复杂腹腔感染（ciai）2010课件

成人与儿童复杂腹腔感染(CIAI) 诊断及治疗指南2010简介 浙江省嘉兴市第二医院ICU 蔡继明 成人与儿童复杂腹腔感染(CIAI) 诊断及治疗指南2010 nDiagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America 四个部分 n指南概要 n抗感染策略推荐 n治疗失败对策 n怀疑急性阑尾炎的诊断治疗路径 一、指南概要 n1初始诊断评估 n2液体复苏 n3开始抗感染治疗时间 n4适时介入因素 n5微生物评估 1初始诊断评估 n1. 常规病史,体检,实验室检查使大多数怀疑 IAI病人被鉴别以进一步评估与处理 (A-II). n 2. 某些病史不可靠患者如精神迟钝或免疫 抑制脊髓损伤 感染源不明时需考虑IAI (B- III). n3 有明显弥漫性腹膜炎体征的病人应该迅速 外科介入，没必要进一步检查 (B-III). n4.成人不行剖腹手术,首选 (CT) 明确是否是 IAI及部位 (A-II) 2液体复苏 n5.病人必须进行迅速复苏有效血容量，及其 他措施以使生理稳定 (A-II). n6. 脓毒性休克必须一有低血压立即复苏 (A- II). n7. 即使没有容量损耗证据，一旦怀疑IAI也 应开始复苏 (B-III). 3开始抗感染治疗时间 n8. 一旦IAI被怀疑或诊断，抗感染就应开始 。septicshock, antibiotics should be administered as soon as possible(A-III). n9. without septic shock, 应在急诊室开始抗菌 素治疗 (B-III). n10. 介入病灶治疗中要维持有效血药浓度， 介入开始时追加剂量是必要的 (A-I). 4适时介入因素 n11.几乎所有IAI感染源控制都是必要的(B-II) n12.弥漫性腹膜炎一旦可能就应急诊外科介 入，即使术中继续复苏 (B-II). n13.可能时经皮或局部引流优先于外科引流 (B-II). n14. 循环稳定而没有器官功能衰竭，经有效 抗感染，可严密观察24H，而不急于介入手 术 (B-II). 反之循环不稳定? n15. 关于再次剖腹In patients with severe peritonitis, mandatory or scheduled relaparotomy is not recommended in the absence of intestinal discontinuity, abdominal fascial loss that prevents abdominal wall closure, or intra-abdominal hypertension (A-II). n16. 关于局限的感染Highly selected patients with minimal physiological derangement and a well-circumscribed focus of infection, such as a periappendiceal or pericolonic phlegmon, may be treated with antimicrobial therapy alone without a source control procedure, provided that very close clinical follow-up is possible(B-II). 5微生物评估 n17. 血培养对CAI不推荐 (B-III). n18. 临床有中毒症状或免疫抑制患者血培养 有益 (B-III). n19. CAI无证据常规细菌染色(C-III). n20. HCAI染色怀疑yeast有益 (C-III). n21. 低危CAI常规 aerobic and anaerobic 培养 无益 (B-II). n22. 社区分离菌高耐药 (ie, resistance in 10% 20% of isolates) ,穿孔阑尾炎及其他CAI建议 培养 (B-III). n23. CAI没必要厌氧菌培养,只要常规覆盖 (B- III). n24.高危患者,尤 之前使用抗生素患者更易耐 药菌感染,应常规感染部位培养 (A-II). n25. 腹腔标本确可代表临床感染源 (B-III). n26. 关于标本采集送检Cultures should be performed from 1 specimen, provided it is of suffi cient volume (at least 1 mL of fl uid or tissue, npreferably more) and is transported to the laboratory in an nappropriate transport system. For optimal recovery of aerobic n bacteria, 110 mL of fl uid should be inoculated directly into n an aerobic blood culture bottle. In addition, 0.5 mL of fl uid nshould be sent to the laboratory for Gram stain and, if indicated, fungal cultures. If anaerobic cultures are requested, atleast 0.5 mL of fl uid or 0.5 g of tissue should be transported nin an anaerobic transport tube. Alternately, for recovery of n anaerobic bacteria, 110 mL of fl uid can be inoculated directly ninto an anaerobic blood culture bottle (A-I). n27. Susceptibility testing for Pseudomonas, Staphylococcus aureus, and predominant Enterobacteriaceae, as determined by moderate- to-heavy growth, should be performed, because these species are more likely than others to yield resistant organisms (A-III). 二、抗感染策略推荐 n成人轻中度CAI n成人高危CAI n成人HCAI nAntifungal Therapy nAnti-enterococcal Therapy nAnti-MRSA Therapy n成人胆囊炎与胆管炎 nPediatric Infection nPharmacokinetic Considerations n微生物结果对临床意义 n成人抗感染疗程 nUse of Oral or Outpatient Intravenous Antimicrobial Therapy 成人轻中度CAI n28. CAI经验治疗需覆盖enteric gram-negative aerobic and facultative bacilli and enteric gram-positive streptococci (A-I). n29. 覆盖厌氧菌 distal small bowel, appendiceal, and colon-derived infection and for more proximal gastrointestinal perforations in the presence of obstruction or paralytic ileus (A-I). n30. (Table 2) (A-I). n34. CAI不需覆盖肠球菌(A-I). 成人高危 CAI n38.high-severity CAI in Table 1 (Table2) (A-I). n41.aminoglycoside 无证据不常规推荐(A-I). n42. 肠球菌经验治疗被推荐 (B-II). n43. (MRSA) or yeast 无证据不推荐 (B-III). HCAI in Adults n45. -47 Antifungal Therapy n48. 腹腔念珠菌培养阳性在重CAI或H CAI推荐(B-II). n49. Fluconazole is an appropriate choice for treatment if nCandida albicans is isolated (B-II). n 50. For fl uconazole-resistant Candida species, therapy with an echinocandin (caspofungin, micafungin, or anidulafungin)is appropriate (B-III). n51. For the critically ill patient, initial therapy with an echinocandin instead of a triazole is recommended (B-III). nAnti-enterococcal Therapy n Anti-MRSA Therapy n如需要均推荐万古霉素 成人胆囊胆管炎 n 60. Ultrasonography is the fi rst imaging technique used for suspected acute cholecystitis or cholangitis (A-I). Pediatric Infection n64.-69 nPharmacokinetic Considerations 微生物指导临床 n75.引流液阳性(B-II).或2次血培养阳性有重 要意义 (A-I) CIAI抗感染疗程 n79. Bowel injuries attributable to penetrating, blunt, or iatrogenic trauma that are repaired within 12 h and any other n intraoperative contamination of the operative fi eld by enteric ncontents should be treated with antibiotics for 24 h (A-I). n80. Acute appendicitis without evidence of perforation, ab- nscess, or local peritonitis requires only prophylactic adminis- ntration of narrow spectrum regimens active against aerobic and nfacultative and obligate anaerobes; treatment should be discontinued within 24 h (A-I). n81. The administration of prophylactic antibiotics to pa- ntients with severe necrotizing pancreatitis prior to the diagnosis nof infection is not recommended (A-I). 三、治疗失败对策 n89. 经4-7天的治疗症状继续或复发,应开始包 括CT及BUS在内的再诊断，并应该继续有 效抗感染治疗 (A-III). n90. 腹腔外及非感染病应该被考虑 (A-II). n91. 病原学再调查both aerobic and anaerobic cultures should be performed from 1 specimen, provided it is of suffi cient volume (at least 1.0 mL of fl uid or tissue) and is transported to the laboratory in an anaerobic transport system(C- III). Inoculation of 110 mL of fl uid directly into an anaerobic blood culture broth bottle may improve yield. 四、怀疑急性阑尾炎诊治路径 n92. Local hospitals should establish clinical pathways to standardize diagnosis, in-hospital management, discharge, and out-patient management (B-II). n临床路径 There is now compelling evidence that the use of protocols forThere is now compelling evidence that the use of protocols for patient care management patient care management improves both the process of care and patient outcomesimproves both the process of care and patient outcomes n93. Pathways should be designed by collaborating clinicians involved in the care of these patients, including but not limited to surgeons, infectious diseases specialists, primary care practitioners, emergency medicine physicians, radiologists, nursing providers, and pharmacists, and should refl ect local resources and local standards of care (B-II). n 94. 病史体征Although no clinical fi ndings are unequivocal in identifying patients with appendicitis, a constellation of fi ndings,including characteristic abdominal pain, localized abdominal tenderness, and laboratory evidence of acute infl ammation, will generally identify most patients with suspected appendicitis(A-II). n95. 增强腹腔及盆腔Helical CT在怀疑急性阑尾炎病 人被推荐 with intravenous,but not oral or rectal (B-II). n96. All female patients should undergo diagnostic imaging.Those of child-bearing potential should undergo pregnancy testing prior to imaging and, if in the fi rst trimester of pregnancy, should undergo ultrasound or magnetic resonance instead of imaging ionizing radiation (B-II). If these studies do not defi ne the pathology present, laparoscopy or limited CT scanning may be considered (B-III). n97. Imaging should be performed for all children, particu- nlarly those aged !3 years, when the diagnosis of appendicitis nis not certain. CT imaging is preferred, although to avoid use nof ionizing radiation in children, ultrasound is a reasonable nalternative (B-III). n 98. For patients with imaging study fi ndings negative for nsuspected appendicitis, follow-up at 24 h is recommended to nensure resolution of signs and symptoms, because of the low nbut measurable risk of false-negative results (B-III). n99. For patients with suspected Appendicitis that can neither be confi rmed nor excluded by diagnostic imaging, careful follow-up is recommended (A-III). n100. Patients may be hospitalized if the index of suspicion is high (A-III). n101. Antimicrobial therapy should be administered to all patients who receive a diagnosis of appendicitis (A- II). n102. Appropriate antimicrobial therapy includes agents effective against facultative and aerobic gram-negative organisms and anaerobic organisms, as detailed in Table 2 for the treatment of patients with community- acquired intra-abdominal infection (A-I). n103. For patients with suspected appendicitis whose diag- nnostic imaging studies are equivocal, antimicrobial therapy nshould be initiated along with appropriate pain medication and nantipyretics, if indicated. For adults, antimicrobial therapy nshould be provided for a minimum of 3 days, until clinicalsymptoms and signs of infection resolve or a defi nitive diagnosis nis made (B-III). n104. Operative intervention for acute, nonperforated ap- npendicitis may be performed as soon as is reasonably feasible. nSurgery may be deferred for a short period of time as appro- npriate according to individual institutional circumstances (B- nII). n105. 腔镜与手术切除等效 (A-I). n106. Nonoperative management of selected patients with acute, nonperforated appendicitis can be considered if there is a marked improvement in the patients condition prior to operation (B-II). n107. Nonoperative management may also be considered as n part of a specifi c approach for male patients, provided that the npatient is admitted to the hospital for 48 h and shows sustained nimprovement in clinical symptoms and signs within 24 h while nreceiving antimicrobial therapy (A-II). n108. Patients with perforated appendicitis should undergo nurgent intervention to provide adequate source control (B-III). n109. Patients with a well-circumscribed periappendiceal abscess can be managed with percutaneous drainage or operative ndrainage when necessary. Appendectomy is generally deferred nin such patients (A-II). n110. Selected patients who present several days after devel- n opment of an infl ammatory process and have a periappendiceal nphlegmon or a small abscess not amenable to percutaneous ndrainage may delay or avoid a source control procedure to navert a potentially more morbid procedure than simple ap- npendectomy. Such patients are treated with antimicrobial ther-apy and care