重症医生在控制多重耐药菌（mdr）感染中的作用胡振杰课件

重症医生在控制多重耐药菌 (MDR)感染中的作用 河北医科大学第四医院ICU 胡振杰 多重耐药菌(MDR)感染及其危险因素； MDR in ICU HAI的风口浪尖； 重症医生应对多重耐药菌(MDR)感染的 措施； 重症医生在控制MDR感染中的作用 多重耐药菌(MDR)感染及其危险因素 Multidrug-resistant (MDR) bacterial pathogens, such as Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant Staphylococcus aureus(MRSA). Extendedspectrum-lactamaseproducing Enterobacteriaceae. American Journal of Respiratory and CCM.2005;171:388-416 Antimicrobial therapy in preceding 90 d Current hospitalization of 5 d or more High frequency of antibiotic resistance in the community or in the specific hospital unit Presence of risk factors for HCAP: Hospitalization for 2 d or more in the preceding 90 d Residence in a nursing home or extended care facility Home infusion therapy (including antibiotics) Chronic dialysis within 30 d Home wound care Family member with multidrug-resistant pathogen Immunosuppressive disease and/or therapy 多重耐药菌(MDR)感染及其危险因素 RISK FACTORS FOR MULTIDRUG-RESISTANT PATHOGENS CAUSING HOSPITAL-ACQUIRED PNEUMONIA, HEALTHCARE-ASSOCIATED PNEUMONIA, AND VENTILATOR-ASSOCIATED PNEUMONIA American Journal of Respiratory and CCM.2005;171:388-416 ICU patients tend to have more risk factors have the highest infection rates 多重耐药菌(MDR)感染及其危险因素； MDR in ICU HAI的风口浪尖； 重症医生应对多重耐药菌(MDR)感染的 措施； 重症医生在控制MDR感染中的作用 Development of Resistant Bacteria Critically Ill Inappropriate Infection Control Measures Inadequate Antimicrobial treatment Wards + ICU Ann Intern Med 2001; 134: 298-314. MDR in ICU HAI的风口浪尖 Contamination Gowns, Gloves and Hand of HCWs Infect Control Hosp Epidemiol 2010; 31(7):716-721 Outbreak of Acinetobacter Baumannii First outbreak （MICU Pat 29, Col 27 Inf 2） Second outbreak (MICU n=4 ) Dust in the interior of a mechanical ventilator and filters inside the Patient Warmer (Bair Hugger) Patient Dust in the interior of CVVH machines Patient Infect Control Hosp Epidemiol 2004, 25:1002 ICU中严格的感染控制措施就能够控制 MDR感染? MDR in ICU HAI的风口浪尖 How many infections are caused by patient-to-patient transmission in ICU? 了解ICU病人间致病菌传播在ICU获得性感染的地位,以 确定感染的来源内源性外源性; 18个月的前瞻性研究 2个大学的5家ICU, ICU住院2d 监测ICU常见的致病菌(indicator organisms)-基因型 Acinetobacter baumannii-complex, Enterobacter aerogenes Enterobacter cloacae, Escherichia coli, Enterococcus faecium,/Enterococcus faecalis, Klebsiella pneumoniae, Pseudomonas aeruginosa, S. aureus, Stenotrophomonas maltophilia Crit Care Med 2005; 33:946 951 How many infections are caused by patient-to-patient transmission in ICU? During 28,498 pat.d 431 ICU-acquired infections and 141 episodes of nosocomial transmissions 病人间致病菌的传播是ICU获得性感染的主要途径？ Crit Care Med 2005; 33:946 951 ICU的MDR还有其他来源吗？ MDR in ICU HAI的风口浪尖 39% 7% 54% MDR率 阴性率 MDR 2010年4月-9 月共160例患 者，入科24 小时内培养 阳性149例 (93%)，其中 MDR62例 (39%)。 入科细菌定植及/或感染率 Unpublished data 6% 41% 53% MDR率 阴性 MDR 2010年4月-9 月共160例患 者，出科时 细菌培养阳 性151例 (94%)，其中 MDR85例 (53%)。 出科细菌定植及/或感染率 Unpublished data 19% 4% 44% 7% 7% 1% 18%金葡 肠球菌 绿 不动 肺克 大肠 粘滞沙雷 阴沟肠 变形 其 他 35% 2% 5% 25% 5% 6% 2% 20% 31 24 22 45 00 17 22 0 4 51 88 100 20 0 10 20 30 40 50 60 金葡 肠球菌 绿脓 不动 肺克 大肠 粘滞沙雷 阴沟肠 变形 其他 入科时出科时 出入科时MDR的变化情况 Unpublished data Does antibiotic exposure increase the risk of MRSA isolation? A systematic review and meta-analysis Journal of Antimicrobial Chemotherapy (2008) 61, 2638 ICU 承担全院抗生素应用的后果； 全院MDRO的显示器，而不是驱动器； ICU可作为全院感控的监测窗口； MDR in ICU HAI的风口浪尖 多重耐药菌(MDR)感染及其危险因素； MDR in ICU HAI的风口浪尖； 重症医生应对多重耐药菌(MDR)感染的 措施； 重症医生在控制MDR感染中的作用 重症感染、感染性休克相关概念 SEPSIS SIRS INFECTION SEPSIS 其他 创伤 烧伤 胰腺炎 菌血症 真菌血症 寄生虫血症 病毒血症 其 他 Chest.1992;101:1644-1655 重症患者及相关感染概念 (ACCP/SCCM) Sepsis(全身性感染、脓毒症)=感染+SIRS； Septic shock(感染性休克)=Sepsis + 血流动 力学改变； Severe sepsis(严重感染)：Sepsis + 器官功能 障碍； MODS的诊断可以理解为：SIRS or Sepsis + 2个以上器官功能障碍； Chest.1992;101:1644-1655 应明确：炎症反应 = 感染 应对多重耐药菌(MDR)感染的措施 应对MDR感染的非抗生素防治策略： 抗生素相关策略-合理、规范使用抗生素 ； American Journal of Respiratory and CCM.2005;171:388-416 Clin Infect Dis.2009;49(1):1-45 Intensive care med.2008;34(1):17-60 Crit care med.2004;32:858-873 1. Effective infection control measures: staff education, compliance with alcohol-based hand disinfection, and isolation to reduce cross-infection with MDR pathogens should be used routinely (Level I) . 2. Surveillance of ICU infections, to identify and quantify endemic and new MDR pathogens, and preparation of timely data for infection control and to guide appropriate, antimicrobial therapy in patients with suspected HAP or other nosocomial infections, are recommended (Level II) American Journal of Respiratory and CCM.2005;171:388-416 应对MDR感染的非抗生素防治策略 (HAP、VAP) 1. Intubation and mechanical ventilation: 1). Intubation and reintubation should be avoided, if possible, as it increases the risk of VAP (Level I). 2). Noninvasive ventilation should be used whenever possible in selected patients with respiratory failure (Level I). 3). Orotracheal intubation and orogastric tubes are preferred over nasotracheal intubation and nasogastric tubes to prevent nosocomial sinusitis and to reduce the risk of VAP, although direct causality has not been proved (Level II). American Journal of Respiratory and CCM.2005;171:388-416 应对MDR感染的非抗生素防治策略 (HAP、VAP) 1. Intubation and mechanical ventilation: 4). Continuous aspiration of subglottic secretions can reduce the risk of early-onset VAP, and should be used,if available. 5). The endotracheal tube cuff pressure should be maintained at greater than 20 cm H2O to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract . 6). Contaminated condensate should be carefully emptied from ventilator circuits and condensate should be prevented from entering either the endotracheal tube or inline medication nebulizers (Level II). American Journal of Respiratory and CCM.2005;171:388-416 应对MDR感染的非抗生素防治策略 (HAP、VAP) 7). Passive humidifiers or heatmoisture exchangers decrease ventilator circuit colonization, but have not consistently reduced the incidence of VAP, and thus they cannot be regarded as a pneumonia prevention tool (Level I). 8). Reduced duration of intubation and mechanical ventilation may prevent VAP and can be achieved by protocols to improve the use of sedation and to accelerate weaning. 9). Maintaining adequate staffing levels in the ICU can reduce length of stay, improve infection control practices, and reduce duration of mechanical ventilation (Level II) . 1. Intubation and mechanical ventilation: American Journal of Respiratory and CCM.2005;171:388-416 应对MDR感染的非抗生素防治策略 (HAP、VAP) 应对MDR感染的非抗生素防治策略 (HAP、VAP) American Journal of Respiratory and CCM.2005;171:388-416 2. Aspiration, body position, and enteral feeding. 3. Modulation of colonization: oral antiseptics and antibiotics. 4. Stress bleeding prophylaxis, transfusion, and hyperglycemia. N Engl J Med 2006;355:2725-32 An evidence-based intervention 1981 ICU-months of data and 375,757 catheter-days 应对MDR感染的非抗生素防治策略 (Catheter-Related Bloodstream infections) An Intervention to Decrease CRBI the ICU N Engl J Med 2006;355:2725-32 应对MDR感染的非抗生素防治策略 (Catheter-Related Bloodstream infections) 应对MDR感染的非抗生素防治策略 (Catheter-Related Bloodstream infections) 应对MDR感染的抗生素治疗策略 (Catheter-Related Bloodstream infections) CRBI的诊断: 1.怀疑CRBSI时，应从外周静脉和导管取得配对血 液标本，在抗菌治疗应用前进行采集。标本小瓶 应做好标记，以表明血液样本的采集部位； 2.确诊CRBSI需要至少一份经皮采样血液培养和导 管尖端培养培养出同一种微生物，或者两份血液 培养结果满足CRBSI的定量培养或阳性结果差异 时间的诊断标准。 Clin Infect Dis.2009;49(1):1-45 应对MDR感染的抗生素治疗策略 (Catheter-Related Bloodstream infections) CRBSI的一般处理措施: 23.医院环境中耐甲氧西林金黄色葡萄球菌流行率 升高时，万古霉素作为经验治疗药物；在 MRSA 分离株中的优势株对万古霉素的MIC2g/ml，应 使用替代药物如达托霉素； 24.利奈唑胺不应作为经验治疗药物(例如对怀疑但 无证据支持的CRBSI病例)； Clin Infect Dis.2009;49(1):1-45 应对MDR感染的抗生素治疗策略 (Catheter-Related Bloodstream infections) CRBSI的一般处理措施: 26.对于中性粒细胞减少患者，患脓毒症的重症患者 ，已知有该类病原体定植的患者怀疑CRBSI时，应 该使用能覆盖多重耐药革兰阴性菌(如铜绿假单胞菌 )的药物进行经验性联合治疗，直到培养结果和药敏 结果数据后，再降阶梯使用抗感染药物； 30.应使用抗菌药物封管作为导管感染的补救措施； 如果抗菌药物栓疗法不能应用，则应通过细菌定植 的导管进行全身给药； Clin Infect Dis.2009;49(1):1-45 应对MDR感染的抗生素治疗策略 (HAP、VAP) 1. If P. aeruginosa pneumonia is documented, combination therapy is recommended. The principal justification is the high frequency of development of resistance on monotherapy. Although combination therapy will not necessarily prevent the development of resistance, combination therapy is more likely to avoid inappropriate and ineffective treatment of patients (Level II) . 2. If Acinetobacter species are documented to be present, the most active agents are the carbapenems, sulbactam, colistin, and polymyxin. There are no data documenting an improved outcome if these organisms are treated with a combination regimen (Level II) . American Journal of Respiratory and CCM.2005;171:388-416 应对MDR感染的抗生素治疗策略 (HAP、VAP) 3. If ESBL Enterobacteriaceae are isolated, then monotherapy with a third-generation cephalosporin should be avoided. The most active agents are the carbapenems (Level II) . 4. Adjunctive therapy with an inhaled aminoglycoside or polymyxin for MDR gram-negative pneumonia should be considered, especially in patients who are not improving with systemic therapy (Level III). More studies of this type of therapy are needed. American Journal of Respiratory and CCM.2005;171:388-416