e5吸科耐藥革蘭陰性桿菌與治療策略.ppt

1、2020/9/18,Dr.HU Bijie,1,呼吸科耐藥革蘭陰性桿菌與治療策略,株洲市二醫(yī)院 劉和平副主任醫(yī)師,2020/9/18,Dr.HU Bijie,2,CAP: Outpatient,Previously Healthy No recent antibiotic therapy: A macrolidea or doxycycline Recent antibiotic therapy: A respiratory fluoroquinolone (RFQ) alone, an advanced macrolide (AM) plus high-dose amoxicillin or

2、 AM plus high-dose amoxicillin-clavulanate Comorbidities (COPD, Diabetes, Renal or Congestive Heart Failure, or Malignancy) No recent antibiotic therapy: AM or RFQ Recent antibiotic therapy: RFQ alone or AM plus a B-lactam Suspected aspiration with infection: Amoxicillin-clavulanate or clindamycin I

3、nfluenza with bacterial superinfection: B-lactam or a RFQ,2020/9/18,Dr.HU Bijie,3,CAP: Inpatient,Medical Ward No recent antibiotic therapy: RFQ alone or AM plus B-lactam Recent antibiotic therapy: AM plus B-lactam or RF alone (regimen selected will depend on nature of recent antibiotic therapy) Inte

4、nsive Care Unit (ICU) Pseudomonas infection is not an issue: B-lactam plus either AM or RFQ Pseudomonas infection is not an issue but patient has B-lactam allergy: RFQ, with or without clindamycin Pseudomonas infection is an issue: Either (1) an antipseudomonal agent plus ciprofluoxacin, or (2) an a

5、ntipseudomonal agent plus an aminoglycoside plus RFQ or a macrolide Pseudomonas infection is an issue but patient has a -lactam allergy: the Either (1) aztreonam plus levofluoxacin or (2) aztreonam plus moxifluoxacin or gatifluoxacin, with or without an aminoglycoside Nursing Home Receiving treatmen

6、t in nursing home: RFQ alone or amoxicillin-clavulanate plus AM Hospitalized: Same as for medical ward and ICU,2020/9/18,Dr.HU Bijie,4,NNIS報(bào)告的醫(yī)院內(nèi)肺炎,2020/9/18,Dr.HU Bijie,5,銅綠假單胞菌、肺炎克雷伯菌和鮑曼不動桿菌是HAP常見的革蘭陰性桿菌,Antimicrob Agents Chemother. 2003 Nov;47(11):3442-7,2020/9/18,Dr.HU Bijie,6,Nosocomial tracheo

7、bronchitis in MV patients:incidence, aetiology and outcome,Eur Respir J 2002; 20: 14831489.,2020/9/18,Dr.HU Bijie,7,醫(yī)院內(nèi)肺炎病原菌（Meta分析，全國19901998年，6062株菌）,2020/9/18,Dr.HU Bijie,8,52例VAP病原分布(9901),2020/9/18,Dr.HU Bijie,9,NLRTI前五位病原菌在6個常見科室的比較,謝紅梅，胡必杰，何禮賢，等. 2819例醫(yī)院下呼吸道感染病原和預(yù)后分析.上海醫(yī)學(xué)2003；26：880-885,2020/

8、9/18,Dr.HU Bijie,10,醫(yī)院內(nèi)肺炎病原,早期,中期,晚期,1 3 5 10 15 20,鏈球菌,流感桿菌,金葡菌 MRSA,腸桿菌,肺克，大腸,綠膿桿菌,不動桿菌,嗜麥芽窄食單胞菌,入院天數(shù),2020/9/18,Dr.HU Bijie,11,呼吸科常見耐藥革蘭陰性桿菌,肺炎克雷伯桿菌，大腸埃希菌 腸桿菌屬，沙雷菌，枸櫞酸菌，變形桿菌 銅綠假單胞菌，其他假單胞菌 鮑曼不動桿菌，其他不動桿菌 嗜麥芽窄食單胞菌屬 伯克霍爾德菌屬 產(chǎn)堿桿菌屬，黃桿菌屬 NPRS結(jié)果顯示，銅綠和鮑曼作為MDR問題正在凸現(xiàn),2020/9/18,Dr.HU Bijie,12,細(xì)菌耐藥是否會影響病死率 ?,治

9、療肺炎桿菌ESBL菌株血液感染 (n=31),合適治療 (n=19) 病死率 5% 不恰當(dāng)治療(n=12)病死率 42% P=0.02,Source:Schiappa et al JID 1996; 74:529-36,2020/9/18,Dr.HU Bijie,13,2020/9/18,Dr.HU Bijie,14,在ICU中肺部感染耐藥菌問題尤為突出,2020/9/18,Dr.HU Bijie,15,MDR引起肺炎的防治策略,預(yù)防醫(yī)院內(nèi)肺炎（HAP、VAP、HCAP） 早期、準(zhǔn)確的病原學(xué)診斷，不要治療定植菌和污染菌 停止無效、耐藥的抗生素，避免更嚴(yán)重的后果 加大劑量：從藥敏單中尋找中介（低

10、敏）的藥物聯(lián)合使用，在安全范圍內(nèi)的最大劑量，時(shí)間依賴性的藥在允許范圍縮短用藥間隔，甚至24h連續(xù)點(diǎn)滴 舊藥新用：多粘菌素E，舒巴坦對不動桿菌等 聯(lián)合用藥：MIC為16ug/ml的頭孢他啶和16ug/ml的阿米卡星合用可能有效；特門汀與氨曲南聯(lián)合治不發(fā)酵糖菌效果有時(shí)很好；氨曲南可耐受金屬酶,2020/9/18,Dr.HU Bijie,16,Managing Infection In The Critical Care Unit: How Can Infection Control Make The ICU Safe? Crit Care Clin. 2005 Jan;21(1):111-28 S

11、hulman L, Ost D Division of Pulmonary and Critical Care Medicine, North Shore University Hospital, Manhasset, NY 11030, USA,2020/9/18,Dr.HU Bijie,17,VAP預(yù)防方法的有效性評價(jià),Route of intubation Search for sinusitis Circuit changes Humidifier Humidifier changes Endotracheal suctioning Subglottic secretion drain

12、age Chest physiotherapy Tracheostomy Kinetic beds Semi-recumbent position Prone position Stress ulcer prophylaxis Prophylactic antibiotics,2020/9/18,Dr.HU Bijie,18,2020/9/18,Dr.HU Bijie,19,Antiseptic impregnated endotracheal tubes for the prevention of bacterial colonization,在實(shí)驗(yàn)室氣道模型中建立不同對MRSA, PA,

13、AB 和產(chǎn)氣腸桿菌有抗菌作用的氣管插管(ETTs) ，包裹有洗必泰和碳酸銀 抗菌ETT和對照 ETT (未包裹）用濃度108cfu/ml的菌液污染，5天孵育，管腔的遠(yuǎn)端和近端分別采樣細(xì)菌培養(yǎng) 抗菌ETT細(xì)菌定植量為1-100 cfu/管，而對照ETT達(dá)106cfu/管(P 0.001). 結(jié)論：抗菌導(dǎo)管可有效預(yù)防VAP相關(guān)細(xì)菌在ETT上的生長,J Hosp Infect. 2004 Jun;57(2):170-4,2020/9/18,Dr.HU Bijie,20,Efficacy of heat and moisture exchangers in preventing VAP: meta-a

14、nalysis of RCT,OBJECTIVE: Several RCT have examined the effect of antibacterial humidification strategies, particularly the replacement of heated humidifiers (HH) by heat and moisture exchangers (HME), in preventing VAP. The present meta-analysis reviews these RCTs. METHODS: RCTs were identified by

15、searching the Medline and Cochrane Central Register of Controlled Trials databases from 1990 to 2003. We included RCTs using HMEs in the treatment group and HHs in the control group and reporting the incidence of pneumonia as a study outcome. Two investigators independently abstracted key data on de

16、sign, population, intervention and outcome of the studies. RESULTS: Between 1990 and 2003 eight RCTs met the inclusion criteria of this analysis. Pooling the results from these studies revealed a reduction in the relative risk of VAP in the HME group (0.7), particularly in MV with a duration of at l

17、east 7 days (five RCTs, relative risk 0.57). CONCLUSIONS: This meta-analysis found a significant reduction in the incidence of VAP in pts humidified with HMEs during MV, particularly in pts ventilated for 7 days or longer. This finding is limited by the exclusion of pts at high risk for airway occlu

18、sion from some of the studies. Contraindications (tenacious secretions, airway obstructive disease, hypothermia) and technical issues of HMEs must be considered. Further RCTs are necessary to examine the wider applicability of HMEs and their extended use.,Intensive Care Med. 2005 Jan;31(1):5-11,2020

19、/9/18,Dr.HU Bijie,21,Ventilator-associated pneumonia using a closed versus an open tracheal suction system,OBJECTIVE: The aim of this study was to analyze the prevalence of VAP using a closed-tracheal suction system (CS) vs. an open system (OS). SETTING: A 24-bed medical-surgical ICU in a 650-bed te

20、rtiary hospital. PATIENTS: Patients requiring MV for 24 hrs. INTERVENTIONS: Patients were randomized into two groups; one group was suctioned with CS and another group with the OS. MEASUREMENTS: Throat swabs were taken at admission and twice a week until discharge to classify pneumonia in endogenous

21、 and exogenous. MAIN RESULTS: A total of 443 pts (210 with CS, 233 with OS) were included. There were no significant differences between groups of patients in age, sex, diagnosis groups, mortality, number of aspirations per day, and APCHE II score. No significant differences: in percentage of pts wh

22、o developed VAP (20.47% vs. 18.02%); in the number of VAP cases per 1000 MVDs (17.59 vs. 15.84); in the VAP incidence by MV duration; in the incidence of exogenous VAP; in the microorganisms responsible for pneumonia. Patient cost per day for the CS was more expensive than the OS (11.11 US dollars +

23、/- 2.25 US dollars vs. 2.50 US dollars +/- 1.12 US dollars, p .001). 結(jié)論:閉合痰液吸引系統(tǒng)不能降低VAP發(fā)病率，包括外源性肺炎,Crit Care Med. 2005 Jan;33(1):115-9,2020/9/18,Dr.HU Bijie,22,Early antibiotic treatment for BAL-confirmed ventilator-associated pneumonia: a role for routine endotracheal aspirate cultures,方法：299需要機(jī)械通氣

24、至少48 h的病例，每周兩次采集氣管內(nèi)吸引物（EA）定量培養(yǎng)。發(fā)生VAP后用 BAL培養(yǎng)確定病原體，并與EA結(jié)果進(jìn)行比較。 最后有75例診斷VAP，41例BAL培養(yǎng)陽性，先前常規(guī)EA培養(yǎng)中有34例 (83%)陽性，1例早發(fā)肺炎發(fā)生VAP時(shí)還沒有采集EA；4例結(jié)果不一致但抗菌藥物選用合適，2例選用藥物有延遲 結(jié)論：每周兩次常規(guī)EA培養(yǎng)對早期正確選用VAP治療抗菌藥物是合適的,Chest. 2005 Feb;127(2):589-97,2020/9/18,Dr.HU Bijie,23,Blind and bronchoscopic sampling methods in suspected VAP

25、- A multicentre prospective study.,OBJECTIVE: To compare 4 sampling methods: blind tracheal aspirate (blind TA), blind protected telescoping catheter (blind PTC), bronchoscopic PTC and bronchoscopic BAL, for diagnosis of VAP. DESIGN 30(7):1319-26,2020/9/18,Dr.HU Bijie,24,Combination therapy with pol

26、ymyxin B for the treatment of multidrug-resistant Gram-negative respiratory tract infections,BACKGROUND: The treatment of infections caused by multidrug-resistant (MDR) Gram-negative organisms poses a therapeutic challenge. The use of polymyxin B has been resurrected specifically for this purpose. P

27、ATIENTS AND METHODS: We retrospectively reviewed the clinical and microbiological efficacy, and safety profile of polymyxin B in the treatment of MDR Gram-negative bacterial infections of the respiratory tract. Twenty-five critically ill patients received a total of 29 courses of polymyxin B adminis

28、tered in combination with another antimicrobial agent. RESULTS: Patients were treated with intravenous, and/or aerosolized polymyxin B. Mean duration of polymyxin B therapy was 19 days (range 2-57 days). End of treatment mortality was 21%, and overall mortality at discharge was 48%. Nephrotoxicity w

29、as observed in three patients (10%) and did not result in discontinuation of therapy. CONCLUSIONS: Polymyxin B in combination with other antimicrobials can be considered a reasonable and safe treatment option for MDR Gram-negative respiratory tract infections in the setting of limited therapeutic op

30、tions.,J Antimicrob Chemother. 2004 Aug;54(2):566-9,2020/9/18,Dr.HU Bijie,25,銅綠假單胞菌 Pseudomonas aeruginosa,2020/9/18,Dr.HU Bijie,26,A 7-year study of severe hospital-acquired pneumonia requiring ICU admission,在16張和20張內(nèi)科-外科ICU中，連續(xù)觀察需要入住ICU的重癥HAP，共7年。 96次重癥HAP中，GNB占51，PA最常見（24）。 51例（53）死亡，曲菌和PA引起的肺炎病死

31、率最高。 感染性休克(OR: 14.27)和COPD (OR: 6.11) 是影響預(yù)后的獨(dú)立危險(xiǎn)因素。,Intensive Care Med. 2003 Nov;29(11):1981-8,2020/9/18,Dr.HU Bijie,27,鮑曼不動桿菌 Acinetobacter baumannii,2020/9/18,Dr.HU Bijie,28,Effect from multiple episodes of inadequate empiric antibiotic therapy for ventilator-associated pneumonia on morbidity and

32、mortality among critically ill trauma patients,BACKGROUND: The purpose of this retrospective study was to determine the effect of inadequate empiric antibiotic therapy (IEAT) on the outcome for adult trauma patients with VAP. METHODS: This study enrolled 82 patients with multiple VAP episodes (200 V

33、AP episodes; mean 2.4; range 2-5). An episode of IEAT was a VAP episode with empiric therapy having no in vitro activity against causative bacteria. There were 78 (39%) IEAT episodes involving 54 patients. Most often, IEAT was attributable to the presence of Acinetobacter spp, Stenotrophomonas malto

34、philia, or Alcaligenes xylosoxidans. All the patients received appropriate definitive therapy according to the final culture. The patients were classified by number of IEAT episodes: 0 (n = 28), 1 (n = 34), and more than 1 (n = 20). RESULTS: Demographics and injury severity were similar among the gr

35、oups. The mortality rate was 3.6% for no episodes, 8.8% for one episode, and 45% for more than one episode (p 0.001). On the basis of multiple logistic regression, experiencing multiple IEAT episodes was independently associated with the risk of death (odds ratio, 4.28; 95% confidence interval, 1.44-12.71). Additionally, experiencing multiple IEAT episodes was associated with prolonged intensive care unit stay (p = 0.007) and prolonged mechanical ventilation (p = 0.005). CONCLUS