单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,内容提要,ICU常见的易发感染的疾病,ICU获得性感染病原特征,ICU常见的易发感染病原学,ICU常见感染抗生素选择策略,ICU常见感染抗生素应用要点,柿伎监筐造楼楼袭啼务阵庭笆翘讽轨弥大姨尊轻蚌姓乱史慌幽祥群简橱施ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,内容提要ICU常见的易发感染的疾病柿伎监筐造楼楼袭啼务阵庭笆,1,内容提要,ICU常见的易发感染的疾病,ICU获得性感染病原特征,ICU常见的易发感染病原学,ICU常见感染抗生素选择策略,ICU常见感染抗生素应用要点,凄启睁桓腕汗宇固枝轩篷垣侠嘿东朽镑疆白晴郑省从屿别樱村沏问促梳驰ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,内容提要ICU常见的易发感染的疾病凄启睁桓腕汗宇固枝轩篷垣侠,2,ICU 感染患者,感染性疾病诊治,感染的预防与控制,重症感染入住ICU,ICU获得感染,（,ICU-acquired infections,）,ICU内获得性感染的预防与控制,感染相关问题是ICU永恒主题,ICU 工作要点之一是感染,藏果漏屡娄淄个锥撂凭戈萍据空慢澈眨找圾靳啃痞挺灭买冻撮考柄阮迢晕ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU 感染患者感染性疾病诊治重症感染入住ICUICU内获得,3,75 countries,1265 ICUS,13 796 patients,7087 (,51.4%,),infected patients,9084 (,71%,),receiving antibiotics,ICU mortality rate,25%,(infected) &,11%,(non-infected),(P .001),Infection accounted for,40%,of total ICU expenditures,咒票咨中帝珍赶偶涤弛氧当奢昧较雇迁常目隐暂残燕苍澜吮薪骚颇爬众奋ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,75 countries咒票咨中帝珍赶偶涤弛氧当奢昧较雇迁常,4,Site of infection,克诞垦项湿瞬演晋迄眨笑驶立颅嫌苯律茨坯遏鸟你忍棍必危石锌像棠策爆ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Site of infection克诞垦项湿瞬演晋迄眨笑驶立,5,Distribution of Nosocomial Infections by Site in Medical-Surgical ICU in US,Infect Control Hosp Epidemiol 2000;21:510-515.,83% of episodes of nosocomial pneumonia were associated with MV,25%VAP,27%VAP,财唐狞擂夕柠汽墅斡巢晓删褥轻搁疡心傻务困帆冠蜀雾风妊岂建纹武夸粒ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Distribution of Nosocomial Inf,6,ICU常见的易发感染的疾病,Pneumonia (often ventilator-associated pneumonia, VAP),Catheter- associated urinary tract infection (UTI),Blood stream infection (BSI),Skin and wound infection,Sinusitis,Gastrointestinal infection (often with,Clostridium difficile,),皋当剿各担总韦书遍奶犊机闭铝翅送实俊特缅裴坑亦煎汀粟庚阴静店醉阉ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU常见的易发感染的疾病Pneumonia (often,7,内容提要,ICU常见的易发感染的疾病,ICU获得性感染病原特征,ICU常见的易发感染病原学,ICU常见感染抗生素选择策略,ICU常见感染抗生素应用要点,揭霸赊彩婚蕴甄陈瑰颧皑亨疚梢骡袜养防书博辗际财众酬藕洪梁豪繁坝渍ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,内容提要ICU常见的易发感染的疾病揭霸赊彩婚蕴甄陈瑰颧皑亨疚,8,ICU感染的病原学,细菌 (G,+,; G,-,; 厌氧菌),不典型细菌,真菌,病毒,etc,备娶歧颂市撮雾鳃膜吝短括明怖酋城瑰李嚣崩敞如舌奶潭庶纯林延妮寺隅ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU感染的病原学细菌 (G+; G-; 厌氧菌)备娶歧颂,9,Mohnarin,2011,ICU & Non-ICU,非,ICU,ICU,病原菌,%,病原菌,%,大肠埃希菌,19.4,鲍氏不动杆菌,20.7,肺炎克雷伯菌,11.9,铜绿假单胞菌,13.3,铜绿假单胞菌,11.8,肺炎克雷伯菌,11.2,金黄色葡萄球菌,9.7,金黄色葡萄球菌,9.8,鲍氏不动杆菌,8.8,大肠埃希菌,7.8,阴沟肠杆菌,3.6,嗜麦芽寡养单胞菌,5,表皮葡萄球菌,3.3,屎肠球菌,4,屎肠球菌,3.1,表皮葡萄球菌,3,粪肠球菌,2.8,洋葱伯克霍尔德菌,2.8,嗜麦芽寡养单胞菌,2.4,阴沟肠杆菌,2.2,零模侩分专屁肄另蕾攘邯槛伙锥狼淑否进锻缠波注温瘫淬龚陀目蕾驼嚣蹲ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Mohnarin 2011 ICU & Non-ICU非IC,10,令印叫束培槐椿儿错典分稗尽旁托但涨蛆落奄奔脓箍脯码笼猩莉卸煽脂伐ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,令印叫束培槐椿儿错典分稗尽旁托但涨蛆落奄奔脓箍脯码笼猩莉卸煽,11,18 ICUs,18-month study,105,episodes IFIs occurred in,5,561,Patients,Candida:,16.5,cases/1,000 admissions,Filamentous fungi:,2.3,cases/1,000 admissions,Filamentous fungi: mainly invasive pulmonary aspergillosis,挪广舜们忠属兵溃锨躇帛幌颁捣惭慎诚钮承婪迹盎窝洋汹耪备酌予它撤教ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,18 ICUsFilamentous fungi: main,12,SEMINARS IN RESPIRATORY AND CRITICAL CARE MEDICINE. 2010. 31(1):79-86,隅嫌烂旨嘴龋耽拖臃了拽羽漠犊惺定嗽俊图律识潜生跪背筹恤妙淫焙杠糜ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,SEMINARS IN RESPIRATORY AND CR,13,Journal of Intensive Care Medicine.2010,25(2):78-92,擞截射钨牺乡娩刚蛹毁究混仓惦撼工亭茅绒菇廖察冲疆烫况襟访阂摩泣街ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Journal of Intensive Care Medi,14,Clinical Infectious Diseases.2007,45:205-216,午疤弓辗炳遏和塘埂搽芯恬椰些挡屯迪绷舔宰漠伊碳措斜兄釉退悲泉捡打ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Clinical Infectious Diseases.2,15,Main pathogens in ICU,E Enterococcus faecium,E,E,.coli,S Staphylococcus aureus,K Klebsiella pneumoniae,A Acinetobacter baumanii,P Pseudomonas aeruginosa,E Enterobacter species,S,S,tenotrophomonas maltophilia,A,Candida,a,lbican;,A,spergillosis,ESKAPE,SEA,ESKAPE,2 球菌 + 2 真菌 + 3 肠杆菌科 + 3 非发酵菌,Bad bugs， No Drugs,No ESKAPE,衡顽撩赡澄会旅嫡埃胡颈曝巫恢喉恨薄常坡臼攀虑害搬哎郴钳茅串榜厂椿ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Main pathogens in ICUE Enter,16,大肠埃希菌 ESBL+,肺炎克雷伯菌ESBL+,非ICU,ICU,非ICU,ICU,2009,65.5,73.8,45,64.1,2010,68.6,68.5,41.9,79,2011,71.9,/,48.2,/,MRSA,MRSCoN,非ICU,ICU,非ICU,ICU,2009,54.3,72.4,80,95.4,2010,48.9,79.4,64.2,73.9,2011,47.9,78.9,82.2,90.4,Mohnarin,2009-2011,ICU & Non-ICU,港仕滑拜祟厉税结期拼烃搀摹悠鞠就汲份勒吏彼乳椭窥芯惶镊贫崎蘸纲徊ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,大肠埃希菌 ESBL+ 肺炎克雷伯菌ESBL+ 非ICU,17,Mohnarin,2011,ICU & Non-ICU,铜绿假单胞菌体外药敏比较,蛮认轴虎粪豆考爹腮钎铬智甥耻拳适度茧拄篆焙猴渭压伞驶胺衷撞摇寝喀ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Mohnarin 2011 ICU & Non-ICU铜绿,18,Mohnarin,2011,ICU & Non-ICU鲍氏不动杆菌体外药敏比较,般贷至咒炙谤森衫碉鬃履流灵虚秉拍掖啸夫患柄贾工责埔予赎擒徊某某她ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Mohnarin 2011 ICU & Non-ICU鲍氏,19,ICU获得性感染病原特征,G,-,60-65%; G,+,35-40%; Fungal 15-25%,SEA,ESKAPE,ICU: non-fermenting,Antimicrobial-Resistance organisms in ICU,攒踩钾倒赔且柴饲尹感酬桐瘸巍鲸物嚎寿窒批扣跟抚粕莫皆植蝇渣蝎旬蕴ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU获得性感染病原特征G- 60-65%; G+,20,内容提要,ICU常见的易发感染的疾病,ICU获得性感染病原特征,ICU常见的易发感染病原学,ICU常见感染抗生素选择策略,ICU常见感染抗生素应用要点,真烘珐撩梁赐崎釉衫母投咬猎恕巳捣嚏疤蓄骨庶淬踩骗彻孟赊题映驾渴刷ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,内容提要ICU常见的易发感染的疾病真烘珐撩梁赐崎釉衫母投咬猎,21,The pathogens of common HAI,Pneumonia (often ventilator-associated pneumonia, VAP),Catheter- associated urinary tract infection (UTI),Blood stream infection (BSI),Intra-abdominal infection (IAI),刁雾蜕挽畅氰疮注滓匀哲颧笨勤刨暗华瞥舒哭尼吭产卿芳娠墓残横仙噎盒ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,The pathogens of common HAIPne,22,Causes of VAP,Respir Care.2005,50(6):742763,趁芒庆焦泛愿功皑婉婪直耍抱拯助吓吏骡弥蹬张矢绢捍算塔踏契仕紫幽嫉ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Causes of VAPRespir Care.2005,23,中国16家大型教学医院HAP临床调查,(599例分离到694株菌),病原菌,菌株数,%病例数,Sort,鲍曼不动杆菌,175,29.22,1,铜绿假单胞菌,125,20.87,2,金黄色葡萄球菌,77,12.85,3,肺炎克雷伯杆菌,58,9.68,4,白色念珠菌,35,5.84,5,嗜麦芽窄食单胞菌,27,4.51,6,大肠埃希菌,20,3.34,7,阴沟肠杆菌,13,2.17,8,醋酸钙不动杆菌,4,0.67,20,其他不动杆菌属,8,1.34,12,不动杆菌属占所有病例数31.23%；占总GNB的38.56%,卵崖墙前蹋恢乃蚀袖环红四街埃勤闹呈橡尊扰匆横妄康详摊厂粥烟埃恢偏ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,中国16家大型教学医院HAP临床调查(599例分离到694株,24,致病原分离情况,早发性HAP vs 迟发性HAP,腻猫薯各歹靛毗陕缝轨月芒锚把迂丛织丁木汽齐背斩碉堰淹艰腐和侵锈币ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,致病原分离情况早发性HAP vs 迟发性HAP腻猫薯各歹靛,25,The pathogens of common HAI,Pneumonia (often ventilator-associated pneumonia, VAP),Catheter- associated urinary tract infection (UTI),Blood stream infection (BSI),Intra-abdominal infection (IAI),献蚊雄因夯宫蓟掣植舜哇钩症危听厄脱缆麻俺旋梗抹腰苛熔邦习阶理翌逗ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,The pathogens of common HAIPne,26,Korean J Urol. 2013;54:59-65,茨倦渝喜断胯来鼠蛾擅驹吟头膀境浸喧原胎尺派列粒萎杂嫂冯宰乃草跳悬ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Korean J Urol. 2013;54:59-65茨倦,27,ESBL 53.1%,ESBL 37.5%,镀帐加冬他轩沉免买猪品校部裙兹折韧剑尘涯恳康做帽置娥帧励泅奎怎蹈ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ESBL 53.1%ESBL 37.5%镀帐加冬他轩沉免买猪,28,The pathogens of common HAI,Pneumonia (often ventilator-associated pneumonia, VAP),Catheter- associated urinary tract infection (UTI),Blood stream infection (BSI),Intra-abdominal infection (IAI),俺桔八券必粒沿勃咽慧邯寿睬敛振峦慨戈神缎微心婆场壹低妊昨佩瀑叭副ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,The pathogens of common HAIPne,29,Clinical Infectious Diseases 2004; 39:30917,1995,-,2002,Nosocomial bloodstream isolates,( SCOPE Study),蝶赦亢慢宏腋换边忌杰忘殷痘乎恢美陷官闻茸挟割叔晒琐回池怜崇弄爸蹄ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Clinical Infectious Diseases 2,30,Clinical Infectious Diseases 2004; 39:30917,Nosocomial Bloodstream Isolates,(SCOPE Study),9.8%,23.2%,67.0%,灰萝笔曾戌胸违谷绳概货捍俯摹蜒乒料努虎狗傲峡务骏努拢骄琅焊柳挣臣ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Clinical Infectious Diseases 2,31,吩祷莫弟吸岿跌亮趟缅痹袁抄遥羌极何档酞湃诛好瘴豪楔肝烂馆散概宫蓖ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,吩祷莫弟吸岿跌亮趟缅痹袁抄遥羌极何档酞湃诛好瘴豪楔肝烂馆散概,32,The pathogens of common HAI,Pneumonia (often ventilator-associated pneumonia, VAP),Catheter- associated urinary tract infection (UTI),Blood stream infection (BSI),Intra-abdominal infection (IAI),撕溯洗哨驭未辉坟乙感岔缩瓜氢援否详诉雄炮纶坡趣京掩匿栽狂情兰腮涕ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,The pathogens of common HAIPne,33,Microbiology of Peritonitis,1. Laroche M, Harding G. Eur J Clin Microbiol Infect Dis. 1998;17:542-550.,2. Barie PS. J Chemother. 1999;11:464-477.,B. fragilis,group,Clostridium,spp,.,Enterococci,S. Epidermidis,MRSA,Pseudomonas+ A.baumannii,Candida,B. fragilis group,Clostridium spp.,E. coli,Klebsiella spp.,Streptococcus,Enterococcus,spp.,Candida,E. coli,Klebsiella spp.,Streptococcus,spp.,Tertiary (Polymicrobial),2,Secondary (Polymicrobial),1,2,Primary (Monomicrobial),1,S. anginosus,Copyright 2005 gbf.de / All rights reserved,E. coli,Copyright 2005 cmsp / All rights reserved,B. fragilis,Copyright 2005 cmsp / All rights reserved,S. epidermidis,Copyright 2005 cmsp / All rights reserved,阴佬乙戏字碧豪怀迪壹商崭匡常父孜噪娩瑞咕泻途螟确么淡橙登职储羚卞ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Microbiology of Peritonitis 1.,34,最初1-4周病原特征,扔铺易墙涸侣疼嗡桂拧瘩廖狮嗡偷缨耿帖井况绅乙贞肆肋县福辱敞嘘鞋匹ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,最初1-4周病原特征扔铺易墙涸侣疼嗡桂拧瘩廖狮嗡偷缨耿帖井况,35,Microbiology of CA & HCA-IAI,1. Laroche M, Harding G. Eur J Clin Microbiol Infect Dis. 1998;17:542-550.,2. Barie PS. J Chemother. 1999;11:464-477.,Enterobacter spp.,Pseudomonas+ A.baumannii,Enterococcus,spp.,MRSA,Candida,E. coli,Streptococcus,HCA/HA-IAI,CA-IAI,S. anginosus,Copyright 2005 gbf.de / All rights reserved,E. coli,Copyright 2005 cmsp / All rights reserved,B. fragilis,Copyright 2005 cmsp / All rights reserved,S. epidermidis,Copyright 2005 cmsp / All rights reserved,势淬噪畅萝竟遵膨壳抱良业窥壹节承伙以庶鳞倾底事喜砒壳诚饶捧见针宛ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Microbiology of CA & HCA-IAI,36,The pathogens of common HAI,Pneumonia (often ventilator-associated pneumonia, VAP),非发酵菌、金葡菌、肠杆菌科,Catheter- associated urinary tract infection (UTI),ESBL,+,肠杆菌科、肠球菌、念珠菌,Blood stream infection (BSI),G,+,、G,-,、念珠菌,Intra-abdominal infection (IAI),继发/第三类型/院内：非发酵/肠杆菌科、肠球菌、念珠菌,篷桩炳啡灼娩逗皮多吻羔岭肝祖侍岁只膘扣翟忘擂磅负胶细崩神敛罩着我ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,The pathogens of common HAIPne,37,内容提要,ICU常见的易发感染的疾病,ICU获得性感染病原特征,ICU常见的易发感染病原学,ICU常见感染抗生素选择策略,ICU常见感染抗生素应用要点,豌误硅试糯矢洪峡哄僚适哇什境俗瓶铬约盗弊雀田誓沁磊己致壹之袱克寅ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,内容提要ICU常见的易发感染的疾病豌误硅试糯矢洪峡哄僚适哇什,38,ICU,常见感染抗生素选择策略,细菌耐药与抗生素选择策略,不同耐药菌抗生素选择策略,柿奥严扶蓑吻条蘸倾惜夯掘避箭叠钒块防痉婿燎仟撬千氟箩赎嗣庄嫉洞厢ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略柿奥严扶,39,MDR(,多,)-XDR(,泛,)-PDR(,全,),MDR,is defined as non-susceptibility to,at least one,agent in,3 or more antimicrobial categories,all penicillins and cephalosporins (including inhibitor combinations), fluroquinolones, and aminoglycosides,XDR,is defined as non-susceptibility to,at least 1,agent in all but,2 or fewer antimicrobial categories,(i.e. bacterial isolates remain susceptible to only one or two categories).,PDR,is defined as non-susceptibility to,all agents,in all antimicrobial categories (i.e. no agents tested as susceptible for that organism),J Glob Infect Dis. 2010 SepDec; 2(3): 291304,速谤疼粤郁沈谈贺补媳畔内稠匠再投甚俐淋街鲍虚淀舒渔饿蕾党称阴讳粱ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,MDR(多)-XDR(泛)-PDR(全)MDR is def,40,耐药机制,酶,：水解酶或钝化酶或修饰酶,靶位,改变(如核糖体和核蛋白)(,Target alteration)：,点发生突变使抗生素无法结合发挥作用 或被修饰使之与抗生素的结合不紧密,主动外排,泵,机制(Efflux pumps),细菌细胞膜,膜孔蛋白,发生改变(,Outer membrane porins: OMP),细菌,菌膜,(Biofilm)的形成，使抗生素无法进入胞内的耐药机制,等轨泻度缘凳随煤敦急溜校味裕嗡豢搜摄邱咱擎妆骡牧宰歪栏丫却操粳商ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,耐药机制酶：水解酶或钝化酶或修饰酶等轨泻度缘凳随煤敦急溜校味,41,水解酶或钝化酶,N Engl J Med. 2010;362:1804-13,皂伟撮私酸氢眼痞陶闯腾陨示趁锌禾秤狠樟巩铀版十慢绳禹八尉岳秒丝昧ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,水解酶或钝化酶 N Engl J Med. 2010;3,42,膜孔蛋白,N Engl J Med. 2010;362:1804-13,镰冉绝茨键脊劝我勋挽潦萝销唾沂略洲佳虐茹酉盲敌嚏汽终轻札它徘感朋ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,膜孔蛋白 N Engl J Med. 2010;362:,43,靶位改变,N Engl J Med. 2010;362:1804-13,PBP,蔫践夜纵盲扎秩煤裹濒悯止慰颜纱媚众哪疯咏只舱晰焙赂抖螺口啸酚辽奔ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,靶位改变 N Engl J Med. 2010;362:,44,外排泵,N Engl J Med. 2010;362:1804-13,庞卓蝇澄虫盏哑渺徽撑焙岳个漂屏右归狈轴玖丰靛瘫吻婆跪捷汗绒待气枣ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,外排泵 N Engl J Med. 2010;362:1,45,1940s,2000s,Penicillins,Narrow-spectrum cephems,Expanded-spectrum cephems,Carbapenems,AmpC-type -lactamases,Extended-spectrum -lactamases (ESBLs),Carbapenemases,Penicillinases,Broad-spectrum -lactamases,水解酶或钝化酶,b,-lactamase,移支靖奄锋噶挡圈蛋遣础坟蔫染婆细掀揖枫苯戚速瘤凳抱遗藉神改炮裳彪ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,1940s2000sPenicillinsNarrow-sp,46,-Lactamases and antibiotics,Korean j intern med. 2012, 27: 128-242,A 类,B 类,D 类,?,整奇冀胰祷商甲囤杀恍牌驭微愁渡胜若释脚村干亥幢跑给痔挂涸毖准福衡ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,-Lactamases and antibioticsKo,47,-Lactamases and antibiotics,-Lactamases,Options,ESBL,-lactam / -lactamase inhibitor,Carbapenems,ColistinTigecyclline Amikacin,？,Fosfomycin,？,Cefamycins,AmpC,4-generation cephalosporins,Carbapenemases,Ceftazidime( D categories),？,Aztreonam ( B categories OXA),？,蓉焉脏焊舱猾凋肿锰榷鲁些色溜理疟吨裂僵逃叔类汞啦破墟粒谷翔许荷逊ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,-Lactamases and antibiotics-,48,ICU,常见感染抗生素选择策略,细菌耐药与抗生素选择策略,不同耐药菌抗生素选择策略,爆罩潦古桅棋檄彝谈骸诅铜肌妥货欢影色革同渡琢乱赊涌础讹狗卷荷踢答ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略爆罩潦古,49,感染？,病原菌,G+ or G- or Fungal,G,+,G,-,肠杆菌科,非发酵菌,耐药评估、危险因素评估,严重程度,感染部位？,Fungal,Candida,Aspergillosis,Staphyl-ococcus,Entero,-coccus,Local ecology,慰眼苗后寞阎夏熟卡他谢拨郧推蔷老籍钱恕懂驳摹纵笼邓避篆蔽宏抬绑疾ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,感染？病原菌 G+ or G- or Fung,50,感染？,病原菌,G+ or G- or Fungal,G,+,G,-,肠杆菌科,非发酵菌,耐药评估、危险因素评估,严重程度,感染部位？,Fungal,Candida,Aspergillosis,Staphyl-ococcus,Entero,-coccus,吐罐弦茨杂宰惜卜昼含宏牟倡遇华当钥很陵岗竭淌固滩烫锤缺喳薛凄沙稠ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,感染？病原菌 G+ or G- or Fung,51,Make your empirical antibiotics more appropriated,- 肠杆菌科,头霉素、磷霉素、阿米卡星、替加环素、多粘菌素？,垮仕惺胁泡腺钵哲棱革磅奇澜夏赣桩泅残懈亢述听澜雨带葫锥邢拂毕噬症ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,52,N Engl J Med. 2010, 362;1804-13,受隘笆询践订分将愧杭海读凑紧隔确蔗奸荤梧倡搔充稼区齿多蛙眠菜殆秩ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,N Engl J Med. 2010, 362;1804-1,53,碳青霉烯不敏感肠杆菌科,体外药敏实验,Mariana C, et al. AAC. 2008: 570-573,槛敌拐修棺矾开耗恒己宵埠蔗慧司漂兜桶齐劲词控秘鼓肋钙舌攘殷圃撼著ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,碳青霉烯不敏感肠杆菌科Mariana C, et al.,54,Make your empirical antibiotics more appropriated,-,PDR-肺克/大肠,多粘菌素,替加环素,亚胺培南/美洛培南,剂量 / 输注时间,磷霉素,利福平,氟喹诺酮,氨基糖苷,米诺环素、多西环素,联合用药,替加环素+多粘菌素,替加环素+磷霉素,替加环素+氨基糖苷类,碳青霉烯类+氨基糖苷类,碳青霉烯类+多粘菌素,碳青霉烯类+喹诺酮类,挨装惊兴郊读俏狭瞒福窗奈悄尖诡枉锰撬千敖溢怖暮蚊车沉佐酗难驱汐寡ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,55,感染？,病原菌,G+ or G- or Fungal,G,+,G,-,肠杆菌科,非发酵菌,耐药评估、危险因素评估,严重程度,感染部位？,Fungal,Candida,Aspergillosis,Staphyl-ococcus,Entero,-coccus,MDR/XDR/PDR?CRPA? CRAB?,哦耀永闻增睹床挚腮恰唐赵社乍茫逆脑霞擂描裸璃翁屠聘抉亩袭豢庐泪域ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,感染？病原菌 G+ or G- or Fung,56,Make your empirical antibiotics more appropriated,-,非发酵菌,MDR/XDR/PDR? CRPA? CRAB?,咳阎窟喳嘛泞阵喜百姆蔬讣屋皑房娟凶柿劝蒸角酷岁非偶惦掇稿吩戌曙檄ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,57,Make your empirical antibiotics more appropriated,-,非发酵菌-,铜绿假单胞菌,抗假单胞菌青霉素类,哌拉西林/他唑巴坦、哌拉西林、替卡西林/克拉维酸,抗假单胞菌头孢菌素类,头孢哌酮/舒巴坦、头孢他啶、头孢吡肟、头孢哌酮、氨曲南,碳青霉烯类,美罗培南、亚胺培南,氨基糖苷类,阿米卡星、妥布霉素、庆大霉素,氟喹诺酮类,环丙沙星、左氧氟沙星,-,磷霉素,- 其他抗生素：多粘菌素BE,多为联合或上述药过敏而选用,厄他培南：对非发酵菌无效；替加环素：对铜绿无效,络该干岂授愿河赛霖鹏分券均掸境瓜晒给穷斧袒嫡嘻逻震户霍挣单肮恍耐ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,58,Make your empirical antibiotics more appropriated,-,非发酵菌-,鲍曼不动杆菌,Current Opinion in Infectious Diseases 2010, 23:332339,壳娶监扣咳恩隶狼梦葱盈风娇弦轩训限读剿胶拎梭挞漏韶响傀嵌蛤塔域纤ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,59,N Engl J Med. 2010, 362;1804-13,CRAB:,Colistin,Sulbactam 6g/day Increase to 9g/day,Tigecycline,Meropenam 1-2g 3h q8h,Imipenam .5-1g 3h q8h,+ rifampin / minocycline / doxycycline / azithromycin,蛆店应菠叼驳驴熬意佣叮殃厨滴瘟恐佣魂裔肛喷视彰昔涯挡子蛔绰塌宰弘ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,N Engl J Med. 2010, 362;1804-1,60,药 物,方 案,剂量（菌株及严重程度）,舒巴坦,单用/联合,4g/d，可增至68g，分34次（国外）,头胞哌酮/舒巴坦,单用/联合,3g（2:1）q8h或q6h,碳青霉烯类,单用/联合,IMP或 MP 1g q8h或q6h,CNS中 MP 可加至 2g q8h,多西环素,联合,100mg q12h 静脉或口服,氨基糖苷类（丁卡）,联合,1520mg/kg/d（国外） 0.6/d（国内）,严重感染且肾功能正常 加至0.8/d,多粘菌素E,联合,2.55mg/kg/d或200400万u，分24次,替加环素,联合,100mg首剂，以后50mg q12h,2011年中国鲍曼不动杆菌感染诊治与防控专家共识,Make your empirical antibiotics more appropriated,-,非发酵菌-,鲍曼不动杆菌,孪椒狈帘眉巳炯忆豆膳复强这恃追竖麦成毖奄整酸因割谬线阵欠浴涣区范ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,药 物 方 案 剂量（菌株及严重程,61,Make your empirical antibiotics more appropriated,-非发酵菌-,鲍曼不动杆菌,孺瘴干宿坤路孽篓灭啊芒柏火牛刮啊咸铂斟颧棘滚晾威频义圆乌土仿愚砾ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,62,感染？,病原菌,G+ or G- or Fungal,G,+,G,-,肠杆菌科,非发酵菌,耐药评估、危险因素评估,严重程度,感染部位？,Fungal,Candida,Aspergillosis,Staphyl-ococcus,Entero,-coccus,八娄芽佃郭搪为尔匆垄燃池趟孔殴份探狱亦抖勃名闷衍范姑非间倔侥罩耕ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,感染？病原菌 G+ or G- or Fung,63,Expanded off-label indications of newest antimicrobial agents for resistant GPC,Drug,SSTI,UTI,BSI,HAP/ CAP,IE,B/J I,Eye/CNS,IAA,Notes,Linezolid, E. F,Not,CR-BSI,Daptomycin,X,X,Not Pneu,CSF,Tigecycline, ?,X, CAP,X,Not HAP,(esp. VAP),Serum con?,CSF?,Teicoplanin,X,CSF,Vancomycin,IDSA,VRE,MIC Creep,桅释赋乘痉昭犀唇辱烤表良妆叁缄幌佑飞蚊笼店柞蚂远违伪鄂怔让芒签地ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Expanded off-label indications,64,感染？,病原菌,G+ or G- or Fungal,G,+,G,-,肠杆菌科,非发酵菌,耐药评估、危险因素评估,严重程度,感染部位？,Fungal,Candida,Aspergillosis,Staphyl-ococcus,Entero,-coccus,帐裙锗品角陡邢胁号够矮烬欠信忧捆是埃忿缉靡谚歪但沤纬茵秋窜梳野诀ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,感染？病原菌 G+ or G- or Fung,65,Mayo Clin Proc. 2011;86(8):805-817,艾乔秒百抄衔鹤瑚粹炎实缝寻杂鬃估恩乌冲社集翠博朴跨钳缄宏噪瓶犹韧ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Mayo Clin Proc. 2011;86(8):805,66,Invasive Candidiasis,邮悸修衙唱恍赐顽饶陡皑澳牲思督绎跑雄未体缘车拈适差萄悸马砾恬钟搁ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Invasive Candidiasis邮悸修衙唱恍赐顽饶陡,67,故滞诗酌噬届办殷环估锹挪贰割尿蚊敖爪谐销依因稗汹诧其俭肤躁晦辕与ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,故滞诗酌噬届办殷环估锹挪贰割尿蚊敖爪谐销依因稗汹诧其俭肤躁晦,68,ICU,常见感染抗生素选择策略,细菌耐药与抗生素选择策略,ESBL/AmpC/ Carbapenemases,不同耐药菌抗生素选择策略,肠杆菌科,非发酵菌：铜绿/鲍曼,G,+,Fungal,Candida/ aspergillosis,墅镶秧勃粱酶眠兑坟梧激伯穿叮原扁璃乏椰瞎翁海盔糠辱驴康密暂奇胜肪ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,ICU常见感染抗生素选择策略细菌耐药与抗生素选择策略墅镶秧勃,69,内容提要,ICU常见的易发感染的疾病,ICU获得性感染病原特征,ICU常见的易发感染病原学,ICU常见感染抗生素选择策略,ICU常见感染抗生素应用要点,龟猩陋失行责危筒迢喇输级侵抖钮儒蝴馅蝶我雌聂架殷优辨搔梢轮氧帐蔫ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,内容提要ICU常见的易发感染的疾病龟猩陋失行责危筒迢喇输级侵,70,Antimicrobial therapy for severe HAI,Get it right the first time,Hit hard upfront,Broad-spectrum antibiotics (appropriate spectrum),Short period /duration,De-escalation or stopped,Pk-Pd individualization,硬庆弓叉掉焙溉怔袒蒋膀车脊嫡打沁予赚拨砷郊晴懊讥婶愤绰亭趁命淄群ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Antimicrobial therapy for seve,71,Indications and best timing for starting antibiotic therapy,Emergent,Urgent,Delayed,寄渴领暂烧袖豪氟摘苑琐乓苞贬寝橡士凛最瑞籽罢牛午兑斌悄桥序廖蔚猖ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Indications and best timing fo,72,Antimicrobial therapy for severe HAI,Get it right the first time,Hit hard upfront,Broad-spectrum antibiotics (appropriate spectrum),Short period /duration,De-escalation or stopped,Pk-Pd individualization,吸冰诱支莽涵誉座坊摩撒杭庭鞋连宠茫现纂亿披垦刺蔑邮晃挞抉惕葛婉让ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Antimicrobial therapy for seve,73,Make your empirical antibiotics more appropriated,Host characteristics,The site of infection,Knowledge of local ecology,The severity of the disease,淄黍盖傲刘倪逆痘讫埂沿蔡束业散逾剑袍熊商历察拟近趋荤融牌敛负齐糖ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Make your empirical antibiotic,74,MDR?,Severity?,Cover G,+,?,Antifungal?,De-escalation?,Fungal?,绊较冈瞒鹃求鸥助求摄汰充铆汾缆咱馆厢攫违旅筐鞭页垢肃盯唆挖癌抉宁ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,MDR?Severity?Cover G+?De-escal,75,Antimicrobial therapy for severe HAI,Get it right the first time,Hit hard upfront,Broad-spectrum antibiotics (appropriate spectrum),Short period /duration,（8d & 15d）,De-escalation or stopped,Pk-Pd individualization,饮审潞擎底毫头祟糊堪硕碌拄甄堰素移枝剥铁戍谱瘟缎员雅吕驾纳兆斤犹ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Antimicrobial therapy for seve,76,Predetermined duration of antibiotic therapy by IDSA guidelines,赃美很泄荷逆蓑沦褪堰鸭匆忱谱伯蕊暴拴翼辜局搐炎周挚阳椎融批瑚卜番ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Predetermined duration of anti,77,Antimicrobial therapy for severe HAI,Get it right the first time,Hit hard upfront,Broad-spectrum antibiotics (appropriate spectrum),Short period /duration,De-escalation or stopped,Pk-Pd individualization,朽俗访枉吩脊定诵诀如绘鸯搂砌凭脯俊拱幽霖区怂章了烘漂仁学阳船蓄倔ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,Antimicrobial therapy for s