课件：老年人吸入性肺炎.ppt

* * * * * * * * * * * * * * * * * * * * * * * * Key Recommendations and Principles of Guidelines (cont’d) Early, appropriate, broad-spectrum antibiotic therapy should be prescribed with adequate doses to optimize antimicrobial efficacy. An empiric therapy regimen should include agents that are from a different antibiotic class than the patient has recently received. Combination therapy for a specific pathogen should be used judiciously in the therapy of HAP, and consideration should be given to short-duration (5 days) aminoglycoside therapy when used in combination with β-lactam to treat P aeruginosa pneumonia. Linezolid is an alternative to vancomycin, and unconfirmed preliminary data suggest it may have an advantage for proven VAP due to MRSA. De-escalation of antibiotics should be considered once data are available on the results of LRT cultures and the patient’s clinical response. A shorter duration of antibiotic therapy (7 to 8 days) is recommended for patients with uncomplicated HAP, VAP, or HCAP who have received initially appropriate therapy and have had a good clinical response, with no evidence of infection with nonfermenting Gram-negative bacilli. ATS/IDSA Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med. 2005;171:388-416. * * VAP传统的抗生素治疗至少维持2周，然而伴随着多药耐药菌的增加，多项研究致力于缩短抗生素的疗程。本文对这些研究进行综述。 尽管有关方面的资料不多，但Dennesen 等的研究认为，缩短抗生素疗程是可行的，在使用抗生素治疗6天之内临床指标出现：体温≤ 38.3 ℃，白细胞≤ 10×109/L，PaO2/FiO2 比值≥ 250，这些指标意味着可缩短抗生素疗程。 在西班牙进行的一项针对不同患者治疗方案的研究将患者的抗生素应用分为四种情况：1. 即刻使用抗生素，2. 首先广谱抗生素治疗，然后根据微生物学培养结果进行降阶梯治疗，3.根据患者个体不同的药代动力学特点，服用高剂量个体化剂量，4. 根据肺部穿透力而不是最小抑菌浓度或血液浓度来选择药物。研究建议应用高剂量、短疗程（在明确临床指标如体温、脓性分泌物后72小时撤药）的治疗是可行的。 * * 要点： 小结（见幻灯）。 * * * 亚洲共识：HAP抗菌治疗疗程 存在争议：7～21d 亚洲共识建议： 初始经验治疗持续7～14d 如果检出MDR（MRSA/铜绿/不动杆菌/ESBL+G-菌等），治疗最长持续14d 根据疗效考虑降阶梯治疗 有试验表明铜绿和不动杆菌治疗时间短易复发 Song JH, et al . Am J Infect Control 2008;36:S83-92 通常抗生素治疗HAP/VAP的疗程为7d； 有下列症状和体征者疗程可长于7d： 发热38℃ 白细胞增多