临床进展-HAP2014备注版.pptVIP

Ventilator associated pneumonia is a hospital acquired pneumonia that occurs 48 hours or more after tracheal intubation. Despite the lack of a universally agreed definition, ICU physicians generally agree that pneumonia should be suspected when there are new infiltrates on chest radiography plus two or more of the following: ? Purulent tracheal secretions ? Blood leucocytosis (12×109 white blood cells/L) or leucopenia (4×109 white blood cells/L) ? Temperature greater than 38.3°C. Postmortem studies of patients suspected of having ventilator associated pneumonia suggest that using clinical criteria alone for diagnosis produces 30-35% false negative results and 20-25% false positive results. Because of this lack of sensitivity and specificity, it is good practice to obtain microbiological samples of lower respiratory tract secretions before antibiotics are started. Samples can be obtained invasively or non-invasively. Invasive sampling methods include bronchoalveolar lavage (BAL), protected specimen brushing, and increasingly blind “mini-BAL.” Mini-BAL, which is also referred to as non-bronchoscopic BAL or blind BAL, is performed using specially designed catheters that allow sampling of the distal airways via the tracheal tube. Because a bronchoscope is not needed it is quick and technically simple, with culture results that are comparable to other lavage methods. 心肝脑肺肾功能受损 血流动力学障碍 恶性肿瘤 粒细胞缺乏 网状内皮系统功能受损 内分泌、代谢疾病 自身免疫紊乱 激素、细胞毒药物 肺炎克雷伯菌 铜绿假单胞菌 金黄色葡萄球菌 不动杆菌 肠杆菌 嗜麦芽窄食单胞菌 曲霉菌 PCP CMV 军团菌 肠杆菌 MRSA CoNS 绿脓杆菌 念珠菌 不动杆菌 需氧G-杆菌 使用2个变量： 先前使用抗生素 ADL评分 先前未使用抗生素和ADL评分较高的患者无耐药菌感染。 先前使用抗生素且ADL状况不良的患者，有90%的可能性感染耐药菌 有上述两种危险因素之一的患者感染耐药菌的可能性居中，曾使用抗生素的危险性高于ADL评分 此研究认为： 对NHAP中未使用过抗生素和机体功能状况良好的患者，针对典型的CAP病原菌选择抗生素作为经验性治疗是安全的 鲍曼不动杆菌联合治疗方案 两种抗菌药物联合 三种抗菌药物联合 含舒巴坦合剂或舒巴坦 ＋ 米诺环素/多西环素/多粘菌素/利福平/氨基糖苷类/碳青霉烯类 含舒巴坦合剂或舒巴坦＋多西环素＋碳青霉烯类 2011年《中国鲍曼不动杆菌感染诊治与防控专家共识》 革兰氏阳性