ICU獲得性感染81張課件

1、ICU獲得性感染26、我們像鷹一樣，生來(lái)就是自由的，但是為了生存，我們不得不為自己編織一個(gè)籠子，然后把自己關(guān)在里面。博萊索27、法律如果不講道理，即使延續(xù)時(shí)間再長(zhǎng)，也還是沒(méi)有制約力的。愛(ài)科克28、好法律是由壞風(fēng)俗創(chuàng)造出來(lái)的。馬克羅維烏斯29、在一切能夠接受法律支配的人類的狀態(tài)中，哪里沒(méi)有法律，那里就沒(méi)有自由。洛克30、風(fēng)俗可以造就法律，也可以廢除法律。塞約翰遜ICU獲得性感染ICU獲得性感染26、我們像鷹一樣，生來(lái)就是自由的，但是為了生存，我們不得不為自己編織一個(gè)籠子，然后把自己關(guān)在里面。博萊索27、法律如果不講道理，即使延續(xù)時(shí)間再長(zhǎng)，也還是沒(méi)有制約力的。愛(ài)科克28、好法律是由壞風(fēng)俗創(chuàng)造出來(lái)的

2、。馬克羅維烏斯29、在一切能夠接受法律支配的人類的狀態(tài)中，哪里沒(méi)有法律，那里就沒(méi)有自由。洛克30、風(fēng)俗可以造就法律，也可以廢除法律。塞約翰遜Dept of Critical Care MedicinePeking Union Medical College HospitalICU-acquired Infection and Strategy of Antibiotic TherapyCost of Hospital Stay Associated with ResistanceStudy of Classroom Design and Teaching Methods about Infor

3、mation Technology on Junior High School/Song Xiaojuan Abstract Information technology is a new curriculum which has strong application and comprehensive, classroom teaching was so difficult that the teachers must do a good job teaching design, apply a variety of teaching methods which used to mobili

4、ze the enthusiasm of the students and develop students ability to learn. Authors address Beijing Youanmen Foreign Language School, Beijing, China 100054 初中信息技術(shù)課是一門操作性很強(qiáng)的課程,這就要求信息教師不僅要具有精深的專業(yè)知識(shí)、精湛的操作技能,還必須具有對(duì)教學(xué)進(jìn)行不斷探究、不斷創(chuàng)新的精神。尤其是新課改的開(kāi)展和不斷深入,對(duì)以前的教學(xué)方式和思路形成很大的沖擊,必須對(duì)以前教學(xué)的方方面進(jìn)行重新審視,認(rèn)真地思考,完善、創(chuàng)新,形成一套行之有效的教學(xué)方

5、式。 1 課堂教學(xué)前應(yīng)認(rèn)真做好教學(xué)設(shè)計(jì) 要想提高學(xué)生的學(xué)習(xí)興趣,首先要有一個(gè)周密的、有目的性的,能夠吸引他們的教學(xué)設(shè)計(jì)。這樣的教學(xué)設(shè)計(jì)可以讓學(xué)生應(yīng)用信息技術(shù)去解決實(shí)際問(wèn)題,以任務(wù)來(lái)激發(fā)探索、研究的興趣,不斷學(xué)習(xí)新的知識(shí),在完成任務(wù)的過(guò)程中培養(yǎng)自學(xué)和相互學(xué)習(xí)的能力。特別是在新教材的教學(xué)模式中,貼近生活的教學(xué)設(shè)計(jì)顯得尤為突出和重要。在學(xué)習(xí)的過(guò)程中,遇到很多的問(wèn)題,學(xué)生通過(guò)嘗試、探索和討論等方式,有些問(wèn)題可以自己解決,而一些解決不了的問(wèn)題,或者大家公認(rèn)的問(wèn)題,通過(guò)教師的及時(shí)總結(jié)和講解也得到解決。這樣,學(xué)生不僅掌握了課本上要學(xué)習(xí)的知識(shí),也進(jìn)一步提高了計(jì)算機(jī)操作的技能,又能培養(yǎng)主動(dòng)學(xué)習(xí)的習(xí)慣,增強(qiáng)為班級(jí)

6、爭(zhēng)光的集體主義精神,更有效地拓展自身的潛能,進(jìn)而激發(fā)創(chuàng)新意識(shí)。 2 應(yīng)用多種教學(xué)方法改進(jìn)教學(xué)效果 2.1 任務(wù)驅(qū)動(dòng)法 所謂任務(wù)驅(qū)動(dòng),就是學(xué)生通過(guò)完成教師布置的任務(wù),建構(gòu)真正屬于自己的知識(shí)與技能。通過(guò)布置任務(wù),驅(qū)動(dòng)學(xué)生主動(dòng)地參與學(xué)習(xí)、自主探索,培養(yǎng)其創(chuàng)造力。任務(wù)既要?jiǎng)?chuàng)設(shè)情境,激發(fā)學(xué)生興趣,又要注意課程整合,不獨(dú)立于其他學(xué)科之外,同時(shí)還要滲透教學(xué)方法,注重學(xué)生能力的培養(yǎng)。 首先,教師要提前精心設(shè)計(jì)任務(wù),根據(jù)任務(wù)的力度,給學(xué)生營(yíng)造討論學(xué)習(xí)的氛圍,適當(dāng)分組,按組來(lái)完成任務(wù)。這是培養(yǎng)學(xué)生團(tuán)隊(duì)精神最好的方法。學(xué)生接受了任務(wù)后,提出問(wèn)題,找出解決方法,進(jìn)行自主學(xué)習(xí)。教師對(duì)學(xué)生的指導(dǎo)始終貫穿于任務(wù)的完成過(guò)程中

7、,對(duì)學(xué)生進(jìn)行適時(shí)指導(dǎo)。學(xué)生在提出問(wèn)題、解決問(wèn)題、接受指導(dǎo)的學(xué)習(xí)過(guò)程中,知識(shí)的獲取能力、運(yùn)用能力逐步提高。在學(xué)生任務(wù)完成后,教師選擇不同層次水平的作業(yè),組織學(xué)生進(jìn)行討論、點(diǎn)評(píng),最后將任務(wù)中涉及的知識(shí)點(diǎn)進(jìn)行總結(jié)。通過(guò)這種循序漸進(jìn)、由淺入深的學(xué)習(xí),學(xué)生的理論知識(shí)和操作技能得到加強(qiáng),自主探索問(wèn)題的能力得到提高,學(xué)習(xí)興趣濃厚,在完成任務(wù)的過(guò)程中形成“以任務(wù)為導(dǎo)向、學(xué)生為主體、教師為指導(dǎo)”的教學(xué)主線。 2.2 分層教學(xué)法 目前,計(jì)算機(jī)在我國(guó)正處于普及階段,一些學(xué)生接觸計(jì)算機(jī)較少,這樣就造成學(xué)生的計(jì)算機(jī)水平參差不齊的現(xiàn)象。為全面提高教學(xué)質(zhì)量,在組織教學(xué)的時(shí)候應(yīng)有所側(cè)重。對(duì)教材要求的內(nèi)容已經(jīng)熟悉的學(xué)生,說(shuō)明其

8、對(duì)計(jì)算機(jī)有了一定的認(rèn)識(shí),具備一定的自學(xué)能力,根據(jù)他們的興趣,安排他們另外的任務(wù)。比如,讓他們先預(yù)習(xí)下一節(jié)課的內(nèi)容或者按要求做好課后的練習(xí),做一個(gè)圖文并茂的課件,限定完成的時(shí)間,給他們共享一些圖片資料和文字材料,有關(guān)資料可以隨時(shí)到網(wǎng)上查詢,必要時(shí)給予輔導(dǎo),鞏固每節(jié)課所學(xué)的內(nèi)容。同時(shí)每周檢查一下他們的進(jìn)展,方法是叫一些學(xué)生到講臺(tái)上,按照要求自己操作完成教師提出的問(wèn)題,并讓學(xué)生共同來(lái)檢查對(duì)錯(cuò)和要注意的問(wèn)題,主要是鼓勵(lì)、督促他們開(kāi)闊視野,獨(dú)立完成,讓他們有目的地深入學(xué)習(xí)。 分層教學(xué)法符合新課改中“關(guān)照全體學(xué)生,建設(shè)有特色的信息技術(shù)課程”的基本理念,是解決“零起點(diǎn)”和“非零起點(diǎn)”問(wèn)題的一個(gè)行之有效的方法

9、?？茖W(xué)有效地分層教學(xué),可避免教學(xué)中整齊劃一的弊端,建立一個(gè)表面寬松但又有相互競(jìng)爭(zhēng)的學(xué)習(xí)環(huán)境,既能激勵(lì)學(xué)有余力、學(xué)有專長(zhǎng)的學(xué)生超前發(fā)展,同時(shí)創(chuàng)造條件,鼓勵(lì)促進(jìn)學(xué)習(xí)基礎(chǔ)較差、學(xué)習(xí)上暫時(shí)存在困難的學(xué)生能在學(xué)習(xí)中獲得成功,得到相應(yīng)的發(fā)展。 3 教師適時(shí)組織評(píng)價(jià)、交流 一般來(lái)說(shuō),評(píng)價(jià)總是作為課堂的最后環(huán)節(jié),當(dāng)然也可以在教學(xué)過(guò)程中對(duì)某一個(gè)環(huán)節(jié)的作品進(jìn)行評(píng)價(jià)。一堂課至少應(yīng)該留5分鐘時(shí)間用于作品評(píng)價(jià),評(píng)價(jià)的方法也可以是多種多樣,如學(xué)生互評(píng)、自評(píng),將作品展示出來(lái)讓大家評(píng)價(jià)、教師點(diǎn)評(píng),進(jìn)行最佳作品展示等。教師要不斷地為學(xué)生創(chuàng)設(shè)鍛煉機(jī)會(huì),讓每個(gè)學(xué)生都有機(jī)會(huì)參與評(píng)價(jià),獨(dú)立地闡述自己的觀點(diǎn)。但要組織全班學(xué)生對(duì)所有的學(xué)生

10、作品進(jìn)行評(píng)價(jià)是不現(xiàn)實(shí)也是不可能的,這個(gè)需要信息技術(shù)教師想出各種方法,以擴(kuò)大學(xué)生作品評(píng)價(jià)的面。比如將全班分成若干個(gè)小組,由組里評(píng)出最優(yōu)秀的作品,然后全班評(píng)價(jià),可以是學(xué)生自我評(píng)價(jià),也可以是小組互評(píng)?？傊?評(píng)價(jià)的面要廣,盡可能讓所有的學(xué)生都有評(píng)價(jià)的機(jī)會(huì)。 信息技術(shù)課程是一門新課程,它對(duì)于培養(yǎng)學(xué)生的科學(xué)精神、創(chuàng)新精神和實(shí)踐能力,提高學(xué)生對(duì)信息社會(huì)的適應(yīng)能力等方面都具有重要的意義。在信息技術(shù)教學(xué)中,必須以新的教學(xué)理念和教學(xué)理論為指導(dǎo),探索提高信息技術(shù)課堂教學(xué)效率的方法與途徑,培養(yǎng)學(xué)生的信息素養(yǎng)。 2011年6月22日國(guó)務(wù)院總理溫家寶主持召開(kāi)國(guó)務(wù)院常務(wù)會(huì)議，決定建立全科醫(yī)師制度，總體目標(biāo)是到2020年，在

11、我國(guó)初步建立起充滿生機(jī)和活力的全科醫(yī)師制度，基本形成統(tǒng)一規(guī)范的全科醫(yī)生培養(yǎng)模式和“首診在基層”的服務(wù)模式，基本適應(yīng)人民群眾基本醫(yī)療衛(wèi)生服務(wù)的需求。國(guó)家發(fā)改委等部委提出從2010年起，連續(xù)三年在高等醫(yī)學(xué)院校開(kāi)展免費(fèi)定向全科醫(yī)學(xué)生培養(yǎng)工作，重點(diǎn)為鄉(xiāng)鎮(zhèn)衛(wèi)生院及以下的醫(yī)療機(jī)構(gòu)培養(yǎng)從事全科醫(yī)療的衛(wèi)生人才。學(xué)院被確定為吉林省免費(fèi)定向醫(yī)學(xué)生的培養(yǎng)院校之一，承擔(dān)培訓(xùn)任務(wù)，招收免費(fèi)定向全科醫(yī)學(xué)生150名。 國(guó)家開(kāi)展農(nóng)村訂單定向全科醫(yī)學(xué)生免費(fèi)培養(yǎng)工作是實(shí)現(xiàn)“人人享有基本醫(yī)療衛(wèi)生服務(wù)”，落實(shí)以全科醫(yī)生為重點(diǎn)的基層醫(yī)療衛(wèi)生隊(duì)伍建設(shè)規(guī)劃的具體舉措，是利國(guó)、惠民、關(guān)注民生、深入貫徹科學(xué)發(fā)展觀的具體行動(dòng)。各級(jí)行政部門和培養(yǎng)

12、院校都以高度負(fù)責(zé)的態(tài)度支持和配合此項(xiàng)工作，但要從根本上實(shí)現(xiàn)國(guó)家制定的目標(biāo)，真正把規(guī)劃工作落到實(shí)處，仍有大量的工作需要完成。 一、制定指導(dǎo)性人才培養(yǎng)方案和最低教育標(biāo)準(zhǔn) 從國(guó)家的政策看，免費(fèi)定向全科醫(yī)學(xué)生畢業(yè)后直接到基層醫(yī)療衛(wèi)生機(jī)構(gòu)就業(yè)，經(jīng)過(guò)全科醫(yī)師培訓(xùn)后就要能從事基層的全科醫(yī)師工作。其培養(yǎng)既要符合本科臨床醫(yī)學(xué)專業(yè)教育標(biāo)準(zhǔn)，又要具備基層全科醫(yī)學(xué)工作能力，要求的是高合格率，而非優(yōu)秀率。制定指導(dǎo)性人才培養(yǎng)方案和最低教育標(biāo)準(zhǔn)，既可以給培養(yǎng)院校的人才培養(yǎng)過(guò)程提供指導(dǎo)，通過(guò)相對(duì)統(tǒng)一的課程設(shè)置和教學(xué)內(nèi)容，保證人才培養(yǎng)的統(tǒng)一規(guī)格，又能夠督促培養(yǎng)院校和免費(fèi)定向醫(yī)學(xué)生對(duì)照教育標(biāo)準(zhǔn)，找出差距，彌補(bǔ)不足，保證人才培養(yǎng)質(zhì)

13、量。指導(dǎo)性人才培養(yǎng)方案和最低教育標(biāo)準(zhǔn)的制定應(yīng)由教育行政部門牽頭，商衛(wèi)生行政部門，聯(lián)合培養(yǎng)院校、免費(fèi)定向醫(yī)學(xué)生和共同利益方（如：畢業(yè)生就業(yè)單位的業(yè)務(wù)主管代表）共同制定。 1.指導(dǎo)性人才培養(yǎng)方案。指導(dǎo)性人才培養(yǎng)方案的制定，要體現(xiàn)定向培養(yǎng)集醫(yī)療、預(yù)防、保健、康復(fù)、健康教育、計(jì)劃生育指導(dǎo)為一體的全科醫(yī)師的理念。在課程體系的構(gòu)建上，一是要開(kāi)設(shè)全科醫(yī)學(xué)課程，如全科醫(yī)學(xué)概論等，教學(xué)的重點(diǎn)是全科醫(yī)學(xué)、全科醫(yī)療、全科醫(yī)生、臨床預(yù)防、居民健康檔案以及以家庭為單位的健康照顧等。二是要增加基本衛(wèi)生保健課程和健康教育與健康促進(jìn)課程，如社會(huì)醫(yī)學(xué)、健康教育與健康促進(jìn)等，教學(xué)的重點(diǎn)是初級(jí)衛(wèi)生保健、農(nóng)村新型合作醫(yī)療制度、城市社

14、區(qū)衛(wèi)生服務(wù)、社區(qū)預(yù)防保健和社區(qū)衛(wèi)生診斷等。三是要加入重點(diǎn)人群保健課程，如婦女兒童保健、老年保健等，教學(xué)的重點(diǎn)是小兒營(yíng)養(yǎng)、計(jì)劃免疫、新生兒保健、青春期保健、婚前保健、圍產(chǎn)期保健、計(jì)劃生育、老年常見(jiàn)健康問(wèn)題等。四是要加大中醫(yī)課程學(xué)時(shí)，提高學(xué)生的中醫(yī)藥診治能力。五是要開(kāi)設(shè)常用護(hù)理操作課程，加強(qiáng)學(xué)生護(hù)理操作技能訓(xùn)練。在教學(xué)內(nèi)容的設(shè)置上，應(yīng)以“必須、基本、常見(jiàn)、適用”為原則，充分體現(xiàn)實(shí)用性特點(diǎn)。通過(guò)教學(xué)使學(xué)生掌握全科醫(yī)學(xué)的基本理論、基本知識(shí)和基本技能，熟悉全科醫(yī)療的診療思維模式，提高學(xué)生對(duì)社區(qū)常見(jiàn)健康問(wèn)題和疾病的防治能力，能夠運(yùn)用生物-心理-社會(huì)醫(yī)學(xué)模式，向個(gè)人、家庭、社區(qū)提供公共衛(wèi)生和基本醫(yī)療服務(wù)。在

15、教學(xué)組織和運(yùn)行上，最好是獨(dú)立開(kāi)班，如受到教學(xué)資源和條件的限制，也可考慮“前期趨同，后期分化”的模式。 2.最低教育標(biāo)準(zhǔn)。最低教育標(biāo)準(zhǔn)的制定，必須以本科臨床醫(yī)學(xué)專業(yè)教育標(biāo)準(zhǔn)為準(zhǔn)則，但在內(nèi)容上只需提出對(duì)培養(yǎng)結(jié)果的基本要求，即畢業(yè)生在思想道德與職業(yè)素質(zhì)、專業(yè)知識(shí)和實(shí)踐技能三個(gè)方面應(yīng)達(dá)到的基本要求，無(wú)需提出對(duì)培養(yǎng)過(guò)程的規(guī)范。 二、加強(qiáng)免費(fèi)定向全科醫(yī)學(xué)生學(xué)習(xí)態(tài)度和興趣的培養(yǎng) 免費(fèi)定向全科醫(yī)學(xué)生入學(xué)前已經(jīng)和衛(wèi)生行政部門簽訂了定向就業(yè)協(xié)議，學(xué)生不擔(dān)心就業(yè)問(wèn)題。這將影響到學(xué)生在院校期間的學(xué)習(xí)態(tài)度和興趣，影響培訓(xùn)質(zhì)量。如學(xué)生在校學(xué)習(xí)期間學(xué)習(xí)成績(jī)差，出現(xiàn)留級(jí)或退學(xué)，將無(wú)法正常完成學(xué)業(yè)，影響基層衛(wèi)生機(jī)構(gòu)用人；如學(xué)生

16、畢業(yè)后不能通過(guò)執(zhí)業(yè)醫(yī)師和全科醫(yī)師資格考試，不具備崗位資格，將無(wú)法達(dá)到國(guó)家開(kāi)展此項(xiàng)目的最終目標(biāo)。在校出現(xiàn)留級(jí)或退學(xué)，可以通過(guò)建立補(bǔ)充機(jī)制來(lái)解決，如由省級(jí)教育行政部門協(xié)調(diào)允許同?；蛲?nèi)臨床醫(yī)學(xué)專業(yè)學(xué)生自主申報(bào)補(bǔ)充名額。但如學(xué)生畢業(yè)后始終無(wú)法通過(guò)執(zhí)業(yè)考試，這將直接影響到免費(fèi)培養(yǎng)工作規(guī)劃目標(biāo)的實(shí)現(xiàn)。所以，如何激發(fā)學(xué)生的學(xué)習(xí)興趣，端正學(xué)生的學(xué)習(xí)態(tài)度，培養(yǎng)自主學(xué)習(xí)能力，保證人才培養(yǎng)質(zhì)量是培養(yǎng)免費(fèi)定向醫(yī)學(xué)生需要解決的重要問(wèn)題。應(yīng)從培養(yǎng)院校和用人單位兩方面入手加以解決。 1.培養(yǎng)院校。一是在學(xué)生入學(xué)階段，開(kāi)設(shè)導(dǎo)論課，一方面向?qū)W生介紹國(guó)家開(kāi)展此項(xiàng)目的目的和意義，讓學(xué)生了解相關(guān)的政策和措施，另一方面讓學(xué)生在專業(yè)

17、學(xué)習(xí)前全面了解全科醫(yī)學(xué)的概念、范疇、歷史和發(fā)展現(xiàn)狀，激發(fā)學(xué)生的學(xué)習(xí)興趣，認(rèn)識(shí)到全科醫(yī)學(xué)的重要性。二是在思想政治教育課程中，加入愛(ài)崗敬業(yè)教育，讓學(xué)生真正能夠深入基層、扎根基層、服務(wù)基層，為基層衛(wèi)生機(jī)構(gòu)創(chuàng)造價(jià)值。三是在專業(yè)課教學(xué)中，加強(qiáng)學(xué)生自主學(xué)習(xí)能力的培養(yǎng)，培養(yǎng)學(xué)生的自學(xué)能力、分析問(wèn)題的能力和解決問(wèn)題的能力，使學(xué)生會(huì)做人、會(huì)做事、會(huì)學(xué)習(xí)、會(huì)創(chuàng)新。把職業(yè)指導(dǎo)和職業(yè)素質(zhì)教育貫穿于培養(yǎng)和教育的全過(guò)程，促進(jìn)學(xué)生個(gè)性和才能的全面發(fā)展。 2.用人單位。作為共同利益者，用人單位一方面要全程追蹤人才培養(yǎng)過(guò)程，了解學(xué)生在校學(xué)習(xí)期間的綜合表現(xiàn)，與免費(fèi)定向醫(yī)學(xué)生經(jīng)常接觸，提出學(xué)業(yè)要求，另一方面要全程參與人才培養(yǎng)重大事

18、項(xiàng)的決策，為優(yōu)化免費(fèi)定向醫(yī)學(xué)生培養(yǎng)過(guò)程提供有價(jià)值、有意義的意見(jiàn)和建議。 三、加強(qiáng)基層實(shí)習(xí)基地建設(shè) 臨床實(shí)踐和社區(qū)實(shí)踐（鄉(xiāng)鎮(zhèn)衛(wèi)生院）是全科醫(yī)學(xué)培訓(xùn)的重要內(nèi)容，目前，在綜合性醫(yī)院無(wú)法全部完成免費(fèi)定向醫(yī)學(xué)生的全科醫(yī)學(xué)實(shí)習(xí)，必須建立相應(yīng)的基層實(shí)踐教學(xué)基地?？煽紤]由省級(jí)衛(wèi)生行政部門協(xié)調(diào)，幫助培養(yǎng)院校將免費(fèi)定向醫(yī)學(xué)生的就業(yè)單位建設(shè)為院校實(shí)踐教學(xué)基地。免費(fèi)定向醫(yī)學(xué)生實(shí)習(xí)分為兩個(gè)部分，前一部分在綜合性醫(yī)院進(jìn)行，后一部分在其就業(yè)單位完成。學(xué)生完成綜合性醫(yī)院實(shí)習(xí)后直接到其就業(yè)單位進(jìn)行全科醫(yī)學(xué)實(shí)習(xí)，讓學(xué)生早接觸工作實(shí)際，提前進(jìn)入工作角色。 四、建立順暢的畢業(yè)后教育機(jī)制 免費(fèi)醫(yī)學(xué)定向生的畢業(yè)后教育是其提高自身素質(zhì)、達(dá)

19、到執(zhí)業(yè)標(biāo)準(zhǔn)、獲得執(zhí)業(yè)資格的重要途徑。一是要加大畢業(yè)后教育和培訓(xùn)力度，以住院醫(yī)師培訓(xùn)、全科醫(yī)師規(guī)范化培訓(xùn)為重點(diǎn)，建立有效的畢業(yè)后教育和培訓(xùn)機(jī)制，使其能力和素質(zhì)逐漸提高，不斷進(jìn)步。二是要出臺(tái)讓其在基層踏實(shí)工作的政策。如：制定全科醫(yī)師執(zhí)業(yè)標(biāo)準(zhǔn)，明確全科醫(yī)師注冊(cè)制度，建立全科醫(yī)生職稱系列等。這樣才標(biāo)志著全科醫(yī)生這支新興力量在衛(wèi)生技術(shù)隊(duì)伍中、在衛(wèi)生法規(guī)和人才管理層面上的認(rèn)可，才能夠?yàn)榛鶎有l(wèi)生人才指明自身發(fā)展與提高的方向。 開(kāi)展農(nóng)村訂單定向醫(yī)學(xué)生免費(fèi)培養(yǎng)工作是國(guó)家貫徹以全科醫(yī)生為重點(diǎn)的基層醫(yī)療衛(wèi)生隊(duì)伍建設(shè)規(guī)劃的重大舉措，將推動(dòng)農(nóng)村衛(wèi)生服務(wù)和全科醫(yī)學(xué)教育工作的深入開(kāi)展。培養(yǎng)工作能否達(dá)到預(yù)期效果, 根本問(wèn)題不

20、在于政策的導(dǎo)向，而在于政策執(zhí)行者對(duì)政策的審視和投入。農(nóng)村訂單定向醫(yī)學(xué)生免費(fèi)培養(yǎng)工作才剛剛開(kāi)始，隨著實(shí)施范圍的擴(kuò)大和進(jìn)展的深入，會(huì)遇到更多的困難和阻力, 對(duì)此各級(jí)行政部門、培養(yǎng)院校和用人單位都要以高度負(fù)責(zé)的精神和務(wù)實(shí)的工作作風(fēng)應(yīng)對(duì)可能出現(xiàn)的各種問(wèn)題，認(rèn)真總結(jié)經(jīng)驗(yàn)，努力尋找最佳的培養(yǎng)路徑, 快速建立起一支醫(yī)德高、素質(zhì)好、專業(yè)精的基層衛(wèi)生隊(duì)伍。ICU獲得性感染26、我們像鷹一樣，生來(lái)就是自由的，但是為了Dept of Critical Care MedicinePeking Union Medical College HospitalICU-acquired Infection and Strate

21、gy of Antibiotic TherapyDept of Critical Care MedicineCost of Hospital Stay Associated with ResistanceCost of Hospital Stay AssociatNosocomial Infection in ICUan overall risk of 18% of acquiring an infection during ICU stayone of the most common causes of death in ICUsNosocomial Infection in ICUan N

22、osocomial Infection in ICUEuropean Prevalence of Infection in Intensive Care Study (EPIC)Held on April 29, 1992an overall of 9567 patientsfrom 1417 ICUsNosocomial Infection in ICUEurEPIC Dataa total of 45% of patients had an infectionICU-acquired infection21%community-acquired infection14%hospital-a

23、cquired infection other than ICU10%EPIC Dataa total of 45% of patNosocomial InfectionVincent et al. JAMA 1995; 374: 639-644 (EPIC)Nosocomial InfectionVincent eNosocomial Infection in ICUPredisposing risk factorsprolong length of ICU stayantibiotic usagemechanical ventilationurinary catheterizationpu

24、lmonary artery catheterizationcentral venous accessstress ulcer prophylaxisuse of steroidnutritional statusNosocomial Infection in ICUPreNosocomial Infection in ICUNosocomial Infection in ICUNosocomial Infection in ICUUse of Antibiotics - EPIC dataof 10,038 patients, 62% received antibiotics for eit

25、her prophylaxis or treatmentNosocomial Infection in ICUUseNosocomial Infection in ICUPrevious exposure to antibioticsmodify intestinal flora, leading to colonization with resistant bacteria3rd generation cephalosporinsfluoroquinolonesvancomycinfavor the selection of inducible beta-lactamase producin

26、g GNB, such as Pseudomonoas aeruginosa, Enterobacter clocae, Serratia spp., and Citrobacter freundiiNosocomial Infection in ICUPreNosocomial Infection in ICUCommon pathogens community-acquired infection and early ( 4d) hospital-acquired infectionsEnterobacter spp.Serratia spp.ESBL-producing microorg

27、anismsPseudomonas aeruginosaAcinetobacter spp.MRSAenterococcifungiNosocomial Infection in ICUComEPIC Datamost common pathogensS. aureus30%P. aeruginosa29%Coagulase-negative staphylococci19%E. coli13%Enterococcus spp.12%EPIC Datamost common pathogensICU獲得性感染81張課件ICU獲得性感染81張課件Emerging PathogensData fr

28、om ICU, PUMCH 1999Emerging PathogensData from ICEmerging PathogensEmerging PathogensMechanism of Resistance to Beta-lactam AntibioticsDepartment of Critical Care MedicinePeking Union Medical College HospitalMechanism of Resistance to BetPrinciple of beta-lactam actiona rigid bacterial cell wall prot

29、ects bacteria from mechanical and osmotic insultbeta-lactam inhibits PBPspreventing formation of the peptide bridgesproducing weakened wallactivating cell wall degrading enzymes - autolysinbeta-lactam interferes with normal cell wall biosynthesis, causing impaired cellular function, altered cell mor

30、phology or lysisPrinciple of beta-lactam actioMechanism of Antibiotic ResistanceMechanism of Antibiotic ResistDoes beta-lactamase confer resistance?The amount of enzyme productsits ability to hydrolyse the antibiotic in questionits interplay with the cellular permeability barriersDoes beta-lactamase

31、 confer resInducible Beta-lactamasealso called class I beta-lactamase or constitutive beta-lactamase or AmpC beta-lactamasemost are chromosome-mediatedmajor producersPseudomonas aeruginosaEnterobacter sp.Citrobacter sp.Serratia sp.Morganella morganniiInducible Beta-lactamasealso cInducible Beta-lact

32、amasetransient elevation in beta-lactamase synthesis when a beta-lactam is presentenzyme production returns to a low level when the inducer is removedlow level insufficient to protect bacteria even against drugs rapidly hydrolysed by the enzymesenzyme hyperproducer = mutants that produce Class I enz

33、ymes continuously at a high levelInducible Beta-lactamasetransiInducible Beta-lactamaseInduction is lost within 4 to 6 hrs once the strong inducer is removed.Little need for concern if therapy with a strong inducer is discontinued and the drug replaced by a weak inducer.Inducible Beta-lactamaseInduc

34、tActivity of Drugs Against Organisms with Elevated Beta-Lactamase LevelsDecreased ActivityMonobactamsSecond-, Third-generation cephalosporinsBroad-spectrum penicillinsMaintain ActivityImipenem, MeropenemFourth-generation cephalosporinsCiprofloxacin, ofloxacin, etcSMZ/TMPco (except P. Aeruginosa)Amin

35、oglycosidesActivity of Drugs Against OrgaAntibiogram of EnterobacterAntibiogram of EnterobacterEnterobacter Bacteremia: Clinical Features and Emergence of Antibiotic Resistance during TherapyChow JW, et alAnn Int Med 1991; 115: 585-90Enterobacter Bacteremia: CliniMultiresistant Enterobacter*Antibiot

36、ics received in the 2 weeks before the initial positive blood cultureAssociation of Previously Administered Antibiotics withMultiresistant Enterobacter in the Initial Blood CultureMultiresistant Enterobacter*AnMultiresistant EnterobacterEmergence of Resistance to Cephalosporin, Aminoglycoside, and O

37、ther Beta-Lactam Therapy* Cefotaxime, ceftazidime, ceftriaxone, ceftizoxime* Gentamicin, tobramicin, amikacin, netilmicin* Imipenem, piperacillin, ticarcillin, aztreonam, mezlocillin, ticarcillin-clavulanateMultiresistant EnterobacterEmeMultiresistant EnterobacterFactors Associated with Mortality in

38、 Patients with Enterobacter BacteremiaMultiresistant EnterobacterFacExtended spectrum beta-lactamaseMost are plasmid mediated1 to 4 amino acid changes from broad-spectrum beta-lactamases, therefore greatly extending substrate rangeMajor producersE. Coli (TEM)Klebsiella sp. (SHV)inhibited by beta-lac

39、tamase inhibitorsExtended spectrum beta-lactamaReliable (relatively) agents for ESBL-producing pathogensCarbapenemsAmikacinCephamycins (except MIR-1 type; 30% of strains)Beta-lactamase inhibitorspip/tazo30% R in Chicago 199626% R in ICU, PUMCH 1999Reliable (relatively) agents fAntibiogram of E. coli

40、Antibiogram of E. coliAntibiogram of KlebsiellaAntibiogram of KlebsiellaPrevalence of CAZ-R KlebsiellaFrom Itokazu G, et al. Nationwide Study of Multiresistance Among Gram-Negative Bacilli from ICU patientsClinical Infectious Diseases 1996; 23: 779-85Prevalence of CAZ-R KlebsiellaCross-Resistance in

41、CAZ-R KlebsiellaFrom Itokazu G, et al. Nationwide Study of Multiresistance Among Gram-Negative Bacilli from ICU patientsClinical Infectious Diseases 1996; 23: 779-85Cross-Resistance inCAZ-R KlebPrevalence of ESBLData from Intensive Care Unit, Peking Union Medical College Hospital, 1999Prevalence of

42、ESBLData from InCross-Resistance inCAZ-R KlebsiellaData from Intensive Care Unit, Peking Union Medical College Hospital, 1995-1999Cross-Resistance inCAZ-R KlebEffect of ESBL on MortalityAnalysis of mortality in 216 bacteremic patients caused by Klebsiella pneumoniaePatterson et al. 37th ICAAC, 1997,

43、 Abstr J-210Effect of ESBL on MortalityAnaEffect of ESBL on MortalityPatterson et al. 37th ICAAC, 1997, Abstr J-210Empiric antibiotic therapy in 32 bacteremic patients caused by ESBL-positive Klebsiella pneumoniaeEffect of ESBL on MortalityPatMolecular Epidemiology of CAZ-R E. Coli and K. Pneumoniae

44、 Blood IsolatesSchiappa D, et alRush University and University of Illinois, Chicago ILJournal of infectious Diseases 1996; 174: 529-37Molecular Epidemiology of CAZ-Risk Factors for CAZ-RKlebsiella BacteremiaRisk Factors for CAZ-RKlebsieCAZ-R Klebsiella Bacteremia* p = 0.02Outcome of Patients with CA

45、Z-R Bacteremia Who Received Appropriate vs. Inappropriate Therapy Within 72 Hours of Bacteremic EventCAZ-R Klebsiella Bacteremia* pCeftazidime - emergence of resistanceEmergence of Antibiotic-Resistant Pseudomonas aeruginosa: Comparison of Risks Associated with Different Antipseudomonal Agentsby Car

46、meli Y, et al.Antimicrobial Agents and Chemotherapy 1999; 43 (6): 1379-82Ceftazidime - emergence of reCeftazidime - emergence of resistancea 320-bed urban tertiary-care teaching hospital in Boston, Mass.11,000 admissions per year4 study agents with antipseudomonal activityceftazidime, ciprofloxacin,

47、 imipenem, piperacillina total of 271 patients (followed for 3,810 days) with infections due to P. Aeruginosa were treated with the study agentsresistance emergence in 28 patients (10.2%), with an incidence of 7.4 per 1,000 patient-daysCeftazidime - emergence of reCeftazidime - emergence of resistan

48、ceTable. Multivariable Cox hazard models for the emergence of resistance to any of the four study drugsCeftazidime - emergence of reClassification of Antibiotic TherapyProphylactic UseTherapeutic UseEmpiric therapyDefinitive therapyClassification of Antibiotic TEmpiric Antibiotic TherapyDepartment o

49、f Critical Care MedicinePeking Union Medical College HospitalEmpiric Antibiotic TherapyDepaEmpiric Antibiotic TherapyWhen treating seriously ill patients who are at risk of developing septic shockwhen pathogens are unknown or not confirmedantibiotic selection according toepidemiology of NI in the wa

50、rdresistance profile of most common pathogensEmpiric Antibiotic TherapyWhenEmpiric Antibiotic TherapySearching for infection focuscollecting samples for culturestarting empiric antibiotic therapy as soon as possiblereferring to definitive antibiotic therapy as soon as possibleEmpiric Antibiotic Ther

51、apySearAntibiotic Therapy and PrognosisObjective: To evaluate the relationship between the adequacy of antibiotic treatment for BSI and clinical outcomes among ICU ptsDesign: Prospective cohort studySetting: A medical ICU (19 beds) and a surgical ICU (18 beds) from a university-affiliated urban teac

52、hing hospitalPatients: 492 pts from July 1997 to July 1999Intervention: NoneAntibiotic Therapy and PrognosAntibiotic Therapy and Prognosis147 (29.9%) pts received inadequate antimicrobial treatment for their BSIThe most commonly identified bloodstream pathogens and their associated rates of inadequa

53、te antimicrobial treatment includedvancomycin-resistant enterococci (n = 17; 100%)Candida species (n = 41; 95.1%)MRSA (n = 46; 32.6%)SCoN (n = 96; 21.9%)Pseudomonas aeruginosa (n = 22; 10.0%) Antibiotic Therapy and PrognosAntibiotic Therapy and PrognosisHospital mortality ratepts with a BSI receivin

54、g inadequate antimicrobial tx(61.9%)pts with a BSI receiving adequate antimicrobial tx(28.4%)(RR, 2.18; 95% CI, 1.77 to 2.69; p 0.001)Independent determinant of hospital mortality by multiple logistic regression analysisadministration of inadequate antimicrobial tx(OR, 6.86; 95% CI, 5.09 to 9.24; p

55、0.001)Antibiotic Therapy and PrognosAntibiotic Therapy and PrognosisIndependent predictor of the administration of inadequate antimicrobial tx by multiple logistic regression analysisBSI attributed to Candida species(OR, 51.86; 95% CI, 24.57 to 109.49; p 0.001)prior administration of antibiotics dur

56、ing the same hospitalization(OR, 2.08; 95% CI, 1.58 to 2.74; p = 0.008)decreasing serum albumin concentrations (1-g/dL decrements) (OR, 1.37; 95% CI, 1.21 to 1.56; p = 0.014)increasing central catheter duration (1-day increments) (OR, 1.03; 95% CI, 1.02 to 1.04; p = 0.008)Antibiotic Therapy and Prog

57、nosInappropriate empiric antibiotic therapyObjective:to assess the incidence, risk, and prognosis factors of NP acquired during mechanical ventilation (MV)Settingsa 1,000-bed teaching hospitalApril 1987 through May 1988Patients78 (24%) episodes of NP in 322 consecutive mechanically ventilated patien

58、tsInappropriate empiric antibiotInappropriate empiric antibiotic therapyFrom: Torres et al. Incidence, risk, and prognosis factors of nosocomial pneumonia in mechanically ventilated patients. Am Rev Respir Dis 1990 Sep;142(3):523-8Inappropriate empiric antibiotDifficulty in empiric antibiotic therap

59、yObjective:To assess the frequency of and the reasons for changing empiric antibiotics during the treatment of pneumonia acquired in ICUDesign:A prospective multicenter study of 1 years durationSetting:Medical and surgical ICUs in 30 hospitals all over Spain.Patients:Of a total of 16,872 patients in

60、itially enrolled into the study, 530 patients developed 565 episodes of pneumonia after admission to the ICU.Difficulty in empiric antibiotDifficulty in empiric antibiotic therapyEmpiric antibiotics in 490 (86.7%) of the 565 episodes of pneumoniaThe most frequently used antibioticsamikacin120 casest