关注附加损害优化的抗菌治疗.pptVIP

目前对抗?-内酰胺酶的主要策略有：1）研发新的对?-内酰胺酶稳定的?-内酰胺类抗生素。如碳青霉烯类（包括亚胺培南）和四代头孢菌素（如头孢吡肟）。其中碳青霉烯类由于临床应用十分广泛，目前已发现越来越多的细菌对其出现耐药；而四代头孢菌素虽然对抗I型?-内酰胺酶-AmpC酶效果良好，但对抗危害最严重的ESBLs无效，仍未真正解决临床耐药问题。2）发展特异的?-内酰胺酶抑制剂。现在已开发的?-内酰胺酶抑制剂主要有三种—他佐巴坦、舒巴坦和克拉维酸，它们因具有?-内酰胺环，可以和?-内酰胺酶结合，而使其失去耐药作用；而且，这一类药能有效地抑制ESBLs，临床获益很大。前面我们已对这三种抑制剂的活性做了比较，他佐巴坦是它们中抗耐药活性最强的?-内酰胺酶抑制剂。3）抗生素干预策略。主要包括减少三代头孢菌素的使用等措施，它能有效地预防并减少ESBLs的发生和耐万古霉素肠球菌（VRE)的发生。而只有这一点是每一个临床医生在抗感染治疗中所能涉及并且能够控制的，因而抗生素干预策略显得尤为重要。 Slide * The most challenging issue in treating HAP is selecting appropriate empiric antibiotics for patients in group 3. ATS recommends the addition of antimicrobial agents effective against P. aeruginosa and Acinetobacter species to the group 1 antibiotics; this includes an aminoglycoside or fluoroquinolone in combination with an antipseudomonal b-lactam, with or without a b-lactamase inhibitor (e.g., piperacillin/tazobactam), antipseudomonal cephalosporin, aztreonam, or carbapenem. Vancomycin is recommended for patients at risk of S. aureus infection until MRSA is excluded (in groups 2 and 3). 目前的治疗选择包括单药治疗(头孢他啶、头孢吡肟、亚胺培南、美罗培南、或哌拉西林/他唑巴坦)。两种药物联合治疗 (氨基糖苷类+一种广谱?-内酰胺类，两种?-内酰胺类联合，或者一种?-内酰胺类+一种氟喹诺酮类)。最后，还可以选择在单药治疗或两种药物治疗的基础上，加用万古霉素。如果有粘膜炎或静脉穿刺部位感染的证据，或者患者以前有携带甲氧西林耐药金葡菌（MRSA）的病史，或者曾经用氟喹诺酮类预防感染，这些情况下经验治疗方案中可以包含万古霉素。 In a univariate analysis of a comparison of the mean values of the group with a PRPA VAP and the group with a PSPA VAP: Prior antimicrobial therapy with imipenem (P=.04) or a fluoroquinolone (P=.007) was associated with piperacillin-resistant P aeruginosa ventilator-associated pneumonia. This was in addition to more different classes of antibiotics administered before VAP (P=.01 [Data not shown]). A third-generation cephalosporin had been prescribed more frequently to the PRPA group, but the difference between the 2 groups did not reach statistical significance. The analysis was conducted, and this chart was organized according to the antibiotic class of antimicrobial therapy that had been prescribed