泌尿系膿毒癥的診斷與治療課件

泌尿系膿毒癥的診斷與治療上海市第一人民醫(yī)院急診危重病科錢永兵2022/11/301病例介紹女，87歲，2015-10-3因“右股骨粗隆間骨折”急診入骨科，肝腎功能（-），擬限期行右股骨內(nèi)固定手術(shù)，無糖尿病史10-9日上午，突發(fā)寒顫、高熱39℃，意識模糊，RR30bpm，HR145bpm，Af律，BP90/50mmHg，Lac7mmol/L,肺部聽診（-），導(dǎo)尿為“膿尿”，ICU會診初始診斷及處理？2022/11/302輔助檢查2022/11/303SubjectsofUrosepsisCountryPopulationUrosepsisUKPCNLAntibiotic:13.5%Noantibiltic:33%IndiaPCNLAntibiotic:19%Noantibiltic:49%TaiwanCommunityUTIESBL:41.7%NotESBL:4.4%TaiwanESBLurosepsisCommunity:0Health-care:19.5%Hospital:14.4%KoreaComplicatedpyelonehritisCommunity:19.2%Hospital:46%IsraelWomen,Complicatedpyelonephritis13.3%Nicolle,CritCareClin29(2013)699–7152022/11/305尿源性膿毒血癥危險因素患者狀況：糖尿病、低齡、女性和截癱尿路解剖異常：神經(jīng)源性膀胱及尿流改道結(jié)石特征：腎盂腎盞擴張和結(jié)石負(fù)荷過大術(shù)前：既往同側(cè)PCNL史，腎盂腎盞梗阻擴張、腎造瘺管術(shù)中：腎盂尿培養(yǎng)陽性、結(jié)石培養(yǎng)陽性、多次腎穿刺和輸血尿路感染診斷與治療中國專家共識(2015版)2022/11/306Dateofdownload:2/23/2016Copyright?2016AmericanMedicalAssociation.Allrightsreserved.From:TheThirdInternationalConsensusDefinitionsforSepsisandSepticShock(Sepsis-3)JAMA.2016;315(8):801-810.doi:10.1001/jama.2016.0287Dateofdownload:2/23/2016Copyright?2016AmericanMedicalAssociation.Allrightsreserved.From:TheThirdInternationalConsensusDefinitionsforSepsisandSepticShock(Sepsis-3)JAMA.2016;315(8):801-810.doi:10.1001/jama.2016.0287PathophysiologyofUrosepsis:DtschArzteblInt2015;112:8372022/11/3010PCTasanearlydiagnosticandmonitoringtoolinurosepsisfollowingPCNLZhengJ,Urolithiasis(2015)43:41–47PCT0.30ng/mlSensitivity90.3%Specificity94.3%2022/11/3012PathogenspectruminurospesisTandogdu,WorldJUrol2015,122022/11/3014ICU內(nèi)尿路感染病原菌構(gòu)成比汪海源，中華泌尿外科雜志，2015（36）：3802022/11/3015BacteremicUTIinKoreanelderlyptsChin,ArchivesofGerontologyandGeriatrics52(2011)e50–e552022/11/3016院內(nèi)獲得性urosepsis病原菌構(gòu)成比Johansen,InternationalJournalofAntimicrobialAgents28S(2006)S91–S1072022/11/3017UTIinDMvs.non-DMfemales(DM)(non-DM)Garg,JournalofClinicalandDiagnosticResearch.2015,9(6):122022/11/3018Resistanceprofileofantibiotics-GPIU2015AntibioticsEurope(%)Asia(%)Africa(%)Americas(%)EuroAsiaAfricaAmericasAmx/BLI58709275CAZ+CIP38563367TZP34405067CAZ+GEN30522567TMP/SMZ56508663CAZ+TMP/SMZ30502567CIP59614722TZP+CIP33325067LVX59575067TZP+GEN20265067CXM57567167TZP+TMP/SMZ20365067CTX52423156CIP+GEN31444425CAZ42713356CIP+TMP/SMZ37425025IPM813002022/11/3020AntimicrobialsensitivityinKoreanelderlypts頭孢噻肟、頭孢哌酮/舒巴坦、氨曲南在老年患者中具有顯著差別！2022/11/3021細菌培養(yǎng)結(jié)果2022/11/3023病例總結(jié)帕尼培南可樂必妥ICUstay血/尿：大腸埃希菌2022/11/3024TigercyclineasrescuetreatmentforMDRKP/ABurosepsisJOURNALOFCLINICALMICROBIOLOGY,May2009,p.1613JOURNALOFCLINICALMICROBIOLOGY,Feb.2008,p.817–8202022/11/3026抗生素治療時間復(fù)雜性尿路感染10-14天歐洲泌尿協(xié)會建議癥狀緩解后3-5天停藥感染性腎囊腫4-6周腎膿腫直至膿腫清除免疫缺陷患者需延長時間，具體不清2022/11/3027抗菌藥物選擇策略品種選擇

根據(jù)感染部位、發(fā)病場所、既往用藥史、耐藥監(jiān)測數(shù)據(jù)等，給予經(jīng)驗性治療

根據(jù)藥代學(xué)特點，感染部位等選擇二.給藥劑量

上尿路，治療劑量高限

下尿路，治療劑量低限三.給藥途徑

上尿路，初始給予靜脈

下尿路，口服四.給藥次數(shù)

時間依賴性