PCT临床应用--指导抗生素治疗.ppt

PCT临床应用指导抗生素治疗,浙江省人民医院ICU孙仁华,内容,PCT特点、应用指导抗生素治疗,PCT,PCT是降钙素无激素活性的前肽物质，116个氨基酸组成的糖蛋白，分子质量约13ku，由甲状腺C细胞合成，生理情况下血浓度AUCCRP(p1.0ng/ml,从第一天高于1.0ng/ml时开始计算非报警值:从第一天高于1.0ng/ml时开始减少,并以后数值均1.0ng),Jensenetal.,CritCareMed,2006,PCT浓度变化与ICU脓毒症患者生存率的关系,指导抗生素治疗,是否需要抗生素处方？评估抗生素治疗成功与否？什么时候停抗生素?,抗生素治疗每延迟1小时，死亡率上升7%,Kumaretal.,CCM2006,D.AntimicrobialTherapy,Werecommendthatintravenousantimicrobialtherapybestartedasearlyaspossibleandwithinthefirsthourofrecognitionofsepticshock(grade1B)andseveresepsiswithoutsepticshock(grade1C).Appropriateculturesshouldbeobtainedbeforeinitiatingantibiotictherapybutshouldnotpreventpromptadministrationofantimicrobialtherapy,D.AntimicrobialTherapy,Wesuggesttheuseoflowprocalcitoninlevelsorsimilarbiomarkersmightbeusefultoassisttheclinicianinthediscontinuationofempiricantibioticsinpatientswhoappearedseptic,buthavenosubsequentevidenceofinfection(grade2C).,Thirty-threestudiesfulfilledinclusioncriteria(3,943patients,1,828males,922females;meanage:56.1yrs;1,825patientswithsepsis,severesepsis,orsepticshock;1,545withonlysystemicinflammatoryresponsesyndrome);eightstudiescouldnotbeanalyzedstatistically.Globalmortalityratewas29.3%,Globaloddsratiosfordiagnosisofinfectioncomplicatedbysystemicinflammationwere15.7forthe25studies(2,966patients)usingprocalcitonin(95%confidenceinterval,9.127.1)and5.4forthe15studies(1,322patients)usingC-reactiveprotein(95%confidenceinterval,3.29.2).,CritCareMed2006;34:19962003,Globaldiagnosticaccuracyoddsratiosforprocalcitonin(PCT,circle,solidline)andC-reactiveprotein(CRP,triangle,dashedline);n15studies.OR,oddsratio;CI,confidenceinterval.,Summaryreceiveroperatingcharacteristicscurvesforprocalcitonin(circle,solidline)andCreactiveprotein(triangle,dashedline),accordingtoMosesandLittenbergmodel;n15studies,Lancet2004;363,600-607,研究背景：在西方国家，下呼吸道感染(LRTI)是应用抗生素最常见的指征目前临床症状、体征以及常用的实验室检查，均无法准确分辨LRTI的病原体(细菌?病毒?)，因此约75%的患者接受抗生素的治疗，尽管有时候是病毒感染针对细菌感染，PCT是一个敏感性较高的生物学指标，它在一定程度上可以协助临床内科医师管理抗生素的使用,研究病例组成,标准组PCT指导组Goodclinicaloutcome好的临床效果97%97%ATBprescribed抗生素用率83%44%DurationofATBtreatment(d)抗生素治疗天数12.810.9ATBcostperpatients(US$)抗生素成本202.596.3,两组临床结果比较,两组抗生素使用率比较,抗生素的使用及成本减少50（8344）,p=0.03,p=0.003,p1ng/ml)=建议结束抗生素治疗,Hochreiteretal.,Anaesthesist2008;57:571-577,抗生素治疗时间:-PCT组：5.91.7d-对照组：7.90.5d=无明显副作用.,5-8天就足够了吗？,PCT指导ICU患者的抗生素治疗,Nobreetal,AmJRespirCritCareMed.2008;177(5):498-505,PCT指导抗生素治疗,SchuetzPetal,JAMA.2009;302(10):1059-1066,目的：监测血清PCT水平是否能在不增加严重并发症风险的情况下,最大程度地减少滥用抗生素对象：2006年10月-2008年3月瑞士6家医院的1359例严重LRTI患者设计：该研究是一项多中心、非劣性、随机控制研究将入选患者随机分为对照组和PCT指导治疗组(PCT组)对照组根据标准指南确定的抗生素治疗方案，PCT组则同时参考血清PCT水平终点：死亡、入ICU、发生并发症以及30天内复发感染需要抗生素治疗,入选患者流程图,PhillipSchuetz,etal.JAMA,2009(302)10:1059-1066,PCT组与对照组抗生素使用比较,PCT组抗生素使用时间低于对照组,PCT组的总体抗生素使用水平比对照组平均低25.7%38.7%,研究后列入时间(天),PhillipSchuetz,etal.JAMA,2009(302)10:1059-1066,Primaryoutcomesincludedthedurationofantibiotictherapyforthefirstepisodeofinfectionand28-daymortality.SecondaryoutcomesincludedlengthofICUstay,lengthofhospitalisation,antibiotic-freedayswithinthefirst28daysofhospitalisation,recurrences,andsuperinfections,2,199patientswereincludedinthetrials,ofwhich1,098wereassignedtothePCT-guidedtreatmentarmand1,101wereassignedtothecontrolgroup.,antibioticswerediscontinuedwhenPCTwaslowerthanavaluethatrangedfrom0.5to1ng/ml.,.IntensiveCareMed2012,DurationofantibiotictherapyforthefirstepisodeofinfectionwasreducedinfavourofPCT-guidedtreatmentpooledweightedmeandifference(WMD)=-3.15days,randomeffectsmodel,95%confidenceinterval(CI)-4.36to-1.95,P0.001.,MatthaiouDKetal.IntensiveCareMed2012,MatthaiouDKetal.IntensiveCareMed2012,MatthaiouDKetal.IntensiveCareMed2012,MatthaiouDKetal.IntensiveCareMed2012,Secondaryoutcomes,ThelengthofICUstaywereprovidedinsixoutofsevenoftheincludedRCTs.TherewasnodifferenceinlengthofICUstayThelengthofhospitalisationwereprovidedinthreeofsevenoftheincludedRCTs.Therewasnodifferenceinlengthofhospitalisation,Secondaryoutcomes,Antibiotic-freedayswithinthefirst28daysofhospitalisationwereprovidedinthreeoutofsevenoftheincludedRCTs.Therewasanincreaseinantibiotic-freedayswithinthefirst28daysofhospitalisationinfavourofthePCT-guidedtreatmentarmwithapooledWMDof3.08days(P=0.71,I2=0%,FEM:95%CI2.064.10,P0.001).,Secondaryoutcomes,RecurrenceswereprovidedinthreeofsevenoftheincludedRCTs.TherewasnodifferenceinrecurrencesSuperinfectionswereprovidedinthreeoutofsevenoftheincludedRCTs.Therewasnodifferenceinsuperinfections,脓毒症患者抗生素有治疗效果判断,(n=109),F.Stber,UniversityBonn,LectureatISICEM,Brussels2001,通过PCT浓度的变化，提示抗生素治疗的成功与否,随着患者对抗生素治疗的响应，引起了PCT血中浓度水平的典型变化过程,持续升高的PCT水平，提示比较差的预后（程度加重，死亡）,连续的监测PCT血中浓度可以更好的评估患者的预后,严重外伤导致脓毒血症患者，生存者,PCT呈快速下降趋势，预示着成功的治疗效果（感染控制、存活）,连续的监测PCT血中浓度可以更