严重感染治疗策略-邱海波.ppt

非发酵革兰阴性杆菌对三种碳青霉烯的敏感性 G-杆菌耐药对预后的影响 Prospective cohort study. Dec 1996 to Sep 2000 Inpatient surgical wards at a university hosp N=924 pats with GNR infections Outcomes were compared between GNR infections with and without antibiotic res rGNRs: resistant to one or more of the following all aminoglycosides, including amikacin all cephalosporins all carbapenems all fluoroquinolones rGNR:入住ICUMVCRRT抗生素更换住院时间病死率 小 结 ESBL和AmpC是ICU重症感染致病菌耐药的重要原因 三代头胞大量使用是导致G-菌出现ESBL和AmpC 的 主要原因 ESBL和AmpC使ICU重症感染患者的病死率明显增加 近3年, ICU非发酵糖细菌的比例从41.2%升高到47.9%铜绿假单胞菌、不动杆菌属、嗜麦芽窄食单胞菌分别位居1、4、7位 碳青霉烯类抗生素、酶抑制剂制剂等敏感性较高 ICU重症感染的重要性 细菌耐药机制及ICU细菌流行情况 重症感染的治疗策略 －感染灶的充分引流 －早期经验性治疗与降阶梯策略 －正确的目标性治疗 Source control-Grade E Every pats presenting with severe sepsis should be evaluated for the presence of a focus of infection amenable to source control measures Drainage of an abscess or local focus of infection Removal of a potientially infected device 重症感染的重要性 细菌耐药机制及ICU细菌流行情况 重症感染的治疗策略 －感染灶的充分引流 －早期经验性治疗与降阶梯策略 －正确的目标性治疗 早期经验性治疗的对象 对有急性而危及生命的全身性感染患者 无法及时得到细菌学资料 应根据本病房的细菌流行病学调查结果 选择对常见致病菌有效的广谱抗生素 经验性治疗＝推理性治疗 ICU严重感染病人起始抗生素治疗覆盖面不足--死亡率增加 Bloodstream infections Leibovici et al Adequate vs inadequate initial antibiotic: Mortality: 20% vs 34% From J Intern Med, 1998, 244: 379 早期及时抗生素治疗的重要性 In a retrospective cohort study of pneumonia in 18,209 patients Administering antibiotics within 4 h of hospital arrival was associated with improved survival. Antibiotic therapy 1. Grade E Intravenous antibiotic therapy should be started within 1st h of recognition of severe sepsis, after appropriate cultures have been obtained Antibiotic therapy 2. Grade D Initial empiric anti-infective therapy should include one or more drugs that have activity against the likely pathogens The choice of drug should be guided by the susceptibility patterns of microorganisms in the community and the hospital 如何保证起始治疗的准确性Getting it right (A--protocol) Treatment protocols and guidelines---important