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1、2018/8/29,Dr.HU Bijie,1,呼吸科耐药革兰阴性杆菌 与治疗策略,株洲市二医院 刘和平副主任医师,2018/8/29,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 o
2、r 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,2018/8/29,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,2018/8/29,Dr.HU Bijie,4,NNIS报告的医院内肺炎,2018/8/29,Dr.HU Bijie,5,铜绿假单胞菌、肺炎克雷伯菌和鲍曼不动杆菌 是HAP常见的革兰阴性杆菌,Antimicrob Agents Chemother. 2003 Nov;47(11):3442-7,2018/8/29,Dr.HU Bijie,6,Nosocomial trache
7、obronchitis in MV patients: incidence, aetiology and outcome,Eur Respir J 2002; 20: 14831489.,2018/8/29,Dr.HU Bijie,7,医院内肺炎病原菌 （Meta分析，全国19901998年，6062株菌）,2018/8/29,Dr.HU Bijie,8,52 例 VAP 病 原 分 布 (9901),2018/8/29,Dr.HU Bijie,9,NLRTI前五位病原菌在6个常见科室的比较,谢红梅，胡必杰，何礼贤，等. 2819例医院下呼吸道感染病原和预后分析.上海医学2003；26：880
8、-885,2018/8/29,Dr.HU Bijie,10,医院内肺炎病原,早期,中期,晚期,1 3 5 10 15 20,链球菌,流感杆菌,金葡菌 MRSA,肠杆菌,肺克，大肠,绿脓杆菌,不动杆菌,嗜麦芽窄食单胞菌,入院天数,2018/8/29,Dr.HU Bijie,11,呼吸科常见耐药革兰阴性杆菌,肺炎克雷伯杆菌，大肠埃希菌 肠杆菌属，沙雷菌，枸橼酸菌，变形杆菌 铜绿假单胞菌，其他假单胞菌 鲍曼不动杆菌，其他不动杆菌 嗜麦芽窄食单胞菌属 伯克霍尔德菌属 产碱杆菌属，黄杆菌属NPRS结果显示，铜绿和鲍曼作为MDR问题正在凸现,2018/8/29,Dr.HU Bijie,12,细菌耐药是否会
9、影响病死率 ?,治疗肺炎杆菌ESBL菌株血液感染 (n=31),合适治疗 (n=19) 病死率 5%不恰当治疗(n=12)病死率 42%P=0.02,Source:Schiappa et al JID 1996; 74:529-36,2018/8/29,Dr.HU Bijie,13,2018/8/29,Dr.HU Bijie,14,在ICU中肺部感染耐药菌问题尤为突出,2018/8/29,Dr.HU Bijie,15,MDR引起肺炎的防治策略,预防医院内肺炎（HAP、VAP、HCAP） 早期、准确的病原学诊断，不要治疗定植菌和污染菌 停止无效、耐药的抗生素，避免更严重的后果 加大剂量：从药敏单
10、中寻找中介（低敏）的药物联合使用，在安全范围内的最大剂量，时间依赖性的药在允许范围缩短用药间隔，甚至24h连续点滴 旧药新用：多粘菌素E，舒巴坦对不动杆菌等 联合用药：MIC为16ug/ml的头孢他啶和16ug/ml的阿米卡星合用可能有效；特门汀与氨曲南联合治不发酵糖菌效果有时很好；氨曲南可耐受金属酶,2018/8/29,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):1
11、11-28 Shulman L, Ost D Division of Pulmonary and Critical Care Medicine, North Shore University Hospital, Manhasset, NY 11030, USA,2018/8/29,Dr.HU Bijie,17,VAP预防方法的有效性评价,Route of intubation Search for sinusitis Circuit changes Humidifier Humidifier changes Endotracheal suctioning Subglottic secretio
12、n drainage Chest physiotherapy Tracheostomy Kinetic beds Semi-recumbent position Prone position Stress ulcer prophylaxis Prophylactic antibiotics,2018/8/29,Dr.HU Bijie,18,2018/8/29,Dr.HU Bijie,19,Antiseptic impregnated endotracheal tubes for the prevention of bacterial colonization,在实验室气道模型中建立不同对MRS
13、A, PA, AB 和产气肠杆菌有抗菌作用的气管插管(ETTs) ，包裹有洗必泰和碳酸银 抗菌ETT和对照 ETT (未包裹）用浓度108cfu/ml的菌液污染，5天孵育，管腔的远端和近端分别采样细菌培养 抗菌ETT细菌定植量为1-100 cfu/管，而对照ETT达106cfu/管(P 0.001). 结论：抗菌导管可有效预防VAP相关细菌在ETT上的生长,J Hosp Infect. 2004 Jun;57(2):170-4,2018/8/29,Dr.HU Bijie,20,Efficacy of heat and moisture exchangers in preventing VAP:
14、 meta-analysis 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 identif
15、ied by 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 dat
16、a on design, 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
17、of at least 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 occlusion 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.,
