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ICU感染的治疗北京协和医院杜斌ICU感染:患病率医院获得性感染的患病率为5–30%ICU患者感染的患病率约为18–50%较普通患者高3–18倍ICU床位=医院总床位数的5%医院获得性感染=25%SpencerRC.EpidemiologyofinfectioninICUs.IntensiveCareMed1994;20:S2-6.BatesDW,MillerEB,CullenDJ,etal.Patientriskfactorsforadversedrugeventsinhospitalizedpatients.ADEPreventionStudyGroup.ArchInternMed1999;159:2553-60.SinghN,YuVL.RationalempiricantibioticprescriptionintheICU.Chest2000;117:1496-9.ICU危重病患者的感染EuropeanPrevalenceofInfectioninIntensiveCareStudy(EPIC)1992年4月29日进行1417个ICU参加总计9567名ICU患者ICU危重病患者的感染21%14%10%ICU获得性感染社区获得性感染其他医院感染ICU感染的组成EPIC内科外科ICUNNISPUMC下呼吸道感染2418652753泌尿系感染433118205手术部位感染1112916血行性感染151022112其他1830132014感染对患者预后的影响增加住院日额外医疗费用手术部位感染7.33,152肺炎5.95,683血行性感染7.43,517泌尿系感染1.0680总计4.02,100ICU感染的致病菌耐药菌NNIS(1996–2000)北京协和医院ICU(1995–2000)平均耐药率(%)10%百分位数90%百分位数MRSA46.515.466.787MRSE74.956.986.795亚胺培南耐药的铜绿假单胞菌16.70.031.327头孢他啶耐药的铜绿假单胞菌11.70.025.028哌拉西林耐药的铜绿假单胞菌15.00.031.638三代头孢菌素耐药的肠杆菌25.910.050.954亚胺培南耐药的肠杆菌0.90.04.05三代头孢菌素耐药的肺炎克氏菌5.40.018.522三代头孢菌素耐药的大肠杆菌0.90.06.517氟喹诺酮耐药的大肠杆菌4.20.011.1671.DuB,ChenDC,LiuDW,XuYC,XieXL,ChenMJ.NatlMedJChina1996;76:262-6.2.LiY,DuB,ChenDC,LiuDW.BeijingMedJ2002;24:3-53.DuB.NatlMedJChina2001;81:1278-800%20%40%60%80%100%Luna,1997Ibrahim,2000Kollef,1998Kollef,1999Rello,1997Alvarez-Lerma,1996最初充分治疗最初不充分治疗*病死率指总病死率或感染相关病死率Alvarez-LermaFetal.IntensiveCareMed1996;22:387-394.RelloJetal.AmJRespirCritCareMed1997;156:196-200.KollefMHetal.Chest1999;115:462-474KollefMHetal.Chest1998;113:412-420.IbrahimEHatal.Chest2000;118:146-155.LunaCMetal.Chest1997;111:676-685.病死率*ICU中重度感染的危重病患者最初不充分抗生素治疗的病死率*ESBL阳性菌感染不适当抗生素治疗与病死率0%20%40%60%不适当适当病死率OR=4.701P=0.016BinDu,YunLong,HongzhongLiu,DechangChen,DaweiLiu,YingchunXu,XiuliXie.Extended-spectrumbeta-lactamase-producing-EscherichiacoliandKlebsiellapneumoniaebloodstreaminfection:riskfactorsandclinicaloutcome.IntensiveCareMed2002;28(12):1718-237/1414/71ICU感染的抗生素治疗:指征经验性抗生素治疗致病菌未知广谱抗生素针对性抗生素治疗(降阶梯治疗)根据致病菌及药敏结果结合临床疗效换用窄谱抗生素ICU感染的抗生素治疗:意义经验性抗生素治疗覆盖可能的致病菌降低病死率针对性抗生素治疗(降阶梯治疗)减少广谱抗生素的使用避免耐药发生抗生素治疗前后血培养的阳性率139名患者抗生素治疗前抗生素治疗过程中开始抗生素治疗83名患者(60%)血培养阴性或分离出污染菌0/83(0%)分离到致病菌56名患者(40%)分离到致病菌26/56(45%)分离到致病菌25名患者(45%)分离到致病的葡萄球菌19/25(76%)分离到葡萄球菌14名患者(25%)分离到致病的链球菌5/14(36%)分离到链球菌17名患者(30%)分离到革兰阴性杆菌2/17(12%)分离到革兰阴性杆菌1/139(0.72%)分离到新的致病菌GraceCJ,LiebermanJ,PierceK,etal.UsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.ClinInfectDis2001;32:1651-5临床意义应用抗生素前进行血培养分离到致病菌的可能性增加2.2倍在开始抗生素治疗最初72小时内,连续进行血培养的结果,可以根据应用抗生素前血培养的结果预测极少分离到新的致病菌医生可以等待应用抗生素前的血培养结果回报后,再进行新的血培养GraceCJ,LiebermanJ,PierceK,etal.UsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.ClinInfectDis2001;32:1651-5医院获得性肺炎的抗生素治疗目的:评价频繁更换抗生素对VAP患者预后的影响方法:回顾性分析56名VAP患者的临床资料根据更换抗生素的频率分为4组第1组(n=19)最初抗生素治疗无更改第2组(n=8)最初抗生素治疗更改1次第3组(n=19)最初抗生素治疗更改2次第4组(n=10)最初抗生素治疗更改3次降阶梯治疗及简化治疗除外KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S医院获得性肺炎的抗生素治疗12.78.16.95.9051015第1组第2组第3组第4组最初抗生素治疗错误比例(%)KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S医院获得性肺炎的抗生素治疗37.515.8141.2523.737.201020304050第2组第3组第4组百分比(%)根据培养结果调整抗生素无明确原因调整抗生素KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S医院获得性肺炎的抗生素治疗21.12557.980020406080100第1组第2组第3组第4组住院病死率(%)P=0.004P=0.04KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S如何鉴别真正的致病菌和污染菌常见致病菌(95%)金黄色葡萄球菌大肠杆菌肠杆菌铜绿假单胞菌肺炎链球菌白色念珠菌常见污染菌(5%)棒状杆菌属芽孢杆菌属疮疱丙酸杆菌TownsML,QuarteySM,WeinsteinMP,etal.Theclinicalsignificanceofpositivebloodcultures:aprospective,multicenterevaluation,abstr.C-232.InAbstractsofthe93rdGeneralMeetingoftheAmericanSocietyforMicrobiology1993.AmericanSocietyforMicrobiology,Washington,D.C.WeinsteinMP,TownsML,QuarteySM,etal.Theclinicalsignificanceofpositivebloodculturesinthe1990s:aprospectivecomprehensiveevaluationofthemicrobiology,epidemiology,andoutcomeofbacteremiaandfungemiainadults.ClinInfectDis1997;24:584-602.鉴别困难的分离株TownsML,QuarteySM,WeinsteinMP,etal.Theclinicalsignificanceofpositivebloodcultures:aprospective,multicenterevaluation,abstr.C-232.InAbstractsofthe93rdGeneralMeetingoftheAmericanSocietyforMicrobiology1993.AmericanSocietyforMicrobiology,Washington,D.C.WeinsteinMP,TownsML,QuarteySM,etal.Theclinicalsignificanceofpositivebloodculturesinthe1990s:aprospectivecomprehensiveevaluationofthemicrobiology,epidemiology,andoutcomeofbacteremiaandfungemiainadults.ClinInfectDis1997;24:584-602.真正菌血症的比例(%)草绿色链球菌38%肠球菌78%凝固酶阴性葡萄球菌15%鉴别困难的分离株细菌阳性预期值凝固酶阴性葡萄球菌0.28(0.26–0.31)草绿色链球菌0.54(0.45–0.61)棒状杆菌属0.16(0.11–0.23)痤疮丙酸杆菌0.00(0.00–0.03)杆菌属0.09(0.03–0.20)微球菌属0.00(0.00–0.08)总计0.27(0.25–0.29)GeffersC,FarrBM.Positivepredictivevalueofapercutaneouslydrawnbloodculturegrowingskinfloravariesmarkedlybyorganism.InfectControlHospEpidemiol200
本文标题:ICU感染的治疗
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