雾化吸入抗生素治疗呼吸机相关感染

Ventilator-associated infection: the role for inhaled antibiotics,Lucy B. PalmerCurrent opinion in pulmonary medicine 2015, 21:239249,IntroductionPathophysiology and rationaleClinical trialsDrug resistanceConclusion,outline,Ventilator-associated pneumonia (VAP) Ventilator-associated tracheobronchitis (VAT) multidrug resistant (MDR) extensively drug-resistant (XDR) inhaled antibioticsnebulizers,Introduction,Subglottic secretions，disturbed mucociliary clearance,damaged mucosa, bacterial biofilm.,Pathophysiology and rationale,Pathophysiology and rationale,2007，Ioannidou et al，meta-analysis，higher rates of resolution of signs and symptoms of VAP，OR 3.14recent studies （listed below）,Clinical trials,Clinical trials,1.2.3.4.5.6.,Clinical trials,7.8.9.10.,Clinical trials,11.12.,多研究VAP，1提及VAT，2、12VAT，同一作者。细菌鲍曼不动、铜绿假单胞、肺炎克雷伯多见。抗生素粘菌素多见，万古、庆大、阿米卡星+头孢他啶、妥布等。雾化器多样，部分未描述雾化器。雾化吸入多联合静脉用药。多未见副作用，6提及低氧血症、滤器堵塞、心脏骤停？结论：雾化吸入无耐药、缩短全身抗生素使用时间、减少抗生素使用量。细菌根除率高？临床治愈率高？存活率高？,Peak antibiotic concentrations 200-fold(AA+i.v.) Vs (placebo+i.v.): signs of respiratory infection extubated more often need of additional antibiotics bacterial resistanceVAT VAP,VAT Clinical trials,X,VAT Clinical trials,Clinical Pulmonary Infection Scorevolume of secretions（ml/4h）AA：eradication drug-resistance,Colistin neurological and renal toxicity stop for 40 years drug-resistance AA,Colistin Clinical trials,Colistin Clinical trials,7.AA+i.v.: more MDROs (52.6 vs. 14.9%) , higher APACHE II scores (21.45.7 vs. 17.55.3), But Survive more.,8.Lu et al.，AA/(AA+i.v. 3 days) to resistant vs. i.v. to susceptible organisms: cure rate/mortality no difference.AA+i.v. better？11. Tumbarello et al.，AA+i.v. vs. i.v. to COS: cure rate (69.2 vs. 54.8%) , mechanical ventilation (8 vs. 12 days), Eradication (63.4 vs. 50%, p=0.08), mortality, ICU stay, AKI: No differences.,Colistin Clinical trials,10.Doshi et al.，AA+i.v. vs. i.v. to MDROs:Cure rate(54.5 vs. 39.2%;p=0.135) ,Eradication(44.4 vs. 40.7%;p=0.805),Motality(40 vs. 70%;p=0.055),High quality culture subgroup cure rate(57.1 vs. 31.3%;p=0.033).,Colistin Clinical trials,3. AA+i.v.: no new resistance,1. AA/AA+i.v.: no new resistance,2.AA/AA+i.v. vs. placebo+i.v.: 0 vs.33%,6. AA vs. i.v.: 0 vs. 45%,12. AA+i.v. vs. placebo+i.v.: 0 vs. 56%,8.AA/AA+i.v. to resistant vs. i.v. to susceptible organisms : 25% susceptible vs.75% resistant.Hypothesis：AA very high antibiotic concentration eradicate the highly resistant organismsdrug-resistance,Drug resistance,The concentrations