气管插管与机械通气.PPT

Module 2: HAP - New 医院获得性感染/肺炎防治进展 内容提要 HAP流行病学和MDR在ICU的重要性 HAP的机制与MDR的危险因素 HAP的诊断 HAP的非抗生素预防策略 HAP的抗生素治疗策略 早期的有效的经验性治疗 降阶梯策略 MDR耐药的预防 定义 Hospital-acquired pneumonia (HAP) 入院48h后 Ventilator-associated pneumonia (VAP) 插管 48–72h Healthcare-associated pneumonia (HCAP) Any patient 出现感染的90天内在ICU住院2天以上 Resided in a nursing home Received recent iv antibiotic, chemotherapy or wound care last 30 days Attended a hospital or hemodialysis clinic 流行病学 高发病率---最常见的院内感染之一(第二位) 5-15 cases / 1000 admissions 6 to 20 fold higher in MV patients 25% of all ICU infections 50% of all antibiotics prescribed 常见病原菌 - Aerobic gram-negative bacilli P. aeruginosa、K. pneumoniae、Acinetobacter spp. - Gram-positive ： MRSA - Anaerobes are uncommon Extra-ICU/hosp stay NP/VAP: ICU stay increased 3 fold 10 ~32 d additional hosp stay 9.2 d of additional hospital stay Median length of ICU stay for VAP 21 d vs 15 d for control pat VAP对患者医疗费用和预后的影响 MDR－Multi-Drug-resistance G-菌对四类抗生素中3/4类耐药 Ceftazidine, Ciprofloxacin, Gentamicin, Imipenem Pseudomonas aeruginosa Acinetobacter species ESBLs/AmpC COS, CCOS PDR G+ MRSA 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 治疗过程中铜绿假单胞产生耐药----病死率明显增加 N=489 pats with NP 耐药：对PIP, CFZ, IMP, CIP至少1个耐药 入组时耐药 n=144 治疗过程中(14d)出现耐药 n=30 Mortality: 敏感组 7.5% vs 耐药组 7.6% (p=0.96, RR0.94) 治疗过程持续敏感组 6.3% vs 新耐药组 26.6% (p=0.03, RR 2.9) 继发性菌血症 治疗过程持续敏感组 1.4% vs 新耐药组 14% (p0.001, RR 9) Hospital mortality: 17.2% P aeruginosa vs MSSA [30.6% vs 16.2%, p 0.036] P aeruginosa and MRSA [30.6% vs 13.5%, p 0.007] Acinetobacter in critically ill patients:High mortality and LOS in ICU Crit C