细菌耐药趋势及临床应对策略

1细菌耐药趋势及临床应对策略北京协和医院细菌室王辉2您在临床工作中遇到的最多的耐药菌是哪一类？•A多重耐药的铜绿假单胞•B产ESBLs细菌•C产Ampc酶•D碳青霉烯类耐药不动杆菌•EVRE•FMRSA3监测项目•NPRS（1994～2005，G-，重症病房，自测）•CMSS(2003~2006,10hospitals,G-,53%fromRTI)•SEANIR(2005to2008,15hospitals,all,45%fromRTI)•GPRS(2005to2006,5hospitals,G+；2006年7家)4广州杭州上海北京武汉成都新疆沈阳中国2005年启动SEANIR监测项目SurveillancebyEtestandAgardilutionofNationwideIsolateResistanceinChina(2005-2007)深圳广西陕西江苏吉林青岛大连5大肠杆菌3年耐药监测变迁2003-1562004-1612005-353药物RES%RES%RES%INT%SUS%RES_CI%头孢西丁17.611.371.113.9-22.1头孢哌酮/舒巴坦9.69.39.117.373.76.4-12.7哌拉西林/三唑巴坦4.53.122.895.20.9-4.2头孢噻肟34.632.934.319.546.229.4-39.5头孢噻肟/克拉维酸1.11.497.50.3-3.0头孢他啶10.610.915.34.580.211.8-19.6头孢他啶/克拉维酸1.70.697.70.7-3.8头孢吡肟16.716.913.99.976.210.6-18.1亚胺培南00.6001000.0-1.3美罗培南00001000.0-1.3环丙沙星71.877.675.11.123.870.2-79.56协和北京上海浙江深圳广州南宁新疆西安武汉南京沈阳长春大连青岛CTX20837322637325239622828354633CAZ8013418222612825816133617FEP80170916262030422444728CSL40740321831252809717IMP000000000000000大肠杆菌在15家医院的耐药率2005年798.895.388.678.67371.660.545.14038.128.620.30%10%20%30%40%50%60%70%80%90%100%IPMETPTZPAMKCSLCAZFEPTCCCTXCROGENCIP%R%I%S2004年大肠埃希菌敏感性（430株）8肺炎克雷伯菌3年耐药监测变迁2003-1302004-1232005-300药物RES%RES%RES%INT%SUS%RES_CI%头孢西丁17.7676.313.6-22.6头孢哌酮/舒巴坦1014.61511.373.711.3-19.7哌拉西林/三唑巴坦8.514.68.7487.35.9-12.6头孢噻肟23.12219.71664.315.4-24.8头孢噻肟/克拉维酸1.73.794.70.6-4.1头孢他啶16.225.2203.376.715.7-25.1头孢他啶/克拉维酸8.30.7915.5-12.2头孢吡肟12.314.68.78.782.75.9-12.6亚胺培南0.82.5001000.0-1.6美罗培南0.83.3001000.0-1.6环丙沙星39.238.236.7360.331.3-42.59300株肺炎克雷伯菌（SEANIR)1098.491.871.568.268.267.955.151.149.247.944.939.30%10%20%30%40%50%60%70%80%90%100%IPMETPFEPTZPAMKCSLCAZGENCTXCIPCROTCC%R%I%S2004年肺炎克雷伯菌敏感性11协和北京上海浙江深圳广州南宁新疆西安武汉南京沈阳长春大连青岛CTX041924123017201254432125218CAZ0819202540335603640163812FEP00118019086364842418CSL00193208335612274082918IMP000000000000000肺炎克雷伯菌的耐药率2005年121-258-256-274-253-272-261-2512-2513-25kpn14-251305041120广州CTX-M3,9SHV-2杭州CTX-M-3,9,14,22,24SHV-11,12,2上海(CTX-M3)北京(CTX-M-3,9,11,14SHV-2,3,14)武汉(CTX-M3)成都(CTX-M3)天津(CTX-M3)新疆CTX-M-3,9，SHV-12沈阳(CTX-M3)RateofCTX-MtypesinESBLsare70-90%inCHNsincefirstreportin2000toprecent近5年国内医学文献报道140%20%40%60%80%100%Eco(64)Kpn(24)CTX-M-９组+DHAPERSHV+CTX-M-9组CTX-M组CTX-M-1+９组CTX-M-９组CTX-M-1组北京大学第三医院ESBL基因型150%20%40%60%80%100%EcoKpnSHV+DHACTX-M-1组+DHACTX-M-９组+SHV+DHACTX-M-９组+DHASHV+CTX-M-9组CTX-M组CTX-M-1+９组CTX-M-９组CTX-M-1组中国10家医院ESBL基因型（2003）16奇异变形杆菌3年耐药监测变迁2003-462004-452005-78药物RES%RES%RES%INT%SUS%RES_CI%头孢西丁001000.0-5.8头孢哌酮/舒巴坦2.20001000.0-5.8哌拉西林/三唑巴坦02.201.398.70.0-5.9头孢噻肟2.28.902.697.40.0-5.8头孢噻肟/克拉维酸001000.0-5.8头孢他啶4.34.4001000.0-5.8头孢他啶/克拉维酸001000.0-5.8头孢吡肟2.22.2001000.0-5.8亚胺培南00001000.0-5.8美罗培南02.2001000.0-5.8环丙沙星32.635.626.92.670.517.8-38.317阴沟肠杆菌3年耐药监测变迁2003-192004-212005-187药物RES%RES%RES%INT%SUS%RES_CI%头孢西丁96.31.12.792.2-98.4头孢哌酮/舒巴坦21.329.910.717.172.76.8-16.3哌拉西林/三唑巴坦16.922.78.610.281.35.2-13.8头孢噻肟40.453.633.717.648.727.1-41.0头孢噻肟/克拉维酸15.521.463.110.8-21.7头孢他啶51.751.536.546.51.639.2-53.9头孢他啶/克拉维酸27.311.261.521.2-34.4头孢吡肟20.229.9155.979.110.4-21.1亚胺培南00001000.0-2.5美罗培南00001000.0-2.5环丙沙星43.849.524.64.870.618.7-31.518187株阴沟肠杆菌（SEANIR)1998.788.574.464.762.858.35045.538.531.430.1250%10%20%30%40%50%60%70%80%90%100%IPMETPAMKCSLFEPTZPCIPGENCAZCROCTXTCC%R%I%S2004年阴沟肠杆菌敏感性（156）20弗劳地枸橼酸杆菌3年耐药监测变迁2003-562004-482005-70药物RES%RES%RES%INT%SUS%RES_CI%头孢西丁84.34.311.473.2-91.5头孢哌酮/舒巴坦14.310.615.711.472.98.5-26.8头孢曲松41.139.63022.947.119.9-42.3头孢噻肟42.931.232.921.445.722.4-45.3头孢噻肟/克拉维酸14.318.667.17.4-25.2头孢他啶39.329.22018.661.411.7-31.6头孢他啶/克拉维酸37.11.461.426.1-49.5头孢吡肟17.918.85.712.981.41.8-14.7亚胺培南02.1001000.0-6.5美罗培南02.1001000.0-6.5环丙沙星44.637.544.32.952.932.6-56.62170株弗劳地枸橼酸菌（SEANIR)22非发酵糖菌：•绿脓杆菌•鲍曼不动杆菌23绿脓杆菌3年耐药监测变迁2003-1232004-1212005-299药物耐%耐%耐%中%敏%RES_CI%头孢哌酮/舒巴坦15.41924.417.458.219.7-29.7哌拉西林/三唑巴坦2623.126.8073.221.9-32.3头孢他啶23.619.835.1559.929.8-40.8头孢吡肟13.819.825.416.158.520.6-30.8亚胺培南222419.7575.315.4-24.8美罗培南5.714.910.41178.67.3-14.6环丙沙星23.631.427.17.465.622.2-32.6左氧沙星28.86.764.523.8-34.3多粘菌素B4.3095.72.4-7.424300株绿脓杆菌（SEANIR)25协和北京上海浙江深圳广州南宁新疆西安武汉南京沈阳长春大连青岛CAZ404440161717176519335225166838FEP2824260177173125205625205833CSL28287121772530127602986814IMP12363712013823120402186133MEM1612080317156024482619绿脓杆菌在15家医院的耐药率举例2005年261－2513－2412－258－266－294－252－2516－2114－25PAE2770.266.762.360.358.653.450.74745.418.88.48.40%10%20%30%40%50%60%70%80%90%100%AMKTZPIPMCAZCSLCIPFEPGENTCCETPCROCTX%I%R%S2004年铜绿假单胞菌的敏感性（406株）28鲍曼不动杆菌3年耐药监测变迁2003-882004-992005-239药物RES%RES%RES%INT%SUS%RES_CI%头孢哌酮/舒巴坦11.413.111.73256.38.0-16.7哌拉西林/三唑巴坦2731.338.514.347.232.3-45.1头孢他啶46.650.553.77.838.547.0-60.2头孢吡肟51.552.548.112.139.841.5-54.7亚胺培南4.518.216.5380.512.1-22.1美罗培南4.317.216.97.875.312.4-22.5环丙沙星53.458.658.91.339.852.2-65.3阿米卡星40.951.550.61.348.144.0-57.2多粘菌素B1.7098.30.5-4.6复方磺胺38.1061.919.0-61.3米诺环素22.521.256.317.4-28.529浙江北京大连广西广州吉林南京协和青岛上海陕西深圳武汉新疆CSL060014401328000000IMP604433004416000008美平5644170041232000008多粘040000440000208米诺6852429808282504083400不动杆菌在15家医院的耐药率举例2005年30331株鲍曼不动杆菌（SEANIR)3175.75442.439.536.535.935.135.133.327.618.312.40%10%20%30%40%50%60%70%80%90%100%IPMCSLAMKTZPCIPFEPCAZTCCGENETPCTXCRO%R%I%S