医院获得性感染肺炎防治进展.doc

医院获得性感染肺炎防治进展 /东南大学医学院附属中大医院东南大学急诊与危重病医学研究所?HAP流行病学和MDR在ICU的重要性?HAP的机制与MDR的危险因素?HAP的诊断?HAP的非抗生素预防策略?HAP的抗生素治疗策略早期的有效的经验性治疗降阶梯策略MDR耐药的预防?Hospital-acquired pneumonia(HAP)入院48h后?Ventilator-associated pneumonia(VAP)插管4872h?Healthcare-associated pneumonia(HCAP)Any patient出现感染的90天内在ICU住院2天以上Resided in a nursinghomeReceived recentiv antibiotic,chemotherapy orwound carelast30daysAttended ahospital orhemodialysis clinicATS.Am J Respir Crit Care Medxx;171:388?高发病率-最常见的院内感染之一(第二位)5-15cases/1000admissions6to20fold higherin MVpatients25%of allICU infections50%of allantibiotics prescribed?常见病原菌-Aerobic gram-negative bacilliP.aeruginosa、K.pneumoniae、Aciobacter spp.-Gram-positive?MRSA-Anaerobes areunmon Am J Respir Crit Care,xx;165:867MMWR RemRep,xx;53(RR-3):1-36Extra-ICU/hosp stay?NP/VAP:ICU stayincreased3fold?1032d additionalhosp stay?9.2d ofadditional hospital stay?Median lengthof ICU stay forVAP21d vs15d forcontrol patFagon et al.Am J Med1993,94:281-288.Jimenez et al.Crit Care Med1989,17:882-885.Leu et al.Am JEpidemiol1989,129:1258-1267VAP P0.001J Relloet alEpidemiology&outes of VAP ina largeUS database.-?33-50%attributable mortalityMDR infectionMDR Multi-Drug-resistance?G-菌对四类抗生素中3/4类耐药Ceftazidine,Ciprofloxacin,Gentamicin,ImipenemPseudomonas aeruginosa Aciobacter speciesESBLs/AmpC?COS,CCOS PDR?G+MRSA G-?Prospective cohortstudy.Dec1996to Sep2000Inpatient surgicalwards ata universityhospN=924pats withGNR infections?Outes werepared betweenGNR infectionswith andwithout antibioticres?rGNRs:resistant toone ormore ofthe followingall aminoglycosides,including amikacinall cephalosporinsall carbapenemsall fluoroquinolonesCrit Care Medxx;31:10351041rGNR:入住ICU MVCRRT抗生素更换住院时间病死率-?N=489pats withNP耐药?对PIP,CFZ,IMP,CIP至少1个耐药入组时耐药n=144治疗过程中(14d)出现耐药n=30?Mortality:敏感组7.5%vs耐药组7.6%(p=0.96,RR0.94)治疗过程持续敏感组6.3%vs新耐药组26.6%(p=0.03,RR2.9)?继发性菌血症治疗过程持续敏感组1.4%vs新耐药组14%(p0.050.04环境和手?主要为G+菌Hand ofPat Handof staffG+high highG-low lowColonization AspirationHAP MRSA*?传播途径?误吸?最重要的NP/VAP的原因?经空气和血源性感染?并不常见MDR-MV135episodes inICU0510152025%+/+/+/P.aeruginosaA.baumannii MRSAAm J Respir Crit Care Med.1998;157:531Variable ORP MV7d6.0.009Prior ABs13.5103CFU/ml)bronchoalveolar lavage(104CFU/ml)endotrachealaspirate(106CFU/ml)?Antibiotic usemore appropriate、aurate?Improved survivalBaughman RP.Chest.2000;117:203S FagonJY,et al.Ann InternMed2000;132:621Cook D,et al.Chest.2000;117:195S?气管插管与机械通气?插管路径?NIV/IV?气囊的管理?声门下的积液?湿化与雾化?管路与冷凝水?MV时间?误吸/体位?体位/胃肠道返流?营养途径?口鼻咽腔/肠道定植?溃疡预防/血糖控制?ICU的医强A.-Hand washing漂白粉消毒手Ignaz PhilippSemmelweis(1818-1865)Hand washing-important underusedmeasure toprevent NPNOW消毒剂对手部细菌的清除作用99.93.099.02.090.01.00.00.0含有乙醇的刷手液?70%异丙醇?抗菌肥皂?4%洗必太?普通肥皂杀灭细菌比例%log0180分钟60消毒后时间Hosp EpidemiolInfect Control,2nd Edition,1999.?The useof protectivegowns andgloves duringpatient contactcan notbe remendedfor theroutine preventionof VAP?Must beconsidered Whenhandling respiratorysecretions Duringpatient contactwhen thepatient carriesan MDRpathogen(MRSA)B. (1)MV RelloJ.Crit Care Medxx;31:25442551Ibrahim EHet al.Chestxx?120:555-61?Casecontrol studyin France?N=50pats withCOPD exacerbationand cardiogenicpul edema0%10%20%30%40%50%60%Nosoial inf(P0.001)NP(P=0.04)Antibiotic forNI(0.01)Crude mortality(p=0.002)NIVMVJAMA2000,284:2361-2367. (2)NIV-COPD exacerbationand cardiogenicedema NIVMV PMV时间6d10d0.01LOS ofICU9d15d0.0295.50%22.50%0%20%40%60%80%100%鼻窦炎患病率/%经鼻插管经口插管Rouby JJ,et al.Am JRespir CritCareMed.150:776783经鼻/口插管后1周鼻窦炎和VAP患病率67.00%43.00%0%20%40%60%80%VAP发生率/%鼻窦炎者非鼻窦炎者 (3)Am JRespir CritCareMed1995,152:137Case-match studyn=40Previous durationof MV=2d (4)Re-intubation ControlsP NP/%47%10%0.001Mortality Total35%20%0.14Related17.5%0%0.01ICU stay/d19+/-1014+/120.02)Non-antibioticgroup(P2048h (8)呼吸机管路的更换频率Ventilator circuitchange q48h NoP VAP31.4%28.6%0.8Duration ofMV10.1d9.1d0.7Mortality17.1%25%0.4Deaths withVAP8.6%7.1%0.8?VAP6%16%0%5%10%15%20%HME(n=140)Humidifier(n=140)VAP/%2443389xx00200030004000HME(n=140)Humidifier(n=140)Circuit cost/group?HEM reducedhosp-,not munity-acquired VAP?HEM reducedICUstay?HEM reducedcircuit costKirton OC.Chest1997,112:1055-1059. (9)HME?Aspiration pattern:time dependentfor proneposition TorresAT.Ann InterMed,1992,116:540C./ (1)?Multicenter,prospective,randomized,single-blind study?Enteral nutritionstarted in101pats duringfirst36h?Nasogastric tubevs nasogastrojejunaltube?Results:Gastrointestinal plications:57%vs25%P48h?Sucralfate1g/6h in604patients?IV ranitidine50mg/8h in596patients P221umol/L96(12.3%)69(9%)BUN19.2mmol/L88(11.2%)59(7.7%)RRT64(8.2%)37(4.8%)ICU5d20.2%10.6%Bloodstream infection(n)6132(P10ds(n)13486(P5days)or riskfactorsfor MDR PathogensNo YesLimited Spectrum Therapy BroadSpectrumTherapyforMDRPathogens ATS.Am JRespir CritCareMed.xx,171:388-416HAP MDRPotential PathogenStreptocous pneumoniaeHaemophilus influenzaeMethicillin-sensitive Staphylocousaureus Entericgram-negative bacilli(Antibiotic sensitive)Enterobacter speciesEscherichia coliKlebsiella speciesProteus speciesSerratia marcescensRemended AntibioticCeftriaxone orLevofloxacin orMoxifloxacin orCiprofloxacin orAmpicillin/sulbactam orErtapenem ATS.AmJRespirCritCareMed.xx,171:388-416Potential PathogensP.aeruginosa ESBL(+)K.pneumoniae Aciobacterspecies MRSAL.pneumophila TherapyAntipseudomonal cephalosporin(cefepime,ceftazidime)or Antipseudomonalcarbapenem(?mipenem,meropenem)or Piperacillin-tazobactam plusCiprofloxacin orlevofloxacin orAminoglycoside Linezolidor vanycinATS.AmJRespirCritCareMed.xx,171:388-416MDR起始经验治疗晚发型或具有MDR病原菌危险因素的HAP、VAP和HCAP患者和所有重症感染患者MDR病原菌抗生素*联合治疗铜绿假单胞菌肺炎克雷伯菌?ESBL+?不动杆菌属抗假单胞菌头孢菌素?头孢他啶、头孢吡肟?或抗假单胞菌碳青霉烯类?亚胺培南、美罗培南?或-内酰胺/-内酰胺酶抑制剂?哌拉西林-他唑巴坦?加抗假单胞菌氟喹诺酮类?环丙沙星或左氧氟沙星?或氨基糖苷类?阿米卡星、庆大霉素或妥布霉素?*抗菌活性范围、抗生素的有效剂量、药动学特性、各种抗菌药物的不良反应和单药治疗的作用都经过委员会的仔细审核?评价de-escalation在VAP抗生素治疗中的意义前瞻性观察性研究(43m)MICU andSICU115pats withVAP?121次VAP抗生素改变56.2%,deescalation抗生素改变的主要原因,占31.4%ICU-mortality32.2%不合适起始抗生素9%,增加14.4%病死率CritCareMedxx;32:21832190抗生素轮换Strategy ofantibiotic rotation?Pellegrin UniversityHospital,France?Medical ICU:16beds?Time:7years study?2856pats withMV-VAP(early/late onset)?Period:1:1995-1996对照2:1997-1998阶段轮换阶段3:1999-xx扩大样本轮换?Rotation:1months CCMxx,31 (7):1908-14Cycling inthe Managementof Resistance?Cycling protocols(cefepime,pip/tazobactam,IMP,ticarcillin-clavulanic,可合用Amk/Tob/Net,限制Cipro等)at1month intervalsinaMICU?Oute:resistance inG-and incidenceof VAP?Before period(1995-1996):n=1044/After period(1997-998):n=1022patients withMV48h?MDR-铜绿/洋葱/不动/嗜麦牙:140to79?P.aeruginosa/B.cepa