氣道分泌物培養(yǎng)的臨床意義課件

氣道分泌物培養(yǎng)的臨床意義北京協(xié)和醫(yī)院杜斌ConflictsofInterestAstellasAstraZenecaBayerDainipponSumimotoPharmaEliLillyGlaxoWellcomeMSDPfizer(Wyeth)…臨床病例臨床病例2021/3/13ICUDay12BT39.8°CWCC16.8體格檢查雙肺濕羅音呼吸機條件升高PEEP816FiO20.40.6PaO2/FiO216580臨床病例考慮VAP準備應用經(jīng)驗性抗生素住院醫(yī)師意見一周前曾留取痰培養(yǎng)銅綠假單胞菌有助于確定目前致病菌?VAP發(fā)生前的微生物學檢查739名可疑VAP患者入選281名(39%)患者入選前1–3日有培養(yǎng)結果130名(46%)患者培養(yǎng)出致病微生物SandersKM,AdhikariNKJ,FriedrichJO,etal.Previousculturesarenotclinicallyusefulforguidingempiricantibioticsinsuspectedventilator-associatedpneumonia:secondaryanalysisfromarandomizedtrial.JCritCare2021;23:58-63VAP發(fā)生前的微生物學檢查SandersKM,AdhikariNKJ,FriedrichJO,etal.Previousculturesarenotclinicallyusefulforguidingempiricantibioticsinsuspectedventilator-associatedpneumonia:secondaryanalysisfromarandomizedtrial.JCritCare2021;23:58-63VAP發(fā)生前的微生物學檢查SandersKM,AdhikariNKJ,FriedrichJO,etal.Previousculturesarenotclinicallyusefulforguidingempiricantibioticsinsuspectedventilator-associatedpneumonia:secondaryanalysisfromarandomizedtrial.JCritCare2021;23:58-63VAP發(fā)生前的微生物學檢查經(jīng)驗性抗生素錯誤率根據(jù)革蘭染色結果 16%(11–33%)根據(jù)別離所有微生物 37%(29–45%)根據(jù)藥敏結果 39%(31–48%)SandersKM,AdhikariNKJ,FriedrichJO,etal.Previousculturesarenotclinicallyusefulforguidingempiricantibioticsinsuspectedventilator-associatedpneumonia:secondaryanalysisfromarandomizedtrial.JCritCare2021;23:58-63VAP發(fā)生前的微生物學檢查BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學檢查VAP診斷標準CXR出現(xiàn)新發(fā)浸潤影或原有浸潤影加重以下標準中2條或2條以上:發(fā)熱(38.5C)或低體溫(<36C)白細胞升高(12x109/L)膿性氣管分泌物過去48小時內(nèi)PaO2/FIO2下降15%或CPIS>6TBX診斷標準膿性氣管分泌物CXR沒有肺炎導致的浸潤影以下標準中2條或2條以上:發(fā)熱(38.5C)或低體溫(<36C)白細胞升高(12x109/L)呼吸道分泌物細菌計數(shù)明顯升高BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學檢查VAP患病率 7.87%(28/356)發(fā)病率 34.5例/1,000機械通氣日TBX患病率 8.15%(29/356)發(fā)病率 31.13例/1,000機械通氣日BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學檢查微生物學監(jiān)測1626個標本平均每名患者4.562.8個標本[2–30]預測準確性VAP 1/28TBX 1/29BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前微生物培養(yǎng)結果BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前微生物培養(yǎng)結果BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學檢查致病菌僅能發(fā)現(xiàn)33%(73/220)的致病菌呼吸道別離細菌的陽性預期值<72h:56%72h:13%患者對38%(47/125)的病例完全沒有幫助僅31%(39/125)的病例致病菌完全吻合BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.VAP發(fā)生前的微生物學檢查結論VAP發(fā)生前常規(guī)進行微生物檢查僅能發(fā)現(xiàn)少量致病菌由于別離的多數(shù)細菌并不參與其后的VAP發(fā)病,因此培養(yǎng)結果常常引起誤導耐藥細菌在引發(fā)感染前能夠別離到敏感性<70%不能作為經(jīng)驗性抗生素選擇的唯一依據(jù)經(jīng)驗性抗生素治療應當覆蓋VAP發(fā)生前72小時內(nèi)呼吸道別離出的細菌HayonJ,FiglioliniC,CombesA,TrouilletJL,KassisN,DombretMC,GibertC,ChastreJ.RoleofSerialRoutineMicrobiologicCultureResultsintheInitialManagementofVentilator-associatedPneumonia.AmJRespirCritCareMed2002;165:41-46VAP發(fā)生前的微生物學檢查結 論既往培養(yǎng)結果與疑心VAP時培養(yǎng)結果一致性很差不應根據(jù)既往培養(yǎng)結果指導經(jīng)驗性抗生素治療SandersKM,AdhikariNKJ,FriedrichJO,etal.Previousculturesarenotclinicallyusefulforguidingempiricantibioticsinsuspectedventilator-associatedpneumonia:secondaryanalysisfromarandomizedtrial.JCritCare2021;23:58-63臨床病例決定不考慮既往呼吸道分泌物培養(yǎng)結果經(jīng)驗性抗生素選擇?主治醫(yī)師問題是否等待痰涂片結果?北京協(xié)和醫(yī)院檢驗科細菌室姓名：XXX 性別：男性年齡：75 病房：MICU標本：痰 日期：2021/3/12鏡檢結果上皮細胞 <10/LPFWCC >25/LPF涂片結果革蘭陰性桿菌 大量革蘭陽性球菌 可見VAP治療

–革蘭染色結果QuestionsAnswersInthecaseofanegativeGram’sstainofarespiratorysampleofapatientwithasuspicionofVAP,wouldyouwaitforculturestostartantibiotics?NoDependingonthepatient*(10/12)(2/12)RelloJ,PaivaJA,BaraibarJ,etal.Internationalconferenceforthedevelopmentofconsensusonthediagnosisandtreatmentofventilator-associatedpneumonia.Chest2001;120:955-970*YesiftheclinicalsituationclearlysuggestiveofpneumoniaandifpatientathighriskorclinicallydeterioratingVAP治療

–革蘭染色結果完全符合部分符合不符合Allaouchiche(n=51)26205Duflo(n=67)261922Davis(n=155)715430Raghavendran(n=186)903750Albert(n=705)389108208總計(n=1164)602(51.7)238(20.4)324(27.8)僅有1/2的VAP病例ETA革蘭染色結果與培養(yǎng)結果相符AllaouchicheB,JaumainH,ChassardD,etal.Gramstainofbronchoalveolarlavagefluidintheearlydiagnosisofventilator-associatedpneumonia.BrJAnaesth1999;83:845-849DufloF,AllaouchicheB,DebonR,etal.AnevaluationoftheGramstaininprotectedbronchoalveolarlavagefluidfortheearlydiagnosisofventilator-associatedpneumonia.AnesthAnalg2001;92:442-447DavisKA,EckertMJ,ReedRLII,etal.Ventilator-associatedpneumoniaininjuredpatients:doyoutrustyourGramstain?JTrauma2005;58:462-466RaghavendranK,WangJ,BelberC,etal.PredictivevalueofsputumGramstainforthedeterminationofappropriateantibiotictherapyinventilator-associatedpneumonia.JTrauma2007;62:1377-1383AlbertM,FriedrichJO,AdhikariNKJ,etal.UtilityofGramstainintheclinicalmanagementofsuspectedventilator-associatedpneumonia:secondaryanalysisofamulticenterrandomizedtrial.JCritCare2021;23:74-81VAP治療

–革蘭染色結果VeinsteinA,Brun-BuissonC,DerrodeN,etal.Validationofanalgorithmbasedondirectexaminationofspecimensinsuspectedventilator-associatedpneumonia.IntensiveCareMed2006;32:676-683SuspectedVAPPTCGramstain-veETAGramstain+veETA&PTC*ETAGramstain-vePTCGramstain+veEmpiricTherapyWithholdTherapySeverityCriteria**YesNo*ETA,endotrachealaspirate;PTC,protectedtelescopingcatheter**extensivelunginvolvementorseverehypoxemia(P/Fratio<200),oroccurrenceofseveresepsisorsepticshockVAP治療

–革蘭染色結果VeinsteinA,Brun-BuissonC,DerrodeN,etal.Validationofanalgorithmbasedondirectexaminationofspecimensinsuspectedventilator-associatedpneumonia.IntensiveCareMed2006;32:676-683SuspectedVAP(n=76)PTCGramstain-ve(n=40)ETAGramstain–ve(n=21)PTCGramstain+ve(n=36)EmpiricTherapyTherapyWithheldPendingCulturesSeverityCriteriaYes(n=7)No(n=12)ETAGramstain+ve(n=19)ConfirmedVAP(n=30)ConfirmedVAP(n=4)ConfirmedVAP(n=4)ConfirmedVAP(n=3)VAP治療–革蘭染色結果SeSpPPVNPVSimplifiedCPIS>632665245CPISETA-Gramstain>676406058CPISPTC-Gramstain>666546358Strategystudies83747979VeinsteinA,Brun-BuissonC,DerrodeN,etal.Validationofanalgorithmbasedondirectexaminationofspecimensinsuspectedventilator-associatedpneumonia.IntensiveCareMed2006;32:676-683這一治療策略提示PTC革蘭染色敏感性73%，特異性83%，PPV83%，NPV73%，可能漏診VAPETA革蘭染色敏感性88%，特異性51%，PPV68%，NPV78%，可能誤診VAPWhentostartabx疑心VAP后盡早開始12h內(nèi)?不應等待痰涂片結果即使痰涂片陰性，也需使用經(jīng)驗性抗生素臨床病例長期機械通氣患者下呼吸道的細菌定植目的：檢查接受長期機械通氣患者肺泡內(nèi)細菌負荷背景：大學醫(yī)院及長期護理院的呼吸監(jiān)護病房患者：接受長期機械通氣且無肺炎臨床表現(xiàn)的14名患者指標：右中葉及舌葉BALF的定量培養(yǎng)結果：在進行檢查的32個肺葉中的29個,至少有一種微生物定量培養(yǎng)>104cfu/mL.多數(shù)肺葉有多種微生物生長BaramD,HulseG,PalmerLB.StablePatientsReceivingProlongedMechanicalVentilationHaveaHighAlveolarBurdenofBacteria.Chest2005;127:1353-1357機械通氣患者的細菌定植(n=356)BouzaE,PérezA,Mu?ozP,etal.Ventilator-associatedpneumoniaafterheartsurgery:Aprospectiveanalysisandthevalueofsurveillance.CritCareMed2003;31:1964–1970.下呼吸道別離出念珠菌的意義25名非粒細胞缺乏的機械通氣(>72h)患者去世后立即進行肺活檢去世后立即進行下呼吸道采樣氣道內(nèi)吸取物保護性毛刷[PSB]肺泡支氣管灌洗[BAL]盲目活檢[平均每例患者14塊組織]雙側纖維支氣管鏡指導下活檢[每例患者2塊組織]肺組織標本的組織學檢查呼吸道標本區(qū)分為念珠菌陽性及其他elEbiaryM,TorresA,FabregasN,etal.SignificanceoftheisolationofCandidaspeciesfromrespiratorysamplesincriticallyill,non-neutropenicpatients:animmediatepostmortemhistologicstudy.AmJRespirCritCareMed1997;156:583-590下呼吸道別離出念珠菌的意義25名非粒細胞缺乏的機械通氣患者(>72h)去世后立即進行尸體解剖,并采取下呼吸道標本肺組織病理檢查念珠菌病 8%(2/25)呼吸道標本培養(yǎng)念珠菌 40%(10/25)VS.elEbiaryM,TorresA,FabregasN,etal.SignificanceoftheisolationofCandidaspeciesfromrespiratorysamplesincriticallyill,non-neutropenicpatients:animmediatepostmortemhistologicstudy.AmJRespirCritCareMed1997;156:583-590下呼吸道別離出念珠菌的意義XIII.WhatisthesignificanceofCandidaisolatedfromrespiratorysecretions?Recommendation59.GrowthofCandidafromrespiratorysecretionsrarelyindicatesinvasivecandidiasisandshouldnotbetreatedwithantifungaltherapy(A-III)PappasPG,KauffmanCA,AndesD,etal.Clinicalpracticeguidelinesforthemanagementofcandidiasis:2021updatebytheInfectiousDiseasesSocietyofAmerica.ClinInfectDis2021;48:503-535醫(yī)院獲得性肺炎的診斷:痰培養(yǎng)的準確性敏感性=82%肺炎患者培養(yǎng)陽性比例82%肺炎患者培養(yǎng)陰性比例18%特異性=0–33%非肺炎患者培養(yǎng)陰性比例0–33%非肺炎患者培養(yǎng)陽性比例67–100%臨床病例如果沒有痰培養(yǎng)結果，是否仍然考慮肺炎?臨床表現(xiàn)BT39.8°C

,WCC16.8

呼吸機條件升高(PEEP8

16,FiO20.4

0.6,PaO2/FiO2165

80)體格檢查雙肺濕羅音氣道分泌物白色，量少腹腔引流轉(zhuǎn)為膿性腹部出現(xiàn)壓痛/反跳痛/肌緊張臨床病例如果沒有痰培養(yǎng)結果，是否仍然考慮肺炎?臨床表現(xiàn)高度提示肺以外部位感染腹腔感染明確尚需除外其他部位感染肺炎診斷不明確氣道分泌物性狀CXR對稱性改變痰培養(yǎng)=定植臨床病例如果沒有痰培養(yǎng)結果，是否仍然考慮肺炎?臨床表現(xiàn)BT39.8°C

,WCC16.8

呼吸機條件升高(PEEP8

16,FiO20.4

0.6,PaO2/FiO2165

80)體格檢查雙肺大量痰鳴音氣道分泌物黃色膿性，大量其他部位無明顯感染表現(xiàn)腹部，泌尿系，靜脈導管氣管內(nèi)吸取物常規(guī)培養(yǎng)的診斷價值某些致病菌(如銅綠假單胞菌)培養(yǎng)為陰性時,可以除外其感染致病菌定植菌臨床病例考慮肺部化膿性細菌感染氣道分泌物培養(yǎng)結果2021/3/12鮑曼不動桿菌2021/3/13MRSA2021/3/13銅綠假單胞菌氣道分泌物培養(yǎng)結果不一致致病菌=?抗生素選擇?臨床病例考慮肺部化膿性細菌感染氣道分泌物培養(yǎng)結果2021/3/12鮑曼不動桿菌2021/3/13鮑曼不動桿菌2021/3/13鮑曼不動桿菌氣道分泌物培養(yǎng)結果一致提示：不動桿菌=致病菌針對性應用抗生素頭孢哌酮/舒巴坦米諾環(huán)素可以考慮停用萬古霉素氣管內(nèi)吸取物常規(guī)培養(yǎng)的診斷價值痰培養(yǎng)陰性致病菌=其他菌?(如MRSA)致病菌=MRSA=1-敏感性 =100%-82%=18%連續(xù)三次未培養(yǎng)出致病菌的概率 =18%x18%x18%=0.6%臨床病例2021/3/31臨床表現(xiàn)BT36.8°C,WCC10.8呼吸機條件降低PEEP4,FiO20.35,PaO2/FiO2248間斷脫機體格檢查雙肺呼吸音明顯改善氣道分泌物白色，量少其他部位無明顯感染表現(xiàn)氣道分泌物培養(yǎng)結果依然陽性VAP停用抗生素的臨床指標確認引起肺部浸潤影的非感染性因素(如肺不張,肺水腫)從而無需抗生素治療病癥及體征提示感染得到控制體溫38.3C白細胞計數(shù)<10,000/L[10x109/L]或較最高值下降>25%胸片表現(xiàn)改善或無進展膿性痰消失PaO2/FiO2>250(停用抗生素時須滿足所有上述標準)MicekST,WardS,FraserVJ,KollefMH.ARandomizedControlledTrialofanAntibioticDiscontinuationPolicyforClinicallySuspectedVentilator-AssociatedPneumonia.Chest2004;125:1791–1799VAP停用抗生素的策略MicekST,WardS,FraserVJ,KollefMH.ARandomizedControlledTrialofanAntibioticDiscontinuationPolicyforClinicallySuspectedVentilator-AssociatedPneumonia.Chest2004;1