临床常见病原微生物.ppt

病例分析 日期 血常规 抗菌药使用 微生物送检 12.25 WBC7.42 N56.2 12.24-30-阿莫西林/克拉维酸 01.05血培养(-) 01.06 WBC15.28 N86.4 01.05-奥硝唑、头孢匹罗 01.15血培养(-) 01.08 WBC16.75 N84.5 01.06-庆大、地塞米松 01.14痰培养(+) 01.12 WBC18.32 N80.3 01.12-左氧氟沙星 01.15痰培养(+) 01.16 WBC15.72 N84.3 01.14-氟康唑、伊曲康唑 01.16痰培养(+) 01.22 WBC8.81 N82.14 01.18-美罗培南 产ESBL大肠杆菌 01.30 WBC9.00 N65.0 入院诊断　风湿性心脏病　出院诊断　①风湿性心脏病②感染性心内膜炎③肺部感染　　 (7) Much resistance that occured in Gram negative bacteria has been due to the presence of B- lactamases. Here I have the definition of B lactamases which are enzyme proteins, inactivite B-lactam antibiotics by the destroying the B-lactam rings. Extended-spectrum B-lactamases(ESBL) which are subsite of B-lactamases. They are again enzymes present in bacteria and an extended B-lactemases which are plasmid-mediated. They are extra-chromosomal DNA in the bacteria, they are capable to hydrolyze B-lactam rings, paticularly ceftazidime and aztreonam. This ESBL was firstly discovered in Germany in 1983. They involved from older common enzymes, such as the B-lactam TEM2 which was the common B-lactamas causing ampicillin resistance in Gram negative bacteria. They emerged by mutation at 1-4 amino acids. These ESBLs are seen most often in Klebsiella pneumoniae and E. coli. It is very important to show that they are on plasmids, often code for resistance to other antibiotics. 以下情况提示产ESBLs菌感染 肠杆菌科细菌，尤其大肠、克雷伯菌 对一个或多个三代头孢敏感性下降 常伴有氨基糖苷、喹诺酮多重耐药 三代头孢用药史 对头孢呋新耐药 对碳青霉烯敏感 头霉素、部分酶抑制剂有效 三、四代头孢临床治疗效果不好 ESBL敏感报告 临床分离到大肠埃希菌或克雷伯菌属细菌，均应检测是否产ESBL，如确认为产ESBL菌株，不管体外药敏试验的结果如何，对所有青霉素,头孢菌素和氨曲南均应报告耐药。对头霉素和碳青霉烯类按实际报告。 Performance Standards for Antimicrobial Susceptibility Testing－CLSI 结果分析（大肠和肺克） 大肠埃希菌和肺炎克雷伯菌对不同药物的耐药率（R％） 各国ESBL（＋）大肠杆菌发生率比较 ESBL菌株的治疗原则 针对ESBL特性和耐药特点，推荐使用 （1）碳青霉烯类抗菌药物，如亚胺培南/西司他丁 （2）氨基糖甙类抗菌药物，如阿米卡星 （3）头霉烯类抗菌药物，如头孢西丁、头孢美唑 （4）?-内酰胺酶/酶抑制剂，如头孢哌酮/舒巴坦 是肠杆菌科中最常见的环境菌群，医院感染的重要病原菌。在临床微生物室检出率最高的是阴沟肠杆菌和产气肠杆菌，可引起泌尿道感染、呼吸道感染、伤口感染以及败血症。 肠杆菌属 肠杆菌属细菌常产生AmpC酶，尤以阴沟肠杆菌最为突出。是导致革兰阴性菌对1～3代头孢菌素、单