复杂腹腔感染

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%in1900to23%in2002IAI不同来源感染的死亡率

appendix(0.25%)stomach/duodenum(21%)pancreas(33%)smallbowel(38%)largebowel(45%)biliarytract(50%)JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007IAI定义分类f.M.pieracci,p.S.barie,ManageMentofSevereSepSiSofabdoMinalorigin,ScandinavianJournalofSurgery96:184–196,2007单纯腹腔感染复杂腹腔感染Intra-abdominalinfectionsalsocanbecategorizedasuncomplicatedversuscomplicated,althoughthedistinctionisnotalwaysclearJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007UncomplicatedIAI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BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007Primarybacterialperitonitis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Secondarybacterialperitonitis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Itmaybecommunity-acquiredorhealthcare–associated.Tertiaryperitonitis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，版作了扩展

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005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PathogensassociatedwithperitonitisJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007cIAI综合治疗策略液体复苏、感染源控制(ie,surgicaldebridement,drainage,andrepair)、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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007如有脏器功能不全、免疫抑制的病人则归为重度腹腔感染感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔biliarytract(50%)抗真菌治疗基于先前抗生素使用情况及基础危险因素上述药物不能单药治疗B.已经合并广泛IAI的上述病人应该给予超过24h的抗感染治疗(Level3).pieracci,p.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improvesboththeprocessofcareandpatientoutcomesItmaybecommunity-acquiredorhealthcare–associated.Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Advancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppressionExpertOpinPharmacother.cIAI如何选择抗生素腹腔感染(IAI)概述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β-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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005cIAI危险分层JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74•SUPPLEMENT4AUGUST2007High-severityIAIAdvancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppressionIDSofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.;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Bacteroidesfragilis对下列药物普遍耐药clindamycin,cefotetan,cefoxitin,andquinolones

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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007MAZUSKIJE,Antimicrobialtreatmentforintra-abdominalinfections.ExpertOpinPharmacother.2007Dec;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,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005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-infectivetherapyforCandidashouldbewithhelduntiltheinfectingspeciesisidentified(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amphotericinB,caspofungin,orvoriconazole(B-3).肾功能不全选择后二者(A-1).

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005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pancreas(33%)Advancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppression创伤或医源性肠损伤致腹腔污染12h内修补的病人(Level1)以及胃肠穿孔24h内修补的病人(Level3)不认为已经合并IAI，仅需给予24h或更短的预防用药原发、继发性腹膜炎经治疗后症状仍持续或48小时后症状复苏ExpertOpinPharmacother.胃肠道穿孔的病人白念或其他真菌的分离率约∼20%可为革兰氏阴性杆菌、肠球菌或条件致病菌，多为耐药菌。感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔largebowel(45%)DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；stomach/duodenum(21%)Itmaybecommunity-acquiredorhealthcare–associated.腹腔感染氨基糖苷类的治疗应该个体化(A-1)WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74•supplement4august2007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(Level1)以及胃肠穿孔24h内修补的病人(Level3)不认为已经合并IAI，仅需给予24h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24h或更短的预防用药(Level2)已经合并广泛IAI的上述病人应该给予超过24h的抗感染治疗(Level3).theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,200281.Theadministrationofprophylacticantibioticstopatientswithseverenecrotizingpancreatitispriortothediagnosisofinfectionisnotrecommended(A-I).DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；ClinicalInfectiousDiseases;50:133–64TertiaryperitonitiscIAI更多地与不良预后相关，其最大挑战是早期识别胃、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。氟康唑耐药的念珠菌可选择amphotericinB,caspofungin,orvoriconazole(B-3).Anti-infectivetherapyforCandidashouldbewithhelduntiltheinfectingspeciesisidentified(C-3).可合并休克、脏器功能损害，多为重度腹腔感染Advancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppressionInfectiousDiseasesSocietyofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.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(Level3).病原体类似于其他院内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Theadministrationofprophylacticantibioticstopatientswithseverenecrotizingpancreatitispriortothediagnosisofinfectionisnot