ICU感染的治疗

ICU感染的治疗北京协和医院杜斌ICU感染:患病率医院获得性感染的患病率为5–30%ICU患者感染的患病率约为18–50%较普通患者高3–18倍ICU床位=医院总床位数的5%医院获得性感染=25%SpencerRC.EpidemiologyofinfectioninICUs.IntensiveCareMed1994;20:S2-6.BatesDW,MillerEB,CullenDJ,etal.Patientriskfactorsforadversedrugeventsinhospitalizedpatients.ADEPreventionStudyGroup.ArchInternMed1999;159:2553-60.SinghN,YuVL.RationalempiricantibioticprescriptionintheICU.Chest2000;117:1496-9.ICU危重病患者的感染EuropeanPrevalenceofInfectioninIntensiveCareStudy(EPIC)1992年4月29日进行1417个ICU参加总计9567名ICU患者ICU危重病患者的感染21%14%10%ICU获得性感染社区获得性感染其他医院感染ICU感染的组成EPIC内科外科ICUNNISPUMC下呼吸道感染2418652753泌尿系感染433118205手术部位感染1112916血行性感染151022112其他1830132014感染对患者预后的影响增加住院日额外医疗费用手术部位感染7.33,152肺炎5.95,683血行性感染7.43,517泌尿系感染1.0680总计4.02,100ICU感染的致病菌耐药菌NNIS(1996–2000)北京协和医院ICU(1995–2000)平均耐药率(%)10%百分位数90%百分位数MRSA46.515.466.787MRSE74.956.986.795亚胺培南耐药的铜绿假单胞菌16.70.031.327头孢他啶耐药的铜绿假单胞菌11.70.025.028哌拉西林耐药的铜绿假单胞菌15.00.031.638三代头孢菌素耐药的肠杆菌25.910.050.954亚胺培南耐药的肠杆菌0.90.04.05三代头孢菌素耐药的肺炎克氏菌5.40.018.522三代头孢菌素耐药的大肠杆菌0.90.06.517氟喹诺酮耐药的大肠杆菌4.20.011.1671.DuB,ChenDC,LiuDW,XuYC,XieXL,ChenMJ.NatlMedJChina1996;76:262-6.2.LiY,DuB,ChenDC,LiuDW.BeijingMedJ2002;24:3-53.DuB.NatlMedJChina2001;81:1278-800%20%40%60%80%100%Luna,1997Ibrahim,2000Kollef,1998Kollef,1999Rello,1997Alvarez-Lerma,1996最初充分治疗最初不充分治疗*病死率指总病死率或感染相关病死率Alvarez-LermaFetal.IntensiveCareMed1996;22:387-394.RelloJetal.AmJRespirCritCareMed1997;156:196-200.KollefMHetal.Chest1999;115:462-474KollefMHetal.Chest1998;113:412-420.IbrahimEHatal.Chest2000;118:146-155.LunaCMetal.Chest1997;111:676-685.病死率*ICU中重度感染的危重病患者最初不充分抗生素治疗的病死率*ESBL阳性菌感染不适当抗生素治疗与病死率0%20%40%60%不适当适当病死率OR=4.701P=0.016BinDu,YunLong,HongzhongLiu,DechangChen,DaweiLiu,YingchunXu,XiuliXie.Extended-spectrumbeta-lactamase-producing-EscherichiacoliandKlebsiellapneumoniaebloodstreaminfection:riskfactorsandclinicaloutcome.IntensiveCareMed2002;28(12):1718-237/1414/71ICU感染的抗生素治疗:指征经验性抗生素治疗致病菌未知广谱抗生素针对性抗生素治疗(降阶梯治疗)根据致病菌及药敏结果结合临床疗效换用窄谱抗生素ICU感染的抗生素治疗:意义经验性抗生素治疗覆盖可能的致病菌降低病死率针对性抗生素治疗(降阶梯治疗)减少广谱抗生素的使用避免耐药发生抗生素治疗前后血培养的阳性率139名患者抗生素治疗前抗生素治疗过程中开始抗生素治疗83名患者(60%)血培养阴性或分离出污染菌0/83(0%)分离到致病菌56名患者(40%)分离到致病菌26/56(45%)分离到致病菌25名患者(45%)分离到致病的葡萄球菌19/25(76%)分离到葡萄球菌14名患者(25%)分离到致病的链球菌5/14(36%)分离到链球菌17名患者(30%)分离到革兰阴性杆菌2/17(12%)分离到革兰阴性杆菌1/139(0.72%)分离到新的致病菌GraceCJ,LiebermanJ,PierceK,etal.UsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.ClinInfectDis2001;32:1651-5临床意义应用抗生素前进行血培养分离到致病菌的可能性增加2.2倍在开始抗生素治疗最初72小时内,连续进行血培养的结果,可以根据应用抗生素前血培养的结果预测极少分离到新的致病菌医生可以等待应用抗生素前的血培养结果回报后,再进行新的血培养GraceCJ,LiebermanJ,PierceK,etal.UsefulnessofBloodCultureforHospitalizedPatientsWhoAreReceivingAntibioticTherapy.ClinInfectDis2001;32:1651-5医院获得性肺炎的抗生素治疗目的:评价频繁更换抗生素对VAP患者预后的影响方法:回顾性分析56名VAP患者的临床资料根据更换抗生素的频率分为4组第1组(n=19)最初抗生素治疗无更改第2组(n=8)最初抗生素治疗更改1次第3组(n=19)最初抗生素治疗更改2次第4组(n=10)最初抗生素治疗更改3次降阶梯治疗及简化治疗除外KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S医院获得性肺炎的抗生素治疗12.78.16.95.9051015第1组第2组第3组第4组最初抗生素治疗错误比例(%)KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S医院获得性肺炎的抗生素治疗37.515.8141.2523.737.201020304050第2组第3组第4组百分比(%)根据培养结果调整抗生素无明确原因调整抗生素KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S医院获得性肺炎的抗生素治疗21.12557.980020406080100第1组第2组第3组第4组住院病死率(%)P=0.004P=0.04KawabataM,Corla-SouzaA,NiedermanM,etal.Theimpactofchangesinantimicrobialtherapyonpatientswithventilator-associatedpneumonia.Chest2003;124(Suppl4):79S如何鉴别真正的致病菌和污染菌常见致病菌(95%)金黄色葡萄球菌大肠杆菌肠杆菌铜绿假单胞菌肺炎链球菌白色念珠菌常见污染菌(5%)棒状杆菌属芽孢杆菌属疮疱丙酸杆菌TownsML,QuarteySM,WeinsteinMP,etal.Theclinicalsignificanceofpositivebloodcultures:aprospective,multicenterevaluation,abstr.C-232.InAbstractsofthe93rdGeneralMeetingoftheAmericanSocietyforMicrobiology1993.AmericanSocietyforMicrobiology,Washington,D.C.WeinsteinMP,TownsML,QuarteySM,etal.Theclinicalsignificanceofpositivebloodculturesinthe1990s:aprospectivecomprehensiveevaluationofthemicrobiology,epidemiology,andoutcomeofbacteremiaandfungemiainadults.ClinInfectDis1997;24:584-602.鉴别困难的分离株TownsML,QuarteySM,WeinsteinMP,etal.Theclinicalsignificanceofpositivebloodcultures:aprospective,multicenterevaluation,abstr.C-232.InAbstractsofthe93rdGeneralMeetingoftheAmericanSocietyforMicrobiology1993.AmericanSocietyforMicrobiology,Washington,D.C.WeinsteinMP,TownsML,QuarteySM,etal.Theclinicalsignificanceofpositivebloodculturesinthe1990s:aprospectivecomprehensiveevaluationofthemicrobiology,epidemiology,andoutcomeofbacteremiaandfungemiainadults.ClinInfectDis1997;24:584-602.真正菌血症的比例(%)草绿色链球菌38%肠球菌78%凝固酶阴性葡萄球菌15%鉴别困难的分离株细菌阳性预期值凝固酶阴性葡萄球菌0.28(0.26–0.31)草绿色链球菌0.54(0.45–0.61)棒状杆菌属0.16(0.11–0.23)痤疮丙酸杆菌0.00(0.00–0.03)杆菌属0.09(0.03–0.20)微球菌属0.00(0.00–0.08)总计0.27(0.25–0.29)GeffersC,FarrBM.Positivepredictivevalueofapercutaneouslydrawnbloodculturegrowingskinfloravariesmarkedlybyorganism.InfectControlHospEpidemiol200