假体周围感染.ppt

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1、PJI术后，如何使用抗生素？浙江中医药大学附属第一医院童培建2017.09.03什么是什么是PJI关节假体周围感染（Periprosthetic joint infection，PJI），发生于关节置换术后，以膝关节（2%）、髋关节（0.45-0.57%）多见。Two-stage Revision for Periprosthetic Hip and Knee Joint Infections.The open orthropaedics journal.2017Biofilm and the Role of Antibiotics in the Treatment of Periprosth

2、etic Hip and Knee Joint Infections.The Open Orthopaedics Journal,2016存在于假体相通的窦道受累人工关节部位2处组织或关节液样本中分离出同一病原体以下4条满足3条或以上ESR或CRP水平升高滑膜或关节液白细胞升高滑膜或关节液中性粒细胞百分比升高组织或关节液单次细菌培养阳性PJI诊断标准（诊断标准（AAOS标准）标准）*Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty:Current Concepts.JAAOS-D-15-00017,2016 PJI

3、临床表现临床表现红肿热红肿热痛，切口不愈合痛，切口不愈合急性急性慢性慢性PJI夜间夜间痛，休息痛痛，休息痛窦道窦道形成形成脓脓液流出液流出Two-stage Revision for Periprosthetic Hip and Knee Joint Infections.The open orthropaedics journal.2017Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint Infections.The Open Orthopaedics Journ

4、al,2016PJI常见病原菌常见病原菌*初次人工全膝关节置换术后假体周围感染的病原菌分布及药敏分析.Chinese Journal of Reparative and Reconstructive Surgery.2014、类感染金黄色葡萄球菌类感染凝固酶隐性葡萄球菌屎肠球菌革兰阳性杆菌大肠埃希菌阴沟肠杆菌真菌分支杆菌链球菌沙门菌鲍曼不动杆菌铜绿假单胞菌金黄色葡萄球菌凝固酶阴性葡萄球菌病原菌主要病原菌主要来源于血液来源于血液及皮肤及皮肤生物膜生物膜-PJI药物治疗的关键药物治疗的关键病原体基质多糖聚合物蛋白DNABiofilm and the Role of Antibiotics in t

5、he Treatment of Periprosthetic Hip and Knee Joint Infections.The Open Orthopaedics Journal,2016The role of microbial biofilms in prosthetic joint infections A review.Acta Orthopaedica 2015普遍存在难以清除抗生素抗生素抗体抗体生物生物膜内膜内容物容物聚集聚集生物膜生物膜DNADNA片段片段骨骨 科科 内内 植植 物物细菌细菌吞噬细胞吞噬细胞Correlationbetweeninvivo&invitroeffi

6、cacyofantimicrobialagentagainstforeignbodyinfection,Rev Infect Dis.江荣林院长授课摘录江荣林院长授课摘录Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint Infections.The Open Orthopaedics Journal,2016The role of microbial biofilms in prosthetic joint infections A review.Acta Orth

7、opaedica 2015惰性惰性细胞覆盖胞覆盖多重多重细菌感染菌感染基因异常表达基因异常表达患者患者应激反激反应生物膜致感染生物膜致感染难愈愈PJI分期分期早期感染：24个月*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.根据术后PJI发生的时间，可分为早期感染、迟发感染、晚期感染。行清创术是否行清创术视具

8、体情况而定*Executive summary of management of prosthetic joint infections.Clinical practice guidelines by the Spanish Society of InfectiousDiseases and Clinical Microbiology(SEIMC).Enferm Infecc Microbiol Clin.2017.PJI2017年年SIMIC治疗指南治疗指南适应症感染症状、体征持续时间3周以内的术后早期早期深部感染或急性急性血源性感染无假体松动假体松动或感染感染的影像学改变软组织条件好，无大

9、量疤痕无大量疤痕或窦道窦道形成经血或组织培养，病原体明确且对药物敏感敏感开放清创推荐，关节镜清创慎重！术后抗生素治疗方案静脉用药4-6周后续口服给药7-14天治疗期间监测白细胞及CRPThemanagementofaninfectedtotalkneearthroplasty.Bone Joint J,2015An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Re

10、v Anti Infect Ther.2015.清创术+抗生素+假体保留（DAIR）如条件允许，早期感染推荐行清创术+抗生素+假体保留（debridement,antibiotics,implant retention）DAIR。第一阶段 假体取出关节内假体完全取出彻底清创抗生素骨水泥垫片置入长期抗生素治疗第二阶段 假体再植入（或关节融合/切除成形）抗生素骨水泥垫片取出彻底清创假体再植入抗生素治疗Two-stageRevisionforPeriprostheticHipandKneeJointInfections.Open Orthop J.2016Two stage revision hip

11、 arthroplasty in periprosthetic joint infection.Comparison study:with or without the use of a spacer.Int Orthop.2017假体取出术术后抗生素治疗方案术后抗生素治疗方案静脉用药静脉用药4-6周周间歇间歇期停抗生素期停抗生素2-8周周治疗期间监测治疗期间监测ESR及及CRP血及组织培养病原体是否阳性血及组织培养病原体是否阳性静脉用药静脉用药5-7天天适应症病原体明确长期使用的口服抗生素无毒性作用患者可行长期随访术后抗生素治疗方案清创术在抗生素使用之前，术后静脉使用抗生素至少7天病原体诊断

12、明确，选择敏感抗生素除特殊病例，不建议联合使用抗生素或加用利福平因毒性作用，不宜使用利奈唑胺推荐使用内酰胺酶抑制剂或低剂量复方新诺明不建议长期使用抗生素假体保留+抗生素压制（SAT）适当清创，保留假体，不试图清除感染无法缓解因假体松动无法缓解因假体松动或不稳引起的疼痛或不稳引起的疼痛*Executive summary of management of prosthetic joint infections.Clinical practice guidelines by the Spanish Society of InfectiousDiseases and Clinical Microbi

13、ology(SEIMC).Enferm Infecc Microbiol Clin.2017.治疗治疗PJI抗生素选择抗生素选择革兰阳性球菌感染革兰阴性杆菌感染其它感染多重感染培养阴性的感染革兰阳性球菌感染革兰阳性球菌感染常见病原菌葡萄球菌链球菌*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.用药推荐氟喹诺酮

14、类左氧氟沙星（750mg/24h）环丙沙星（500-750mg/12h）利福平+利奈唑胺（10mg/kg/24h）复方新诺明（20mg/kg/day）达托霉素+利福平（10mg/kg/day）万古霉素（15 mg/kg/12h）革兰阴性杆菌感染革兰阴性杆菌感染常见病原菌铜绿假单胞菌*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect

15、Ther.2015.用药推荐内酰胺酶抑制剂+环丙沙星/氨基糖苷类清创术+氟喹诺酮类左氧氟沙星（750mg/24h）环丙沙星（500-750mg/12h）碳青霉烯类其它感染其它感染真菌念珠菌：假体取出+清创+伏立康唑/两性霉素BFungal Periprosthetic Joint Infection after Total Knee Arthroplasty.J Med Assoc Thai 2014.ManagementofResistant,AtypicalandCulture-negativePeriprostheticJointInfectionsafterHipandKneeArth

16、roplasty.Open Orthop J.2016.分枝杆菌非结核分支杆菌（抗痨治疗9个月）异烟肼+利福平+吡嗪酰胺或/和乙胺丁醇三/四联治疗，2个月异烟肼+利福平二联治疗，4-7个月偶然分支杆菌/龟分支杆菌（根据培养及药敏结果选择敏感抗生素）静脉用药6周口服用药3-6个月多重感染多重感染高危因素年龄65岁伴有严重基础疾病术后引流手术切口开裂常见病原体金黄色葡萄球菌肠球菌需氧G-杆菌（铜绿）广谱抗生素联合应用内酰胺酶抑制剂氨基糖苷类利奈唑胺或达托霉素Themanagementofaninfectedtotalkneearthroplasty.Bone Joint J,2015An upda

17、te on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.培养阴性的感染培养阴性的感染培养阴性的原因1.取样备前使用抗生素2.培养基选取不当3.培养时间过短（2周）抗生素使用原则覆盖范围足够广革兰阳性菌革兰阴性菌耐药菌（MASA）厌氧菌使用时间足够长至少2周监测WBC及CRP联合用药Themanagementofaninfectedt

18、otalkneearthroplasty.Bone Joint J,2015An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.病原体病原体静脉用静脉用药备选方案方案后后续口服用口服用药新青新青敏感葡萄球菌敏感葡萄球菌新青新青或氯唑西林或氯唑西林或头孢唑林或头孢唑林万古霉素或替考拉宁万古霉素或替考拉宁或达托霉素或或

19、达托霉素或利奈利奈唑胺胺左氧氟沙星左氧氟沙星+利福平利福平克林霉素克林霉素/复方新复方新诺明明夫西地酸或夫西地酸或利奈利奈唑胺胺耐新青耐新青葡萄球菌葡萄球菌万古霉素万古霉素达托霉素或达托霉素或替考拉宁或替考拉宁或利奈利奈唑胺胺克林霉素克林霉素/复方新复方新诺明明夫西地酸或夫西地酸或利奈利奈唑胺胺青霉素敏感青霉素敏感肠球菌球菌青霉素青霉素G或氨或氨苄西林西林万古霉素万古霉素/替考拉宁替考拉宁或或利奈利奈唑胺胺，或，或氨氨苄西林西林+头孢曲松曲松利奈利奈唑胺胺氨氨苄西林西林耐青霉素耐青霉素肠球菌球菌万古霉素万古霉素替考拉宁或替考拉宁或利奈利奈唑胺胺利奈利奈唑胺胺-溶血性溶血性链球菌球菌青霉素青霉素

20、G或或头孢曲松曲松万古霉素或替考拉宁或万古霉素或替考拉宁或利利奈奈唑胺胺阿莫西林或阿莫西林或利奈利奈唑胺胺一般一般肠内杆菌内杆菌环丙沙星丙沙星厄他培南厄他培南环丙沙星丙沙星或或头孢类/复方新复方新诺明明某些特殊某些特殊肠内杆菌内杆菌环丙沙星丙沙星厄他培南或厄他培南或头孢吡吡肟环丙沙星丙沙星铜绿假假单胞菌胞菌头孢他他啶/环丙沙星丙沙星美美罗培南培南/环丙沙星丙沙星环丙沙星丙沙星厌氧菌氧菌阿莫西林克拉阿莫西林克拉维酸或酸或哌拉拉西林他西林他唑巴坦或碳青霉巴坦或碳青霉烯克林霉素克林霉素/甲硝甲硝唑克林霉素克林霉素/甲硝甲硝唑清创术+抗生素+假体保留药物推荐*An update on surgical

21、 and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.G+所致的PJI，后续口服用药推荐利奈唑胺。抗生素抗生素药物含量物含量最大血最大血药浓度度（mg/ml）半衰期（小半衰期（小时）每日每日剂量量青霉素G3g130-2350.5-0.6720-24万单位，q4h或持续阿莫西林2/0.2g110/141.0-1.52g/8h氟氯西林1g130-2101.0-1

22、.52g/4h头孢唑林1g1881.5-2.02g/8h头孢曲松1g2008.02g/24h头孢他啶1g902.0-2.52g/8h头孢吡肟1g1631.02g/8h利奈唑胺0.6g21.24.260.6g/12h美罗培南0.5g521.02g/8h万古霉素-4.0-6.015 mg/kg/12h替考拉宁400mg7050-7010-12 mg/kg/day达托霉素350mg1408-96-10 mg/kg/day环丙沙星400mg4.64400 mg/12h常用抗生素剂量及用法*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.总结总结1.PJI明确病原体，根据培养及药敏结果选择合适的抗生素2.手术+抗生素联合治疗，单纯抗生素治疗效果不佳3.术后抗生素覆盖范围足够广，时间足够长，必要时多种抗生素或利福平联合用药（SAT除外）。谢谢谢谢