革兰阳性菌所致院内获得性肺炎诊疗进展课件

1、N Engl J Med 2003;348:1546-54.0%0%20%20%40%40%60%60%Bonten MJ et al. Am J Respir Crit Care Med 2005;171:388-416.Bonten MJ et al. Am J Respir Crit Care Med 2005;171:388-416.* Philippines: VAP dataAsian HAP Working Group. Am J Infect Control 2008;36:S83-92.121. Ibrahim EH, et al. Chest. 2000;118:146-1

2、55. 2. Valles J, et al. Chest. 2003;123:1615-1624. 3. Khatib R, et al. Eur J Clin Microbiol Infect Dis. 2006;25:181-185. 4. Teixeira PJZ, et al. J Hosp Infect. 2007;65:361-367. 5. The American Thoracic Society and the Infectious Diseases Society of America. Am J Respir Crit Care Med. 2005;171:388-41

3、6. a 研究使用了名词“不充分治疗”01020304050607080菌血症菌血症社区获得性社区获得性-菌血症菌血症金葡菌金葡菌菌血症菌血症呼吸机相关呼吸机相关肺炎肺炎病死率病死率(患者患者% )正确的抗菌治疗正确的抗菌治疗不恰当的抗菌治疗不恰当的抗菌治疗P .0011a3P .05P = .0224aP = .02不恰当初始治疗使死亡率上升不恰当初始治疗使死亡率上升研究显示，研究显示，不恰当治疗是病死率高的不恰当治疗是病死率高的重要独立危险因素重要独立危险因素1-4不恰当初始治疗定义为：不恰当初始治疗定义为：分离到的病原菌对分离到的病原菌对所使用的药物不敏感所使用的药物不敏感51. Lod

4、ise TP, et al. Clin Infect Dis. 2003;36:1418-1423. 2. Iregui MI, et al. Chest. 2002;122:262-268.051015202530354045菌血症菌血症1 1 呼吸机相关肺炎呼吸机相关肺炎2 2病死率病死率 ( (患者的患者的%)%)早期治疗早期治疗延误治疗延误治疗P = .05P .01金葡菌金葡菌早期早期12.5h晚期晚期28.6h 2“延迟延迟”、“及及早早”分界点为分界点为44.5h 1早期有效的抗生素治疗早期有效的抗生素治疗: 黄金黄金6小时小时Crit Care Med 2006; 34:158

5、91596Marin H. Kollef. CHEST 2006; 129:12101218铜绿假单胞菌铜绿假单胞菌金葡菌金葡菌不动杆菌属不动杆菌属Kollef MH Clinical Inf Diseases 31 Suppl 4:131-8, Sept 20001. MRSA Infection. MayoC 2007. . 2. Graffunder EM, Venezia RA. J Antimicrob Chemother. 2002;49:999-1005. 3. Safdar N, Maki DG. Ann Intern Med. 2002;136:834-844. 4. Mor

6、an GJ, et al. N Engl J Med. 2006;355:666-74. *万古霉素的谷浓度必须达到：万古霉素的谷浓度必须达到：15-20 g/mLWunderink R.et al. Chest. 2003;124:1789-97.利奈唑胺利奈唑胺 VS 万古霉素：治疗万古霉素：治疗MRSA院内肺炎院内肺炎临床治愈率和存活率比较临床治愈率和存活率比较随机、双盲、多中心、对照、前瞻性研究，进行的回顾性分析随机、双盲、多中心、对照、前瞻性研究，进行的回顾性分析Wunderink R.et al. Chest. 2003;124:1789-97.Wunderink R.et al.

7、 Chest. 2003;124:1789-97. Kollef MH. et al. Intensive Care Med. 2004;30:388-94利奈唑胺利奈唑胺 VS 万古霉素：治疗万古霉素：治疗G+菌呼吸机相关菌呼吸机相关性肺炎的临床治愈率和存活率比较性肺炎的临床治愈率和存活率比较随机、双盲、多中心、对照、前瞻性研究，进行的回顾性分析随机、双盲、多中心、对照、前瞻性研究，进行的回顾性分析斯沃斯沃万古霉素万古霉素(63/128)(44/112)(41/90)(31/93)(23/38)(8/35) Kollef MH. et al. Intensive Care Med. 2004

8、;30:388-94.Kollef MH. et al. Intensive Care Med. 2004;30:388-94.Kollef MH. et al. Intensive Care Med. 2004;30:388-94. Kollef MH. et al. Intensive Care Med. 2004;30:388-94.M crucianiet al. Journal of Antimicrobial Chemotherapy. 1996;38:865-869肺上皮细胞衬液肺上皮细胞衬液血清血清金葡菌金葡菌MIC90Time After Last Dose (hours)E

9、LF (肺上皮细胞衬液肺上皮细胞衬液)血清血清MIC90, 金黄色葡萄球菌金黄色葡萄球菌MIC90, 肠球菌属肠球菌属MIC90, 肺炎链球菌肺炎链球菌010010203040506070481224Mean Concentration ( g/mL)Studied in 25 healthy volunteers given linezolid 600 mg orally for a total of 5 doses. Conte JE et al. Antimicrob Agents Chemother. 2002;46:1477,1478.Steinkraus G et al. J An

10、timicrob Chemother. 2007;60:788-9401020304050607080901000.1250.190.250.380.50.7511.523495万支万支0 0International Journal of Antimicrobial Agents 32 (2008) 241249International Journal of Antimicrobial Agents 32 (2008) 241249International Journal of Antimicrobial Agents 32 (2008) 241249International Jour

11、nal of Antimicrobial Agents 32 (2008) 241249C Caution, risk of toxicity, avoid or reduce dose L Limitations, dosage reduction recommended or likelyS Standard dose and precautions, no dose adjustment requiredSCLCLLLSSSSSCSLJaksic B.et al. Clin Infect Dis. 2006;42:597-607皮肤软组织感染泌尿道感染其他27(8.9)2(0.7)34(11.2)20(6.6)3(1.0)41(13.6)Jaksic B.et al. Clin Infect Dis. 2006;42:597-607Jaksic B.et al. Clin Infect Dis. 2006;42:597-607Jaksic B.et