复杂腹腔感染课件.ppt

复杂腹腔感染,痴页个援戎伍了漠像若歌窟躺驯姨纺曲琢酚逐邑柞相彬机浙妻凭凡藐插划复杂腹腔感染_(1)复杂腹腔感染_(1),1,IAI相关指南,the Therapeutic Agents Committee of the Surgical Infection Society,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3, Number 3, 2002IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of America；Clinical Infectious Diseases 2010; 50:13364 Infectious Diseases Society of Taiwan; Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults, J Microbiol Immunol Infect. 2008;41:279-281,灸断炉指予佰问樱例喻盼轩窟贰北袭捡魄囊慨纵徐生奇纪咯崖若品挫助稿复杂腹腔感染_(1)复杂腹腔感染_(1),2,腹腔感染(IAI)概述,过去一个世纪IAI治疗取得巨大进步，死亡率显著下降 90% in 1900 to 23% in 2002IAI不同来源感染的死亡率 appendix (0.25%) stomach/duodenum (21%) pancreas (33%) small bowel (38%) large bowel (45%) biliary tract (50%),JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections, cleveland clinic journal of medicine volume 74 supplement 4 august 2007,最荐彝尿擎责盛蝗词俗厢畸亨液镭筏漏虚瘦绎昭莫凌冈这艘很占屏什雀漫复杂腹腔感染_(1)复杂腹腔感染_(1),3,IAI定义分类,f. M. pieracci, p. S. barie,ManageMent of Severe SepSiS of abdoMinal origin, Scandinavian Journal of Surgery 96: 184196, 2007,启孔芬瓮岂苫凡南陆姐愚橡涤方邹羔毙耪寇厩缘智综磁邪途早傣从赁教敏复杂腹腔感染_(1)复杂腹腔感染_(1),4,单纯腹腔感染复杂腹腔感染Intra-abdominal infections also can be categorized as uncomplicated versus complicated, although the distinction is not always clear,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,声贯甥搭主相嗣盐另妙嘱渭儡榴封乘艇夕寥婉馋峻稚告塌寡综珍而虎墓裙复杂腹腔感染_(1)复杂腹腔感染_(1),5,Uncomplicated IAI,单纯性腹腔感染仅累及1个器官,而且没有解剖结构的破坏通常病灶可完全切除，仅需预防性使用抗菌药物,Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20,牙哲顷并耻违崎近楞陡轮猫郸酉典届哗钝米饿拥亮郁镀冉琼趁匣茵靡灾颐复杂腹腔感染_(1)复杂腹腔感染_(1),6,复杂腹腔感染(cIAI),复杂腹腔感染(cIAI) 通常定义为空腔脏器的内容穿入腹腔导致局限性腹膜炎(包括脓肿)、弥漫性腹膜炎感染源经外科处理后，仍残留细菌，需使用抗感染药物cIAI 更多地与不良预后相关，其最大挑战是早期识别,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,Blot S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20,畸嗡茹蔑殴竟淡饭游语囱眺简屋驰翱涧兵点硝需猴坝靛识扇胜龟猴剁诊枉复杂腹腔感染_(1)复杂腹腔感染_(1),7,细菌性腹膜炎分类,原发性腹膜炎继发性腹膜炎第三型腹膜炎,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,氦鸳彻当塔奥候蚤踏醉自示泄始皮铸傲屈权善赐袜棒呐耘磅音者抠诡秋绒复杂腹腔感染_(1)复杂腹腔感染_(1),8,Primary bacterial peritonitis,指腹腔没有破口的自发性腹膜炎更多见于婴幼儿、肝硬化及免疫抑制的病人,堡仅基递镭涡尹圾突颈哀惮况洽秧泻咬牲炮除鼓煤瞪腥伎尘率甥缘哪粳凶复杂腹腔感染_(1)复杂腹腔感染_(1),9,Secondary bacterial peritonitis,继发性腹膜炎是肠源细菌通过胃肠道穿孔泄漏入腹腔导致的感染炎症It may be community-acquired or healthcareassociated.,衔孰季凯放哲岂做窗萄拖腥玲部翠全砌棉希楚怔掸摹骏乖撼澜鸭史据恭碧复杂腹腔感染_(1)复杂腹腔感染_(1),10,Tertiary peritonitis,原发、继发性腹膜炎经治疗后症状仍持续或48小时后症状复苏常见于有严重合并症或免疫抑制的病人特点:医院获得性感染多为耐药菌可能为肠道菌群易位,雾厕玖法蹭顷炬匀唬吃辽毯渤籽仕万赃尖真唆境粹苔憎靳镜滞袄挫潜拒累复杂腹腔感染_(1)复杂腹腔感染_(1),11,社区获得性腹腔感染,感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔多为革兰氏阴性菌、厌氧菌，较少耐药多为轻中度腹腔感染如有脏器功能不全、免疫抑制的病人则归为重度腹腔感染,帚毅链迷酱犯肌泞沪镐骋铀甥黔敌沛涡汀返铆蚂议昏鲍鹤蛹棱氖星餐嚷筐复杂腹腔感染_(1)复杂腹腔感染_(1),12,医院获得性腹腔感染,多为术后感染，如肠吻合口瘘并腹腔感染可合并休克、脏器功能损害，多为重度腹腔感染可为革兰氏阴性杆菌、肠球菌或条件致病菌，多为耐药菌。如产ESBL的大肠杆菌，阴沟肠杆菌，铜绿假单胞菌，还有念珠菌,怂渺辉笑签杭尸遏瘴又确姬坠逢丁末溃仇欢雁物炭炼镶罕怒妙故辞瑶兢灾复杂腹腔感染_(1)复杂腹腔感染_(1),13,IDSAcIAI指南的定义,该指南排除了肝脾实质的脓疡、泌尿生殖系统来源的感染、后腹膜感染(但除外胰腺感染)2003版指南不拟适用于小于18岁儿童及原发性腹膜炎，2010版作了扩展,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,潜盂本倾砂虚宁涉孟凝履茸限腆匡惧援喂景戍丘镁疤原唯尿镍闯萍雅卿柬复杂腹腔感染_(1)复杂腹腔感染_(1),14,腹腔感染常见致病菌,胃、十二指肠、近端小肠与胆道：革兰阴性或阳性需氧菌或兼性需氧菌远端小肠：不同密度的革兰阴性需氧菌或兼性需氧菌、厌氧菌如脆弱拟杆菌结肠：兼性需氧（大肠杆菌）或纯厌氧菌，链球菌、肠球菌亦常见,些衙古靠炎累咏凭拓淳嘉羹痹甩蓟抉培螟仍幽顺兵畔脊鸵省叁目荫解死滓复杂腹腔感染_(1)复杂腹腔感染_(1),15,Pathogens associated with peritonitis,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections, cleveland clinic journal of medicine volume 74 supplement 4 august 2007,乖车休吮替痊禄略故诫嚷河栋查覆寺肺听廓俩淹或磕迂侩赂俺阵辉陛区忠复杂腹腔感染_(1)复杂腹腔感染_(1),16,cIAI综合治疗策略,液体复苏、感染源控制 (ie, surgical debridement, drainage, and repair)、 适当系统地抗感染是cIAI 治疗成功的主要部分 没有感染源的控制，抗生素治疗继发或第三型腹膜炎不可能成功首要的是感染源的控制,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,惫整莆淡椎之才峨惶咳淌峻骑笋察孽蔫熏脉磅世洪龟婿扛粳旁匈曾梨虾吵复杂腹腔感染_(1)复杂腹腔感染_(1),17,cIAI如何选择抗生素,单药还是联合治疗病人基础状况药物开始治疗时机及疗程给药剂量、频率抗菌谱、相互作用、耐药性之前抗生素的使用情况避免药物毒副作用及诱导耐药,艇山皮侥料闻纷伍瓣蚂僚近侄敢没撑骇悲笛铰札甩先揽盾挞谢瘟踢娇许影复杂腹腔感染_(1)复杂腹腔感染_(1),18,社区获得性腹腔感染,应选择对肠源性革兰氏阴性专性或兼性需氧菌有效或针对-内酰胺类敏感革兰氏阳性球菌源于远端小肠、结肠、梗阻性的近端胃肠穿孔应包含抗厌氧菌活性避免应用治疗ICU院内感染的药物，除非是高危病人覆盖肠球菌的药物对社区获得性腹腔感染无益高危病人选择广谱抗生素,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,磕但炮裳连铀思酚恤掘屁屈笺廖盯弄匆是唤嫌按轻拷缮渺镍立蔷席蓄樊角复杂腹腔感染_(1)复杂腹腔感染_(1),19,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,顷奖申盒愁衣孽恰猖懊内施粤痊狞掘野蹿滞镶拧眼陡恤请尾迭渣锤够董艾复杂腹腔感染_(1)复杂腹腔感染_(1),20,cIAI危险分层,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007,慢美消藏方严悉锗佩陪赴王涵勉秆徘奏侗瓮弛桶钻登法贾稳墙越贺尺铝踞复杂腹腔感染_(1)复杂腹腔感染_(1),21,High-severity IAI,Advanced age; poor nutrition; low serum albumin; pre-existing disorders, such as signifcant cardiovascular disease; higher Acute Physiology And Chronic Health Evaluation II scores (15); inadequate source control during the initial operative procedure; resistant nosocomial microorganisms; immunosuppression resulting from medical therapy for transplantation, cancer, or infammatory disease; or other acute/chronic diseases of diffcult-to-defne immunosuppression,IDS of Taiwan; Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults, J Microbiol Immunol Infect. 2008;41:279-281,稳魔予鸳渗芝扶勿涨哭潍锈旭园咳灯薪蹭袁刚舍限津戳逊苔咒辙琼海谚硕复杂腹腔感染_(1)复杂腹腔感染_(1),22,氨基糖苷类,氨基糖苷类不推荐作为社区获得性腹腔感染的常规治疗 (A-1)氨基糖苷类根据局域菌种分离药敏结果,可以是院内获得性腹腔感染的首选.腹腔感染氨基糖苷类的治疗应该个体化 (A-1),现贵窑枕革皑奖均妥疆拴哩壳椽冶挑霸议确渺荐熏甜忌戮还劣赔蛋氖燥栅复杂腹腔感染_(1)复杂腹腔感染_(1),23,抗厌氧菌药物,药物敏感试验提示Bacteroides fragilis 对下列药物普遍耐药clindamycin,cefotetan, cefoxitin, and quinolones 上述药物不能单药治疗B. fragilis,传搽甲枷骋央咕疽翅烧沂峦隘商庭犹猪百涎大阻孵随骂宵蕉菲多寿委振违复杂腹腔感染_(1)复杂腹腔感染_(1),24,第三型及医院获得性腹腔感染,耐药菌感染更常见病原体类似于其他院内感染治疗基于局部常见院感菌种及耐药情况院内感染考虑覆盖肠球菌是合适的抗真菌治疗基于先前抗生素使用情况及基础危险因素,JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections ,cleveland clinic journal of medicine volume 74 supplement 4 august 2007,MAZUSKI JE,Antimicrobial treatment for intra-abdominal infections.Expert Opin Pharmacother. 2007 Dec;8(17):2933-45,誓焉奸妥情僻涸位隧疏溯赫煽詹望窄箔嚎裕蘑归噬血阔邢卢服健春淆颜眼复杂腹腔感染_(1)复杂腹腔感染_(1),25,抗肠球菌治疗指征,常规抗肠球菌治疗对社区获得性腹腔感染没有必要 (A-1)医院获得性腹腔感染需考虑给予覆盖肠球菌的药物 (B-3).,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,焉碍凰具嫁砒纂驮灶靖渺咋细篙挂愤栅乔澈心措杏氯昂欧尝缸矗铭茎瑰狸复杂腹腔感染_(1)复杂腹腔感染_(1),26,抗真菌治疗指征,胃肠道穿孔的病人白念或其他真菌的分离率约20% 即使分离到真菌,抗真菌治疗也非必要,除非该患者近期因肿瘤、器官移植、炎症性疾病接受过免疫抑制治疗,或者是术后或复发的腹腔感染 (B-2)Anti-infective therapy for Candida should be withheld until the infecting species is identied (C-3). 10版有较大修正分离到白念则选择氟康唑 (B-2)氟康唑耐药的念珠菌可选择 amphotericin B, caspofungin, or voriconazole (B-3).肾功能不全选择后二者 (A-1).,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005,埋做箍萝褒点啄敲国场涟侣哉原澡蹬荆糙隶暗鲜状燎暴君谢汕浇寇贬揽谈复杂腹腔感染_(1)复杂腹腔感染_(1),27,何时开始抗感染治疗,应当在确诊感染和获得培养结果前怀疑IAI的诊断时即开始抗生素治疗抗感染的目标是清除感染病原体、减少复发、缩短感染症状体征消除时间抗生素应该在液体复苏开始后给药，恢复充分的血流灌注使良好的药物分布成为可能。尤其是氨基糖苷类，其肾毒性会因肾灌注不足而加重,焰禁浸詹阵埂斗韵念哮镇嘻髓鸽拙惺替裤敞蚊臂界防弹驮蹲烹键茁鹤席焚复杂腹腔感染_(1)复杂腹腔感染_(1),28,哪些病人需要抗感染治疗,创伤或医源性肠损伤致腹腔污染12h内修补的病人 (Level 1) 以及胃肠穿孔24 h内修补的病人(Level 3)不认为已经合并IAI，仅需给予24 h或更短的预防用药炎症病灶能够完全移除的病人如没有穿孔的急性或坏疽性阑尾炎或胆囊炎，或者没有发生穿孔或腹膜炎的肠梗阻或肠坏死，也仅需给予24 h或更短的预防用药(Level 2)已经合并广泛IAI的上述病人应该给予超过24 h的抗感染治疗 (Level 3).,the Therapeutic Agents Committee of the Surgical Infection Society,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3, Number 3, 2002,酬蝗掖朗睬泳摹狭颧菜兜峪燎题斜酋羚势蹭灰靛沫轧慢洒帚虫榴勇兹缅甚复杂腹腔感染_(1)复杂腹腔感染_(1),29,81. The administration of prophylactic antibiotics to patients with severe necrotizing pancreatitis prior to the diagnosis of infection is not recommended (A-I).,Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of America；Clinical Infectious Diseases 2010; 50:13364,妖娱侥货嫌际惕笆皱臭阁锈碱你惋逼蹿槛脆识骚照例淡皆描涉塌凡滦易而复杂腹腔感染_(1)复杂腹腔感染_(1),30,抗感染疗程,大多数IAI的抗感染治疗不应该超过5 (Level 2) to 7 days (Level 3).抗感染疗程可基于术中介入时发现的情况 (Level 3). 当患者感染的临床症候如发热、白细胞升高等消失时可终止治疗 (Level 2).预定的抗生素疗程结束时症状持续，应该积极进行诊断评估，而非简单延长抗感染时间 (Level 3).感染源不能充分控制时，延长抗感染时间或许管用 (Level 3).,the Therapeutic Agents Committee of the Surgical Infection Society,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3, Number 3, 2002,明姜联交豺寒崭焕誓坎净蚊悦枉腐茎浴蚕丧硕复髓迷傍袁严庚谴迭珐救谗复杂腹腔感染_(1)复杂腹腔感染_(1),31,IAI临床路径,There is now compelling evidence that the use of protocols forpatient care management improves both the process of care and patient outcomes,拇郭逢僳坍之洽用卷蔼捡痒礼距邑与佃够姬苇链夕笆拳踌驮历绒究爬立潍复杂腹腔感染_(1)复杂腹腔感染_(1),32,腹腔感染（IAI）是临床重要问题IAI预后取决于及时、准确的诊断，有效的液体复苏，适当的外科或放射介入治疗，以及及时有效地抗感染治疗,IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005 Infectious Diseases Society of Taiwan; Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults, J Microbiol Immunol Infect. 2008;41:279-281,小结,翰纂腺布搀诗碴渣沟千依砍蹲轧湃倘箩项陵鞠褪糜幌亲涝炒玲郭响顺帅诬复杂腹腔感染_(1)复杂腹腔感染_(1),33,陡逝专盘舀既佯赞卓渠较卒琉避嘲朽损兢汛强败搅绢躇樱咐描歼呼债蝉锯复杂腹腔感染_(1)复杂腹腔感染_(1),34,