0.08失語2.1 (0.76.1)0.18發(fā)音困難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.錢樹星,龍軍,等.中華神經(jīng)醫(yī)學(xué)雜志, 2006,10(5):1050-1052總的感染發(fā)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腦卒中感染患者第7天時(shí)亞組Kaplan-Meier生存曲線吸入性肺炎泌尿系感染 吸入性肺炎泌尿系感染無感染 死亡率%P0.05，RR:3.3Ruediger Hilker.MD,et al. Stroke,2003;34:975-981124例NICU急性腦卒中患者住院期間死亡率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急性腦卒中患者隨訪期間死亡率余霞,翟云霞.中國老年學(xué)雜志2003,23:466P0.01P0.01死亡率%錢樹星,龍軍,等.中華神經(jīng)醫(yī)學(xué)雜志, 2006,10(5):1050-10522004年9月一2006年5月珠江醫(yī)院神經(jīng)外科重癥監(jiān)護(hù)病房(ICU）臨床痰標(biāo)本中共分離出102株致病菌G-菌：71.6%G+菌：28.4%王寧,陳文進(jìn),等.中國現(xiàn)代神經(jīng)疾病雜志,2006,6(1):40-43G+菌：31.25%G-菌：68.75%神經(jīng)外科重癥監(jiān)護(hù)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 (%)抗菌藥物%鮑曼不動(dòng)桿菌大腸埃希菌銅綠假單胞菌肺炎克雷伯菌哌拉西林88.287.557.171.4亞胺培南5.912.542.90氨曲南88.287.5100.085.7頭孢吡肟100.0100.071.435.7錢樹星,龍軍,等.中華神經(jīng)醫(yī)學(xué)雜志, 2006,10(5):1050-1052抗菌藥物%金黃色葡萄球菌糞腸球菌凝固酶陰性葡萄球菌克林霉素88.287.557.1頭孢哌酮/舒巴坦5.912.542.9萬古霉素050.00頭孢西丁63.6100.033.3G-菌G+菌20

12、04年9月一2006年5月，102株致病菌抗菌藥物銅綠假單胞菌肺炎克雷伯菌鮑曼不動(dòng)桿菌大腸埃希菌氨芐西林/舒巴坦1009891100頭孢曲松44294241亞胺培南1121413左氧氟沙星8482100-抗菌藥物金黃色葡萄球菌凝固酶陰性葡萄球菌糞腸球菌克林霉素8991-氨芐西林/舒巴坦98100-左氧氟沙星917467青霉素100100-G-G+王寧,陳文進(jìn),等.中國現(xiàn)代神經(jīng)疾病雜志,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.開始應(yīng)用抗菌藥物經(jīng)驗(yàn)治療的

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. 卒中后發(fā)熱應(yīng)考慮是否有肺炎發(fā)生，且應(yīng)給予合適的抗菌素治療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.懷疑懷疑HAP, VAP 或或HCAP取得取得LRTLRT標(biāo)本培養(yǎng)標(biāo)本培養(yǎng)( (定量或者半定量定量或者半定量) &) &顯微鏡檢查顯微鏡檢查48 -72 48 -72 小時(shí)臨床改善小時(shí)臨床改善 降階梯治療，降階梯治療，如果可能如果可能. 治療治療7- 8天和再評(píng)估

16、天和再評(píng)估尋找其它病原體尋找其它病原體,并發(fā)癥并發(fā)癥, 其它診斷或者感染部位其它診斷或者感染部位2 &3天天:培養(yǎng)結(jié)果培養(yǎng)結(jié)果& 臨床反應(yīng)評(píng)估臨床反應(yīng)評(píng)估: (體溫體溫, WBC,胸部胸部X線片線片,氧合，膿痰氧合，膿痰,血液動(dòng)力學(xué)改變以及器官功能）血液動(dòng)力學(xué)改變以及器官功能）是是無無除非臨床懷疑程度低或者除非臨床懷疑程度低或者LRT標(biāo)本顯微鏡檢查陰性，應(yīng)開始經(jīng)驗(yàn)性抗標(biāo)本顯微鏡檢查陰性，應(yīng)開始經(jīng)驗(yàn)性抗感染治療感染治療: ATS分組和當(dāng)?shù)匚⑸飳W(xué)資料分組和當(dāng)?shù)匚⑸飳W(xué)資料培養(yǎng)培養(yǎng)- -考慮停藥考慮停藥調(diào)整抗感染方案調(diào)整抗感染方案, 尋找其它病原體尋找其它病原體,并發(fā)癥并發(fā)癥, 其

17、它診斷或者感染部位其它診斷或者感染部位培養(yǎng)培養(yǎng)+ +培養(yǎng)培養(yǎng)+ +培養(yǎng)培養(yǎng)- -1、劉長庭，張進(jìn)川.現(xiàn)代纖維支氣管鏡診斷治療學(xué). 北京：人民軍醫(yī)出版社,(997.24)2、賴國祥,陳學(xué)香,賴紅兵,等. 解放軍醫(yī)學(xué)雜志,2002,27:7303、林航,賴國祥等.臨床神經(jīng)病學(xué)雜志,2003,16(6):372-373林航,賴國祥等.臨床神經(jīng)病學(xué)雜志,2003,16(6):372-373患者比例%Hendrik Harms,et al. .PLoS ONE 3(5): e2158.P=0.032腦卒中后感染率%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