【優(yōu)秀】復(fù)雜腹腔感染課件

1、【優(yōu)秀】復(fù)雜腹腔感染【優(yōu)秀】復(fù)雜腹腔感染IAI定義分類(lèi)f. M. pieracci, p. S. barie,ManageMent of Severe SepSiS of abdoMinal origin, Scandinavian Journal of Surgery 96: 184196, 2007IAI定義分類(lèi)f. M. pieracci, p. S. b單純腹腔感染復(fù)雜腹腔感染Intra-abdominal infections also can be categorized as uncomplicated versus complicated, although the disti

2、nction is not always clearJOHN 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單純腹腔感染JOHN A. WEIGELT, MD,EmpiUncomplicated IAI單純性腹腔感染僅累及1個(gè)器官,而且沒(méi)有解剖結(jié)構(gòu)的破壞通常病灶可完全切除，僅需預(yù)防性使用抗菌藥物Blo

3、t S, De Waele JJ. Critical issues in the clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20 Uncomplicated IAI單純性腹腔感染僅累及1個(gè)器復(fù)雜腹腔感染(cIAI)復(fù)雜腹腔感染(cIAI) 通常定義為空腔臟器的內(nèi)容穿入腹腔導(dǎo)致局限性腹膜炎(包括膿腫)、彌漫性腹膜炎感染源經(jīng)外科處理后，仍殘留細(xì)菌，需使用抗感染藥物cIAI 更多地與不良預(yù)后相關(guān)，其最大挑戰(zhàn)是早期識(shí)別JOHN A. WEIGELT, MD,Empiric

4、 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 clinical management of complicated intra-abdominal infections. Drugs. 2005;65(12):1611-20 復(fù)雜腹腔感染(cIAI)復(fù)雜腹腔

5、感染(cIAI) 通常定義為細(xì)菌性腹膜炎分類(lèi)原發(fā)性腹膜炎繼發(fā)性腹膜炎第三型腹膜炎JOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007細(xì)菌性腹膜炎分類(lèi)原發(fā)性腹膜炎JOHN A. WEIGELT,Primary bacterial peritonitis指腹腔沒(méi)有破口的自發(fā)性腹膜炎更多見(jiàn)于嬰幼兒、肝硬

6、化及免疫抑制的病人Primary bacterial peritonitis指結(jié)腸：兼性需氧（大腸桿菌）或純厭氧菌，鏈球菌、腸球菌亦常見(jiàn)哪些病人需要抗感染治療2005;65(12):1611-20醫(yī)院獲得性腹腔感染需考慮給予覆蓋腸球菌的藥物 (B-3).炎癥病灶能夠完全移除的病人如沒(méi)有穿孔的急性或壞疽性闌尾炎或膽囊炎，或者沒(méi)有發(fā)生穿孔或腹膜炎的腸梗阻或腸壞死，也僅需給予24 h或更短的預(yù)防用藥(Level 2)腹腔感染（IAI）是臨床重要問(wèn)題WEIGELT, MD,Empiric treatment options in the management of complicated intra-

7、abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007原發(fā)、繼發(fā)性腹膜炎經(jīng)治療后癥狀仍持續(xù)或48小時(shí)后癥狀復(fù)蘇2007 Dec;8(17):2933-45WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections ,cleveland clinic journal of medicine volume 74 supplement 4

8、 august 2007液體復(fù)蘇、感染源控制 (ie, surgical debridement, drainage, and repair)、 適當(dāng)系統(tǒng)地抗感染是cIAI 治療成功的主要部分大多數(shù)IAI的抗感染治療不應(yīng)該超過(guò)5 (Level 2) to 7 days (Level 3).應(yīng)當(dāng)在確診感染和獲得培養(yǎng)結(jié)果前懷疑IAI的診斷時(shí)即開(kāi)始抗生素治療該指南排除了肝脾實(shí)質(zhì)的膿瘍、泌尿生殖系統(tǒng)來(lái)源的感染、后腹膜感染(但除外胰腺感染)復(fù)雜腹腔感染(cIAI) 通常定義為空腔臟器的內(nèi)容穿入腹腔導(dǎo)致局限性腹膜炎(包括膿腫)、彌漫性腹膜炎可合并休克、臟器功能損害，多為重度腹腔感染Diagnosis an

9、d Management of Complicated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of America；2003版指南不擬適用于小于18歲兒童及原發(fā)性腹膜炎，2010版作了擴(kuò)展Secondary bacterial peritonitis繼發(fā)性腹膜炎是腸源細(xì)菌通過(guò)胃腸道穿孔泄漏入腹腔導(dǎo)致的感染炎癥It may be community-acquired or hea

10、lthcareassociated.結(jié)腸：兼性需氧（大腸桿菌）或純厭氧菌，鏈球菌、腸球菌亦常見(jiàn)STertiary peritonitis原發(fā)、繼發(fā)性腹膜炎經(jīng)治療后癥狀仍持續(xù)或48小時(shí)后癥狀復(fù)蘇常見(jiàn)于有嚴(yán)重合并癥或免疫抑制的病人特點(diǎn):醫(yī)院獲得性感染多為耐藥菌可能為腸道菌群易位Tertiary peritonitis原發(fā)、繼發(fā)性腹膜炎經(jīng)社區(qū)獲得性腹腔感染感染發(fā)生于社區(qū)，如化膿性闌尾炎，結(jié)腸憩室穿孔多為革蘭氏陰性菌、厭氧菌，較少耐藥多為輕中度腹腔感染如有臟器功能不全、免疫抑制的病人則歸為重度腹腔感染社區(qū)獲得性腹腔感染感染發(fā)生于社區(qū)，如化膿性闌尾炎，結(jié)腸憩室穿醫(yī)院獲得性腹腔感染多為術(shù)后感染，如腸吻合口

11、瘺并腹腔感染可合并休克、臟器功能損害，多為重度腹腔感染可為革蘭氏陰性桿菌、腸球菌或條件致病菌，多為耐藥菌。如產(chǎn)ESBL的大腸桿菌，陰溝腸桿菌，銅綠假單胞菌，還有念珠菌醫(yī)院獲得性腹腔感染多為術(shù)后感染，如腸吻合口瘺并腹腔感染IDSAcIAI指南的定義 該指南排除了肝脾實(shí)質(zhì)的膿瘍、泌尿生殖系統(tǒng)來(lái)源的感染、后腹膜感染(但除外胰腺感染)2003版指南不擬適用于小于18歲兒童及原發(fā)性腹膜炎，2010版作了擴(kuò)展 IDSA, the Surgical Infection Society, the American Society for Microbiology, and the Society of Inf

12、ectious Disease Pharmacists,Guidelines for the Selection of Antiinfective Agents for Complicated Intra-abdominal Infections，CID2003, 37:9971005IDSAcIAI指南的定義 該指南排除了肝脾實(shí)質(zhì)的膿瘍、泌尿腹腔感染常見(jiàn)致病菌胃、十二指腸、近端小腸與膽道：革蘭陰性或陽(yáng)性需氧菌或兼性需氧菌遠(yuǎn)端小腸：不同密度的革蘭陰性需氧菌或兼性需氧菌、厭氧菌如脆弱擬桿菌結(jié)腸：兼性需氧（大腸桿菌）或純厭氧菌，鏈球菌、腸球菌亦常見(jiàn)腹腔感染常見(jiàn)致病菌胃、十二指腸、近端小腸與膽道：革

13、蘭陰性或陽(yáng)Pathogens associated with peritonitisJOHN A. WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections, cleveland clinic journal of medicine volume 74 supplement 4 august 2007Pathogens associated with peri原發(fā)、繼發(fā)性腹膜炎經(jīng)治療后癥狀仍持續(xù)或48小時(shí)后癥狀復(fù)蘇Critical issues in the

14、 clinical management of complicated intra-abdominal infections.高危病人選擇廣譜抗生素pieracci, p.大多數(shù)IAI的抗感染治療不應(yīng)該超過(guò)5 (Level 2) to 7 days (Level 3).WEIGELT, MD,Empiric treatment options in the management of complicated intra-abdominal infections, cleveland clinic journal of medicine volume 74 supplement 4 august

15、 2007抗真菌治療基于先前抗生素使用情況及基礎(chǔ)危險(xiǎn)因素2003版指南不擬適用于小于18歲兒童及原發(fā)性腹膜炎，2010版作了擴(kuò)展pieracci, p.應(yīng)當(dāng)在確診感染和獲得培養(yǎng)結(jié)果前懷疑IAI的診斷時(shí)即開(kāi)始抗生素治療原發(fā)、繼發(fā)性腹膜炎經(jīng)治療后癥狀仍持續(xù)或48小時(shí)后癥狀復(fù)蘇barie,ManageMent of Severe SepSiS of abdoMinal origin, Scandinavian Journal of Surgery 96: 184196, 2007液體復(fù)蘇、感染源控制 (ie, surgical debridement, drainage, and repair)、

16、適當(dāng)系統(tǒng)地抗感染是cIAI 治療成功的主要部分Pathogens associated with peritonitis應(yīng)當(dāng)在確診感染和獲得培養(yǎng)結(jié)果前懷疑IAI的診斷時(shí)即開(kāi)始抗生素治療可為革蘭氏陰性桿菌、腸球菌或條件致病菌，多為耐藥菌。cIAI綜合治療策略液體復(fù)蘇、感染源控制 (ie, surgical debridement, drainage, and repair)、 適當(dāng)系統(tǒng)地抗感染是cIAI 治療成功的主要部分 沒(méi)有感染源的控制，抗生素治療繼發(fā)或第三型腹膜炎不可能成功首要的是感染源的控制JOHN A. WEIGELT, MD,Empiric treatment options in

17、the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007原發(fā)、繼發(fā)性腹膜炎經(jīng)治療后癥狀仍持續(xù)或48小時(shí)后癥狀復(fù)蘇cIcIAI如何選擇抗生素單藥還是聯(lián)合治療病人基礎(chǔ)狀況藥物開(kāi)始治療時(shí)機(jī)及療程給藥劑量、頻率抗菌譜、相互作用、耐藥性之前抗生素的使用情況避免藥物毒副作用及誘導(dǎo)耐藥cIAI如何選擇抗生素單藥還是聯(lián)合治療社區(qū)獲得性腹腔感染應(yīng)選擇對(duì)腸源性革蘭氏陰性專(zhuān)性或兼性需氧菌有效或針對(duì)-內(nèi)酰胺類(lèi)敏感革蘭氏陽(yáng)

18、性球菌源于遠(yuǎn)端小腸、結(jié)腸、梗阻性的近端胃腸穿孔應(yīng)包含抗厭氧菌活性避免應(yīng)用治療ICU院內(nèi)感染的藥物，除非是高危病人覆蓋腸球菌的藥物對(duì)社區(qū)獲得性腹腔感染無(wú)益高危病人選擇廣譜抗生素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社區(qū)獲得性腹腔感染應(yīng)選擇對(duì)腸源性革蘭氏陰性專(zhuān)性或兼性需氧菌有 IDSA,

19、 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 Infections，CID2003, 37:9971005 IDSA, the Surgical InfeccIAI危險(xiǎn)分層JOHN A. WEIGELT, MD,Empiric tr

20、eatment options in the management of complicated intra-abdominal infections CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 74 SUPPLEMENT 4 AUGUST 2007cIAI危險(xiǎn)分層JOHN A. WEIGELT, MD,EmHigh-severity IAIAdvanced age; poor nutrition; low serum albumin; pre-existing disorders, such as signifcant cardiovascular

21、 disease; higher Acute Physiology And Chronic Health Evaluation II scores (15); inadequate source control during the initial operative procedure; resistant nosocomial microorganisms; immunosuppression resulting from medical therapy for transplantation, cancer, or infammatory disease; or other acute/

22、chronic diseases of diffcult-to-defne immunosuppressionIDS of Taiwan; Taiwan Surgical Society of Gastroenterology,etal,Guidelines for antimicrobial therapy of intra-abdominal infections in adults, J Microbiol Immunol Infect. 2008;41:279-281High-severity IAIAdvanced age;氨基糖苷類(lèi)氨基糖苷類(lèi)不推薦作為社區(qū)獲得性腹腔感染的常規(guī)治療

23、(A-1)氨基糖苷類(lèi)根據(jù)局域菌種分離藥敏結(jié)果,可以是院內(nèi)獲得性腹腔感染的首選.腹腔感染氨基糖苷類(lèi)的治療應(yīng)該個(gè)體化 (A-1)氨基糖苷類(lèi)氨基糖苷類(lèi)不推薦作為社區(qū)獲得性腹腔感染的常規(guī)治療 抗厭氧菌藥物藥物敏感試驗(yàn)提示Bacteroides fragilis 對(duì)下列藥物普遍耐藥clindamycin,cefotetan, cefoxitin, and quinolones 上述藥物不能單藥治療B. fragilis抗厭氧菌藥物藥物敏感試驗(yàn)提示Bacteroides frag第三型及醫(yī)院獲得性腹腔感染耐藥菌感染更常見(jiàn)病原體類(lèi)似于其他院內(nèi)感染治療基于局部常見(jiàn)院感菌種及耐藥情況院內(nèi)感染考慮覆蓋腸球菌是合適

24、的抗真菌治療基于先前抗生素使用情況及基礎(chǔ)危險(xiǎn)因素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 2007MAZUSKI JE,Antimicrobial treatment for intra-abdominal infections.Expert Opin Pharmacother. 2007 D

25、ec;8(17):2933-45 第三型及醫(yī)院獲得性腹腔感染耐藥菌感染更常見(jiàn)JOHN A. W抗腸球菌治療指征常規(guī)抗腸球菌治療對(duì)社區(qū)獲得性腹腔感染沒(méi)有必要 (A-1)醫(yī)院獲得性腹腔感染需考慮給予覆蓋腸球菌的藥物 (B-3). 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 Com

26、plicated Intra-abdominal Infections，CID2003, 37:9971005抗腸球菌治療指征常規(guī)抗腸球菌治療對(duì)社區(qū)獲得性腹腔感染沒(méi)有必要抗真菌治療指征胃腸道穿孔的病人白念或其他真菌的分離率約20% 即使分離到真菌,抗真菌治療也非必要,除非該患者近期因腫瘤、器官移植、炎癥性疾病接受過(guò)免疫抑制治療,或者是術(shù)后或復(fù)發(fā)的腹腔感染 (B-2)Anti-infective therapy for Candida should be withheld until the infecting species is identied (C-3). 10版有較大修正分離到白念則選

27、擇氟康唑 (B-2)氟康唑耐藥的念珠菌可選擇 amphotericin B, caspofungin, or voriconazole (B-3).腎功能不全選擇后二者 (A-1). 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-abdomi

28、nal Infections，CID2003, 37:9971005抗真菌治療指征胃腸道穿孔的病人白念或其他真菌的分離率約20何時(shí)開(kāi)始抗感染治療應(yīng)當(dāng)在確診感染和獲得培養(yǎng)結(jié)果前懷疑IAI的診斷時(shí)即開(kāi)始抗生素治療抗感染的目標(biāo)是清除感染病原體、減少?gòu)?fù)發(fā)、縮短感染癥狀體征消除時(shí)間抗生素應(yīng)該在液體復(fù)蘇開(kāi)始后給藥，恢復(fù)充分的血流灌注使良好的藥物分布成為可能。尤其是氨基糖苷類(lèi)，其腎毒性會(huì)因腎灌注不足而加重何時(shí)開(kāi)始抗感染治療應(yīng)當(dāng)在確診感染和獲得培養(yǎng)結(jié)果前懷疑IAI的哪些病人需要抗感染治療創(chuàng)傷或醫(yī)源性腸損傷致腹腔污染12h內(nèi)修補(bǔ)的病人 (Level 1) 以及胃腸穿孔24 h內(nèi)修補(bǔ)的病人(Level 3)不認(rèn)為

29、已經(jīng)合并IAI，僅需給予24 h或更短的預(yù)防用藥炎癥病灶能夠完全移除的病人如沒(méi)有穿孔的急性或壞疽性闌尾炎或膽囊炎，或者沒(méi)有發(fā)生穿孔或腹膜炎的腸梗阻或腸壞死，也僅需給予24 h或更短的預(yù)防用藥(Level 2)已經(jīng)合并廣泛IAI的上述病人應(yīng)該給予超過(guò)24 h的抗感染治療 (Level 3). the Therapeutic Agents Committee of the Surgical Infection Society,The Surgical Infection Society Guidelines on Antimicrobial Therapy for Intra-Abdominal

30、Infections:An Executive Summary,SURGICAL INFECTIONS Volume 3, Number 3, 2002哪些病人需要抗感染治療創(chuàng)傷或醫(yī)源性腸損傷致腹腔污染12h內(nèi)修81. 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 Compl

31、icated Intra-abdominal Infection in Adults and Children:Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of America；Clinical Infectious Diseases 2010; 50:1336481. The administration of prop抗感染療程大多數(shù)IAI的抗感染治療不應(yīng)該超過(guò)5 (Level 2) to 7 days (Level 3).抗感染療程可基于術(shù)中介入時(shí)發(fā)現(xiàn)的情況 (Level 3). 當(dāng)患者感染的臨床癥候如發(fā)熱、白細(xì)胞升高等消失時(shí)可終止治療 (Level 2).預(yù)定的抗生素療程結(jié)束時(shí)癥狀持續(xù)，應(yīng)該積極進(jìn)行診斷評(píng)估，而非簡(jiǎn)單延長(zhǎng)抗感染時(shí)間 (Level 3).