医院获得性肺炎诊治进展.ppt

文档介绍：医院获得性肺炎诊治进展
复旦大学附属中山医院
何礼贤
临床策略和细菌学策略结合
经验性抗菌治疗的指南推荐和主要耐药菌的治疗选择(药物、剂量、疗程)
降阶梯策略的最新文献评述
预防和控制要点
提纲
Gram's stain and culture
Unreliable due to contamination with bacteria colonizing the oropharynx
The presence of many polymorphonuclear leukocytes (and few epithelial cells) and bacteria, which are morphologically consistent with bacteria found on culture, improve the predictive power
In addition, the lack of isolation of a pathogen (eg, MRSA or Pseudomonas) from a well-collected and adequate expectorated sputum sample can be used to narrow the antimicrobial regimen
Blood cultures are extremely helpful when positive, but the yield is low
病原学诊断困难
Gram's stain and culture
 Negative direct staining :
- previous antibiotic therapy
- steroids
- presence of Pseudomonas aeruginosa 1
Microbiological findings are useful mainly based on two rules:
1. the presence of intracellular bacteria
2. a positive Gram stain (or other direct tests)
may be of great help in selecting the initial antibiotic regimen but not in making the diagnosis of pneumonia 2
 The diagnostic technique used, bronchoscopic or tracheal aspirate with quantitative cultures, does not influence either the rate of de-escalation or of mortality 3
1. Eur J Microbiol Infect Dis 1994;13:549–558
2. Chest 2001;120:955–70
3. Crit Care Med 2004;32:2183–90
诊断策略和方法
临床策略(经验性治疗)
细菌学策略(目标治疗)
呼吸机相关性肺炎
治疗得当
治疗不当
Luna C, et al. Chest 1997; 111: 676-685
Álvarez-Lerma F, et al. Intensive Care Med 1996; 22: 387-394
Rello J, et al AmJ Resp Crit Care Med 1997; 156; 196-200
Kollef MH, et al. Ann Inter Med 1995; 122: 743-748
Clec’h C, et al. Intensive Xare Med 2004; 30: 1327-1333
Garnacho-Montero J, et al. Intensive Care Med 2005; 31: 649--55
存活率%
抗生素治疗不当对病死率的影响
脓毒症低血压发生后第1h(H1)内接受有效抗生素治疗者: 存活率 %
脓毒症低血压发生后接受有效抗生素每延误1h:%
早期有效的抗生素治疗: 6h黄金时间
Crit Care Med 2006; 34:1589–1596
Mortality risk
time
早期治疗需要临床策略
强调对怀疑患有HAP的患者尽早开始经验治疗。因为对HAP患者延迟恰当抗菌药物治疗会导致死亡率升高。
放射学检查有新的或进展性的浸润,加上三个临床特征(发热>38℃,白细胞