细菌耐药的临床对策-关注抗菌药物临床管理及合理应用.ppt

Factors Selected by Multivariate Analysis Independently Related to Mortality Importance of Adequate and Appropriate Antimicrobial Treatment Effect of Early Administration of Antibiotics on Outcomes Infectious Diseases Expert Resources 选择哪种抗菌药物(which antibiotic?) 感染部位的常见病原学(possible pathogens on site of infection) 选择能够覆盖病原体的抗感染药物(antibiotics requirement) -抗菌谱/组织穿透性/耐药性/安全性/费用 考虑药代动力学/药效动力学(PK/PD) 考虑病人生理和病理生理状态( physiologic and pathophysiology) 高龄/儿童/孕妇/哺乳(advanced age/children/pregnant women/breast feeding) 肾功能不全/肝功能不全/肝肾功能联合不全(renal/heptic dysfunction/combined) 其它因素(other considerations) 杀菌和抑菌/单药和联合/静脉和口服/疗程 (cidal vs static/ mono vs combination/ IV vs PO/ duration) Risk factors for infection with ESBL producers outside hospital Prevalence of rectal carriage of Extended-Spectrum β-lactamase -producing Escherichia Coli among elderly people in a community setting in Shenyang 横断面研究/整群抽样-276名社区老人、直肠拭子/大肠杆菌ESBL检测、分子分型和PEGF 结果:－直肠拭子ESBL+大肠杆菌携带率7.0%（19/270）. －19株ESBL+菌株ESBL基因型均为CTX-M 型 －12株为CTX-M-14 型（63.2%), 3株 CTX-M-22型, 1株 CTX-M-24型， 2株 CTX-M-57-like型，1株同时产CTX-M-24和CTX-M-57-like型. －序列分析表明CTX-M-57-like基因序列中第865位点发生G→A替换,导致 氨基酸序列中第289位点发生D→N替换,该基因序列不同于 GenBank数 据库已发表序列，提示新型ESBLs基因型(GenBank 序列号 EF426798) 产ESBL细菌感染的危险因素 Prospective study of 455 episodes of K. pneumoniae bacteremia (253 nosocomial) in 12 hospitals 30.8% 为医院获得, ICU中43.5%产ESBL’s ESBLs危险因素 －先期使用氧亚氨基β-内酰胺类抗菌药物 －过去14天内使用2 d (OR= 3.9). 其它危险因素 －TPN, 肾功衰竭,烧伤 非ESBL危险:碳青霉烯、头孢吡肟、喹诺酮、氨基糖苷类 Paterson et al: Ann Intern Med 2004; 140:26-32. VAP－耐药菌感染的危险因素 Appropriate Carbapenems Based on Risk for MDR Gram-Negative Pathogens 选择哪种抗菌药物(which antibiotic?) 感染部位的常见病原学(possible pathogens on site of infection) 选择能够覆盖病原体的抗感染药物(antibiotics requirement) -抗菌谱/组织穿透性/耐药性/安全性/费用 考虑药代动力学/药效动力学(PK/PD) 考虑病人生理和病理生理状态( physiologic and pathophysiology) 高龄/儿童/孕妇/哺乳(ad