呼吸机相关肺炎PPT课件

呼吸机相关性肺炎,李祥全,1,-,概念,气管插管或气管切开患者在接受机械通气48h后发生的肺炎；撤机、拔管48h内出现的肺炎仍属VAP；MV4d内发生的肺炎为早发VAP,5d者为晚发VAP；早发VAP：敏感病原菌；晚发VAP：耐药病原菌；,2,-,流行病学,机械通气患者发生率在10-33%之间；增加ICU住院时间，显著增加治疗费用；,3,-,流行病学,VAP的菌群超过40%是由革兰氏阴性杆菌组成，耐药越来越多；aerobicEnterobacteriaceae(25%，需氧肠杆菌),Staphylococcusaureus(20%，金葡菌),Pseudomonasaeruginosa(20%，绿脓杆菌),Haemophilusinfluenza(10%，流感嗜血杆菌),streptococci（链球菌）；,4,-,危险因素,上呼吸道和胃腔内定植菌的误吸；吸入含有细菌的微粒；血行感染；由周围脏器直接感染而来；气管导管细菌生物被膜的形成；,5,-,危险因素,广谱抗生素的应用是MDR性VAP的危险因素；microaspiration（微误吸）是误吸的常见类型；,6,-,危险因素,胃肠道是常见的病菌库；吸入污染气溶胶引起的VAP较少，从其他器官转移而来的病原菌也少见；血源性的传播比例约为10%；,7,-,临床诊断,胸部X线影像可见新发生的或进展性的浸润阴影，如同时满足下列至少2项可考虑VAP的诊断；体温38或10109或6分者连续1021d抗感染治疗；,22,-,PCT的指导,血清PCT0.25g/L时可不使用或停止使用抗菌药物；血清PCT0.250.5g/L或与治疗前相比下降幅度80%可采用降阶梯治疗或停止使用抗菌药物；血清PCT0.5g/L或与治疗前相比下降幅度80%可继续沿用原抗菌治疗方案；血清PCT0.5g/L或高于治疗前水平，则应更换抗菌药物；,23,-,革兰阴性杆菌VAP,耐药增加；治疗困难；病程明显延长；,24,-,25,-,26,-,Pseudomonasaeruginosa（绿脓）,P.aeruginosahasthecapacitytodevelopresistancetoallVAPantibiotics；Carbapenemresistance（耐碳青霉烯）hasbeendocumentedin16.128.4%ofUSnosocomialpneumoniaisolates；P.aeruginosaresistancetoantipseudomonalpenicillins(e.g.,piperacillin-tazobactam哌拉西林他唑巴坦,15.619.1%)andanti-pseudomonalcephalosporins(e.g,ceftazidime头孢他啶orcefepime头孢吡肟,9.529.4%)isincreasinglycommon；,27,-,Pseudomonasaeruginosa（绿脓）,Theaminoglycosidestobramycin（妥布霉素）andamikacin（阿米卡星）appeartoretaingoodindividualactivityagainstP.aeruginosainsomestudies；Colistin（多粘菌素）remainsactiveagainstP.aeruginosa(9899.6%susceptible)；,28,-,Acinetobacterbaumannii（鲍曼）,FrequentlyMDRandoftencarbapenemresistant；Withresistancerateslessthan5%,colistin（多粘菌素）appearsactive；Resistancetominocycline（米诺环素）wasfoundin14.8%ofisolates；Colistin,minocycline,andtigecycline（替加环素）mayretainactivity；,29,-,KlebsiellaEnterobacteriaceae（肺克）,carrygenesencodingextendedspectrumbeta-lactamases(ESBLs)demonstrablyhighercarbapenem-resistancerates(6.911.5%)；Carbapenem-resistantEnterobacteriaceae(CRE)werefoundin58centersin18Europeancountries,comprising2%ofallEnterobacteriaceae；fewornosafeandeffectivetreatments；,30,-,NewTactics,Fosfomycin（磷霉素）Polymyxins（多粘菌素）Minocycline（米诺环素）Tigecycline（替加环素）,31,-,Fosfomycin（磷霉素）,blocksanearlystageinthesynthesisofpeptidoglycan（肽聚糖）,acomponentofthebacterialcellwall；Approximatelythreefourthsofcarbapenem-resistantK.pneumoniaeisolatesaresusceptibletoFosfomycin；FosfomycinmonotherapyislessactiveagainstP.aeruginosaandA.baumannii,withresistanceemergingrapidly；,32,-,Polymyxins（多粘菌素）,Re-emergedforthetreatmentofMDRGram-negativebacteria,includingP.aeruginosa（假单胞菌属）,Acinetobacterspp（不动杆菌菌属）,E.coli（大肠埃希）,andKlebsiellaspp（克雷伯菌属）；LackactivityagainstsomeotherGram-negatives,suchasProteus（变形杆菌）andSerratiaspp（粘致沙雷）,33,-,Minocycline（米诺环素）,Semisynthetictetracyclinederivative（半合成的四环素类）；Liketigecycline,minocyclinehasGram-negativeactivity，butyieldshigherbloodlevelsthantigecycline，andgoodlungpenetration；MinocyclineisactiveagainstsomeAcinetobacter（不动杆菌）andStenotrophomonasspp（寡养单胞菌）.andsomeEnterobacteriaceae（肠杆菌）butnot.Serratiaspp（沙雷菌）,Proteusspp（变形杆菌）,orP.aeruginosa（绿脓杆菌）；,34,-,Tigecycline（替加环素）,BroadGram-negativeactivityincludingsomeCRE，butnotP.aeruginosa（铜绿）orProteusmira