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,*,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,*,Wang Yao, PUMCH,*,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,*,Wang Yao, PUMCH,*,1,多重耐药的不动杆菌感染控制与进展,徐英春,北京协和医院,1 徐英春,1,全球关注的多重耐药菌株,PRSP,MRSA,ESBLs,株,MDR,的非发酵糖菌,绿脓杆菌,鲍曼不动杆菌,嗜麦芽窄食单胞菌,全球关注的多重耐药菌株PRSP,2,Europe,E. coli,/ ESBL phenotype 8%,Klebsiella,/ ESBL phenotype 24%,Jones, RN. Personal Communications, October 2019 (2019-2019 results),United States,E. coli /,ESBL phenotype 5%,Klebsiella,/ ESBL phenotype 15%,Asia Pacific,E. coli,/ ESBL phenotype 51%,Klebsiella,/ ESBL 49%,Latin America,E. coli,/ ESBL phenotype 16%,Klebsiella,/ ESBL 47%,ESBLs,在世界范围内流行情况,(2019-2019),EuropeJones, RN. Personal Co,3,广州,(,CTX-M3,9,),杭州,(,CTX-M-3,9,14,22,24,SHV-11,12,2),上海,(CTX-M3),北京,(,CTX-M-3,9, 11, 14,SHV- 2,3,14,),武汉,(CTX-M3),成都,(CTX-M3),天津,(CTX-M3),新疆,(CTX-M3,9),沈阳,(CTX-M3),中国,CTX-M,型的,ESBL,爆发流行,近,5,年国内医学文献报道,广州 (CTX-M3,9 )杭州 (CTX-M-3,9,14,4,5,The CTX-M global spread (2019),Cantn Livermore et al., JAC 59:165, 2019,5The CTX-M global spread (2019,5,治疗产,ESBLs,菌株,可能有效的药物,头霉素类：头孢美唑等,加酶抑制类：头孢哌酮,-,舒巴坦等,碳青霉烯类：亚胺培南等,预防传播,治疗产ESBLs菌株,6,肺克，大肠,ESBL,肠杆菌属,AmpC,碳青霉烯类是可靠的武器,碳青霉烯类耐药的不动杆菌、铜绿假单胞菌上升,大量使用,肺克，大肠ESBL肠杆菌属 AmpC碳青霉烯类是可靠的武器,7,铜绿假单胞菌,A,组：头孢他啶,庆大霉素,妥布霉素,哌拉西林,B,组：阿米卡星,氨曲南,头孢吡肟,环丙,左氧,亚胺培南,美罗培南,哌拉西林,-,他唑巴坦,替卡西林,U,组： 罗米沙星或氧氟沙星,诺氟沙星,Clinical and Laboratory Standard Institution,，,2019,，,M100-s18,，,Vol 28 ,No.1,铜绿假单胞菌A组：头孢他啶,Clinical and Lab,8,绿脓杆菌的耐药性变迁,Xu Yingchun, PUMCH,绿脓杆菌的耐药性变迁Xu Yingchun, PUMCH,9,多重耐药的不动杆菌感染控制与进展课件,10,NPRS,：,1994,2019,部分主要可分析菌数,细菌,/,年份,94,95,96,98,99,00,01,02,03,04,05,06,总计,铜绿,143,261,331,311,283,387,410,408,456,406,368,392,4156,大肠,101,156,300,319,260,336,360,403,415,430,494,510,4084,肺克,68,164,150,265,229,309,256,363,339,305,350,343,3141,鲍曼,40,30,80,68,145,211,292,314,307,387,346,351,2571,阴沟,47,120,103,216,221,208,206,172,206,156,140,110,1905,嗜麦芽,15,1,97,50,33,95,106,80,98,76,104,75,830,变形,27,66,38,47,45,53,26,29,27,9,21,36,424,沙雷,13,30,41,43,19,26,31,22,11,33,27,33,329,枸橼酸,29,23,37,40,32,64,42,51,37,36,25,24,440,483,851,1177,1359,1267,1689,1729,1842,1896,1838,1875,1874,17880,注： 这里只列出主要菌株，因此总数少于可分析菌株数,NPRS ： 19942019 部分主要可分析菌数 细菌,11,不动杆菌的危险因素,Acinetobacter,ventilator-associated pneumonia(AVAP),住过神经外科,颅脑外科,吸入肺炎,先前用药,：亚胺培南，氟喹诺酮类,（,OR, 14,，,95% CI, 4.191;,P, .0001,）；亚胺培南耐药,(OR, 4; CI, 1.12 9.8;,P,32 R,他啶,256 R,吡肟,256 R,哌拉,/,三唑,128 R,哌酮,/sul128 R,阿米卡星,64 R,环丙,16R,PFGE,：,P clone,北京协和医院耐药监测,23药MICPFGE：P clone北京协和医院耐药,23,鲍曼不动杆菌流行期间污染环境,吸引器具,导管,床栏杆,加湿器,枕头,尿杯,通风设备,静脉营养,输液泵,药瓶,绷带,手机,洗手盆,领带,病人桌子,不锈钢手推车,坐垫,淋浴器,Pierre EF et al. CID, 2019; 42:6929,Paterson DL,，,et al. CID,；,2019; 43:S438,24,鲍曼不动杆菌流行期间污染环境吸引器具导管24,24,239,株鲍曼不动杆菌的敏感性,Antibiotic name,%R,%S,MIC50,MIC90,Geom.Mean,MIC Range,Piperacillin/Tazobactam,59.8,29.7,128,256,40.946,.125 - 512,Cefoperazone/Sulbactam,27.2,45.2,32,64,16.048,.064 - 512,Ceftazidime,62.8,29.7,64,256,45.849,.125 - 512,Cefepime,66.9,23.4,32,256,31.735,.008 - 512,Imipenem,36,59,2,64,3.192,.032 - 256,Meropenem,37.2,56.1,2,64,2.944,.004 - 512,Ciprofloxacin,64,34.7,16,64,5.668,.002 - 64,Levofloxacin,50.6,30.1,8,16,2.794,.064 - 64,Moxifloxacin,69.9,28,4,16,2.288,.002 - 64,Amikacin,57.3,41.4,256,256,45.584,.125 - 512,Minocycline,20.9,59.4,4,16,2.38,.125 - 64,Tigecycline,1,2,0.873,.016 - 8,Trimethoprim/Sulfamethoxa.,67.9,32.1,64,128,13.005,.064 - 128,Polymixin B,3.8,96.2,0.5,1,0.713,.25 - 128,25,北京协和医院耐药监测,-CARES,项目,239株鲍曼不动杆菌的敏感性Antibiotic,25,26,哌酮舒 哌拉 他定 吡肟 亚胺 美罗 环丙左氧 加替丁卡 多粘 米诺,26哌酮舒 哌拉 他定 吡肟 亚胺 美罗 环丙左氧,26,27,Data were collected from the MYSTIC,（,mystic-data.org,）,27Data were collected from th,27,28,28,28,29,北京协和医院耐药监测,29北京协和医院耐药监测,29,30,Carbapenemases in Acinetobacter spp. in Asia,Woodford N, 2019, IJAA,30Carbapenemases in Acinetobac,30,P,克隆和,D,克隆菌株外排基因相对表达量,克隆,组别,菌株,adeB,表达量,adeM,表达量,P1,1,4A1,1.09,25.56,P1,1,BJ23,0.69,19.22,P1,1,F1,0.63,36.69,P1,1,PU73,0.80,8.15,P2,1,BJ52,0.39,18.19,P2,1,BJ55,0.59,4.68,P3,1,BJ9,0.56,9.36,D1,1,ZJ36,0.00,0.43,D1,1,ZJ58,0.00,0.10,D1,1,ZJ49,0.00,0.33,北京协和医院：王贺 徐英春,P克隆和D克隆菌株外排基因相对表达量克隆组别菌株adeB表达,31,菌株,组别,插入序列,多重,PCR,OXA-51,表达量（相对倍数）,adeB,表达量（相对倍数）,adeM,表达量（相对倍数）,药物,MIC,值,ISF-OXA51R,OXA-51,OXA-23,亚胺培南,美罗培南,PU88,A,+,+,-,52.54,5.80,0.11,6,64,PU98,A,+,+,-,95.68,4.49,0.28,12,64,PU102,A,+,+,-,51.45,14.54,0.53,8,64,PU119,A,+,+,-,26.65,4.37,0.77,12,64,FZ84,A,+,+,-,156.99,0.51,11.72,8,16,NJ59,A,+,+,-,26.23,0.54,0.43,8,8,PU52,A,+,+,-,170.31,1.63,1.98,4,24,DL56,C,-,+,-,0.02,0.03,0.06,0.25,0.25,QD59,C,-,+,-,0.03,0.11,0.1,0.25,0.125,RJ53,C,-,+,-,0.03,0.06,0.02,0.25,0.25,GZ54,C,-,+,-,0.08,0,0.02,0.25,0.25,JL63,C,-,+,-,0.03,0.02,0.03,0.25,0.25,19606,C,-,+,-,1.00,1,1,1,1,北京协和医院：王贺 徐英春,菌株组别插入序列多重PCROXA-51表达量（相对倍数）ad,32,菌株,组别,插入序列,多重,PCR,OXA-51,表达量（相对倍数）,adeB,表达量（相对倍数）,adeM,表达量（相对倍数）,药物,MIC,值,ISF-OXA51R,OXA-51,OXA-23,亚胺培南,美罗培南,4A1,B,-,+,+,18.96,1.09,25.56,32,32,4A22,B,-,+,+,5.72,0.68,12.13,32,16,BJ9,B,-,+,+,3.09,0.56,9.36,64,64,BJ55,B,-,+,+,0.54,0.59,4.68,32,32,SY05,B,-,+,+,0.12,1.31,6.40,64,64,ZJ36,B,-,+,+,0.85,0.00,0.43,32,32,SY01,B,-,+,+,6.68,1.16,8.37,64,64,BJ23,B,-,+,+,4.87,0.69,19.22,64,64,PU73,B,-,+,+,0.64,0.80,8.15,64,32,DL34,B,-,+,+,1.50,0.30,0.73,64,32,F1,B,-,+,+,12.35,0.63,36.69,32,32,ZJ32,B,-,+,+,17.02,0.34,3.34,64,32,DL56,C,-,+,-,0.02,0.03,0.06,0.25,0.25,QD59,C,-,+,-,0.03,0.11,0.1,0.25,0.125,RJ53,C,-,+,-,0.03,0.06,0.02,0.25,0.25,GZ54,C,-,+,-,0.08,0,0.02,0.25,0.25,JL63,C,-,+,-,0.03,0.02,0.03,0.25,0.25,19606,C,-,+,-,1.00,1,1,1,1,北京协和医院,:,王贺 徐英春,2019,菌株组别插入序列多重PCROXA-51表达量（相对倍数）ad,33,34,鲍曼不动杆菌感染治疗对策,氨苄西林,-,舒巴坦：脑膜炎,6/8,有效,舒巴坦 ：部分有效,氟喹诺酮类,+,氨基糖苷类：部分多重耐药株有效,抗假单胞药或抗假单胞,3,代头孢,+,氨基糖苷类,多粘菌素,E,美罗培南,+,舒巴坦,粘菌素,+,亚胺培南,+,利福平,替加环素,*,头孢哌酮,-,舒巴坦,+,米诺环素：有效率,68%,*,石岩，等。中国感染与化疗杂志，,2019,，,7,（,1,）：,34,热病,2019,34鲍曼不动杆菌感染治疗对策氨苄西林-舒巴坦：脑膜炎6/8有,34,痰涂片的判定,分类,WBC,鳞状上皮细胞,252525 10-25,3 2525,10-2525,125,分类中,1,3,类不做培养，要求重新留取标本；,4,、,5,类为合格标本；,6,类为气管穿刺液时，如未见白细胞，而鳞状上皮细胞,10/,低倍，亦应重新留取标本,。,痰涂片的判定分类WBC鳞状上皮细胞,35,36,涂片组,:,快速诊断,北京协和医院耐药监测,36涂片组: 快速诊断北京协和医院耐药监测,36,37,北京协和医院耐药监测,37北京协和医院耐药监测,37,北京协和医院耐药监测,北京协和医院耐药监测,38,多重耐药的不动杆菌感染控制与进展课件,39,多重耐药的不动杆菌感染控制与进展课件,40,多重耐药的不动杆菌感染控制与进展课件,41,多重耐药的不动杆菌感染控制与进展课件,42,43,43,43,44,44,44,45,方法,采样,建议用尼龙植绒拭子于病人肛门内部,1-2,厘米处转圈采样,3次,不方便采直肠拭子患者，可以采用粪便标本，一接种环量即可。,对于灌肠患者，仍然可以采用直肠拭子，可多转几圈。,对于人工肛门患者，可于瘘口采样。,采样后将直肠拭子或一接种环粪便置于,2,ml,无菌生理盐水。,于旋涡振荡器上振荡,30,秒，以充分悬浮标本中细菌。,常规监测： 直肠拭子(或粪便),方法常规监测： 直肠拭子(或粪便),46,方法,接种方法,两小时内取直肠拭或大便悬液2滴于产色培养基,chromID ESBL,上，用,T,或,L,形涂布棒转圈接种。,直肠拭子(或粪便),方法直肠拭子(或粪便),47,1.,结果判读,孵育24小时后判读结果。推荐从平板底部判读结果。,典型菌落：,大肠埃希菌：粉红至酒红色菌落,KESC（,克雷伯菌属、肠球菌、沙雷菌属、柠檬酸杆菌）：蓝绿色或棕绿色,变形杆菌：浅棕或深棕色菌落,不动杆菌：浅棕色菌落,假单胞菌：深棕色菌落,直肠拭子(或粪便),1.结果判读 直肠拭子(或粪便),48,ESBL-ID,大肠埃希菌,奇异变形杆菌,肺炎克雷伯菌,以上图片仅供参考,ESBL-ID大肠埃希菌奇异变形杆菌肺炎克雷伯菌以上图片仅供,49,ESBL-ID :,铜绿假单胞 和 不动杆菌,底部,顶部,以上图片仅供参考,ESBL-ID : 铜绿假单胞 和 不动杆菌底部顶部以上图片,50,结果报告,请报告每个病人的标本中是否含有以下多重耐药细菌（,MDRO）：,产,ESBL,的肠道菌,多重耐药的鲍曼不动杆菌,多重耐药的铜绿假单胞菌,其他产,ESBL,的肠道菌,结果报告请报告每个病人的标本中是否含有以下多重耐药细菌（MD,51,52,传染病专家,Optimal,Patient Care,感染控制专家,流行病学家,临床药学家,临床药理学家,外科感染专家,临床微生物家,有效地诊断和治疗,52传染病专家Optimal 感染控制专家流行病学家临床药学,52,结论,提高感染性疾病的诊断能力和意识是合理使用抗菌药物的基础,抗菌药物应用单一化向多级化转变：对ESBL（+），头孢美唑，碳青霉稀类，酶抑制剂类,超广谱 重锤：窄谱有效也是重锤,涂片-寻找病原菌-药敏-治疗感染-不是定值,53,结论提高感染性疾病的诊断能力和意识是合理使用抗菌药物的基础5,53,54,shl,结论,对多重耐药或泛耐药，加大院感控制的投入,筛查：临床送检鼻拭子、肛拭子,洗手,隔离：使用单独的医用设备,警示： 隔离间，贴“,MRSA,标识”？,告知：,MDR,阳性患者,-,转病房，提前告知？,分型：分子分型法快速确认流行株,PFGE (,脉冲场凝胶电泳,),RAPD,DiversiLab,系统,54shl 结论,54,