耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用課件

1、耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Dr.HU Bijie4N Eng J Med, 2003, 348:1546-1554耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Cr

2、itical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22心血管心血管5%眼耳鼻喉眼耳鼻喉3%肺炎肺炎30%皮膚軟組織皮膚軟組織3%血流血流16%尿路尿路30%胃腸道胃腸道5%下呼吸道下呼吸道6%耐甲氧西林金葡菌醫(yī)院感

3、染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22心血管心血管4%眼耳鼻喉眼耳鼻喉3%肺炎肺炎33%皮膚軟組織皮膚軟組織3%血流血流13%尿路尿路18%胃腸道胃腸道4%手術(shù)切口手術(shù)切口15%下呼吸道下呼吸道6%耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemi

4、ology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22占所有病原菌的占所有病原菌的%革蘭陽(yáng)性菌革蘭陽(yáng)性菌真菌真菌革蘭陰性菌革蘭陰性菌CNS=凝固酶陰性葡萄球菌；凝固酶陰性葡萄球菌；NNIS=美國(guó)全國(guó)醫(yī)院感染監(jiān)測(cè)系統(tǒng)美國(guó)全國(guó)醫(yī)院感染監(jiān)測(cè)系統(tǒng)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and si

5、tes of infections in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22占所有病原菌的占所有病原菌的%革蘭陽(yáng)性菌革蘭陽(yáng)性菌真菌真菌革蘭陰性菌革蘭陰性菌耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Critica

6、l Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infec

7、tions in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨

8、床應(yīng)用Eguia JM, et al. Methicillin-resistant Staphylococci and their tratment in the intensive care unit. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Richards M, et al. Epidemiology, prevalence, and sites of infections in intensive care units. Seminars in Re

9、spiratory and Critical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Spencer et al. Clin Microbiol Inf, 1997, 3: S21.耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用肺炎肺炎 47%下呼吸道感染下呼吸道感染 18%血流感染血流感染 12%泌尿道感染泌尿道感染 18%其他其他 5%Spencer et al. Clin Microbiol Inf, 1997, 3: S21.耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用674株革蘭陽(yáng)性球菌株革蘭陽(yáng)性球菌47.9%80.8%M

10、RSAMRCNS 第七次全國(guó)臨床微生物學(xué)術(shù)年會(huì)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用李毅, 等. ICU細(xì)菌耐藥性監(jiān)測(cè). 北京醫(yī)學(xué), 2002;24(1):3-5耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用21耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用 第七次全國(guó)臨床微生物學(xué)術(shù)年會(huì)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用 第七次全國(guó)臨床微生物學(xué)術(shù)年會(huì)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用EPIC耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用保護(hù)因素：選擇性腸道清潔，全身用抗生素，連續(xù)吸痰，非侵襲性（面罩）通氣保護(hù)因素：選擇性腸道清潔，全身用抗生素，連續(xù)吸痰，非侵襲性（面罩）通氣

11、耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用保護(hù)因素：隧道插管，完全植入插管；含有消毒劑的敷料；含有消毒劑的導(dǎo)管；保護(hù)因素：隧道插管，完全植入插管；含有消毒劑的敷料；含有消毒劑的導(dǎo)管；插管無菌操作和隔離保護(hù)插管無菌操作和隔離保護(hù)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用保護(hù)因素：恥骨上插導(dǎo)尿管；銀合金導(dǎo)管；全身用抗生素保護(hù)因素：恥骨上插導(dǎo)尿管；銀合金導(dǎo)管；全身用抗生素耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用EPIC耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用American Joumal of Respiratory and Critical Care Medicine:2005.Vol

12、.171,4;388-416耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用American Joumal of Respiratory and Critical Care Medicine:2005.Vol.171,4;388-416耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用American Joumal of Respiratory and Critical Care Medicine:2005.Vol.171,4;388-416耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Whitby M, et al. Risk of death from methicillin-resistant St

13、aphylococcus aureus bacteremia: a meta-analysis. Med J Austral 2001;175:264-267耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用1. 吳本權(quán)，等. 中華醫(yī)院感染學(xué)雜志2000年;10(5):3412. Gang RK, et al. Burns 2000;26:359-366死亡率死亡率 %0 05 5101015152020252530303535404045455050MRSAMRSA肺部感染肺部感染MRSAMRSA敗血癥敗血癥耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Eguia JM, et al. Methic

14、illin-resistant Staphylococci and their tratment in the intensive care unit. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-221 MMWR,51:565; 2 MMWR 51: 902; 3 MMWR, 53: 322; 4 耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用1 MMWR,51:565; 2 MMWR 51: 902; 3 MMWR, 53: 322; 4 耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染

15、及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用39耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用American Joumal of Respiratory and Critical Care Medicine:2005.Vol.171,4;388-416耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用American Joumal of Respiratory and Critical Care Medicine:2005.Vol.171,4;388-416耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Eguia JM, et al. M

16、ethicillin-resistant Staphylococci and their tratment in the intensive care unit. Seminars in Respiratory and Critical Care Medicine. 2003;24(1):3-22耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用脂肪酸側(cè)鏈CO- (TA2-1)CO- (TA2-2)CO- (TA2-3)CO- (TA2-4)CO- (TA2-5)ClNHRHOHOOOO2ONH(+)NH31OH

17、OO3HOHNONHOHN5OHOCH2OHOHOHHOHO7(-)OCH2OHCI64ONHOOOCH2OHHOHONHCOOCH3NHCOO3糖糖7肽肽耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用CLSI推薦的藥敏試驗(yàn)判斷標(biāo)準(zhǔn)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Spencer RC,Goering R, Int J Antimicrob Agents 1995;5:169-177Spencer RC,Goering R, Int J Antimicrob Agents 1995;5:169-177耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)

18、用(5.0)2.8(2.0)1.1(6.0)4.0(1.0)27.9(2.7)14.8金黃色葡萄球菌MIC=0.8m mg/ml體液濃度m mg/ml胸腔23支氣管分泌物23滑液24腹膜液25水泡液25軟骨22(0.5)7.9(3.0)4.8(3.0)6.7(3.0)4.8(3.0)5.6(3.0)6.4(3.0)4.1金黃色葡萄球菌MIC=0.8m mg/ml組織濃度m mg/ml肺20骨松質(zhì)21骨密質(zhì)21髖關(guān)節(jié)囊21肌肉21骨髓22靜脈給替考拉寧400mg后的組織和體液濃度(取樣距用藥時(shí)間：h)Harding I. Data on file, Hoechst Marion RousselR

19、osina R et al. In: Prog & Abst, 16th Int Cong Chemother, Jerusalem, 1989; Abst no. 185Lenders HE, WalliserD et al. Munich, 26-29 1987. Abstract No. 124Jacobs F, Rocmans P, New Orleans, 1986; p232Morgan Jr et al. Data on file, Hoecst Marion RousselWise R, Donovan IA et al. J Hosp Infect 1986; 7 (Supp

20、l. A): 47-55耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用168替考拉寧血清濃度(mg/ml)351224487296120 144302520151050時(shí)間時(shí)間(小時(shí)小時(shí))n=1026 mg/kg6 mg/kg100906040201086421.610.80.60.40.200481224時(shí)間時(shí)間(小時(shí)小時(shí))MIC90 金黃色葡萄球菌MIC90 表皮葡萄球菌糞腸球菌替考拉寧血清濃度(mg/ml)3 mg/kg IV6 mg/kg IV3 mg/kg IMN=6 健康者Verbist L, Tjandramaga B, et al. Antimicrob Agents Chemo

21、ther 1984; 26 (6):881-886.Tjandramaga B et al. Data on Marion Roussel.耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用Journal of Antimicrobial Chemotherapy (2003) 51, 971975耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用肌酐清除率肌酐清除率劑量調(diào)整劑量調(diào)整40-60 ml/min 正常劑量的正常劑量的1/2，或正常劑量每?jī)商旖o藥一次，或正常劑量每?jī)?/p>

22、天給藥一次40 ml/min 正常劑量的正常劑量的1/3，或正常劑量每三天給藥一次，或正常劑量每三天給藥一次耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用歐洲的革蘭陽(yáng)性菌多中心試驗(yàn)歐洲的革蘭陽(yáng)性菌多中心試驗(yàn) (n=1431) (n=1431)Lewis et al, 1988, JAC, 21, Suppl A, 61-67 (72%) (14%) (1%) (6%) (7%)耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用他格適他格適 Wood 1996. JAC 37, 209-222 耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用他格適他格適 Wood

23、 1996. JAC 37, 209-222 耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用0102030405060發(fā)生不良事件的病人比例發(fā)生不良事件的病人比例Smith, 1989Kureishi, 1991Charbonneau, 1994Neville, 1995van der Auwera, 1991van Laethem, 1988Gerard, 1987Cony-Makhoul, 1990Hedstrom, 1994Kulmala, 1990Menichetti, 1994overall替考拉寧替考拉寧萬古霉素萬古霉素Comparative adverse event rates

24、for 替考拉寧替考拉寧 and 萬古霉素萬古霉素該研究中沒有報(bào)道該研究中沒有報(bào)道zerozerop0.05p0.05p0.05p0.05p0.05p0.05p0.05他格適他格適替考拉寧和萬古霉素不良事件發(fā)生率比較替考拉寧和萬古霉素不良事件發(fā)生率比較Wood MJ. Antimicrobial Chemotherapy 1996;37:209-222Wood MJ. Antimicrobial Chemotherapy 1996;37:209-222耐甲氧西林金葡菌醫(yī)院感染及替考拉寧的臨床應(yīng)用90%80%70%60%50%40%30%20%10%0%NSNS21.9%13.9%4.8%10.7%臨床有效率臨床有效率細(xì)菌學(xué)清除率細(xì)菌學(xué)清除率不良事件不良事件 腎毒性腎毒性替考拉寧萬古霉素Wood MJ. Antimicrobial Chemotherapy 1