呼吸科耐药革兰阴性杆菌与治疗策略

06 04 2020 Dr HUBijie 1 呼吸科耐药革兰阴性杆菌与治疗策略 株洲市二医院刘和平副主任医师 06 04 2020 Dr HUBijie 2 CAP Outpatient PreviouslyHealthyNorecentantibiotictherapy AmacrolideaordoxycyclineRecentantibiotictherapy Arespiratoryfluoroquinolone RFQ alone anadvancedmacrolide AM plushigh doseamoxicillinorAMplushigh doseamoxicillin clavulanateComorbidities COPD Diabetes RenalorCongestiveHeartFailure orMalignancy Norecentantibiotictherapy AMorRFQRecentantibiotictherapy RFQaloneorAMplusaB lactamSuspectedaspirationwithinfection Amoxicillin clavulanateorclindamycinInfluenzawithbacterialsuperinfection B lactamoraRFQ 06 04 2020 Dr HUBijie 3 CAP Inpatient MedicalWardNorecentantibiotictherapy RFQaloneorAMplusB lactamRecentantibiotictherapy AMplusB lactamorRFalone regimenselectedwilldependonnatureofrecentantibiotictherapy IntensiveCareUnit ICU Pseudomonasinfectionisnotanissue B lactampluseitherAMorRFQPseudomonasinfectionisnotanissuebutpatienthasB lactamallergy RFQ withorwithoutclindamycinPseudomonasinfectionisanissue Either 1 anantipseudomonalagentplusciprofluoxacin or 2 anantipseudomonalagentplusanaminoglycosideplusRFQoramacrolidePseudomonasinfectionisanissuebutpatienthasa lactamallergy theEither 1 aztreonampluslevofluoxacinor 2 aztreonamplusmoxifluoxacinorgatifluoxacin withorwithoutanaminoglycosideNursingHomeReceivingtreatmentinnursinghome RFQaloneoramoxicillin clavulanateplusAMHospitalized SameasformedicalwardandICU 06 04 2020 Dr HUBijie 4 NNIS报告的医院内肺炎 06 04 2020 Dr HUBijie 5 铜绿假单胞菌 肺炎克雷伯菌和鲍曼不动杆菌是HAP常见的革兰阴性杆菌 AntimicrobAgentsChemother 2003Nov 47 11 3442 7 06 04 2020 Dr HUBijie 6 NosocomialtracheobronchitisinMVpatients incidence aetiologyandoutcome EurRespirJ2002 20 1483 1489 06 04 2020 Dr HUBijie 7 医院内肺炎病原菌 Meta分析 全国1990 1998年 6062株菌 06 04 2020 Dr HUBijie 8 52例VAP病原分布 99 01 06 04 2020 Dr HUBijie 9 NLRTI前五位病原菌在6个常见科室的比较 谢红梅 胡必杰 何礼贤 等 2819例医院下呼吸道感染病原和预后分析 上海医学2003 26 880 885 06 04 2020 Dr HUBijie 10 医院内肺炎病原 早期 中期 晚期 135101520 链球菌 流感杆菌 金葡菌MRSA 肠杆菌 肺克 大肠 绿脓杆菌 不动杆菌 嗜麦芽窄食单胞菌 入院天数 06 04 2020 Dr HUBijie 11 呼吸科常见耐药革兰阴性杆菌 肺炎克雷伯杆菌 大肠埃希菌肠杆菌属 沙雷菌 枸橼酸菌 变形杆菌铜绿假单胞菌 其他假单胞菌鲍曼不动杆菌 其他不动杆菌嗜麦芽窄食单胞菌属伯克霍尔德菌属产碱杆菌属 黄杆菌属NPRS结果显示 铜绿和鲍曼作为MDR问题正在凸现 06 04 2020 Dr HUBijie 12 细菌耐药是否会影响病死率 治疗肺炎杆菌ESBL菌株血液感染 n 31 合适治疗 n 19 病死率5 不恰当治疗 n 12 病死率42 P 0 02 Source SchiappaetalJID1996 74 529 36 06 04 2020 Dr HUBijie 13 06 04 2020 Dr HUBijie 14 在ICU中肺部感染耐药菌问题尤为突出 06 04 2020 Dr HUBijie 15 MDR引起肺炎的防治策略 预防医院内肺炎 HAP VAP HCAP 早期 准确的病原学诊断 不要治疗定植菌和污染菌停止无效 耐药的抗生素 避免更严重的后果加大剂量 从药敏单中寻找中介 低敏 的药物联合使用 在安全范围内的最大剂量 时间依赖性的药在允许范围缩短用药间隔 甚至24h连续点滴旧药新用 多粘菌素E 舒巴坦对不动杆菌等联合用药 MIC为16ug ml的头孢他啶和16ug ml的阿米卡星合用可能有效 特门汀与氨曲南联合治不发酵糖菌效果有时很好 氨曲南可耐受金属酶 06 04 2020 Dr HUBijie 16 ManagingInfectionInTheCriticalCareUnit HowCanInfectionControlMakeTheICUSafe CritCareClin 2005Jan 21 1 111 28ShulmanL OstDDivisionofPulmonaryandCriticalCareMedicine NorthShoreUniversityHospital Manhasset NY11030 USA 06 04 2020 Dr HUBijie 17 VAP预防方法的有效性评价 RouteofintubationSearchforsinusitisCircuitchangesHumidifierHumidifierchangesEndotrachealsuctioningSubglotticsecretiondrainageChestphysiotherapyTracheostomyKineticbedsSemi recumbentpositionPronepositionStressulcerprophylaxisProphylacticantibiotics 06 04 2020 Dr HUBijie 18 06 04 2020 Dr HUBijie 19 Antisepticimpregnatedendotrachealtubesforthepreventionofbacterialcolonization 在实验室气道模型中建立不同对MRSA PA AB和产气肠杆菌有抗菌作用的气管插管 ETTs 包裹有洗必泰和碳酸银抗菌ETT和对照ETT 未包裹 用浓度108cfu ml的菌液污染 5天孵育 管腔的远端和近端分别采样细菌培养抗菌ETT细菌定植量为1 100cfu 管 而对照ETT达106cfu 管 P 0 001 结论 抗菌导管可有效预防VAP相关细菌在ETT上的生长 JHospInfect 2004Jun 57 2 170 4 06 04 2020 Dr HUBijie 20 EfficacyofheatandmoistureexchangersinpreventingVAP meta analysisofRCT OBJECTIVE SeveralRCThaveexaminedtheeffectofantibacterialhumidificationstrategies particularlythereplacementofheatedhumidifiers HH byheatandmoistureexchangers HME inpreventingVAP Thepresentmeta analysisreviewstheseRCTs METHODS RCTswereidentifiedbysearchingtheMedlineandCochraneCentralRegisterofControlledTrialsdatabasesfrom1990to2003 WeincludedRCTsusingHMEsinthetreatmentgroupandHHsinthecontrolgroupandreportingtheincidenceofpneumoniaasastudyoutcome Twoinvestigatorsindependentlyabstractedkeydataondesign population interventionandoutcomeofthestudies RESULTS Between1990and2003eightRCTsmettheinclusioncriteriaofthisanalysis PoolingtheresultsfromthesestudiesrevealedareductionintherelativeriskofVAPintheHMEgroup 0 7 particularlyinMVwithadurationofatleast7days fiveRCTs relativerisk0 57 CONCLUSIONS Thismeta analysisfoundasignificantreductionintheincidenceofVAPinptshumidifiedwithHMEsduringMV particularlyinptsventilatedfor7daysorlonger Thisfindingislimitedbytheexclusionofptsathighriskforairwayocclusionfromsomeofthestudies Contraindications tenacioussecretions airwayobstructivedisease hypothermia andtechnicalissuesofHMEsmustbeconsidered FurtherRCTsarenecessarytoexaminethewiderapplicabilityofHMEsandtheirextendeduse IntensiveCareMed 2005Jan 31 1 5 11 06 04 2020 Dr HUBijie 21 Ventilator associatedpneumoniausingaclosedversusanopentrachealsuctionsystem OBJECTIVE TheaimofthisstudywastoanalyzetheprevalenceofVAPusingaclosed trachealsuctionsystem CS vs anopensystem OS SETTING A24 bedmedical surgicalICUina650 bedtertiaryhospital PATIENTS PatientsrequiringMVfor 24hrs INTERVENTIONS Patientswererandomizedintotwogroups onegroupwassuctionedwithCSandanothergroupwiththeOS MEASUREMENTS Throatswabsweretakenatadmissionandtwiceaweekuntildischargetoclassifypneumoniainendogenousandexogenous MAINRESULTS Atotalof443pts 210withCS 233withOS wereincluded Therewerenosignificantdifferencesbetweengroupsofpatientsinage sex diagnosisgroups mortality numberofaspirationsperday andAPCHEIIscore Nosignificantdifferences inpercentageofptswhodevelopedVAP 20 47 vs 18 02 inthenumberofVAPcasesper1000MVDs 17 59vs 15 84 intheVAPincidencebyMVduration intheincidenceofexogenousVAP inthemicroorganismsresponsibleforpneumonia PatientcostperdayfortheCSwasmoreexpensivethantheOS 11 11USdollars 2 25USdollarsvs 2 50USdollars 1 12USdollars p 001 结论 闭合痰液吸引系统不能降低VAP发病率 包括外源性肺炎 CritCareMed 2005Jan 33 1 115 9 06 04 2020 Dr HUBijie 22 EarlyantibiotictreatmentforBAL confirmedventilator associatedpneumonia aroleforroutineendotrachealaspiratecultures 方法 299需要机械通气至少48h的病例 每周两次采集气管内吸引物 EA 定量培养 发生VAP后用BAL培养确定病原体 并与EA结果进行比较 最后有75例诊断VAP 41例BAL培养阳性 先前常规EA培养中有34例 83 阳性 1例早发肺炎发生VAP时还没有采集EA 4例结果不一致但抗菌药物选用合适 2例选用药物有延迟结论 每周两次常规EA培养对早期正确选用VAP治疗抗菌药物是合适的 Chest 2005Feb 127 2 589 97 06 04 2020 Dr HUBijie 23 BlindandbronchoscopicsamplingmethodsinsuspectedVAP Amulticentreprospectivestudy OBJECTIVE Tocompare4samplingmethods blindtrachealaspirate blindTA blindprotectedtelescopingcatheter blindPTC bronchoscopicPTCandbronchoscopicBAL fordiagnosisofVAP DESIGN SETTING Prospectivemulticentrestudy FiveICUinFrance PATIENTS 63ptswithMVformorethan48h norecentantibioticchange 72h andsuspectednosocomialpneumonia INTERVENTIONS Allpatientsunderwentthefoursamplingmethods Directexaminationandquantitativeculturesofthefourspecimenswereperformed MEASUREMENTSANDRESULTS Visiblesecretionsexpelledfromthecatheterwerepresent40times 63 forblindPTCand45times 71 forbronchoscopicPTC Afterexclusionof11uncertaincases 34VAPwerediagnosed DirectexaminationofPTC eitherblindorbronchoscopic didnotdifferfromdirectexaminationofbronchoscopicBALinpredictingVAPdiagnosisandinguidinginitialantibiotictreatmentcorrectly ComparedtothatofbronchoscopicBAL 0 98 theareaunderreceiveroperatingcharacteristics ROC curvewassmallerforblindTA 0 78 p 0 002 blindPTC 0 83 p 0 009 andbronchoscopicPTC 0 85 p 0 01 Whensampleswithvisiblesecretionsexpelledfromthecatheterwereconsidered blindandbronchoscopicPTChadareasunderROCcurveclosetothatofbronchoscopicBAL 0 90 p 0 22and0 91 p 0 27 respectively CONCLUSIONS BlindPTCappearstobeagoodalternativetobronchoscopicsamplingforVAPdiagnosis providedthatthesamplecontainsvisiblesecretionsexpelledfromthecatheter IntensiveCareMed 2004Jul 30 7 1319 26 06 04 2020 Dr HUBijie 24 CombinationtherapywithpolymyxinBforthetreatmentofmultidrug resistantGram negativerespiratorytractinfections BACKGROUND Thetreatmentofinfectionscausedbymultidrug resistant MDR Gram negativeorganismsposesatherapeuticchallenge TheuseofpolymyxinBhasbeenresurrectedspecificallyforthispurpose PATIENTSANDMETHODS Weretrospectivelyreviewedtheclinicalandmicrobiologicalefficacy andsafetypropolymyxinBinthetreatmentofMDRGram negativebacterialinfectionsoftherespiratorytract Twenty fivecriticallyillpatientsreceivedatotalof29coursesofpolymyxinBadministeredincombinationwithanotherantimicrobialagent RESULTS Patientsweretreatedwithintravenous and oraerosolizedpolymyxinB MeandurationofpolymyxinBtherapywas19days range2 57days Endoftreatmentmortalitywas21 andoverallmortalityatdischargewas48 Nephrotoxicitywasobservedinthreepatients 10 anddidnotresultindiscontinuationoftherapy CONCLUSIONS PolymyxinBincombinationwithotherantimicrobialscanbeconsideredareasonableandsafetreatmentoptionforMDRGram negativerespiratorytractinfectionsinthesettingoflimitedtherapeuticoptions JAntimicrobChemother 2004Aug 54 2 566 9 06 04 2020 Dr HUBijie 25 铜绿假单胞菌Pseudomonasaeruginosa 06 04 2020 Dr HUBijie 26 A7 yearstudyofseverehospital acquiredpneumoniarequiringICUadmission 在16张和20张内科 外科ICU中 连续观察需要入住ICU的重症HAP 共7年 96次重症HAP中 GNB占51 PA最常见 24 51例 53 死亡 曲菌和PA引起的肺炎病死率最高 感染性休克 OR 14 27 和COPD OR 6 11 是影响预后的独立危险因素 IntensiveCareMed 2003Nov 29 11 1981 8 06 04 2020 Dr HUBijie 27 鲍曼不动杆菌Acinetobacterbaumannii 06 04 2020 Dr HUBijie 28 Effectfrommultipleepisodesofinadequateempiricantibiotictherapyforventilator associatedpneumoniaonmorbidityandmortalityamongcriticallyilltraumapatients BACKGROUND Thepurposeofthisretrospectivestudywastodeterminetheeffectofinadequateempiricantibiotictherapy IEAT ontheoutcomeforadulttraumapatientswithVAP METHODS Thisstudyenrolled82patientswithmultipleVAPepisodes 200VAPepisodes mean2 4 range2 5 AnepisodeofIEATwasaVAPepisodewithempirictherapyhavingnoinvitroactivityagainstcausativebacteria Therewere78 39 IEATepisodesinvolving54patients Mostoften IEATwasattributabletothepresenceofAcinetobacterspp Stenotrophomonasmaltophilia orAlcaligenesxylosoxidans Allthepatientsreceivedappropriatedefinitivetherapyaccordingtothefinalculture ThepatientswereclassifiedbynumberofIEATepisodes 0 n 28 1 n 34 andmorethan1 n 20 RESULTS Demographicsandinjuryseverityweresimilaramongthegroups Themortalityratewas3 6 fornoepisodes 8 8 foroneepisode and45 formorethanoneepisode p 0 001 Onthebasisofmultiplelogisticregression experiencingmultipleIEATepisodeswasindependentlyassociatedwiththeriskofdeath oddsratio 4 28 95 confidenceinterval 1 44 12 71 Additionally experiencingmultipleIEATepisodeswasassociatedwithprolongedinten