1、呼吸机相关性肺炎呼吸机相关性肺炎HAP/VAP:概要概要 流行病学流行病学 诊断策略诊断策略 抗生素治疗抗生素治疗HAP/VAP:问题问题1 呼吸机相关性肺炎指应用机械通气多呼吸机相关性肺炎指应用机械通气多长时间以后发生的肺炎长时间以后发生的肺炎?1.24小时小时2.48小时小时3.72小时小时4.96小时小时5.48-72小时小时HAP/VAP/HCAP:定义定义 医院获得性肺炎医院获得性肺炎(HAP)住院住院48小时后发生且住院时不处于潜伏期的肺炎小时后发生且住院时不处于潜伏期的肺炎 呼吸机相关性肺炎呼吸机相关性肺炎(VAP)气管插管气管插管48小时以后发生的肺炎小时以后发生的肺炎 因重度
2、因重度HAP需要气管插管者应按照需要气管插管者应按照VAP处理处理 医疗相关肺炎医疗相关肺炎(HCAP)发生感染前发生感染前90天内在急性病医院住院天内在急性病医院住院 2天天 在养护院或长期医疗机构住院在养护院或长期医疗机构住院 近期接受静脉抗生素治疗、化疗或发生感染前近期接受静脉抗生素治疗、化疗或发生感染前30天内接受伤口治疗天内接受伤口治疗 就诊于医院门诊或透析门诊就诊于医院门诊或透析门诊ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and hea
3、lthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416 发病率发病率 美国医院获得性感染的第二位美国医院获得性感染的第二位 5-15例例/1,000住院病例住院病例 罹患率和病死率升高罹患率和病死率升高 预后预后 住院日延长住院日延长7-9天天 医疗费用增加医疗费用增加$40,000Kumpf G,et al.J Clin Epidemiol 1998;54:495-502Lizioli A,et al.J Hosp Infect 2003;54:141-148Richards MJ,et al.Crit
4、Care Med 1999;27:887-8922%/dCook DJ,Walter SD,Cook RJ,Griffith LE,Guyatt GH,Leasa D,Jaeschke RZ,Brun-Buisson C.Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients.Ann Intern Med 1998;129:440迟发性迟发性HAP50%早发性早发性HAP50%510d 总病死率总病死率30-70%:归因病死率归因病死率33-50%H2H2受体拮抗剂
5、进行应激性溃疡预防受体拮抗剂进行应激性溃疡预防“自由自由”输血输血 去白细胞输血去白细胞输血 血糖控制不佳血糖控制不佳 ARDSARDS 深度镇静或肌松深度镇静或肌松FagonKollefPapazianRelloTimsitTorres铜绿假单胞菌192927501628不动杆菌属104501224嗜麦芽窄食单胞菌073000肠杆菌属168004流感嗜血杆菌61810130其他革兰阴性杆菌24102841032金黄色葡萄球菌20302192620肺炎链球菌410744 支气管远端标本培养分离出口咽部定植菌（草绿支气管远端标本培养分离出口咽部定植菌（草绿色链球菌，凝固酶阴性葡萄球菌，奈瑟氏菌属
6、，色链球菌，凝固酶阴性葡萄球菌，奈瑟氏菌属，棒状杆菌属）棒状杆菌属）难以解释难以解释 在免疫抑制甚至免疫正常患者可能引起感染在免疫抑制甚至免疫正常患者可能引起感染Cabello H,Torres A,Celiss R,El-Ebiary M,de la Bellacasa JP,Xaubet A,Gonzalez J,Augusti C,Soler N.Bacterial colonization of distal airways in healthy subjects and cronic lung diseases:a bronchoscopic study.Eur Respir J 1
7、997;10:11371144 金黄色葡萄球菌金黄色葡萄球菌 糖尿病，头颅创伤，住糖尿病，头颅创伤，住ICU 厌氧菌：在厌氧菌：在VAP中的重要性尚不明确中的重要性尚不明确 非插管患者误吸非插管患者误吸 VAP罕见罕见 肺炎军团菌：发生率缺乏数据，但重要性受关注肺炎军团菌：发生率缺乏数据，但重要性受关注 免疫抑制患者如器官移植，免疫抑制患者如器官移植，HIV，糖尿病，基础肺病，糖尿病，基础肺病，终末期肾病终末期肾病012345678Early-onset HAPLate-onset HAPTime from hospitalization(days)012345678Early-onset V
8、APLate-onset VAPTime from Intubation(days)ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-ass
9、ociated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416HAP/VAP:问题问题2 以下哪个不是呼吸机相关性肺炎确切的发病机制以下哪个不是呼吸机相关性肺炎确切的发病机制1.误吸误吸2.直接吸入直接吸入3.血行性播散血行性播散5.以上答案均不对以上答案均不对改变胃排空及胃液pH值的药物有生物膜的装置(气管插管,鼻胃管)既往应用抗生素宿主因素(免疫抑制,烧伤)消化道细菌定植细菌误吸细菌吸入医院获得性肺炎水,药物溶液及呼吸治疗装置污染感染控制措施不够(洗手,隔离衣,手套)医务人员不足经
10、胸种植原发性菌血症胃肠道细菌移位 CXR vs.CT 手术后肺实变：敏感性手术后肺实变：敏感性0.33 1.00，特异性，特异性 0.79 不同医生判读的一致性不同医生判读的一致性 放射科医生：放射科医生：kappa 0.27 ICU医生：医生：12 39%Wunderink RG,Woldenberg LS,Zeiss J,et al.The radiologic diagnosis of autopsy-proven ventilator-associated pneumonia.Chest 1992;101:458-63.Fagon J,Chastre J,Hance A.Evaluat
11、ion of clinical judgment in the identification and treatment of nosocomial pneumonia in ventilated patients.Chest 1993;103:547-53.Beydon L,Saada M,Liu N,et al.Can portable chest x-ray examination accurately diagnose lung consolidation after major abdominal surgery?:a comparison with computed tomogra
12、phy scan.Chest 1992;102:1698-703.胸片新出现浸润影或原有浸润性加重胸片新出现浸润影或原有浸润性加重 以下临床表现中两条：以下临床表现中两条：T 38C 白细胞增多或白细胞缺乏白细胞增多或白细胞缺乏 脓性气道分泌物脓性气道分泌物敏感性敏感性69%，特异性特异性75%The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630高
13、度可疑VAP=临床诊断+BALF 104 cfu/ml;可能VAP=临床诊断The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated pneumonia.N Engl J Med 2006;355:2619-2630The Canadian Critical Care Trials Group.A randomized trial of diagnostic techniques for ventilator-associated p
14、neumonia.N Engl J Med 2006;355:2619-2630Pappas PG,Kauffman CA,Andes D,et al.Clinical practice guidelines for the management of candidiasis:2009 update by the Infectious Diseases Society of America.2009;48:503-535Pugin J,Auckenthaler R,Mili N,Janssens JP,Lew PD,Suter PM.Diagnosis of ventilator-associ
15、ated pneumonia by bacteriologic analysis of bronchoscopic and non-bronchoscopic blind bronchoalveolar lavage fluid.Am Rev Respir Dis 1991;143:1121-1129 Pugin J,Auckenthaler R,Mili N,Janssens JP,Lew PD,Suter PM.Diagnosis of ventilator-associated pneumonia by bacteriologic analysis of bronchoscopic an
16、d non-bronchoscopic blind bronchoalveolar lavage fluid.Am Rev Respir Dis 1991;143:1121-1129 肺不张肺不张 血栓栓塞性疾病血栓栓塞性疾病 胃内容物误吸胃内容物误吸 未治愈社区获得性未治愈社区获得性肺炎肺炎 充血性心力衰竭充血性心力衰竭HAP/VAP:治疗治疗Luna CM,Vujacich P,Niederman MS,et al.Impact of BAL data on the therapy and outcome of ventilator-associated pneumonia.Chest 1
17、997;111:676-685 2000名连续收治的名连续收治的MICU/SICU患者患者 655(25.8%)罹患感染罹患感染 169(8.5%)抗生素治疗不充分抗生素治疗不充分Kollef MH,Sherman G,Ward S,et al.Inadequate antimicrobial treatment of infections.A risk factor for hospital mortality among critically ill patients.Chest 1999;115:462-474HAP/VAP:经验性抗生素经验性抗生素ATS/IDSA.Guidelines
18、 for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit
19、Care Med 2005;171:388-416ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healt
20、hcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416培养阴性培养阳性培养阴性培养阳性培养阴性培养阳性培养阴性培养阴性培养阳性Hamer DH.Treatment of n
21、osocomial pneumonia and tracheobronchitis caused by multidrug-resistant Pseudomonas aeruginosa with aerosolized colistin.Am J Respir Crit Care Med 2000;162:328-330.Brown RB,Kruse JA,Counts GW,Russell JA,Christou NV,Sands ML,Endotracheal Tobramycin Study Group.Double-blind study of endotracheal tobra
22、mycin in the treatment of gram-negative bacterial pneumonia.Antimicrob Agents Chemother 1990;34:269-272Klick JM,du Moulin GC,Hedley-Whyte J,Teres D,Bushnell LS,Feingold DS.Prevention of gram-negative bacillary pneumonia using polymyxin aerosol as prophylaxis.II.Effect on the incidence of pneumonia i
23、n seriously ill patients.J Clin Invest 1975;55:514-519Heyland D,Dodek P,Muscedere J,et al.Randomized trial of combination versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia.Crit Care Med 2008;36(3):737-744Paul M,Benuri-Silbiger I,Soares-Weiser K,et al.-lactam m
24、onotherapy versus-lactam-aminoglycoside combination therapy for sepsis in immunocompetent patients:systematic review and meta-analysis of randomised trials.BMJ 2004;328:668Paul M,Benuri-Silbiger I,Soares-Weiser K,et al.-lactam monotherapy versus-lactam-aminoglycoside combination therapy for sepsis i
25、n immunocompetent patients:systematic review and meta-analysis of randomised trials.BMJ 2004;328:668HAP/VAP:问题问题3 Probability of Survival0102030405060Days after Bronchoscopy0.00.20.40.60.81.015-day 8-dayChastre J,Wolff M,Fagon JY,et al.Comparison of 8 vs 15 days of antibiotic therapy for ventilator-
26、associated pneumonia in adults:a randomized trial.JAMA 2003;290(19):2588-2598 结果：结果：8天与天与15天抗生素疗程相比天抗生素疗程相比:病死率、住院日和机械通气时间无显著差别病死率、住院日和机械通气时间无显著差别 减少了抗生素使用减少了抗生素使用 避免了细菌耐药的发生避免了细菌耐药的发生 PCT指导抗生素治疗指导抗生素治疗 社区获得性下呼吸道感染社区获得性下呼吸道感染 不良预后相似不良预后相似(15.4%vs.18,9%)，抗生素疗程缩短，抗生素疗程缩短(5.7 d vs.8.7 d)AECOPD 减少抗生素使用减
27、少抗生素使用(40%vs.72%)，减少减少6个月内抗生素使用个月内抗生素使用(RR 0.76;95%CI 0.64 0.92)社区获得性肺炎社区获得性肺炎 减少抗生素使用减少抗生素使用(RR 0.52,95%CI 0.48 0.58)Schuetz P,Christ-Crain M,Thomann R,et al.Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections:The ProHOSP randomize
28、d controlled trial.JAMA 2009;302(10):1059-1066Stolz D,Christ-Crain M,Bingisser R,et al.Antibiotic treatment of exacerbations of COPD.Chest 2007;131:9-19Christ-Crain M,Stolz D,Bingisser R,et al.Procalcitonin guidance of antibiotic therapy in community-acquired pneumonia:a randomized trial.Am J Respir
29、 Crit Care Med 2006;174:84-93 PCT 0.25 g/ml 推荐应用抗生素推荐应用抗生素 PCT 0.5 g/ml 强烈推荐应用抗生素强烈推荐应用抗生素Schuetz P,Christ-Crain M,Thomann R,et al.Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections:The ProHOSP randomized controlled trial.JAMA 2009
30、;302(10):1059-1066ATS/IDSA.Guidelines for the management of adults with hospital-acquired,ventilator-associated,and healthcare-associated pneumonia.Am J Respir Crit Care Med 2005;171:388-416床头抬高至少床头抬高至少30经口气管插管经口气管插管经口留置胃管经口留置胃管监测胃残余量并防止腹胀监测胃残余量并防止腹胀减少抗生素的使用减少抗生素的使用尽早开始适当的营养支持尽早开始适当的营养支持严格控制血糖严格控制血糖使用无创通气避免插管使用无创通气避免插管缩短插管时间缩短插管时间保持套囊压力保持套囊压力20 mmHg间断吸引声门下分泌物间断吸引声门下分泌物口腔护理减少耐药菌定植口腔护理减少耐药菌定植避免深度镇静或肌松避免深度镇静或肌松每日唤醒减少镇静药剂量每日唤醒减少镇静药剂量
