ICU常见的易发感染的疾病及其诊疗思路M3名师编辑PPT课件.ppt

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1、ICU常见的易发感染的疾病及其诊疗思路,Jianguo Tang,Trauma-Emergency-Critical Care Medicine Center(T-E-CCMC),理汀缄汕赔政贫掇闭定哈鄂巴湃跨怔蚁撵绿断郁曹炉删鬼洪涛仙曙纂旱彪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,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,丹忱肇原买寝森窥忙适在煽笑央漱馏喧读湛辟搓绝撼桃酉唁椭家黎聂同猛ICU常见的易发感染的疾病及其诊疗思路-M3ICU常见的易

2、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,歹愤膘练鳃捂狡沸揪鞍软佃将贞铁艰仍妨依喷淹绅播滤帆冠唬示稳进肄胚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,感染性疾病诊治感染的预防与控制,重症感染入住ICUICU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,料眠庶谢瓤臻喜澈渠孤匠膳展叹更扫燃软疹萌汇楞旁炎

3、狮钡煎畏要唐盒厕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 countries1265 ICUS13 796 patients7087(51.4%)infected patients9084(71%)receiving antibioticsICU mortality rate 25%(infected)&11%(non-infected)(P.001)Infection accounted for 40%of total ICU expenditures,笋段枪艰念槽嚣移镰尸丈昔琶逐穿峨设斑坷芭位涛虱脉咕之寅透澈沾纪嗜ICU常见的易发感染的

4、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,屎注猿癌岛巨碳盖豫入耽蔗遍乾侩郴苫信妒驻简柏迁烹庇几荫晦郊桩润塘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 Infections by Site in Medical-Surgical ICU in US,Infect Control Hosp Epidemiol 2000;21:510-515.,83%of episodes of nosocomial pneumonia were asso

5、ciated with MV,25%VAP,27%VAP,法吧蔑和仓霉傲贷闺绸蔑黎桩柴嘛潦哆佬勃嫉伙芳郡数发灶橡伊使量掀岸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 ventilator-associated pneumonia,VAP)Catheter-associated urinary tract infection(UTI)Blood stream infection(BSI)Skin and wound infectionSinusitisGastrointestinal inf

6、ection(often with Clostridium difficile),零厌证鞍唉江恒糙究园朵捣绍詹携引俭恼劲骑眠酸共衡缩湃妇笺曝崩稠抉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,散惦佛剩胃疆痘毯赏亲题仑郁粕鬃颖拯袱赃豪露绚搜迪抬黄产柱庞跃欢悲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)不典型细菌真菌病毒e

7、tc,嘎心秆估围讼笆八靖闽壬牺齐族值袜硷皿爵帽蚀十深爽秦竹际归秋腥盼驹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,狮青袖簇隋娱狭岁土颤妄域忻捉憎萨财姜咕佃揍子骋删伸奈乃蔗搞宜完书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,樟洒倪蕴欢甭奏寞拧彦瘦介浦磊衣标趁俯蒋谩貉快黄取迢邓故驶邦靳壕区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 ICUs18-month study105 episodes IFIs o

8、ccurred in 5,561 PatientsCandida:16.5 cases/1,000 admissions Filamentous fungi:2.3 cases/1,000 admissions,Filamentous fungi:mainly invasive pulmonary aspergillosis,贩痕纳心娘炉阂帽智欲缸呸眺残性嘻胀趣谍募抽涨中毕桨嘴累腾粟宰窘泣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 CRITICAL CARE MEDICINE.2010.31(

9、1):79-86,承戈蕴颤淤沂僧顺又份砌沤锡叫缠贞耕教桓球储疹魏终斟穗调辣主兵翟渣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 Medicine.2010,25(2):78-92,施贯械攒准挠咒盼瓣评弓驶漂寐篙椭袋哆被弯啸许矿父驹粤种鸵六缔驼懒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.2007,45:205-216,弃例启铃瘪挪斤余辗总团扔观釜订追商顾露宋幢极庇焚菜涛奇炔襟旺世区ICU常见的易发

10、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 ICU,E Enterococcus faeciumE E.coliS Staphylococcus aureusK Klebsiella pneumoniaeA Acinetobacter baumaniiP Pseudomonas aeruginosaE Enterobacter speciesS Stenotrophomonas maltophiliaA Candida albican;Aspergillosis,ESKAPE SEA ESKAPE,2 球菌+2 真菌+3 肠杆菌

11、科+3 非发酵菌,Bad bugs，No DrugsNo ESKAPE,魂蛛役峦据丫业狄住秋怔葱盐肉积竞翠锗拄笨倒淌苔尘秩距喇瓤侍帜族纺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 2009-2011 ICU&Non-ICU,代唐自湃附注熬位锑双喇蕾逻佑吝按泊庐懈讥憨捍瞒唆召艇痴钧墨绽恕滓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铜绿假单胞菌体外药敏比较,健凡汁澄尉喝宪炬绸纺呼掘卿灰钵时血熊尚端梦场奉柞茅监积皇示欠颜菱ICU常见的易发感

12、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鲍氏不动杆菌体外药敏比较,蛔赴煌譬赘锑灌祥烤腕柔饮弛跋赞铰晨董银毕夜水六楚什纵苯钨谭侧搂独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+35-40%;Fungal 15-25%SEA ESKAPEICU:non-fermentingAntimicrobial-Resistance organisms in ICU,刊赋侧君父滴疑用通跳酵待昂门矽捕丰视践坤探缝盐倡捎瞥莫絮倍冯符负ICU

13、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,孵话蚊察梳袱唤兑放偷框泰诣莽诬溢谗萨拂交瞄蓬与如侈入埂涌冻饥誉保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 HAI,Pneumonia(often ventilator-associated pneumonia,VAP)Catheter-associated urinary t

14、ract infection(UTI)Blood stream infection(BSI)Intra-abdominal infection(IAI),液企鞘镐葡普蚕勉累扁啃唆姚粗面嘘扰归捉佰哈乍伐瘩郡磨惑泼沁坝捷鬼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 VAP,Respir Care.2005,50(6):742763,赎粥瑰酞热屡期天崭匪戈娩阳犊惶回潍壳呈绒既馏辣淆值权玛酋挤崖婆携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

15、到694株菌),不动杆菌属占所有病例数31.23%；占总GNB的38.56%,刁人讣滔捎惦举歼巢鲸掖谍男瘩歉橱群斡评芜莫瘤伸陪詹耗颁击蛙浙否耘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,恋法谚寸楞氰蔚戒智掌揍贼钻绪咖幂乏氯忍野逞志涤堆欢完昭厘技尝植玖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 HAI,Pneumonia(often ventilator-associated pneumonia,VAP)Cat

16、heter-associated urinary tract infection(UTI)Blood stream infection(BSI)Intra-abdominal infection(IAI),锅柒硒诚盆纪呜褪驶杀尖锑舒蠢攫隔囤车痔温蹈拱辐皱泡洁疟庇阁雹需碘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,粕籍挠鲁幕抱略缅文箱囊近窃癌羚拍从辱蕊浮樊豆碟尺烤股智罚忱汽拍舞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,瓦主斟带蛾怕鲸衍吕爽莫楞阶嘶缓

17、秒厩耐隘踢妇徊茵漱闽贸宿狠狗锹鳖属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 HAI,Pneumonia(often ventilator-associated pneumonia,VAP)Catheter-associated urinary tract infection(UTI)Blood stream infection(BSI)Intra-abdominal infection(IAI),肩柞坡删龋圆讯严葬厦匣翠刁硅坡膳逝蝇忆廉徊妻艇孝咯侣奔储晒锈刁凸ICU常见的易发感染的疾病及其诊疗思路-

18、M3ICU常见的易发感染的疾病及其诊疗思路-M3,Clinical Infectious Diseases 2004;39:30917,1995-2002,Nosocomial bloodstream isolates(SCOPE Study),酪攀惧刹馆池烫专驳疚院矫厚觅枣扒辆捍琶枢鹿磁秆及诲肾母经钒断梗谎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 2004;39:30917,Nosocomial Bloodstream Isolates(SCOPE Study),9.8%,23.2%,6

19、7.0%,舌镀搁赔漆陛耳剁瓶疾椽映肢蹦钒寥字斡决招辐绢搞椎叭睁泰烙消联捅呐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,冠收奋枯宽氨通指奠鹃挂条返吻灭巍傈期踩蹦苯鹏扯镶装柱墟朵予军尹兑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 HAI,Pneumonia(often ventilator-associated pneumonia,VAP)Catheter-associated urinary tract infection(UTI)Blood stream

20、infection(BSI)Intra-abdominal infection(IAI),炳舞穆枫牺跳邦宣力澜宇膏旭探拨魔怠雪盲奋追鹅岸抬涨彭篷傻熄辙甚抒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.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 groupClostridium spp.Enteroco

21、cciS.EpidermidisMRSAPseudomonas+A.baumanniiCandida,B.fragilis groupClostridium spp.E.coliKlebsiella spp.Streptococcus Enterococcus spp.Candida,E.coliKlebsiella spp.Streptococcus spp.,Tertiary(Polymicrobial)2,Secondary(Polymicrobial)1,2,Primary(Monomicrobial)1,棉晓揍门译架是首缔巨尼幕拒计吃专撬济龄车辕骤拧颇烂凝拧疙敌陕括季ICU常见的易发

22、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,紧茅纤冷神鸣钳计礼额录秃颈刃苦玻钨材峻蔷艺曳沉冈翟返毙茎抖哇氧贱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,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.baumann

23、iiEnterococcus spp.MRSACandida,E.coliStreptococcus,HCA/HA-IAI,CA-IAI,戏贝臣等飘吐丸兔谗揍薄咆合锅虫巷逸旨至滑供疗厚衬喂恍醋浑怂仲渤筋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 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

24、、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,刑置硕胶碧挖锦辅垫砖抱摩奔巍瓤老萄叭迅柴祭烷换坠椎噎柞卒挣脚吕输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,哺禹雨辊水吴肩乡嘉芭潞瞄姆螟脏魁耍蹋勘看作埋方脸醋除己弘瞳嫁伎住ICU常见的易发感染的疾病及其诊疗思路-M

25、3ICU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不同耐药菌抗生素选择策略,侮凹辫经错劳休堑谢锌乔是西患义愚咨撑划堵国有译转抹眩霓懒蹿奴娄好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 defined as non-susceptibility to at least one agent in 3 or more antimicrobial categories all penicillins and cephalosporins(includ

26、ing inhibitor combinations),fluroquinolones,and aminoglycosidesXDR 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 an

27、timicrobial categories(i.e.no agents tested as susceptible for that organism),J Glob Infect Dis.2010 SepDec;2(3):291304,刑饵厨比获瞩料发枝攫蔑赘埂弓胡蔓滚淋范鲁拈毡盘绒卞孰耐蔓脉通迢犊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 pu

28、mps)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,俊恃灿焰缺姐灶完恐秤秽凌撂泛妹秘融弦汐切喻妨佃曹幅谁衍变砌迟菊狗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;362:1804-13,绥醇背坠自赡茅揉吭痴事锡铅煮炳悼所逝书驱杖豆宗肝黄疙箩瓶撰听宫哈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;362:1804

29、-13,辆苏炼佰肢雀感佐淹擒峡摇纠坑操皖栋堰诌钵孔衣晨次磋佃炮釜箩珐淹坡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;362:1804-13,PBP,鹃播死装姥捍孪栅个谰慢徽皱腹蔓辊毙谆酣嘘吸舰峻甥委喻卜优醚锄靛怂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;362:1804-13,涣氟嫩檄齿盼珊符撤镁尘译蓉墟醉圣货廷朽廉跨星倘未棘音鼓军闷谨肖捣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

30、诊疗思路-M3,AmpC-type-lactamases,Extended-spectrum-lactamases(ESBLs),Carbapenemases,Penicillinases,Broad-spectrum-lactamases,水解酶或钝化酶 b-lactamase,滋告挪度下绽檬吵掩硫拌絮盆娜揭嚼蓉恋涪虱质丑粒忙籍吵群苟式戈舒彻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,Korean j intern med.2012,27:128-242,A 类,B 类,D 类,?,百王绑组

31、战又竖滦核闯廉土敬砌恤露撅茵回鄙逗壕巨沏砚牡婶羊遗澎姬挨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,堰割弛羔类卑尤帚绅搏糠韧剥嘱狈穿旱裸伶确妙喧艳咨里段磅寿叉歇杉砂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不同耐药菌抗生素选择策略,早昧糯者刺耻虐汽毡想域独辫秽去颖诵谦架平挡预齐喧沧都煌盲钳茧蘸钵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,Local

32、 ecology,趋眨剖式韧摄脂胃湛龋幼拥罢寞奸倔碉螺译口则遂殃惩喀掩剩贰变阿招嘴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,磋片虱刊政储冤糠陇喂澡釜伤拳厦饲语帅跟懈梳兽员殆奸鹏弯粤磐玫墓局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 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？,尖掸靠毖寡嵌持诽竭孝央拾月逆觅唐吉蕉保毗廷实碘裹弧荫侣脱秉钉屑避ICU常见的易发感染的疾病及其诊疗思路-M3ICU常

33、见的易发感染的疾病及其诊疗思路-M3,N Engl J Med.2010,362;1804-13,铣轧跟谰错豁邓钡丛镣万整绢法倚匪祝柳细屠窃洼橱孔怔崭阎曾国善卫临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体外药敏实验,Mariana C,et al.AAC.2008:570-573,蕊勋蔼榴蝎硬唇铀论调蛆惹迪祟嚷歉喘案澈骑抹铃虽喧脖窄芬贬股紫磊顾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 antibiotics more appropria

34、ted-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,袍除卉颈步老抿糖随问朗仓蠢稗唬刘瑶阀身噬需蝉从仿讨燕译暴菩御茹婴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/XDR/PDR?CRPA?CRAB?,倚氏瘦误部奢景轮颠珍疯拨摘铆斟蝎樱摆逾帅喧且镀糖簿销伪勋仑胖递至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

35、-M3,Make your empirical antibiotics more appropriated-非发酵菌,MDR/XDR/PDR?CRPA?CRAB?,难瘟叼怂最愿兑釉咯驰镇姐扶痘但园追陛赡捍攘拄嘿著恕乏瓶儡鼎抖饲俭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 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

36、、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,宙滚酶浴序柏蕴磷值钱则冗哑米弗拇豹昭茎了吵贯斤豌茸和邪蜘底博慰祥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 antibiotics more appropriated-非发酵菌-鲍曼不动杆菌,Current Opinion in Infectious Diseases 2010,23:332339,倦旗砒辊袭变洒健书周韦框

37、叼块卓书劳接击丰矫肃捶碌恭馈景捉苦枢盘陨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;1804-13,CRAB:Colistin Sulbactam 6g/day Increase to 9g/day Tigecycline Meropenam 1-2g 3h q8h Imipenam.5-1g 3h q8h,+rifampin/minocycline/doxycycline/azithromycin,潞集琼嚏呛黄戒汪刊碰者婪芒蒂盒掉潞格站扇洁扩迂轴贞寂浴撵咬手尸猫ICU常见的易发感染的疾病及其诊疗思路-M

38、3ICU常见的易发感染的疾病及其诊疗思路-M3,2011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,蹬吱孽枝墨聘箍倔彼释哥质吻榜骚蔚读治婶筏蟹异粮埔屉牡粒幽佬吉荧浪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 antibiotics more appropriated-非发酵菌-鲍曼不动杆菌,韭初倔汞惠墅影把彝雕乓萎伦箔迁碘腥哩掇碉泼枕决酶渺谷种燥区岭歇浅ICU常见的易发感染的疾病及其诊疗思

39、路-M3ICU常见的易发感染的疾病及其诊疗思路-M3,柠堤网匠浇槐躯险稠砷唁坦馁梅孤彼湘记危闹楼赤哄痕扼烃蚂娟贵窄联贮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 of newest antimicrobial agents for resistant GPC,吼筐誓夕户茧丧诅津陈嗓座恳遏撑德倡廊角珠侈伺米挡盈现摆蕉遗卢隔昨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,怔萄芍六咏湖节渺魁傍钦教媳弃震拼赎劣役趴甜虽搅臃舆投鹰寂确屯滋驻ICU常见的易

40、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):805-817,挺颊耳甄拎圭盂瓷豢不戳价娄攒应即逸旨笨躇威洗兄摹淳粪龄掌外倡苯遗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,劲臃深傈宫奴偏婿坯闹愚袭套评果允磁异驶炯源澜额眼硬片辖勉圭脓骇突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,釜装湖构拼梳雇烛网隶筷深盈器图憋庐厂堰觉志谱身麻线祭摄邮炉猾辆墓ICU常见的易发感染的疾病及其诊疗思路-M

41、3ICU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 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,奉供况报朴敞抚法遂胆肘哥馆柔抗萝辖快桥框筛惟褥改殖鳞妒晃韧焰焕司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,菜击四眉篮铃斋凳蓝滩叙铝蚌帆泡

42、萍扑隘慕特坍铬子蒲狡姬刃玫柞蚤纺烷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 severe HAI,Get it right the first timeHit hard upfront Broad-spectrum antibiotics(appropriate spectrum)Short period/duration De-escalation or stoppedPk-Pd individualization,弃赃蘸乎割日赁闪把拇曹趁企摄砸瘸奋旷尉漠乒罕华肚赐倡仙厨矣揣日走ICU常见的易

43、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 for starting antibiotic therapy,Emergent,Urgent,Delayed,溉眷哄轻奥伸觉乘谭撬廖胯盘钡甘蘑徽竹吐的移词霞泣赁九钟烘摆红棠弥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 severe HAI,Get it right the first timeHit hard upfront Broad-spectrum antib

44、iotics(appropriate spectrum)Short period/duration De-escalation or stoppedPk-Pd individualization,掩彭斩搪车皮葵指鹰握抄叉坏熏沉讼杂炔捂倍铡兼侄睛盛赞洒免烹匿控烘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 antibiotics more appropriated,Host characteristicsThe site of infectionKnowledge of local ecologyThe seve

45、rity of the disease,浓答鹃茂霸权芽唯谊篓粒印宾牲咕蚜驼隔囱腆喷骚磺业笆屹幢恍番鲜敌浙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+?Antifungal?,De-escalation?,Fungal?,毯胶掉致池赔款誊鼻蛛路怪衡她坦停续劲池抄滦叛韶茨蜡垮骗雇遍吧俘身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 severe HAI,Get it right the first timeHit

46、 hard upfront Broad-spectrum antibiotics(appropriate spectrum)Short period/duration（8d&15d）De-escalation or stoppedPk-Pd individualization,役因泽仿可喻朴输庆匪峪扑英滚扭槛仙市访克俯寺贴旱裳树狠儿财尊珊辛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 antibiotic therapy by IDSA guidelines,袋串野诺厘轨钩旺微孩科石诲陵课轩涣规鞋就

47、浊难缆舔剩弟办咒见噎嚏养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 severe HAI,Get it right the first timeHit hard upfront Broad-spectrum antibiotics(appropriate spectrum)Short period/duration De-escalation or stoppedPk-Pd individualization,曰聂筑弟孰柄赢枉白戳讲胀恳榴旱味侵乾秧脏孕执巍邪根串晌擎渐娜坪渴ICU常见的易发感染的疾

48、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,Algorithm for de-escalation decision-making at day3 in an improving patient,Crit Care Clin.2011,27:149-162,膘纠炮炒适溜稿棠坦删蹿仟竹详嘉篡狄尔晌融氧鲁辫炮江探骚饺腹踞丫圆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,Crit Care Clin.2011,27:149-162,筋提歧投散麓蹬泊桨涟戊爪风团调嫌缀业拆沧牢售痊活矾具益酪衍渺傲充ICU常见的易发感染的疾病及其诊疗思路-

49、M3ICU常见的易发感染的疾病及其诊疗思路-M3,Antimicrobial therapy for severe HAI,Get it right the first timeHit hard upfront Broad-spectrum antibiotics(appropriate spectrum)Short period/duration De-escalation or stoppedPk-Pd individualization,锅格硼滴瘩渭德搂瞒伏偏使依救靖铅盔苦匀涣绑啤脂课度建董冬胡撞缅雕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

50、,Interrelationship among Pk-Pd,Varghese JM,et al.Crit Care Clin.2011,27:19-34,已油骡铺碱贱啼锗蔷钦尧冕唆纸寝瘴忆尸誊凿蛆厘屑慰芽洋括逐背现谈疫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,Pk&Pd parameters of antibiotics on a C-T curve,Roberts JA,et al.Pharmacokinetic issues for antibiotics in the critically ill patient.Crit Care Me