复杂腹腔感染.ppt

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1、复杂腹腔感染复杂腹腔感染现在学习的是第1页，共31页IAI相关指南相关指南n nthe Therapeutic Agents Committee of the Surgical Infection Societythe Therapeutic Agents Committee of the Surgical Infection Society,The ,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Surgical Infection Society Guidelines on Anti

2、microbial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3,Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3,Number 3,2002Number 3,2002n nIDSA,the Surgical Infection Society,the American Society for IDSA,the Surgical Infection Society,the

3、American Society for Microbiology,and the Society of Infectious Disease Microbiology,and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal InfectionsC

4、omplicated Intra-abdominal Infections，CID2003,37:9971005CID2003,37:9971005n nDiagnosis and Management of ComplicatedDiagnosis and Management of Complicated Intra-abdominal Infection inIntra-abdominal Infection in Adults Adults and Children:Guidelines by the Surgical Infection and Children:Guidelines

5、 by the Surgical Infection Societyand the Infectious Societyand the Infectious Diseases Society of AmericaDiseases Society of America；Clinical Clinical Infectious Diseases 2010;Infectious Diseases 2010;50:13364 50:13364 n nInfectious Diseases Society of Taiwan;Taiwan Surgical Society ofInfectious Di

6、seases Society of Taiwan;Taiwan Surgical Society of GastroenterologyGastroenterology,etal,Guidelines for antimicrobial therapy of intra-,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults,J Microbiol Immunol Infect.2008;41:279-281 abdominal infections in adults,J Micro

7、biol Immunol Infect.2008;41:279-281 现在学习的是第2页，共31页腹腔感染腹腔感染(IAI)概述概述n n过去一个世纪过去一个世纪IAIIAI治疗取得巨大进步，死亡率显著下降治疗取得巨大进步，死亡率显著下降 90%in 1900 to 23%in 200290%in 1900 to 23%in 2002n nIAIIAI不同来源感染的死亡率不同来源感染的死亡率 appendix(0.25%)appendix(0.25%)stomach/duodenum(21%)stomach/duodenum(21%)pancreas(33%)pancreas(33%)sma

8、ll bowel(38%)small bowel(38%)large bowel(45%)large bowel(45%)biliary tract(50%)biliary tract(50%)JOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections,cleveland clinic journal of medicine volume 74 supplement 4 august 2007现在学习的是第3页，共31页IAI定义分类定义分类f.M

9、.pieracci,p.S.barie,ManageMent of Severe SepSiS of abdoMinal origin,Scandinavian Journal of Surgery 96:184196,2007现在学习的是第4页，共31页n n单纯腹腔感染单纯腹腔感染单纯腹腔感染单纯腹腔感染n n复杂腹腔感染复杂腹腔感染复杂腹腔感染复杂腹腔感染n nIntra-abdominal infections also can be categorized as Intra-abdominal infections also can be categorized as uncompl

10、icated versus complicated,although the distinction is uncomplicated versus complicated,although the distinction is not always clearnot always clearJOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SU

11、PPLEMENT 4 AUGUST 2007现在学习的是第5页，共31页Uncomplicated IAIn n单纯性腹腔感染仅累及1个器官,而且没有解剖结构的破坏n n通常病灶可完全切除，仅需预防性使用抗菌药物Blot S,De Waele JJ.Critical issues in the clinical management of complicated intra-abdominal infections.Drugs.2005;65(12):1611-20 现在学习的是第6页，共31页复杂腹腔感染复杂腹腔感染(cIAI)n n复杂腹腔感染(cIAI)通常定义为空腔脏器的内容穿入腹腔导

12、致局限性腹膜炎(包括脓肿)、弥漫性腹膜炎n n感染源经外科处理后，仍残留细菌，需使用抗感染药物n ncIAI 更多地与不良预后相关，其最大挑战是早期识别JOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007Blot S,De Waele JJ.Critical issues in the clinica

13、l management of complicated intra-abdominal infections.Drugs.2005;65(12):1611-20 现在学习的是第7页，共31页细菌性腹膜炎分类细菌性腹膜炎分类n n原发性腹膜炎n n继发性腹膜炎n n第三型腹膜炎JOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT

14、4 AUGUST 2007现在学习的是第8页，共31页Primary bacterial peritonitisn n指腹腔没有破口的自发性腹膜炎n n更多见于婴幼儿、肝硬化及免疫抑制的病人现在学习的是第9页，共31页Secondary bacterial peritonitisn n继发性腹膜炎是肠源细菌通过胃肠道穿孔泄漏入腹腔导致的感染炎症n nIt may be community-acquired or healthcareassociated.现在学习的是第10页，共31页Tertiary peritonitisn n原发、继发性腹膜炎经治疗后症状仍持续或原发、继发性腹膜炎经治疗后症

15、状仍持续或48小时后症状复苏小时后症状复苏n n常见于有严重合并症或免疫抑制的病人常见于有严重合并症或免疫抑制的病人n n特点特点:n n医院获得性感染医院获得性感染n n多为耐药菌多为耐药菌n n可能为肠道菌群易位可能为肠道菌群易位现在学习的是第11页，共31页社区获得性腹腔感染社区获得性腹腔感染n n感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔n n多为革兰氏阴性菌、厌氧菌，较少耐药n n多为轻中度腹腔感染n n如有脏器功能不全、免疫抑制的病人则归为重度腹腔感染现在学习的是第12页，共31页医院获得性腹腔感染医院获得性腹腔感染n n多为术后感染，如肠吻合口瘘并腹腔感染n n可合并休克、脏器

16、功能损害，多为重度腹腔感染n n可为革兰氏阴性杆菌、肠球菌或条件致病菌，多为耐药菌。如产ESBL的大肠杆菌，阴沟肠杆菌，铜绿假单胞菌，还有念珠菌现在学习的是第13页，共31页IDSAcIAI指南的定义指南的定义n n 该指南排除了肝脾实质的脓疡、泌尿生殖系统来源的感染、后腹膜感染(但除外胰腺感染)n n2003版指南不拟适用于小于18岁儿童及原发性腹膜炎，2010版作了扩展 IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious IDSA,th

17、e Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease Pharmacists,GuidelinesDisease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal for the Selection of Antiinfective Agents for Complicated Intra-abdo

18、minal InfectionsInfections，CID2003,37:997CID2003,37:997 10051005现在学习的是第14页，共31页腹腔感染常见致病菌腹腔感染常见致病菌n n胃、十二指肠、近端小肠与胆道：革兰阴性或阳性需氧菌或兼性需氧菌n n远端小肠：不同密度的革兰阴性需氧菌或兼性需氧菌、厌氧菌如脆弱拟杆菌n n结肠：兼性需氧（大肠杆菌）或纯厌氧菌，链球菌、肠球菌亦常见现在学习的是第15页，共31页Pathogens associated with Pathogens associated with peritonitisperitonitisJOHN A.WEIGE

19、LT,MD,Empiric treatment options in the management of complicated intra-abdominal infections,cleveland clinic journal of medicine volume 74 supplement 4 august 2007现在学习的是第16页，共31页cIAI综合治疗策略综合治疗策略n n液体复苏、感染源控制(ie,surgical debridement,drainage,and repair)、适当系统地抗感染是cIAI 治疗成功的主要部分n n 没有感染源的控制，抗生素治疗继发或第三型

20、腹膜炎不可能成功n n首要的是感染源的控制JOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007现在学习的是第17页，共31页cIAI如何选择抗生素如何选择抗生素n n单药还是联合治疗n n病人基础状况n n药物开始治疗时机及疗程n n给药剂量、频率n n抗菌谱、相互作用、耐药性n n之前抗生素的使用情

21、况n n避免药物毒副作用及诱导耐药现在学习的是第18页，共31页社区获得性腹腔感染社区获得性腹腔感染n n应选择对肠源性革兰氏阴性专性或兼性需氧菌有效或针应选择对肠源性革兰氏阴性专性或兼性需氧菌有效或针对对-内酰胺类敏感革兰氏阳性球菌内酰胺类敏感革兰氏阳性球菌n n源于远端小肠、结肠、梗阻性的近端胃肠穿孔应包含抗源于远端小肠、结肠、梗阻性的近端胃肠穿孔应包含抗厌氧菌活性厌氧菌活性n n避免应用治疗避免应用治疗ICUICU院内感染的药物，除非是高危病人院内感染的药物，除非是高危病人n n覆盖肠球菌的药物对社区获得性腹腔感染无益覆盖肠球菌的药物对社区获得性腹腔感染无益n n高危病人选择广谱抗生素高

22、危病人选择广谱抗生素JOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007现在学习的是第19页，共31页 IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infect

23、ious Disease IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal InfectionsPharmacists,Guidelines for the Selection of Antiinfective Agents for

24、 Complicated Intra-abdominal Infections，CID2003,CID2003,37:99737:997 10051005现在学习的是第20页，共31页cIAI危险分层危险分层JOHN A.WEIGELT,MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007现在学习的是第21页，共31页High-s

25、everity IAIn nAdvanced age;poor nutrition;low serum albumin;pre-existing Advanced age;poor nutrition;low serum albumin;pre-existing disorders,such as signifcant cardiovascular disease;higher Acute disorders,such as signifcant cardiovascular disease;higher Acute Physiology And Chronic Health Evaluati

26、on II scores(15);Physiology And Chronic Health Evaluation II scores(15);inadequate source control during the initial operative procedure;inadequate source control during the initial operative procedure;resistant nosocomial microorganisms;immunosuppression resistant nosocomial microorganisms;immunosu

27、ppression resulting from medical therapy for transplantation,cancer,or resulting from medical therapy for transplantation,cancer,or infammatory disease;or other acute/chronic diseases of diffcult-infammatory disease;or other acute/chronic diseases of diffcult-to-defne immunosuppressionto-defne immun

28、osuppressionIDS of Taiwan;Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults,J Microbiol Immunol Infect.2008;41:279-281现在学习的是第22页，共31页氨基糖苷类氨基糖苷类n n氨基糖苷类不推荐作为社区获得性腹腔感染的常规治疗(A-1)n n氨基糖苷类根据局域菌种分离药敏结果,可以是院内获得性腹腔感染的首选.腹腔感染氨基糖苷类的治疗

29、应该个体化(A-1)现在学习的是第23页，共31页抗厌氧菌药物抗厌氧菌药物n n药物敏感试验提示Bacteroides fragilis 对下列药物普遍耐药n nclindamycin,cefotetan,cefoxitin,and quinolones 上述药物不能单药治疗B.fragilis现在学习的是第24页，共31页第三型及医院获得性腹腔感染第三型及医院获得性腹腔感染n n耐药菌感染更常见n n病原体类似于其他院内感染n n治疗基于局部常见院感菌种及耐药情况n n院内感染考虑覆盖肠球菌是合适的n n抗真菌治疗基于先前抗生素使用情况及基础危险因素JOHN A.WEIGELT,MD,Emp

30、iric treatment options in the management of complicated intra-abdominal infections,cleveland clinic journal of medicine volume 74 supplement 4 august 2007MAZUSKI JE,Antimicrobial treatment for intra-abdominal infections.Expert Opin Pharmacother.2007 Dec;8(17):2933-45 现在学习的是第25页，共31页抗肠球菌治疗指征抗肠球菌治疗指征n

31、 n常规抗肠球菌治疗对社区获得性腹腔感染没有必要(A-1)n n医院获得性腹腔感染需考虑给予覆盖肠球菌的药物(B-3).IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease Pharmacists,Guid

32、elines for the Selection of Antiinfective Agents for Complicated Intra-abdominal InfectionsPharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003,37:997CID2003,37:997 10051005现在学习的是第26页，共31页抗真菌治疗指征抗真菌治疗指征n n胃肠道穿孔的病人白念或其他真菌的分离率约胃肠道穿孔的病人白念或其

33、他真菌的分离率约 20%20%n n即使分离到真菌即使分离到真菌,抗真菌治疗也非必要抗真菌治疗也非必要,除非该患者近期因肿瘤、器除非该患者近期因肿瘤、器官移植、炎症性疾病接受过免疫抑制治疗官移植、炎症性疾病接受过免疫抑制治疗,或者是术后或复发的腹或者是术后或复发的腹腔感染腔感染 (B-2)(B-2)n nAnti-infective therapy for Candida should be withheld until the infecting Anti-infective therapy for Candida should be withheld until the infecting

34、 species is identified(C-3).species is identified(C-3).1010版有较大修正版有较大修正n n分离到白念则选择氟康唑分离到白念则选择氟康唑 (B-2)(B-2)n n氟康唑耐药的念珠菌可选择氟康唑耐药的念珠菌可选择 amphotericin B,caspofungin,or amphotericin B,caspofungin,or voriconazole(B-3).voriconazole(B-3).肾功能不全选择后二者肾功能不全选择后二者 (A-1).(A-1).IDSA,the Surgical Infection Society,

35、the American Society for Microbiology,and the Society of Infectious IDSA,the Surgical Infection Society,the American Society for Microbiology,and the Society of Infectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-Disease Pharmacists,Guidelines fo

36、r the Selection of Antiinfective Agents for Complicated Intra-abdominal Infectionsabdominal Infections，CID2003,37:997CID2003,37:997 10051005现在学习的是第27页，共31页何时开始抗感染治疗何时开始抗感染治疗n n应当在确诊感染和获得培养结果前怀疑IAI的诊断时即开始抗生素治疗n n抗感染的目标是清除感染病原体、减少复发、缩短感染症状体征消除时间n n抗生素应该在液体复苏开始后给药，恢复充分的血流灌注使良好的药物分布成为可能。尤其是氨基糖苷类，其肾毒性会因肾

37、灌注不足而加重现在学习的是第28页，共31页哪些病人需要抗感染治疗哪些病人需要抗感染治疗n n创伤或医源性肠损伤致腹腔污染创伤或医源性肠损伤致腹腔污染12h12h内修补的病人内修补的病人 (Level 1)(Level 1)以及胃肠穿孔以及胃肠穿孔24 h24 h内修补的病人内修补的病人(Level 3)(Level 3)不不认为已经合并认为已经合并IAIIAI，仅需给予，仅需给予24 h24 h或更短的预防用药或更短的预防用药n n炎症病灶能够完全移除的病人如没有穿孔的急性或坏疽性炎症病灶能够完全移除的病人如没有穿孔的急性或坏疽性阑尾炎或胆囊炎，或者没有发生穿孔或腹膜炎的肠梗阻或阑尾炎或胆囊

38、炎，或者没有发生穿孔或腹膜炎的肠梗阻或肠坏死，也仅需给予肠坏死，也仅需给予24 h24 h或更短的预防用药或更短的预防用药(Level 2)(Level 2)n n已经合并广泛已经合并广泛IAIIAI的上述病人应该给予超过的上述病人应该给予超过24 h24 h的抗感的抗感染治疗染治疗 (Level 3).(Level 3).n n the Therapeutic Agents Committee of the Surgical Infection Society the Therapeutic Agents Committee of the Surgical Infection Society

39、,The Surgical Infection Society Guidelines on,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3,Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3,Num

40、ber 3,2002Number 3,2002现在学习的是第29页，共31页n n81.The administration of prophylactic antibiotics to patients with severe necrotizing pancreatitis prior to the diagnosis of infection is not recommended(A-I).Diagnosis and Management of ComplicatedDiagnosis and Management of Complicated Intra-abdominal Infec

41、tion inIntra-abdominal Infection in Adults and Adults and Children:Guidelines by the Surgical Infection Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Societyand the Infectious Diseases Society of AmericaSociety of America；Clinical Clinical Infectious Diseases 2010;

42、50:13364Infectious Diseases 2010;50:13364现在学习的是第30页，共31页抗感染疗程抗感染疗程n n大多数大多数IAIIAI的抗感染治疗不应该超过的抗感染治疗不应该超过5(Level 2)to 7 days 5(Level 2)to 7 days(Level 3).(Level 3).抗感染疗程可基于术中介入时发现的情况抗感染疗程可基于术中介入时发现的情况 (Level 3).(Level 3).当患者感染的临床症候如发热、白细胞升高当患者感染的临床症候如发热、白细胞升高等消失时可终止治疗等消失时可终止治疗 (Level 2).(Level 2).n n预

43、定的抗生素疗程结束时症状持续，应该积极进行诊断评预定的抗生素疗程结束时症状持续，应该积极进行诊断评估，而非简单延长抗感染时间估，而非简单延长抗感染时间 (Level 3).(Level 3).n n感染源不能充分控制时，延长抗感染时间或许管用感染源不能充分控制时，延长抗感染时间或许管用 (Level 3).(Level 3).n n the Therapeutic Agents Committee of the Surgical Infection Society the Therapeutic Agents Committee of the Surgical Infection Societ

44、y,The Surgical Infection Society Guidelines on,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3,Antimicrobial Therapy for Intra-Abdominal Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3,Number 3,2002Number 3,2002现在学习的是第31页，共31页