亚洲医院内感染诊治指南解析(何礼贤)PPT.ppt

ACINETOBACTER Epidemiology Iraq/Vietnam: War wounds Australia/Greece: CAP US: HAP – 7%, Bacteremia – 2% Treatment Favored agents: Carbapenems and sulbactam Resistant: Colistin, tigecycline Mortality: 60% (most severe associated disease) Carbapenem resistance in A. baumannii worldwide Perez et al. Antimicrob Agents Chemother 2007;51:3471–3484 Carbapenenem+Sulbactam for A. Baumannii Have synergy effect Successful cases report：Combination carbapenem-sulbactam therapy for critically ill patients with multidrug-resistant Acinetobacter baumannii bacteremia Pharmacotherapy. 2007 Nov; 27(11): 1506-11. In vitro activities of Meropenem＋Sulbactam combination against carbapenem-resistant A. baumannii Diagn Microbiol Infect Dis. 2005: 52 :317–322 协同 部分协同 相加 无关 拮抗 CRAB combination therapy AAC, 2007，51 对COLISTIN 能否寄托希望？ Condition Cure/Survival rate VAP N Colistin Comparator ICU infect Ab/Pa 55 29% Imipenem-29% Cancer Ab/Pa 64 39% BL/FQ-24% VAP Ab/Pa 31 48% Merem-47% VAP Ab/Pa 60 58% Merem-54% Pa=P. aeruginosa Ab=A. baumannii Lancet ID 2008;8:403 Threats to Carbapenems True ‘carbapenemases’ Class A (KPC + obscure types) Class B (VIM, IMP) ‘metallo’ types Class D (OXA – mostly Acinetobacter spp.) ESBL/AmpC together with porin loss VIM in Bolzano, Italy 209 cephalosporin-resistant Enterobacteriaceae 24 Lacked ceph / clavulanate synergy but gave +ve EDTA / imipenem synergy tests Had VIM-1 b-lactamase; conjugative plasmid 10 clonal K. pneumoniae; plus clonally-diverse klebsiellae (5), E. coli (7) C. freundii (2) Carbapenem MICs, VIM-1+ Enterobacteriaceae from Bolzano Aschbacher et al., 2008 JAC 2008;61:515-23 Bolzano VIM+ isolates; Nos. susceptible (n= 24) Co-amoxiclav 0 Aztreonam 6 Pip/taz 0 Ciprofloxacin 6 Cefotaxime 0 Gentamicin 17 Ceftazidime 0 Amikacin 21 Cefpirome 0 Tigecycline 22 Cefoxitin 0 Colistin 24 2 K. oxytoca pan-resist