复杂腹腔感染

复杂腹腔感染,浙江省嘉兴市第二医院ICU 蔡继明,IAI相关指南,the Therapeutic Agents Committee of the Surgical Infection Society,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3, Number 3, 2002IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of America；Clinical Infectious Diseases 2010; 50:13364 Infectious Diseases Society of Taiwan; Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults, J Microbiol Immunol Infect. 2008;41:279-281,腹腔感染(IAI)概述,过去一个世纪IAI治疗取得巨大进步，死亡率显著下降 90% in 1900 to 23% in 2002IAI不同来源感染的死亡率 appendix (0.25%) stomach/duodenum (21%) pancreas (33%) small bowel (38%) large bowel (45%) biliary tract (50%),JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections, cleveland clinic journal of medicine volume 74 supplement 4 august 2007,IAI定义分类,f. M. pieracci, p. S. barie,ManageMent of Severe SepSiS of abdoMinal origin, Scandinavian Journal of Surgery 96: 184196, 2007,单纯腹腔感染复杂腹腔感染Intra-abdominal infections also can be categorized as uncomplicated versus complicated, although the distinction is not always clear,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Uncomplicated IAI,单纯性腹腔感染仅累及1个器官,而且没有解剖结构的破坏通常病灶可完全切除，仅需预防性使用抗菌药物,Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20,复杂腹腔感染(cIAI),复杂腹腔感染(cIAI) 通常定义为空腔脏器的内容穿入腹腔导致局限性腹膜炎(包括脓肿)、弥漫性腹膜炎感染源经外科处理后，仍残留细菌，需使用抗感染药物cIAI 更多地与不良预后相关，其最大挑战是早期识别,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20,细菌性腹膜炎分类,原发性腹膜炎继发性腹膜炎第三型腹膜炎,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Primary bacterial peritonitis,指腹腔没有破口的自发性腹膜炎更多见于婴幼儿、肝硬化及免疫抑制的病人,Secondary bacterial peritonitis,继发性腹膜炎是肠源细菌通过胃肠道穿孔泄漏入腹腔导致的感染炎症It may be community-acquired or healthcareassociated.,Tertiary peritonitis,原发、继发性腹膜炎经治疗后症状仍持续或48小时后症状复苏常见于有严重合并症或免疫抑制的病人特点:医院获得性感染多为耐药菌可能为肠道菌群易位,社区获得性腹腔感染,感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔多为革兰氏阴性菌、厌氧菌，较少耐药多为轻中度腹腔感染如有脏器功能不全、免疫抑制的病人则归为重度腹腔感染,医院获得性腹腔感染,多为术后感染，如肠吻合口瘘并腹腔感染可合并休克、脏器功能损害，多为重度腹腔感染可为革兰氏阴性杆菌、肠球菌或条件致病菌，多为耐药菌。如产ESBL的大肠杆菌，阴沟肠杆菌，铜绿假单胞菌，还有念珠菌,IDSAcIAI指南的定义,该指南排除了肝脾实质的脓疡、泌尿生殖系统来源的感染、后腹膜感染(但除外胰腺感染)2003版指南不拟适用于小于18岁儿童及原发性腹膜炎，2010版作了扩展,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,腹腔感染常见致病菌,胃、十二指肠、近端小肠与胆道：革兰阴性或阳性需氧菌或兼性需氧菌远端小肠：不同密度的革兰阴性需氧菌或兼性需氧菌、厌氧菌如脆弱拟杆菌结肠：兼性需氧（大肠杆菌）或纯厌氧菌，链球菌、肠球菌亦常见,Pathogens associated with peritonitis,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections, cleveland clinic journal of medicine volume 74 supplement 4 august 2007,cIAI综合治疗策略,液体复苏、感染源控制 (ie, surgical debridement, drainage, and repair)、 适当系统地抗感染是cIAI 治疗成功的主要部分 没有感染源的控制，抗生素治疗继发或第三型腹膜炎不可能成功首要的是感染源的控制,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,cIAI如何选择抗生素,单药还是联合治疗病人基础状况药物开始治疗时机及疗程给药剂量、频率抗菌谱、相互作用、耐药性之前抗生素的使用情况避免药物毒副作用及诱导耐药,社区获得性腹腔感染,应选择对肠源性革兰氏阴性专性或兼性需氧菌有效或针对-内酰胺类敏感革兰氏阳性球菌源于远端小肠、结肠、梗阻性的近端胃肠穿孔应包含抗厌氧菌活性避免应用治疗ICU院内感染的药物，除非是高危病人覆盖肠球菌的药物对社区获得性腹腔感染无益高危病人选择广谱抗生素,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,cIAI危险分层,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,High-severity IAI,Advanced age; poor nutrition; low serum albumin; pre-existing disorders, such as signifcant cardiovascular disease; higher Acute Physiology And Chronic Health Evaluation II scores (15); inadequate source control during the initial operative procedure; resistant nosocomial microorganisms; immunosuppression resulting from medical therapy for transplantation, cancer, or infammatory disease; or other acute/chronic diseases of diffcult-to-defne immunosuppression,IDS of Taiwan; Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults, J Microbiol Immunol Infect. 2008;41:279-281,氨基糖苷类,氨基糖苷类不推荐作为社区获得性腹腔感染的常规治疗 (A-1)氨基糖苷类根据局域菌种分离药敏结果,可以是院内获得性腹腔感染的首选.腹腔感染氨基糖苷类的治疗应该个体化 (A-1),抗厌氧菌药物,药物敏感试验提示Bacteroides fragilis 对下列药物普遍耐药clindamycin,cefotetan, cefoxitin, and quinolones 上述药物不能单药治疗B. fragilis,第三型及医院获得性腹腔感染,耐药菌感染更常见病原体类似于其他院内感染治疗基于局部常见院感菌种及耐药情况院内感染考虑覆盖肠球菌是合适的抗真菌治疗基于先前抗生素使用情况及基础危险因素,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections ,cleveland clinic journal of medicine volume 74 supplement 4 august 2007,MAZUSKI JE,Antimicrobial treatment for intra-abdominal infections.Expert Opin Pharmacother. 2007 Dec;8(17):2933-45,抗肠球菌治疗指征,常规抗肠球菌治疗对社区获得性腹腔感染没有必要 (A-1)医院获得性腹腔感染需考虑给予覆盖肠球菌的药物 (B-3).,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,抗真菌治疗指征,胃肠道穿孔的病人白念或其他真菌的分离率约20% 即使分离到真菌,抗真菌治疗也非必要,除非该患者近期因肿瘤、器官移植、炎症性疾病接受过免疫抑制治疗,或者是术后或复发的腹腔感染 (B-2)Anti-infective therapy for Candida should be withheld until the infecting species is identied (C-3). 10版有较大修正分离到白念则选择氟康唑 (B-2)氟康唑耐药的念珠菌可选择 amphotericin B, caspofungin, or voriconazole (B-3).肾功能不全选择后二者 (A-1).,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,何时开始抗感染治疗,应当在确诊感染和获得培养结果前怀疑IAI的诊断时即开始抗生素治疗抗感染的目标是清除感染病原体、减少复发、缩短感染症状体征消除时间抗生素应该在液体复苏开始后给药，恢复充分的血流灌注使良好的药物分布成为可能。尤其是氨基糖苷类，其肾毒性会因肾灌注不足而加重,哪些病人需要抗感染治疗,创伤或医源性肠损伤致腹腔污染12h内修补的病人 (Level 1) 以及胃肠穿孔24 h内修补的病人(Level 3)不认为已经合并IAI，仅需给予24 h或更短的预防用药炎症病灶能够完全移除的病人如没有穿孔的急性或坏疽性阑尾炎或胆囊炎，或者没有发生穿孔或腹膜炎的肠梗阻或肠坏死，也仅需给予24 h或更短的预防用药(Level 2)已经合并广泛IAI的上述病人应该给予超过24 h的抗感染治疗 (Level 3).,the Therapeutic Agents Committee of the Surgical Infection Society,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3, Number 3, 2002,81. The administration of prophylactic antibiotics to patients with severe necrotizing pancreatitis prior to the diagnosis of infection is not recommended (A-I).,Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of America；Clinical Infectious Diseases 2010; 50:13364,抗感染疗程,大多数IAI的抗感染治疗不应该超过5 (Level 2) to 7 days (Level 3).抗感染疗程可基于术中介入时发现的情况 (Level 3). 当患者感染的临床症候如发热、白细胞升高等消失时可终止治疗 (Level 2).预定的抗生素疗程结束时症状持续，应该积极进行诊断评估，而非简单延长抗感染时间 (Level 3).感染源不能充分控制时，延长抗感染时间或许管用 (Level 3)