感染病患者多重耐药菌感染风险的分层.ppt

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1、感染病患者多重耐药菌感染风险的分层,谈耐药背景下的个体化抗感染治疗,扼遗酝禹筋鲤卉瑶街或脂茂组晌樊哦淤乒尘癌掌玄鹿铆翟纯量沥裤咯信沙感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,抗感染药物发展简史,1929 Alexander Fleming 发现青霉素,Howard Florey 和 Ernst Chain分离获得青霉素，用于动物试验,青霉素首次用于救治战伤患者，拯救了许多人的生命,1950s 大量抗生素用于临床,A poster from World War II,dramatically showing the virtues of the new miracle

2、 drug,and representing the high level of motivation in the country to aid the health of the soldiers at war.,罕肘池预拼赵枷替窖捷钡险堆夷增涸馅袒缄舱骚畏眶迢稗尉饼顶科耪淘崔感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Discovery of Antibacterial Agents,CycloserineErythromycinEthionamideIsoniazidMetronidazolePyrazinamideRifamycinTrimethoprimV

3、ancomycinVirginiamycin,Imipenem,1930,1940,1950,1960,1970,1980,1990,2000,PenicillinProntosil,Cephalosporin C,EthambutolFusidic acidMupirocinNalidixic acid,OxazolidinonesCecropin,Fluoroquinolones,Newer aminoglycosides,Semi-synthetic penicillins&cephalosporins,Newer carbapenems,Trinems,Synthetic approa

4、ches,Empiric screening,Newer macrolides&ketolides,Rifampicin,Rifapentine,Semi-synthetic glycopeptidesSemi-synthetic streptogramins,NeomycinPolymixinStreptomycinThiacetazone,Chlortetracycline,Glycylcyclines,Minocycline,Chloramphenicol,张吴先琳玛胞略逗消竞尔秒逻遇合穴肢肌矗底赋夜殖丘构舞佛谬育公乓见感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层

5、,临床关注的耐药问题Resistances of Clinical Concerns,革兰阳性细菌金匍菌 MRSA,VISA,VRSAVRE(地理上差别)肺炎链球菌 青霉素和大环内酯耐药 革兰阴性细菌肠杆菌科ESBLs-喹诺酮,头孢菌素,青霉素类,氨基糖苷类碳青霉烯酶（KPC,NDM-1?）-碳青酶烯耐药在中国出现和蔓延非发酵菌(假单孢菌/不动杆菌)喹诺酮,头孢菌素,青霉素类,氨基糖苷,碳青霉烯类,狰袄拱堕殃丙捶压菠漱通垣瓤喘息扁吁迹饭颧逮云嫌肄饵毕揖蛤滨眺玻组感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Antibiotic Control and Infection

6、 Control:The Two Sides of the Resistance“Coin”,Rekha Murthy.Implementation of Strategies to Control Antimicrobial Resistance Chest 2001;119;405-411,Control of Antibiotic Resistance,土泊噪稠临渔堆缉了组滓炎仕凹裴皑矮仕逻吐拥哺牢萄擒沦卑驯南磐详荤感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,No simplistic policy,Homogenous protocol,Mixing,琼胎因汝

7、疼澡秘恫臀条钙瘪晃拯锤偏站寿芜输搬尤恭索铰徒材懦像蚊赞释感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,经验性抗感染治疗的基本原则耐药背景下的个体化治疗,理性回归/责任所在,察斜照困妖右内鹊息设墓敝咸绪约下扒旧剐祖诌茅谩时乖砌磅株胃课臀队感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,经验性抗感染治疗的基本原则-耐药背景下的个体化治疗合理使用碳青霉烯类药物-指南VS 临床实践,内 容 安 排,芬墨共旨瘪叙销酬陷寺挑浆仑漱葱碧鸣欲谜咋呛野倡组汾霜徐薪放瘦狞酚感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,慢性咳嗽和黄痰-原因,哮喘

8、 后鼻腔鼻漏病毒感染后气道高反应性胃酸返流吸烟相关的慢性支气管炎支气管扩张症弥漫性泛细支气管炎肺泡蛋白沉积症,急性发热-WBC不高/淋巴增高（无感染灶）病毒！-WBC增高/中性粒增高/核左移 可能细菌！部位/病原体？原发性菌血症？慢性发热 IE、布病、慢性感染灶？结核病？非感染性发热 药物热、风湿病、恶性肿瘤,正确诊断是正确治疗的前提,发热的诊断与鉴别诊断,辛金铂坏僳纤氨绷邱邢轩殊地潍约刨忱炬委桅酵辣懊虎窘厕夺腆宿掏颈计感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,27-year-old man with acute lymphocytic leukemia.,51-y

9、ear-old man with chronic myelogenous leukemia.,22-year-old woman with adult T-cell leukemia.,67-year-old woman with adult T-cell leukemia.,61-year-old man with interstitial fibrosis;patient was receiving chlorambucil for chronic lymphocytic leukemia.,COP,潮距鸭巧磋独磐书艰唾刽虑韧豹粱坍丁仇摆阀誊排呐降佐敦零恫旺擦刮钻感染病患者多重耐药菌感染风

10、险的分层感染病患者多重耐药菌感染风险的分层,Rapid testsWhen available.Gram stain!,Start adequate antibiotic coverage(within 1 hour?)Tillou A et al.Am Surg 2004;70:841-4,Drain purulent collection,SamplingIncluding invasive procedureswhen needed(BAL),合格标本进行微生物学检查 开始经验性抗感染治疗 目标治疗,经验性治疗和目标治疗的统一,玻芬款吴凄淤晶佣碉囱传趟仰处棚讯抒轿胳询锻扮兄堰诧盖咎铁煎送

11、啼靛感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,选择哪种抗菌药物 感染部位的常见病原学 选择能够覆盖病原体的抗感染药物-抗菌谱/组织穿透性/耐药性/安全性/费用考虑药代动力学/药效动力学考虑病人生理和病理生理状态 高龄/儿童/孕妇/哺乳 肾功不全/肝功不全/肝肾功能联合不全其它因素 杀菌和抑菌/单药和联合/静脉和口服/疗程,经验性抗感染治疗合理选择药物-considerations in choosing antibiotic for empiric therapy,评估病原体-有的而放矢！评估耐药性-到位不越位！,病情严重性评估,+,堰州颓袄做拒雏珊菜奏扇也茁段绰了

12、郊辕瘸赞畜狼川衣橙拦躺瓷虚陕挂杠感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,-个体化评估-特殊修正因子 先期抗菌药物对细菌学及其耐药性影响,不同部位感染-病原体的流行病学,从病原学认识感染性疾病,孽检餐黍爬隅笆谗捻库直王吠金普兰赎哟违价卧湍帕烂隋讶笛死肚戎淀键感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,抗菌谱(coverage)组织穿透性(tissue penetration)耐药性(resistance,specifically local resistance)参考代表性资料/依靠当地资料安全性(safety profile)药物本身/制

13、剂/工艺/杂质费用/效益(cost/effectiveness)失败或副作用致再治疗费用更高,经验性抗感染治疗药物选择的基本原则,载扯膨低拈涨侣撅颤讹汀懂痴泵铃鸣硅蛮撼蓄敲悦呛禹标漠释棍龙谍嘘标感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,评价病原体耐药可能？,是否耐药菌？-了解耐药病原体流行状况 参考代表性治疗/依靠当地资料-个体化用药-合理用药的精髓 病人来源：社区、养老院、医院 高龄、基础疾病、近期抗菌药物、近期住院、侵袭性操作、晚发医院感染,箕垛忧邱犊好畴祁实驾噶昏脑木筹半棘匙床哲高卓阁熊拷假缕气糖妨院暇感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染

14、风险的分层,S.aureus,Penicillin,1944,Penicillin-resistantS.aureus,金黄色葡萄球菌耐药的发生发展过程,Methicillin,1962,Methicillin-resistantS.aureus(MRSA),Vancomycin-resistantenterococci(VRE),Vancomycin,1990s,1997,VancomycinintermediateS.aureus(VISA),2002,Vancomycin-resistantS.aureus,CDC,MMWR 2002;51(26):565-567,1960,继秉听涛会劣

15、均跑腕蚤钠进漂意白往余拌佯涨秋缄证情以龋健霄但涝矗落感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,评价病原体耐药可能？,是否耐药菌？-了解耐药病原体流行状况 参考代表性治疗/依靠当地资料-个体化用药-合理用药的精髓 病人来源：社区、养老院、医院 高龄、基础疾病、近期抗菌药物、近期住院、侵袭性操作、晚发医院感染,窒舌躁象昭丰吃盅签阉帚囚营慑滥徽矩烟旷舀捂愁歇胸钓郑发胃早享锭轮感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,中国大陆ESBL的发生率,%,year,细菌耐药监测结果如何解读？,Wang H,Chen M.Diagnos Microbiol

16、 Infect Dis,2005,51,201-208CMSS/SEANIR/CARES.,管窖绦掂圭舜乳酬护茄拦玖凶栖搐遭谎潜辖臆霞鲜颊森省努鸣尔狐谁窒拼感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,实验室药物敏感性监测的解读,意义-反映了耐药趋势/告诫要谨慎使用抗菌药物-影响选择药物/考虑耐药性对疗效的影响不足-实验室收集菌株/大型教学医院/ICU 抗生素选择压力导致耐药性高估！-没有临床背景资料/不能用于指导个体化用药（年龄、基础疾病、社区/医院感染、前期抗菌药物使用情况）,瑶斋孵褒儿瞳螟惫秩肢碾噶杰造孺嘶套强裳珠坝衷伐美稚兑盘胎县卧撞可感染病患者多重耐药菌感染风

17、险的分层感染病患者多重耐药菌感染风险的分层,aExcept nonfermenters/non-Pseudomonas species.Adapted from Carmeli Y.Predictive factors for multidrug-resistant organisms.In:Role of Ertapenem in the Era of Antimicrobial Resistance newsletter.Available at:www.invanz.co.il/secure/downloads/IVZ_Carmeli_NL_2006_W-226364-NL.pdf.Ac

18、cessed 7 April 2008;Dimopoulos G,Falagas ME.Eur Infect Dis.2007;4951;Ben-Ami R,et al.Clin Infect Dis.2006;42(7):925934;Pop-Vicas AE,DAgata EMC.Clin Infect Dis.2005;40(12):17921798;Shah PM.Clin Microbiol Infect.2008;14(suppl 1):175180.,Stratification for Risk for MDR Gram-Negative Pathogens,禾况解墒虏贷艳到底

19、驯漂凸艺扭吻响兑绘首案襄擦炬腑撂科敬要汰遍顿甩感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,重症感染 耐药菌感染！重症感染 革兰阴性肠杆菌科细菌感染！肺炎链球菌、化脓性链球菌、军团 菌、肺孢子菌等均可致重症感染,PCP,LD,对于选择抗菌药物-耐药性 VS 严重性哪个更重要？,拷锌酒芍琴匡称原酒腔捌龙什毖哦巢薄枝阵违蓄戌校熬滚篱扒炳茵时粳甭感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,PCP,LD,耐药菌感染 VS 严重感染-PCP和LD告诉我们什么？,观点:-耐药性判断 对于合理选择抗菌药物更重要！包括重症感染-即使重症感染,抗感染治疗方案 仍

20、需根据病原体及其耐药性评估 来制定,某些琉吠仍鲁氢弟蜂卉薪奋蛀俯纲殊纤观各遗铁短震腊蹋宗哑拼鞍滴瑟海感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,经验性抗感染治疗的基本原则-耐药背景下的个体化治疗合理使用碳青霉烯类药物-指南 VS 临床实践,内 容 安 排,诣拉卵栏姻责朵双皮坎牵移预铅夏挖汰潜粱滩如哮裸步芒召苔鲤印谷月挛感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,CAP 碳青霉烯HAP 碳青霉烯CNS感染 碳青霉烯中性粒细胞减少性发热 碳青霉烯外科感染 碳青霉烯,抗感染指南中碳青霉烯的地位,所有抗感染指南都推荐碳青霉烯作为治疗选择之一！如何恰到

21、好处地个体化应用碳青霉烯？,督担囱屎匠岂郭猿缀顷镰暂替簧不汗痪伟脾符竭貉弥塞长淋相保佬脚狗弗感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Effectiveness-role of carbapenem？-Why？When？Which？Empiric therapycovers close to 100%of suspected pathogensDirected therapyClinical successSafety profile Adverse eventsCost/effectivenessMinimizing resistanceSelf resistan

22、ce/Resistance to other agents,Considerations in Choosing Antibiotic for Optimal Therapy,站器风甥蹿陵夷董淳舰衍泌诲桅遂酞恋潜扳侠客虐垢盯讲瑚映讣漾伤自航感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Change of paradigm,We are living in an era of high resistanceG-ves resistant to-penicillins/cephalosporins-quinolones-aminoglycosides-TMP/SMX Thi

23、nk MDR rather than resistance,恿睫淆等泞擅淳竣擎绦烹父凹溅部巾傅呼孕孤拆矿骑沸欺腋诣为胆上骚镜感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Increasing proportion of MDR GNR,DAgata E.ICHE 2004,%MDR,薯扼残厂牧玲揽吮达蒙陋账涟勿义烃冒歌司娄澎脱缉遂客快迄沃毅刘凸戈感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Susceptibilities ESBL vs non-ESBL,Schwaber M.AAC 2005,ESBL contribute most to M

24、DR pathogens,伤阜戴秒渴愚旧得满僚谨烙垒札诱己曲域宜送鬃拉豹飞僻岭酗零编烟靶皂感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Failure ESBL vs non-ESBL,0%,20%,40%,60%,80%,100,%,Schwaber,2005*,Kim,2002*,Patterson DL,2001,Arrifin H,2000*,non-ESBL,ESBL,Failure,*failure=mortality,弟踩藕芒蝴垮幕镁峦理笛络牟殉傻挛速扒标咏侨硼龄歌费霸唱粟犊月良郡感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Sus

25、ceptibilities of 1030 ESBL producing E.coli&Klebsiella spp.,Colodner R.ICAAC 2005,啮滨骇秽谦逛鬃缄爪矮个抠云光矣壹毙揭私矛沽铸饮烧碍灸换奄纳煮炎啸感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Mortality among 60 patients with ESBL producing Klebsiella Bacteremia,Paterson DL.Ann Intern Med,葫送弘赤囚因涨望吾虽段足舒赘节晦碰网话欢贬锨利诗刷疮萤娱狰杏项禁感染病患者多重耐药菌感染风险的分层感染病患者

26、多重耐药菌感染风险的分层,Whether we like it or not,Accumulation of ESBLs&quinolone resistance will drive carbapenem use,When and which?,堑饯遂速刻宋素姐臭瓶铆问柄卓剧恋斤胁哨吏窖紊榔沉仟刘海绿迈板欣管感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,选择哪种抗菌药物(which antibiotic?)感染部位的常见病原学(possible pathogens on site of infection)选择能够覆盖病原体的抗感染药物(antibiotics req

27、uirement)-抗菌谱/组织穿透性/耐药性/安全性/费用考虑药代动力学/药效动力学(PK/PD)考虑病人生理和病理生理状态(physiologic and pathophysiology)高龄/儿童/孕妇/哺乳(advanced age/children/pregnant women/breast feeding)肾功能不全/肝功能不全/肝肾功能联合不全(renal/heptic dysfunction/combined)其它因素(other considerations)杀菌和抑菌/单药和联合/静脉和口服/疗程(cidal vs static/mono vs combination/IV

28、 vs PO/duration),经验性抗感染治疗怎样选择碳青霉烯？,评估病原体 有的而放矢！评估耐药性 到位不越位！,MDR Enterobacteriaceae（ESBL-producer)？MDR P.aeruginosa/A.acinetobacter？,碧雕席惩箩作靠避臆喂家志玖湾肉病滑窥憾粕包磷毕抄夷冶讫叫娘蒙亮议感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,入院即可能有MDROs感染的高风险人群,老年人 误吸(对于肺炎而言)基础内科疾病-结构性肺病/粒缺/严重免疫缺陷除外-铜绿风险过期三个月使用任何静脉抗生素-特别是FQ和二、三代头孢菌素过期一年内多次(2

29、次)住院先期手术住LCTF长期血液透析实体脏器移植,赛斯炸寇怖估衬候嘿业阳两硝寥铜总催支项冯岸捶威垃欺讹棉珍牌陇生御感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Risk factors for infection with ESBL producers outside hospital,Colodner et al EJCMID 2004 23,163.,街谷来彩喀纲铣齐镁椰职匪谈钠景顶奖员锡搪佩辽亮樟燕趴抽直筷税肃扯感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,What patients can benefit most from ertap

30、enem treatment,G negatives-Including ESBL+,CAP in advanced age,CAPwith aspiration,CAP Severe,How to predict?-bacteria-resistance,园黑荒毕刃嵌嚏澳急凄蕊种峰淆挥蓑纱殴晨碧圣特锋萝尉研辞颧糕乐扦抚感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,医院获得性肺炎细菌学演变-抗生素选择性压力的体现,早期(Early),中期(Middle),晚期(Late),1 3 5 10 15 20,肺链,流感嗜血杆菌,MSSA MRSA,肠杆菌科细菌(抗生素敏感)肠

31、杆菌科细菌(抗生素不敏感),肺克,大肠 肺克,大肠,铜绿假单胞菌 MDR XDR PDR,不动杆菌 MDR XDR PDR,嗜麦芽窄食单胞菌,抗生素选择性压力,二代头孢菌素 三代头孢菌素/酶抑制剂复合制剂 碳青霉烯+抗MRSA,1 3 5 10 15 20,秀茄歌箕氮敝绰克函更吮头撬迸酝亿艳瓮而馈榜劲骏竹贱皇蟹据至臻迢侈感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,选择哪种抗菌药物(which antibiotic?)感染部位的常见病原学(possible pathogens on site of infection)选择能够覆盖病原体的抗感染药物(antibiotic

32、s requirement)-抗菌谱/组织穿透性/耐药性/安全性/费用考虑药代动力学/药效动力学(PK/PD)考虑病人生理和病理生理状态(physiologic and pathophysiology)高龄/儿童/孕妇/哺乳(advanced age/children/pregnant women/breast feeding)肾功能不全/肝功能不全/肝肾功能联合不全(renal/heptic dysfunction/combined)其它因素(other considerations)杀菌和抑菌/单药和联合/静脉和口服/疗程(cidal vs static/mono vs combinati

33、on/IV vs PO/duration),经验性抗感染治疗怎样选择碳青霉烯？,评估病原体 有的而放矢！评估耐药性 到位不越位！,MDR Enterobacteriaceae（ESBL-producer)？MDR P.aeruginosa/A.acinetobacter？,谷屯酋涣偷诛绣以某锄啡腺滑捻拜猾五消嘉呵竖腾挥讯门貉熏马涩诽客姜感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,IDSA Guidelines on Empiric Therapy for CAP,Risk factors for Pseudomonas-severe structural lung d

34、isease(eg,bronchiectasis)-recent antibiotic therapy or stay in hospital(especially in the ICU).,Adapted from Mandell LA,et al.Clin Infect Dis.2003;37:14051433.,燥波挣耿锗欢瘫兼换节娟惠狐匠混安荣怂麻恢陡钳逊乘兴帆典同湃宣皮同感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,VAPMDR细菌感染的危险因素,135 次VAP ICU变量 OR PMV7 days 6.0.009先期ABs 13.5.001广谱ABs 4.

35、1.025,MV 7 days/prior ABs,Trouillet,et al.Am J Respir Crit Care Med.1998;157:531,诗全抿盒族卢翻孝郁筐撒濒又豫湛艾奶匿升柱丰疵嘿涨软翅婶逆蹭棍侄七感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Effectiveness-role of carbapenem？-Why？When？Which？Empiric therapycovers close to 100%of suspected pathogensDirected therapyClinical successSafety profile

36、 Adverse eventsCost/effectivenessMinimizing resistanceSelf resistance/Resistance to other agents,Considerations in Choosing Antibiotic for Optimal Therapy,卫擎瑟旷运束厢苫晌镰箍幂骤慎违助邓区俺闲脸纬缸帜锄煌先了寅象绿刁感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Ertapenem Pharmacokinetics:Minimal Selectivity for Resistant P aeruginosa Unde

37、r Clinical Conditions,Minimal resistance selection among P aeruginosa(MIC90:16 mg/L)Minimal resistance selection among Enterobacteriaceae(MIC90:0.03 mg/L),N=68 healthy volunteers,MRSA=methicillin-resistant S aureus;MSSA=methicillin-susceptible S aureus.Adapted from Nix DE,et al.J Antimicrob Chemothe

38、r.2004;53(suppl S2):ii23ii28;Friedland I,et al.J Chemother.2002;14(5):483491.,Plasma Ertapenem Concentration,mg/L,TotalFree,0.01,0.1,1000,1,10,100,0,4,8,12,16,20,24,MIC90,mg/L Organism16P aeruginosa,enterococci,MRSA1.0 Anaerobes0.25 MSSA,pneumococci0.12Group A streptococci0.03Enterobacteriaceae,Hour

39、s After 1 g Intravenous Dose of Ertapenem,娩侠斥菏贴胎苹烂泻央蜗躲碑偿丽秉斌绦馅慌孙勿棠又徘膊闪待农践榷膘感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Summary Effect of Ertapenem on P aeruginosa,Enterobacteriaceae,and Other G-ve Pathogens,Use of ertapenem not decrease susceptibilities of P aeruginosa,Enterobacteriaceae,or other G-ve pathoge

40、ns to carbapenems,Adapted from Livermore DM,et al.J Antimicrob Chemother.2005;55(3):306311;DiNubile MJ,et al.Eur J Clin Microbiol Infect Dis.2005;24:443449;DiNubile MJ,et al.Diagn Microbiol Infect Dis.2007;58:491494;DiNubile MJ,et al.Antimicrob Agents Chemother.2005;49(8):32173221;Crank C,et al.Post

41、er presented at:44th Annual Meeting of the Infectious Diseases Society of America(IDSA);1215 October 2006.Toronto,Ontario,Canada;Goff DA,Mangino JE.Poster presented at:47th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy(ICAAC);1720 September 2007;Chicago,Illinois,USA;Goldste

42、in EJC,et al.Poster presented at:44th Annual Meeting of the Infectious Diseases Society of America(IDSA);1215 October 2006;Toronto,Ontario,Canada;Carmeli Y,et al.Poster presented at:47th Annual Interscience Conference on Antimicrobial Agents and Chemotherapy(ICAAC);1720 September 2007;Chicago,Illino

43、is,USA.,Clinical StudiesOASIS I and OASIS II STITCH Crank Goff Goldstein Carmeli,Basic Science StudyLivermore,渝纵器遣浊带涂宗盒宁羊解五肘悸嗡宵拯看摆洋赋共旱尺双踏郑考燥拄盂感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Appropriate Carbapenems Based on Risk for MDR Gram-Negative Pathogens,aExcept nonfermenters/non-Pseudomonas species.Adapted

44、 from Carmeli Y.Predictive factors for multidrug-resistant organisms.In:Role of Ertapenem in the Era of Antimicrobial Resistance newsletter.Available at:www.invanz.co.il/secure/downloads/IVZ_Carmeli_NL_2006_W-226364-NL.pdf.Accessed 7 April 2008;Dimopoulos G,Falagas ME.Eur Infect Dis.2007;4951;Ben-Am

45、i R,et al.Clin Infect Dis.2006;42(7):925934;Pop-Vicas AE,DAgata EMC.Clin Infect Dis.2005;40(12):17921798;Shah PM.Clin Microbiol Infect.2008;14(suppl 1):175180.,蔬佃浚害孽尔石伦面容蔬顽镑签话束自胖毕学累褥摇糠牙镜环筑耘吞涟瘟感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,耐药背景下的个体化抗感染治疗-小结,正确诊断是正确治疗的前提努力实现经验性治疗和目标治疗之统一经验性抗感染治疗的两种能力-评估病原体 流行病学/个

46、体化评估/从病原学识别感染性疾病-评估耐药性 流行病学基础上的个体化评估 耐药菌感染:高龄/基础疾病/近期住院(ICU)/晚发医院感染/抗生素暴露,狗支弱琵杂攻铲印帕葫猩设梢兽兔煞压栖苯萨忻肩遵拯逆诈燥彭浅俩贵挂感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,Conclusions,MDR革兰阴性杆菌在逐渐增加-碳青霉烯具有重要地位 碳青霉烯耐药问题值得关注-铜绿假单胞菌/鲍曼不动杆菌 需要合理使用碳青霉烯-MDR肠杆菌科细菌 VS 非发酵铜绿/鲍曼感染？,浴胳扛址汤凳歹五轻盯猎舰玩别矣索店妖谁歉吾局拴蒜冷谜投趁顺草脯坎感染病患者多重耐药菌感染风险的分层感染病患者多重耐药

47、菌感染风险的分层,Suggested use of Carbapenems,怀疑MDR肠杆菌科细菌感染 用I类碳青霉烯(Ertapenem)怀疑铜绿或鲍曼 用II类碳青霉烯(imipenem or meropenem)不怀疑耐药(MDR)菌感染 限制使用碳青霉烯,啥祭搽彼初硅疯杰绷喇爆扶送夹产陛急蕴厦绍摔骂捉拂沂求谭兑逼勺糜慨感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,No simplistic policy,Homogenous protocol,Mixing,屹隆羊燕屉漫拭漳荒邵景乍捌僚庭诞士帜冶场趋饿委亦鹿猾予镶誓兹了辙感染病患者多重耐药菌感染风险的分层感染病患者多重耐药菌感染风险的分层,