《传染病学教学课件》11、败血症英文(凌).pptx

败 血 症 重庆医科大学第二临床学院感染病科 概念1 Conception Pathogenic bacteria or conditional pathogenic bacteria invade the blood flowPathogenic bacteria or conditional pathogenic bacteria invade the blood flow致病菌或条件致病菌侵入血流致病菌或条件致病菌侵入血流Grow and produce toxins,enzymes and metabolic productsGrow and produce toxins,enzymes and metabolic products生长繁殖，产生毒素、酶、代谢产物生长繁殖，产生毒素、酶、代谢产物Fever,rash,joint swelling,liver and spleen enlargementFever,rash,joint swelling,liver and spleen enlargement发热、皮疹、关节肿痛、肝脾肿大发热、皮疹、关节肿痛、肝脾肿大Migrating lesions and septic shockMigrating lesions and septic shock迁徙性病灶、感染性休克迁徙性病灶、感染性休克概念2 Conception 菌血症 bacteriemia脓毒血症 sepsis全身炎症反应综合征 Systemic Inflammtory Response Syndrome复数菌败血症 polymicrobial bacteremia毒血症 toxemia概念3 Conception 毒血症：毒血症：病原菌在入侵局部生长繁殖的过程中，将其产生的毒性物质侵入血液，引起机体毒血症状。细菌并不侵入血流。In the process of pathogenic bacteria to grow in the invasion of the local,it produce toxic substances into the blood,cause the toxemic symptoms.Bacteria do not invade the blood flow.菌血症：菌血症：细菌在血流中短暂出现的现象，一般无明显毒血症症状。Bacteria in the bloodstream briefly,generally have no obvious toxemic symptoms.概念3 Conception 脓毒败血症：脓毒败血症：细菌栓子随血流可出现迁徙性炎症，如全身多处脓肿形成。Bacterial emboli can appear along with blood stream migrating,such as abscess formate.复数菌败血症：复数菌败血症：在同一血培养或72h内从同一个病人不同血培养标本检出二个或二个以上的致病菌。Within 72 h of the same blood cultures or different from the same patient blood culture specimens detected two or more than two pathogens.临床符合以下2条或两条以上：(1).T 38或 90次/分 (3).R 20次/分或PCO2 12109/L或10%全身炎症反应综合征（全身炎症反应综合征（SIRS）概念4 Conception 革兰阳性球菌革兰阳性球菌 Gram positive coccusGram positive coccus 革兰阴性杆菌革兰阴性杆菌 Gram negative bacilliGram negative bacilli厌氧菌厌氧菌 anaerobeanaerobe真菌真菌 fungifungi其他其他 病原菌 pathogen 革兰阳性球菌革兰阳性球菌(Gram positive coccus)葡萄球菌葡萄球菌葡萄球菌葡萄球菌(Staphylococcus aureus)：金葡菌金葡菌Staphylococcus aureus,表葡菌表葡菌S.epidermidis 链球菌链球菌链球菌链球菌(streptococcus)：肺炎链球菌Streptococcus pneumoniae、溶血性链球菌Hemolytic streptococcus 肠球菌肠球菌(enterococcus)常见的病原菌常见的病原菌1 1（pathogenpathogen）常见耐药菌1：阳性球菌 VRE：耐万古霉素的肠球菌 Vancomycin Resistant EnterococciPRSP：耐青霉素的肺炎球菌 Penicillin Resistant Streptococcus PneumoniaeMRSA：耐甲氧西林的金黄色葡萄球菌 Methicillin Resistant Staphylococcus aureusMRSE：耐甲氧西林的表皮葡萄球菌 Methicillin Resistant Staphylococcus Epidermidis革兰阴性杆菌革兰阴性杆菌革兰阴性杆菌革兰阴性杆菌(Gram negative bacilliGram negative bacilli)大肠埃希氏菌大肠埃希氏菌 Escherichia coli Escherichia coli肺炎克雷伯菌肺炎克雷伯菌Klebsiella pneumoniaeKlebsiella pneumoniae假单胞菌假单胞菌pseudomonaspseudomonas变形杆菌变形杆菌proteusbacillus proteusbacillus vulgarisvulgaris不动杆菌不动杆菌acinetobacteracinetobacter常见的病原菌常见的病原菌2 2（pathogenpathogen）常见耐药菌2：阴性杆菌 ESBLs：产超广谱内酰胺酶的菌属 Extended Spectyum Lactamase MDR-Pa：多重耐药的铜绿假单胞菌 Multi-drug Resistance Pseudomonas aeruginosa厌氧菌（anaerobe）：脆弱类杆菌Fragile bacteroides、产气荚膜杆菌Bacillus perfringens真菌（Fungus）：）：白色念珠菌Candida albicans、曲霉菌aspergillus、隐球菌隐球菌cryptococcuscryptococcus其它：分枝杆菌 mycobacteria常见的病原菌常见的病原菌3 3（pathogenpathogen）复数菌复数菌 两种或两种以上细菌同时或先后感染，多见于严重烧伤或免疫两种或两种以上细菌同时或先后感染，多见于严重烧伤或免疫功能严重低下者功能严重低下者 two or over two kinds of bacteria infection simultaneously or successively,two or over two kinds of bacteria infection simultaneously or successively,often in patients with serious burns or low immune function.often in patients with serious burns or low immune function.常见的病原菌常见的病原菌4 4（pathogenpathogen）致病菌入侵途径致病菌入侵途径Pathogenic bacteria invasionPathogenic bacteria invasion 人体的防御免疫人体的防御免疫The hosts immune defenseThe hosts immune defense 病原菌的致病力病原菌的致病力The pathogen pathogenicityThe pathogen pathogenicity发病机制 pathogenesis 入入 侵侵 途途 径径wayway of the Invasion of the Invasion革兰阳性球菌:皮肤化脓性炎症、烧伤创面感染、中耳炎、呼吸道炎症及女性生殖道炎症 Skin inflammation,burn wound infection,otitis media,airway inflammation and female genital tract inflammation革兰阴性杆菌:胆道、肠道或泌尿生殖道炎症 Biliary tract,intestinal and urinary tract inflammation厌氧菌:肠道、腹腔及女性生殖道炎症 The intestinal tract,abdominal cavity and female genital tract inflammation真菌:口腔、肠道及呼吸道感染 Oral,intestinal and respiratory infections发病机制发病机制 pathogenesispathogenesis人体因素人体因素 机体防御免疫功能缺陷或下降机体防御免疫功能缺陷或下降 Human factors:The defects or falling defense immune function1).1).中性粒细胞减少中性粒细胞减少（血液系统疾病、药物）（血液系统疾病、药物）neutropenia(blood system diseases,drugs)2).2).某些药物的应用某些药物的应用 (免疫抑制剂、广谱抗生素、细胞毒药物放化疗）免疫抑制剂、广谱抗生素、细胞毒药物放化疗）The application of certain drugs(immunosuppressants,broad-spectrum The application of certain drugs(immunosuppressants,broad-spectrum antibiotics,cytotoxic drugs,radiation and chemotherapy)antibiotics,cytotoxic drugs,radiation and chemotherapy)3).3).有创性检查和治疗有创性检查和治疗 (气管切开插管、呼吸机、气管切开插管、呼吸机、静脉导管、内镜静脉导管、内镜检查及大手术检查及大手术)With invasive examination and treatment(tracheotomy,breathing machine,venous catheter intubation,endoscopy and major surgery)4).4).某些基础病某些基础病 (外伤、烧伤、肝硬化外伤、烧伤、肝硬化,尿毒症尿毒症,糖尿病及风湿性疾病糖尿病及风湿性疾病)Some basic disease(trauma,burns,liver cirrhosis,uremia,diabetes and rheumatoid diseases)发病机制发病机制 pathogenesispathogenesis皮肤粘膜皮肤粘膜阻止病原菌侵入阻止病原菌侵入分泌抑菌或杀菌物质分泌抑菌或杀菌物质 skin and mucosa secrete antimicrobial or antiseptic materialprevent pathogen invasion细菌容易侵入体内细菌容易侵入体内Bacteria enter the body easily发病机制发病机制 pathogenesispathogenesis先天性(获得性）免疫功能不足婴幼儿Congenital(acquired)lack of immune function in infants免疫抑制剂的应用The application of immunosuppressant各种严重的慢性疾病All kinds of severe chronic diseases发病机制发病机制 pathogenesispathogenesis肝硬化败 血 症代谢紊乱、免疫球蛋白合成减少Metabolic disorders,immunoglobulin synthesis decrease 网状内皮细胞系统功能低下Reticular endothelial cells system function low 粒细胞吞噬功能减弱Granulocyte phagocytosis weak白细胞减少 恶 性 肿 瘤 尿 毒 症 糖 尿 病侧枝循环形成，肠道 病原菌直接进入体循环 Collateral circulation formation,the intestinal Pathogens directly into the systemic circulation发病机制发病机制 pathogenesispathogenesis 各种手术操作各种手术操作All kinds of operationAll kinds of operation 内窥镜检查内窥镜检查endoscopyendoscopy 插管插管intubationintubation 血透血透hemodialysishemodialysis 人工瓣膜等装置的放置等人工瓣膜等装置的放置等The placement of artificial The placement of artificial valve devices,etc valve devices,etc 各种诊疗技术应用增多各种诊疗技术应用增多All kinds of diagnosis and treatment technologyAll kinds of diagnosis and treatment technology治疗方法的不断更新治疗方法的不断更新Treatment of constantly updatedTreatment of constantly updated发病机制发病机制 pathogenesispathogenesis保护细菌保护细菌Protect bacteriaProtect bacteria帮助细菌生长繁殖和扩散帮助细菌生长繁殖和扩散 Help the bacteria to grow and spread Help the bacteria to grow and spread 破坏组织破坏组织Damaged tissue Damaged tissue 酶 enzyme外毒素 exotoxin多种症状体征A variety of symptoms and signs发病机制发病机制 pathogenesispathogenesis微循环障碍感染性休克DICDICMOFMOF激活补体激肽凝血纤溶系统Activate complement activated peptide coagulation fibrinolytic system损伤心肌及血管内皮Myocardial injury and vascular endothelium血管活性物质细胞因子Vascular active substances cytokines内毒素endotoxin发病机制发病机制 pathogenesispathogenesis细胞组织水肿、变性、坏死Tissue edema,Degeneration,necrosis毛细血管损伤出现瘀点、皮疹Capillary damagePetechiae,skin rash细菌毒素单核-巨噬细胞系统增生，肝脾肿大-the monocyte/macrophage systemHyperplasia of liver and spleen enlargement病理变化 Pathologic ChangePathologic Change 细菌栓子引起迁徙性病灶Bacterium embolusMigrating lesions 单核单核巨噬细胞系统增生活跃巨噬细胞系统增生活跃 肝脾常肿大肝脾常肿大 骨髓粒系增生活跃骨髓粒系增生活跃-the monocyte/macrophage system hyperplasia of liver and spleen the monocyte/macrophage system hyperplasia of liver and spleen enlargementenlargement-bone marrow hyperplasia of grain active-bone marrow hyperplasia of grain active病理变化 Pathologic ChangePathologic Change 临 床 表 现 clinical manifestationclinical manifestation无特异的临床表现No specific clinical manifestation无明确的潜伏期No confirmed incubation period主要临床表现(main clinical manifestations)原发病灶炎症 Inflammation of the posteromedial 毒血症状 Effects of shape 皮疹The rash 关节症状 Joint symptoms 肝脾肿大 Liver and spleen enlargement 迁徙性病灶 Migrating lesions临床表现临床表现 clinical manifestationclinical manifestation 起病急，寒战高热，呼吸、脉搏加快；Onset nasty,chills high fever,breathing,pulse accelerated;全身不适、肌肉关节疼痛，头痛、恶心、呕吐、腹胀、腹痛；General malaise,muscle joint pain,headache,nausea,vomiting,abdominal distension,abdominal pain;严重者可出现中毒性脑病、中毒性心肌炎、中毒性肝炎、肠麻痹、感染性休克、DIC。Severe cases can appear in the toxic encephalopathy,toxic myocarditis,viral hepatitis,intestinal paralysis,septic shock,DIC.毒血症症状毒血症症状symptoms of toxemia临床表现临床表现 clinical manifestationclinical manifestation 瘀点(petechia)最多见，躯干、四肢多。眼结膜、口腔粘膜等处可见，为数不多 The most common,the torso and limbs.Of conjunctiva,the place such as oral cavity mucous membrane,few 金葡菌败血症：脓疱疹(pustule)等 绿脓杆菌败血症：坏死性皮疹Necrotizing skin rash skin eruptions临床表现临床表现 clinical manifestationclinical manifestation petechia瘀点瘀点 瘀斑瘀斑epidemic cerebrospinal meningitis-petechiaVesiculo-pustular rash 脓疱疹荨麻疹(Urticaria)大关节红、肿、热、痛和活动受限 Large joints:redness,swelling,heat,pain and restricted movement 关节腔积液、积脓 Articular cavity effusion and empyema 多见于革兰阳性球菌、产碱杆菌Among gram-positive cocci,producing alkali bacillus临床表现临床表现 clinical manifestationclinical manifestation joint involvement 一般仅轻度肿大。当发生中毒性肝炎、肝脓肿时肝大明显，并可出现黄疸。Generally only a modest enlargement.When the occurrence of hepatitis,liver abscess liver obviously enlarged,and can appear icteric.Hepatosplenomegaly临床表现临床表现 clinical manifestationclinical manifestation 多见于革兰氏阳性球菌和厌氧菌 more in gram positive bacteria and anaerobic bacteria 皮下脓肿 Subcutaneous abscesses 肺炎、肺脓肿 Pneumonia,lung abscess,化脓性关节炎、骨髓炎 Suppurative arthritis,osteomyelitis 感染性心膜炎、心包炎等 Infective endocarditis meningitis,pericarditis,etc临床表现临床表现 clinical manifestationclinical manifestationMetastasis 多见于革兰氏阴性菌败血症 more in gram-negative bacterial sepsis 表现：烦躁不安，脉搏细速，呼吸急促，血压下降，四肢厥冷，皮肤花斑，尿量减少 Performance:irritation,pulse fine speed,shortness of breath,blood pressure to drop,the limbs of appetite,skin tinea,reduced the volume of urineDIC：Disseminated Intravascular CoagulationMOF：Multiple Organs Failure infectious shock临床表现临床表现 clinical manifestationclinical manifestation各种败血症的特点-革兰阳性细菌败血症 原发病灶：皮肤粘膜、关节、肺部化脓性炎症 The skin mucous membrane inflammation,joints,lungs常见细菌：金葡菌S.aureus bacteria 皮疹形态多样化，瘀点最常见，脓胞疹有利诊断 Most common skin rash form diversification,petechiae,and pus cell rash better diagnosis关节症状明显：1/4病例可出现 A quarter of cases can appear 感染性休克少见 Septic shocks seldomly 易发生迁徙性病灶，如肺炎、脑膜炎、心内膜炎等临床表现临床表现 clinical manifestationclinical manifestation各种败血症的特点-革兰阴性杆菌败血症革兰阴性杆菌败血症 危险因素危险因素:慢性病基础，病前状况差 Chronic diseases,poor disease condition before 原发病灶：胆道、泌尿道、肠道、女性生殖道与呼吸道感染 Biliary tract,urinary tract,intestinal,female genital tract and respiratory tract infection常见细菌：大肠埃希菌、克雷伯菌、铜绿假单胞菌 E.coli,klebsiella bacteria,pseudomonas aeruginosa关节痛、皮疹及迁徙病灶少见 Joint pain,rash and migration are rare lesions早期出现感染性休克临床表现临床表现 clinical manifestationclinical manifestation各种败血症的特点各种败血症的特点-厌氧菌败血症厌氧菌败血症Characteristics of anaerobic bacteria Characteristics of anaerobic bacteria 患者多为新生儿及慢性病病人:newborns and chronic diseases patients致病菌主要为脆弱类杆菌，常与需氧菌掺杂一起，引起复数菌败血症Pathogenic bacteria mainly for the vulnerable class,often with aerobe doping,caused the plural bacterial sepsis原发炎症主要为腹腔内感染，其次为女性生殖道、褥疮及呼吸道感染Primary inflammation mainly in abdominal cavity infection,followed by the female genital tract,bedsore and respiratory infections表现：感染性休克、DIC、黄疸、血栓性静脉炎 Septic shock,DIC,jaundice,thrombophlebitis临床表现临床表现 clinical manifestationclinical manifestation各种败血症的特点各种败血症的特点-真菌败血症真菌败血症The characteristics of fungal septicemiaThe characteristics of fungal septicemia老年、体弱、久病者多见，发生在严重原发疾病的后期 Old,weak,sick men see more,occur in the late stage of severe primary diseases常见细菌：白色念珠菌、热带念珠菌 Candida albicans,candida tropical病情发展缓慢 The illness develops slowly临床表现无特异，全身中毒症状一般较轻，常被原发病的表现所掩盖No specific clinical manifestation,the whole body poisoning symptoms generally lighter,often concealed by the performance of the primary disease诱因：长期应用抗菌药物、激素、免疫抑制剂及留置导管等，绝大多数为院内感染临床表现临床表现 clinical manifestationclinical manifestation革兰阳性球菌与革兰阴性杆菌败血症的鉴别要点革兰阳性球菌与革兰阴性杆菌败血症的鉴别要点 identification points of the Gram-positive bacteria and gram negative bacillus sepsis 革兰阳性球菌败血症 革兰阴性杆菌败血症原发病灶皮肤、关节、呼吸道感染，烧伤尿路、胆道和肠道感染，诱因挤压疖、疮，创伤，切开未成熟的脓肿腹部或尿路手术及诊疗技术操作肝硬化等症状和并发症皮疹、关节症状、心内膜炎及迁徙性损害多见感染性休克、DIC多见鲎试验极大多数阴性 阳性细菌培养 金葡菌、表葡菌 肺炎链球菌、大肠埃希氏菌、肺炎克雷伯菌 假单胞菌临床表现临床表现 clinical manifestationclinical manifestation特殊类型败血症-老年人败血症Special type of sepsis-the elderly sepsisSpecial type of sepsis-the elderly sepsis 常发生在肺心病、胆石症、糖尿病、血液病、前列腺肥大、皮肤褥疮等疾病基础上 Often occur in the lung,cholelith disease,diabetes,blood disease,prostatic hypertrophy,on the basis of bedsore diseases such as skin 致病菌以革兰阴性杆菌及厌氧菌多见 The pathogenic bacteria was gram-negative bacteria and anaerobic bacteria 临床症状多不典型，热型不规则 Clinical symptoms are not typical,irregular heat type 易发生休克及多脏器功能损害，预后严重 Prone to shock and multiple organ function damage,serious prognosis临床表现临床表现 clinical manifestationclinical manifestation特殊类型败血症特殊类型败血症-院内感染败血症院内感染败血症Special type of sepsis-hospital infections septicemiaSpecial type of sepsis-hospital infections septicemia 近年来发病率明显增加，总数的30-50%In recent years the incidence rate increased significantly,30-50%of the total严重的基础疾病，部分为医源性感染Severe basic diseases,part of iatrogenic infection致病菌：大肠杆菌、肺炎杆菌、绿脓杆菌等Coli,klebsiella pneumoniae,pseudomonas aeruginosa and so on病情重，致病菌多有耐药性，治疗效果差 Illness is severe,many pathogenic bacteria drug resistance and treatment effect is poor临床表现临床表现 clinical manifestationclinical manifestation 诊断 diagnosis临床表现Clinical manifestations of常规实验室检查Routine laboratory tests病原学检查：血和骨髓培养阳性为确诊依据。Blood and bone marrow culture positive for diagnosis basis.鲎试验（limulus lysate test，LLT)原理：鲎试剂能与细菌内毒素及-葡聚糖反应形成凝胶检测内毒素血症的一种试验 诊断 diagnosis基因芯片技术Gene chip technology不明原因的寒战高热、无局限于单一系统的症状与体征时，应考虑败血症Chills high fever of unknown origin,not limited to a single system of signs and symptoms,should consider to sepsis新近有皮肤局部炎症，或挤压疖疮史，或有尿路、胆道、呼吸道等处感染，治疗后仍不能控制体温者应高度怀疑败血症的可能 Recently have local inflammation of the skin,or a history of extrusion boils,or have the place such as urinary tract,biliary tract,respiratory tract infection,treatment is still unable to control body temperature should be highly suspected sepsis诊断诊断 diagnosisdiagnosis 病病 史史 The history of disease 少数革兰阴性细菌败血症及机体免疫功能减退者，白细胞总数可正常或稍减低，但中性比仍高Few gram-negative bacterial sepsis decreased and the bodys immune function,the total number of white blood cells can be normal or slightly lower,but a neutral is still high诊断诊断 diagnosisdiagnosis 血血 常常 规规 Routine bloodRoutine blood 白细胞总数及中性比增高，核左移明显及中毒颗粒 The total number of white blood cells and neutral than up,nuclear particles left clear and poisoning细菌培养 bacteria culture 血培养及骨髓培养Blood culture and bone marrow 抗菌药物使用前及寒战、高热时抽血Before use antimicrobial drugs and blood chills and fever 多次，足量。同时做厌氧菌、真菌培养Many times,enough.Anaerobic bacteria and fungi culture at the same time done 已使用抗生素的患者：血块培养Blood clots develop脓液或分泌物的培养The cultivation of the pus or secretions诊断诊断 diagnosisdiagnosis脓液:pus脑脊液:Cerebrospinal fluid胸腹水:hydrothorax and ascite瘀点:petechiae 细菌涂片 smear 诊断诊断 diagnosisdiagnosis 鉴别诊断鉴别诊断 differential diagnosis变应性亚败血症:adult still s diseases型肺结核:type TB伤寒与副伤寒:Typhoid and paratyphoid病毒性感染:Viral infection 变应性亚败血症 adult still s diseases变态反应性疾病，青少年多见:Allergic disease,more in teenagers发热、皮疹、关节痛、白细胞增多和肝脾大五大特点:Fever,rash,joint pain,leukocytosis,and liver and spleen enlargement中毒症状不明显，且可有缓解期:Poisoning symptoms not obvious,and can have a remission皮疹呈多形性可反复多次出现:The rash polymorphism can be repeatedly appeared白细胞及中性分类增高，但嗜酸粒细胞多不减少:Higher leukocyte and neutral,acidophilus granulocyte maybe normal骨髓多次血培养阴性:Bone marrow blood culture negative 抗菌药物治疗无效，肾上腺皮质激素及消炎痛治疗有效:Antimicrobial drug treatm