2018年9mrsa感染2008年抗菌药物学习班讲义-精选文档-文档资料.ppt
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1、0808,湘雅医院感染控制中心吴安华,1,基本知识和耐药机制,0808,湘雅医院感染控制中心吴安华,2,MRSA-耐甲氧西林金黄色葡萄球菌,Multiple-resistant Staphylococcus aureus Oxacillin-resistant Staphylococcus aureus Community-acquired MRSA (CA-MRSA) Hospital-acquired MRSA (HA-MRSA),MRSA是一种对甲氧西林和苯唑西林、青霉素和阿莫西林等-内酰胺类(到目前为止)抗生素耐药的金黄色葡萄球菌,其他名称包括:,0808,湘雅医院感染控制中心吴安华,
2、3,最常见的多重耐药微生物(MDROs),MRSA,VISA,VRSA。 VRE耐万古霉素肠球菌: Vancomycin-resistant Enterococcus MDRTB多重耐药结核杆菌: Multi-drug resistant tuberculosis QRGC: Quinolone-resistant gonococcus ESBL超广谱 -内酰胺酶(extended-spectrum beta-lactamases) resistance seen in E. coli and Klebsiella PRP青霉素耐药肺炎链球菌、PISP青霉素中敏肺炎链球菌 AmpC 非发酵菌(
3、铜、不动) 金属酶 嗜麦芽窄食单胞菌,0808,湘雅医院感染控制中心吴安华,4,金葡菌耐药性的出现时间(年),Chambers, EID 7:178-182, 2001,0808,湘雅医院感染控制中心吴安华,5,0808,湘雅医院感染控制中心吴安华,6,MRSA- mechanism,MSSA,MRSA,New peptidoglycan,Cross-linked wall,PBPs 1,2,3,New peptidoglycan,Cross-linked wall,PBPs 1,2,3,PBP 2青霉素结合蛋白2,0808,湘雅医院感染控制中心吴安华,7,金葡菌 为什么如此让我们担心?,致病
4、性Pathogenicity Community infections Furuncles (boils), carbuncles, endocarditis, toxic shock 传播性Transmissibility Colonized (in addition to infected) persons sources of transmission 耐药性Resistance Decreasing treatment options,0808,湘雅医院感染控制中心吴安华,8,金葡菌感染的病理生理,定植Colonization 局部感染Local infection 全身播散.脓毒症S
5、ystemic dissemination and/or sepsis 转移病灶Metastatic infection 毒血症Toxinosis,0808,湘雅医院感染控制中心吴安华,9,毒力因子Virulence Factors,MRSA, VRSA, and VISA share all of the same virulence factors with antibiotic susceptible S. aureus. Additionally, VISA strains show longer doubling times and reduced autolytic activit
6、ies VRSA and MRSA produce penicillin binding proteins 2 and 2 Reduced cross linking in cell walls through glutamine amidation.,0808,湘雅医院感染控制中心吴安华,10,CA-MRSA 携带PVL基因,117 CA-MRSA 株 33 美国 67 欧洲 (61 法国 6 瑞士) 17 太平洋 (Australia, New Zealand, Western Samoa) 多分离自皮肤和软组织感染 所有菌株携带Panton-Valentine leukocidin位点
7、不同地区携带其他不同的毒素基因,Vandenesch et al. Emerging Infectious Diseases Vol. 9, No. 8 August 2003,0808,湘雅医院感染控制中心吴安华,11,PVL与 原发性皮肤感染和肺炎,172 SA检测 PVL 基因 93% 疖(furunculosis)、 85% 重症坏死性出血性肺炎( severe necrotic hemorrhagic pneumonia) 55% 蜂窝组织炎(cellulitis), 50% 皮肤脓肿(cutaneous abscess), 23% 骨髓炎(osteomyelitis), 13% 指
8、节感染(finger-pulp infection) Not detected:infective endocarditis, mediastinitis, hospital-acquired pneumonia, urinary tract infection, enterocolitis, toxic-shock syndrome,Lina et al. Clin Infect Dis November 1999,既往健康的14 例CA-MRSA 11 皮肤或软组织感染 2 死于坏死性肺炎(necrotizing pneumonia) 均检测出PVL(Panton-Valentine le
9、ukocidin) 基因 Dufour et al. Clin Infect Dis 2002; 35:000000,0808,湘雅医院感染控制中心吴安华,12,MRSA传播,0808,湘雅医院感染控制中心吴安华,13,金葡菌定植 Staphylococcus aureus Colonization,人自然携带Humans natural reservoir Anterior nares 30-50% healthy adults colonized at any one time 60% colonized intermittently 20% persistently colonized
10、20% never colonized Axillae, vagina, pharynx, damaged skin, rectum Hands, intact skin colonized transiently Clearance of nasal colonization eliminates hand, skin carriage,0808,湘雅医院感染控制中心吴安华,14,From: Kluytmans et al. Clin Microbiol Rev, July 1997,不同人群鼻部金葡菌定植率 Rates of S. aureus nasal carriage in vari
11、ous populations,0808,湘雅医院感染控制中心吴安华,15,大多数的革兰阳性菌:如肠球菌(包括耐V万古霉素肠球菌VRE)、金黄色葡萄球菌(包括耐甲氧西林葡萄球菌MRSA)、化脓性链球菌等,都能在干燥环境中存活数月之久。,环境中细菌存活时间,0808,湘雅医院感染控制中心吴安华,16,葡萄球菌和肠球菌在织物和其他表面存活时间,J Clin Microbiol. 2000 February; 38(2): 724726,0808,湘雅医院感染控制中心吴安华,17,表 与临床相关的细菌在干燥环境中的保存时间,0808,湘雅医院感染控制中心吴安华,18,MRSA 可见于任何地方,The
12、 5 cs Crowding Frequent skin-to-skin Contact Compromised skin (i.e. cuts or abrasions) Contaminated items and surfaces Lack of Cleanliness,Common locations Schools Dormitories宿舍 Military barracks Households Correctional facilities Daycare centers,0808,湘雅医院感染控制中心吴安华,19,比一比,看一看,0808,湘雅医院感染控制中心吴安华,20,M
13、RSA 在医务人员中定植,6.2% of HCWs were found to be nasal carriers of MRSA in a 600-bed hospital 4 of 10 MRSA-positive HCWs studied had transmitted to family members Eveillard et al, Carriage of Methicillin-Resistant Staphylococcus aureus Among Hospital Employees: Prevalence, Duration, and Transmission to Ho
14、useholds, Infect Control Hosp Epidemiol. 2004 Feb;25 (2):114-20,0808,湘雅医院感染控制中心吴安华,21,MDROs的传播,直接接触与间接接触 人-人传播尤其是手 接触污染的环境 呼吸道飞沫 直接. 间接:环境被呼吸道飞沫污染,0808,湘雅医院感染控制中心吴安华,22,与金黄色葡萄球菌感染或定植者皮肤-皮肤接触 接触有黄色葡萄球菌的物品或物体表面 皮肤开放性病变 居住(住院)环境拥挤 卫生条件差尤其是手卫生,Incubation period from exposure to infection depends on many
15、 factors,传播方式,0808,湘雅医院感染控制中心吴安华,23,医院内获得性MRSA,85% MRSA感染发生在医疗机构 医院外2/3发生在福利院、家庭护理、透析中心和诊所 在医院内20%的血流感染由金黄色葡萄球菌引起,0808,湘雅医院感染控制中心吴安华,24,金葡菌医院内传播 Transmission/Pathogenesis Nosocomial MRSA,抗生素,阴性病人,定植,感染,皮肤破损侵入性设施,免疫抑制,0808,湘雅医院感染控制中心吴安华,25,社区获得性MRSA,Community Associated MRSA (CA-MRSA): MRSA 感染是指过去一年内
16、没有住院或者没有如透析、手术、留置导管等医疗操作的人员感染MRSA。CDC 发生在基于社区的环境 社区分离株更敏感,0808,湘雅医院感染控制中心吴安华,26,CA-MRSA监测定义,入院48小时内培养分离到MRSA (如果住院) 一年内无住院史No history of hospitalization in past year 一年内无手术史No history of surgery in past year 一年内无住福利院史No history of long-term care in past year 一年内无透析史No history of dialysis in past yea
17、r 无持久的留置导管史或侵入性医疗设施操作No permanent indwelling catheters or percutaneous medical devices 以前未感染或定植MRSA No prior history of MRSA infection or colonization,0808,湘雅医院感染控制中心吴安华,27,CA-MRSA,与医院MRSA的差异 Clinical Skin and soft tissue infections Epidemiology Children and young adults, summertime Prisons, IVDU, s
18、ports teams, aboriginal populations Phenotype Mono-resistant/non-MDR, rapid growth Genotype Type IV SCCmec gene, PVL and other virulence factors, PFGE patterns,Epidemiology No national surveillance Emerged in 1980s, increasing, epidemic levels? Pathogenicity More pathogenic, transmissible than HA-MR
19、SA Different from CA-MSSA? Risk factors Limited studies suggest few identifiable risk factors Antibiotic use usually not a risk factor,0808,湘雅医院感染控制中心吴安华,28,CA-MRSA的医院内传播,Hospital Transmission of CA-MRSA among Postpartum Women Departments of Pediatrics, Columbia University, New York 8 women skin and
20、 soft-tissue MRSA infections mean time of 23 days (range, 4-73 days) after delivery 4 cases of mastitis (3 progressed to breast abscess), a postoperative wound infection, cellulitis, pustulosis Identical by PFGE to CA-MRSA strain MW2 Route of transmission not discovered: cultures from employees of t
21、he hospital, the hospital environment, and newborns negative Saiman et al. Clin Infect Dis. 2003 Nov 15;37(10):1313-9,0808,湘雅医院感染控制中心吴安华,29,CA-MRSA 监测 Minnesota 1996-98,Cases from 10 hospitals 354 patients (median age, 16 years) 299 (84%) skin infections 103 (29%) hospitalized More than 90% of isola
22、tes susceptible to all agents tested, with exception of -lactams and erythromycin 334 treated, 282 (84%) initially treated with agents to which their isolates were nonsusceptible 174 tested, 150 (86%) 1 PFGE clonal group Naimi et al. Clin Infect Dis October 2001,4,612 patients with S. aureus identif
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