最新:医院内肺炎与呼吸机相关肺炎诊断严重程度评估与抗感染治疗-文档资料.ppt
《最新:医院内肺炎与呼吸机相关肺炎诊断严重程度评估与抗感染治疗-文档资料.ppt》由会员分享,可在线阅读,更多相关《最新:医院内肺炎与呼吸机相关肺炎诊断严重程度评估与抗感染治疗-文档资料.ppt(49页珍藏版)》请在三一文库上搜索。
1、Hospital-Acquired Pneumonia (HAP): Definitions,HAP: Arises 48 hours or more after hospital admission Is not incubating at the time of admission Ventilator-associated pneumonia (VAP): Arises 48-72 hours or more after endotracheal intubation Healthcare-associated pneumonia (HCAP): Arises within 90 day
2、s of having been admitted to an acute care facility & pt. has resided in a nursing home or LTCF,(American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416),2008年美国CDC停止使用nosocomical pneumonia这个词,使用“医疗相关感染”(health careassociated infection)或缩写为HAI,不再使用nosocomial(医院内的)一词 医院获得性肺炎也改用医疗相关
3、肺炎(health careassociated pneumonia),英文缩写仍为HAP,停止使用nosocomical pneumonia一词,2019/1/24,Dr.HU Bijie,2,Hospital Location & Relative Frequency of HAP & VAP,HAP 14%,ICU HAP 37.5%,Non-ICU HAP 62.5%,VAP 86%,Non-ICU HAP ICU HAP VAP ICU HAP,HAP,ICU,(Kumpf G et al. J Clin Epidemiol 1998;54:495-502) (Lizioli A e
4、t al. J Hosp Infect 2003;54:141-148) (Richards MJ et al. Crit Care Med 1999;27:887-892),2019/1/24,Dr.HU Bijie,4,Diagnosis 诊断,Non-invasive Strategy for Diagnosing HAP/VAP,Clinical approach New lung infiltrate new onset fever, leukocytosis or purulent sputum non-quantitative bacterial analysis of endo
5、tracheal aspirate Drawback relatively non-specific for HAP Heyland et al. demonstrated adequacy of clinical criteria for VAP diagnosis in RCT (BAL with quantitation vs. non-quantitative endotracheal aspirate): no difference in 28 d mortality or LOS in ICU or hospital,(ATS, Am J Respir Crit Care Med
6、1996;153:1711-1725) (Helling TS, Van Way C, Krantz S, et al. Am J Surg 1996;171:570-575) (Hubmayr RD et al ATS Consensus Statement Intensive Care Med 2002;28:1521-1536) (Canadian Critical Care Trials Group. NEJM 2006;355:2619-2630),2019/1/24,Dr.HU Bijie,6,肺部感染临床诊断困难: “类肺炎”,充血性心衰,肺栓塞 急性肺损伤与ARDS 过敏性肺炎
7、,嗜酸细胞浸润性肺炎 放射性肺炎 血管炎,Wegeners肉芽肿 隐源性机化性肺炎 过敏性肺曲霉菌病 肺泡蛋白沉积症 结缔组织病肺累及 肿瘤引起阻塞性肺炎 增生性淋巴性疾病,假性/淋巴瘤 白血病肺内浸润,2019/1/24,Dr.HU Bijie,7,呼吸道分泌物细菌检查 要重视定量或半定量培养,HAP特别是VAP痰标本病原学检查的问题主要是假阳性; 培养结果意义的判断需参考细菌浓度; 要常规作血培养(敏感性25%; 阳性也可能肺外感染) 咳痰标本分离的CoNS、除奴卡菌外的其他GPB、除流感嗜血杆菌外的嗜血杆菌属、微球菌、肠球菌、念珠菌属和厌氧菌临床意义不明确; 部分重症肺炎在经验性治疗失败
8、后,应尽早衡量利弊开展稍带创伤的病原学采样技术如PSB采样和防污染BAL。 ICH应重视特殊病原体(真菌、肺孢子菌、分支杆菌、CMV)的检查,必要时经支气管肺活检甚至开胸活检。,Diagnosis of VAP in the ICU: Quantitative BAL vs. Nonquantitative Endotracheal Aspirate (ETA),Primary Outcome,Secondary Outcomes,Response,18.9%,18.4% *,74.2%,74.6%*,10.4d,10.6d*,12.3d,12.2d*,8.3,8.6*,(Canadian C
9、ritical Care Trials Group. NEJM 2006;355:2619-2630),* = NS,Non-invasive Strategy for Diagnosing HAP/VAP,Clinical approach: CPIS clinical pulmonary infection score Quantitative prediction model using clinical criteria May improve clinical diagnosis of HAP 72%-85% sensitive, 85%-91% specific Only vali
10、dated in several small studies,(Pugin J, Auckenthaler R, Mili N, et al. Am Rev Respir Dis 1991;143:1121-1129) (Hubmayr RD et al ATS Consensus Statement Intensive Care Med 2002;28:1521-1536),2019/1/24,Dr.HU Bijie,10,临床肺部感染指数(CPIS),CPIS 6,则高度怀疑存在HAP,(Pugin J, et al. Am Rev Respir Dis 1991; 143:1121-11
11、29),Short Course Therapy of Suspected VAP Using the CPIS,CPIS on diagnosis with 5 criteria: fever, WBC, trach secretions, oxygen, X-ray CPIS on day 3 with 7 criteria: add x-ray progression, culture data.,(Singh N et al. AJRCCM 2000;162:505-511),Invasive Strategy for Diagnosing HAP/VAP,Quantitative c
12、ulture approach: bronchoscopic protected specimen brush (103 CFU/ml) 67% sensitive, 95% specific bronchoalveolar lavage (104 CFU/ml) 73% sensitive, 82% specific quantitative endotracheal aspirate (105 CFU/ml) 38-100% sensitive, 14-100% specific Antibiotic use more appropriate and accurate Claim of i
13、mproved survival at 28 days,(Fagon JY, Chastre J, Wolff M, et al. Ann Intern Med 2000;132:621-630) (Craven DE, and Steger KA, et al. Infect Cont Hosp Epidemiol 1997;18:783-795) (Grossman RF and Fein A. Chest 2000;117:177S-181S),(Shorr Crit Care Med 2005;33:46-53),Meta-analysis of Bronchoscopy: Morta
14、lity,Figure 1 Diagnostic Algorithm for HAP,Figure 1 (contd) Diagnostic Algorithm for HAP,Figure 2 Diagnostic Algorithm for VAP,Figure 2 (cont) Diagnostic Algorithm for VAP,2019/1/24,Dr.HU Bijie,18,特殊和危重病例的快速结果,当天涂片报告 次日初步培养结果:有无细菌生长,大致细菌种类和浓度 2448h药敏结果(可能尚无细菌鉴定) 缩短时间方法:减少不必要的菌落纯分,快速鉴定和药敏,改进报告形式与发送方式
15、,微生物实验室需要改变流程,2019/1/24,Dr.HU Bijie,19,Severity assessment 严重度评估,2019/1/24,Dr.HU Bijie,20,重症肺炎标准,次要标准:3条 呼吸30次/分 PaO2/FiO2 250 多肺叶浸润 意识障碍 尿毒症UN20mg/dL 血WBC 4000 /mm3 血小板100,000 /mm3 体温(深部)36C 低血容量性休需要大量静脉补液,主要标准:1条 感染性休克需用升压药物 急性呼吸衰竭,需要气管插管/机械通气 肾衰? 肺炎快速发展?,IDSA/ATS: Consensus Guidelines on the Mana
16、gement of Community-Acquired Pneumonia in Adults (Clinical Infectious Diseases 2007; 44:S2772),2019/1/24,Dr.HU Bijie,21,Antimicrobial therapy 抗感染治疗,2019/1/24,Dr.HU Bijie,22,2019/1/24,Dr.HU Bijie,22,医院内肺炎的病原构成,Pathogens to Consider When Treating HAP/VAP,(American Thoracic Society/IDSA. Am J Respir Cr
17、it Care Med 2005;171:388-416),Frequency of bacterial pathogens in HAP in North America: 2,712 strains (SENTRY, Antimicrobial Surveillance Program, Jan.-June 2000),(Hoban DJ et al. Diag Microbiol Infect Dis 2003;45:279-285),Microbiology of VAP at Three Barnes-Jewish Christian HealthCare Hospitals (Te
18、aching, Community & Pediatric), 1998-2001 (N=753 Episodes),(Babcock HM et al. Infect Control Hosp Epidemiol 2003;24:853-858),2019/1/24,Dr.HU Bijie,26,SICU64例VAP病原谱构成 (20032005年复旦大学附属中山医院),2019/1/24,Dr.HU Bijie,27,Figure 1. Initial Empiric Antibiotic Therapy of HAP,Diagnosis of HAP,Mild-Moderate Pres
19、entation Group 1,Mild-Moderate Presentation + Risk Factors for Resistance Group 2,Severe Presentation Group 3,Treat on Ward with IV/Oral Monotherapy for Core Pathogens for 7-8 days,Treat on Ward with IV/Oral Monotherapy for Core Pathogens and Possible Resistant Pathogens for 7-8 days,Treat in ICU wi
- 配套讲稿:
如PPT文件的首页显示word图标,表示该PPT已包含配套word讲稿。双击word图标可打开word文档。
- 特殊限制:
部分文档作品中含有的国旗、国徽等图片,仅作为作品整体效果示例展示,禁止商用。设计者仅对作品中独创性部分享有著作权。
- 关 键 词:
- 最新 医院 肺炎 呼吸 相关 诊断 严重 程度 评估 感染 治疗 文档 资料
链接地址:https://www.31doc.com/p-1935757.html