医院获得性感染肺炎防治进展(杨毅).ppt

医院获得性感染/肺炎防治进展;内容提要;定义;流行病学;Extra-ICU/hosp stay;VAP对患者医疗费用和预后的影响;MDR－Multi-Drug-resistance;G-杆菌耐药对预后的影响;rGNR:入住ICUMVCRRT抗生素更换住院时间病死率;治疗过程中铜绿假单胞产生耐药----病死率明显增加;Hospital mortality: 17.2% P aeruginosa vs MSSA [30.6% vs 16.2%, p 0.036] P aeruginosa and MRSA [30.6% vs 13.5%, p 0.007];Acinetobacter in critically ill patients:High mortality and LOS in ICU;发病机理;Air of word G+ G- ICU 26% 8.1% Other word 23.6% 2.6% P 0.05 0.04 环境和手－－主要为G+菌 Hand of Pat Hand of staff G+ high high G- low low ;Colonization 　　　　　　　　Aspiration;MDR危险因素----MV和既往抗生素应用;MDR的危险因素---抗生素应用(3G Cepha);MDR的危险因素----Quinolone应用;Antibiotics: Aminoglycosides Fluoroquinolones beta-lactamase inhibitor combinations Carbapenems all cephalosporins + aztreonam Multivariate analysis for the rate of carbapenem-res A baumannii and CFZ-res A baumannii Only cephalosporins + aztreonam P=0.04 P=0.03;Efflux pump AdeDE was identified in acinetobacters belonging to genomic DNA group 3 Amikacin Ceftazidime Chloramphenicol Ciprofloxacin Erythromycin Meropenem Rifampin, Tetracycline. ;Preferential use Special concerns ;HAP / VAP / HCAP合并MDR感染危险因素 ;HAP的临床诊断;HAP的实验室诊断;非抗生素治疗策略;A. 一般预防措施---Hand washing;消毒剂对手部细菌的清除作用;The use of protective gowns and gloves during patient contact can not be recommended for the routine prevention of VAP Must be considered When handling respiratory secretions During patient contact when the patient carries an MDR pathogen (MRSA);B.气管插管与机械通气(1)缩短MV时间;Case–control study in France N=50 pats with COPD exacerbation and cardiogenic pul edema;Rouby JJ, et al. Am J Respir Crit Care Med. 150: 776~783; Am J Respir Crit Care Med 1995, 152:137;患者魏XX，男，35岁 胆囊切除术，心肺脑复苏术后入院 鼻饲胃管14天 不明原因发热, 40oC 副鼻窦CT检查May-8;普通气管插管/ 气管切开管 分泌物在声门下间隙潴留 声门下气道及口鼻咽腔细菌定植 声门下分泌物及口鼻咽腔分泌物的误吸;Am J　Respir Crit Care Med 1996, 154:111-115.;Randomized study n=73 pats who need MV 48h;HEM reduced hosp-, not community-acquired VAP HEM reduced ICU stay HEM reduced