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1、气道分泌物培养的临床意义北京协和医院 杜斌Conflicts of Interestv Astellas v AstraZeneca v Bayer v Dainippon Sumimoto Pharma v Eli Lilly v GlaxoWellcome v MSD v Pfizer (Wyeth) v 临床病例vM/75 yo vPMHx: 无 v2010/3/1 结肠癌穿孔 继发性腹膜炎 v术后收入ICU 感染性休克 急性肾功能衰竭 DIC v住ICU后病情逐渐稳定临床病例v2010/3/13 ICU Day 12 BT 39.8C WCC 16.8 v体格检查 双肺湿罗音 呼吸机条
2、件升高 PEEP 8 16 FiO2 0.4 0.6 PaO2/FiO2 165 80临床病例v考虑VAP 准备应用经验性抗生素v住院医师意见 一周前曾留取痰培养 铜绿假单胞菌 有助于确定目前致病菌?北京协和医院检验科细菌室姓名：XXX性别：男性 年龄：75病房：MICU 标本：痰日期：2010/3/5铜绿假单胞菌(Pseudomonas aeruginosa)头孢他啶R 哌拉西林/他唑巴坦R 头孢哌酮/舒巴坦R 亚胺培南S 美罗培南SVAP发生前的微生物学检查v739名可疑VAP患者入选 v281名(39%)患者入选前1 3日有培养结果 v130名(46%)患者培养出致病微生物Sanders
3、 KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not clinically useful for guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63VAP发生前的微生物学检查Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previou
4、s cultures are not clinically useful for guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63VAP发生前的微生物学检查Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not clinically useful for guidin
5、g empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63VAP发生前的微生物学检查经验性抗生素错误率 v根据革兰染色结果16% (11 33%) v根据分离所有微生物37% (29 45%) v根据药敏结果39% (31 48%)Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not c
6、linically useful for guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63VAP发生前的微生物学检查v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 v患者: 356名心脏手术患者 v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
7、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 v CXR出现新发浸润影或原有浸润影 加重 v 下列标准中2条或2条以上: 发热( 38.5C)或低体温( 6TBX诊断标准 v 脓性气管分泌物 v CX
8、R没有肺炎导致的浸润影 v 下列标准中2条或2条以上: 发热( 38.5C)或低体温( 25 /LPF涂片结果 革兰阴性杆菌大量 革兰阳性球菌可见VAP治疗 革兰染色结果QuestionsAnswersIn the case of a negative Grams stain of a respiratory sample of a patient with a suspicion of VAP, would you wait for cultures to start antibiotics?NoDepending on the patient*(10/12)(2/12)Rello J, P
9、aiva JA, Baraibar J, et al. International conference for the development of consensus on the diagnosis and treatment of ventilator-associated pneumonia. Chest 2001; 120: 955-970*Yes if the clinical situation clearly suggestive of pneumonia and if patient at high risk or clinically deterioratingVAP治疗
10、 革兰染色结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总计(n = 1164)602 (51.7)238 (20.4)324 (27.8)仅有1/2的VAP病例ETA革兰染色结果与培养结果相符Allaouchiche B, Jaumain H, Chassard D, et al. Gram stain of bronchoalveolar lavage fluid in t
11、he early diagnosis of ventilator-associated pneumonia. Br J Anaesth 1999; 83: 845-849 Duflo F, Allaouchiche B, Debon R, et al. An evaluation of the Gram stain in protected bronchoalveolar lavage fluid for the early diagnosis of ventilator-associated pneumonia. Anesth Analg 2001; 92: 442-447 Davis KA
12、, Eckert MJ, Reed RL II, et al. Ventilator-associated pneumonia in injured patients: do you trust your Gram stain? J Trauma 2005; 58: 462-466 Raghavendran K, Wang J, Belber C, et al. Predictive value of sputum Gram stain for the determination of appropriate antibiotic therapy in ventilator-associate
13、d pneumonia. J Trauma 2007; 62: 1377-1383 Albert M, Friedrich JO, Adhikari NKJ, et al. Utility of Gram stain in the clinical management of suspected ventilator-associated pneumonia: secondary analysis of a multicenter randomized trial. J Crit Care 2008; 23: 74-81VAP治疗 革兰染色结果Veinstein A, Brun-Buisson
14、 C, Derrode N, et al. Validation of an algorithm based on direct examination of specimens in suspected ventilator-associated pneumonia. Intensive Care Med 2006; 32: 676-683Suspected VAPPTC Gram stain -ve ETA Gram stain +veETA PTC, protected telescoping catheter *extensive lung involvement or severe
15、hypoxemia (P/F ratio 632665245CPIS ETA-Gram stain 676406058CPIS PTC-Gram stain 666546358Strategy studies83747979Veinstein A, Brun-Buisson C, Derrode N, et al. Validation of an algorithm based on direct examination of specimens in suspected ventilator-associated pneumonia. Intensive Care Med 2006; 32
16、: 676-683这一治疗策略提示 PTC革兰染色敏感性73%，特异性83%，PPV 83%，NPV 73%，可能漏诊VAP ETA革兰染色敏感性88%，特异性51%，PPV 68%，NPV 78%，可能误诊VAPWhen to start abxv怀疑VAP后尽早开始 12 h内? v不应等待痰涂片结果 即使痰涂片阴性，也需使用经验性抗生素临床病例v经验性抗生素选择 亚胺培南 米诺环素 万古霉素 vICU day 15 痰培养结果回报 v是否根据培养结果更换 抗生素?北京协和医院检验科细菌室姓名：XXX性别：男性 年龄：75病房：MICU 标本：痰日期：2010/3/12鲍曼不动杆菌(Acinetobacter baumannii)头孢他啶R 哌拉西林/他唑巴坦R 头孢哌酮/舒巴坦S 亚胺培南I 美罗培南I长期机械通气患者下呼吸道的细菌定植v目的：检查接受长期机械通气患者肺
