气道分泌物培养的临床意义-精选文档.ppt
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1、Conflicts of Interest,Astellas AstraZeneca Bayer Dainippon Sumimoto Pharma Eli Lilly GlaxoWellcome MSD Pfizer (Wyeth) ,临床病例,M/75 yo PMHx: 无 2010/3/1 结肠癌穿孔 继发性腹膜炎 术后收入ICU 感染性休克 急性肾功能衰竭 DIC 住ICU后病情逐渐稳定,临床病例,2010/3/13 ICU Day 12 BT 39.8C WCC 16.8 体格检查 双肺湿罗音 呼吸机条件升高 PEEP 8 16 FiO2 0.4 0.6 PaO2/FiO2 165
2、80,临床病例,考虑VAP 准备应用经验性抗生素 住院医师意见 一周前曾留取痰培养 铜绿假单胞菌 有助于确定目前致病菌?,北京协和医院 检验科细菌室 姓名:XXX 性别:男性 年龄:75 病房:MICU 标本:痰 日期:2010/3/5 铜绿假单胞菌(Pseudomonas aeruginosa) 头孢他啶 R 哌拉西林/他唑巴坦 R 头孢哌酮/舒巴坦 R 亚胺培南 S 美罗培南 S,VAP发生前的微生物学检查,739名可疑VAP患者入选 281名(39%)患者入选前1 3日有培养结果 130名(46%)患者培养出致病微生物,Sanders KM, Adhikari NKJ, Friedric
3、h JO, et al. Previous cultures are not clinically useful for guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63,VAP发生前的微生物学检查,Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not clinic
4、ally useful for guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63,VAP发生前的微生物学检查,Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not clinically useful for guiding empiric antibiotics i
5、n suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63,VAP发生前的微生物学检查,经验性抗生素错误率 根据革兰染色结果 16% (11 33%) 根据分离所有微生物 37% (29 45%) 根据药敏结果 39% (31 48%),Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not clinically useful for
6、 guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Crit Care 2008; 23: 58-63,VAP发生前的微生物学检查,目的: 确定微生物学监测对于诊断呼吸机相关肺炎(VAP)及化脓性气管支气管炎(TBX)的价值 患者: 356名心脏手术患者 微生物学监测 方法: PSB + ETA 频率: 心脏手术结束后, 拔除气管插管前, 手术后3天, 以及每周一次 终止时间: 拔除气管插管, 发生VAP或
7、TBX, 死亡,Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.,VAP发生前的微生物学检查,VAP诊断标准 CXR出现新发浸润影或原有浸润影加重 下列标准中2条或2条以上: 发热( 38.5C)或低体温( 6,TBX诊断标准 脓性气管分泌物 CXR没有肺炎导致的浸润影 下列标准中2条或2条以上: 发热
8、( 38.5C)或低体温( 36C) 白细胞升高( 12 x 109/L) 呼吸道分泌物细菌计数明显升高,Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.,VAP发生前的微生物学检查,VAP 患病率 7.87% (28/356) 发病率 34.5例/1,000机械通气日 TBX 患病率 8.15% (2
9、9/356) 发病率 31.13例/1,000机械通气日,Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.,VAP发生前的微生物学检查,微生物学监测 1626个标本 平均每名患者4.56 2.8个标本2 30 预测准确性 VAP 1/28 TBX 1/29,Bouza E, Prez A, Muoz P
10、, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.,VAP发生前微生物培养结果,Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillanc
11、e. Crit Care Med 2003; 31:1964 1970.,VAP发生前微生物培养结果,Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.,VAP发生前的微生物学检查,致病菌 仅能发现33% (73/220)的致病菌 呼吸道分离细菌的阳性预期值 72 h: 56% 72 h: 13% 患者
12、对38% (47/125)的病例完全没有帮助 仅31% (39/125)的病例致病菌完全吻合,Bouza E, Prez A, Muoz P, et al. Ventilator-associated pneumonia after heart surgery: A prospective analysis and the value of surveillance. Crit Care Med 2003; 31:1964 1970.,VAP发生前的微生物学检查,结论 VAP发生前常规进行微生物检查仅能发现少量致病菌 由于分离的多数细菌并不参与其后的VAP发病, 因此培养结果常常引起误导 耐药
13、细菌在引发感染前能够分离到 敏感性 70% 不能作为经验性抗生素选择的唯一依据 经验性抗生素治疗应当覆盖VAP发生前72小时内呼吸道分离出的细菌,Hayon J, Figliolini C, Combes A, Trouillet JL, Kassis N, Dombret MC, Gibert C, Chastre J. Role of Serial Routine Microbiologic Culture Results in the Initial Management of Ventilator-associated Pneumonia. Am J Respir Crit Care
14、Med 2002; 165: 41-46,VAP发生前的微生物学检查,结 论 既往培养结果与怀疑VAP时培养结果一致性很差 不应根据既往培养结果指导经验性抗生素治疗,Sanders KM, Adhikari NKJ, Friedrich JO, et al. Previous cultures are not clinically useful for guiding empiric antibiotics in suspected ventilator-associated pneumonia: secondary analysis from a randomized trial. J Cr
15、it Care 2008; 23: 58-63,临床病例,决定不考虑既往呼吸道分泌物培养结果 经验性抗生素选择 ? 主治医师问题 是否等待痰涂片结果?,北京协和医院 检验科细菌室 姓名:XXX 性别:男性 年龄:75 病房:MICU 标本:痰 日期:2010/3/12 镜检结果 上皮细胞 25 /LPF 涂片结果 革兰阴性杆菌 大量 革兰阳性球菌 可见,VAP治疗 革兰染色结果,Rello J, Paiva JA, Baraibar J, et al. International conference for the development of consensus on the diagno
16、sis and treatment of ventilator-associated pneumonia. Chest 2001; 120: 955-970,*Yes if the clinical situation clearly suggestive of pneumonia and if patient at high risk or clinically deteriorating,VAP治疗 革兰染色结果,仅有1/2的VAP病例ETA革兰染色结果与培养结果相符,Allaouchiche B, Jaumain H, Chassard D, et al. Gram stain of b
17、ronchoalveolar lavage fluid in the early diagnosis of ventilator-associated pneumonia. Br J Anaesth 1999; 83: 845-849 Duflo F, Allaouchiche B, Debon R, et al. An evaluation of the Gram stain in protected bronchoalveolar lavage fluid for the early diagnosis of ventilator-associated pneumonia. Anesth
18、Analg 2001; 92: 442-447 Davis KA, Eckert MJ, Reed RL II, et al. Ventilator-associated pneumonia in injured patients: do you trust your Gram stain? J Trauma 2005; 58: 462-466 Raghavendran K, Wang J, Belber C, et al. Predictive value of sputum Gram stain for the determination of appropriate antibiotic
19、 therapy in ventilator-associated pneumonia. J Trauma 2007; 62: 1377-1383 Albert M, Friedrich JO, Adhikari NKJ, et al. Utility of Gram stain in the clinical management of suspected ventilator-associated pneumonia: secondary analysis of a multicenter randomized trial. J Crit Care 2008; 23: 74-81,VAP治
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