復(fù)雜腹腔感染

復(fù)雜腹腔感染第1頁/共35頁IAI相關(guān)指南theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,2002IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；Clinical

InfectiousDiseases2010;50:133–64InfectiousDiseasesSocietyofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.2008;41:279-281第2頁/共35頁腹腔感染(IAI)概述過去一個(gè)世紀(jì)IAI治療取得巨大進(jìn)步，死亡率顯著下降90%in1900to23%in2002IAI不同來源感染的死亡率

appendix(0.25%)stomach/duodenum(21%)pancreas(33%)smallbowel(38%)largebowel(45%)biliarytract(50%)JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74?supplement4august2007第3頁/共35頁IAI定義分類f.M.pieracci,p.S.barie,ManageMentofSevereSepSiSofabdoMinalorigin,ScandinavianJournalofSurgery96:184–196,2007第4頁/共35頁單純腹腔感染復(fù)雜腹腔感染Intra-abdominalinfectionsalsocanbecategorizedasuncomplicatedversuscomplicated,althoughthedistinctionisnotalwaysclearJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007第5頁/共35頁UncomplicatedIAI單純性腹腔感染僅累及1個(gè)器官,而且沒有解剖結(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BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Drugs.2005;65(12):1611-20

第6頁/共35頁復(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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007BlotS,DeWaeleJJ.

Criticalissuesintheclinicalmanagementofcomplicatedintra-abdominalinfections.Drugs.2005;65(12):1611-20

第7頁/共35頁細(xì)菌性腹膜炎分類原發(fā)性腹膜炎繼發(fā)性腹膜炎第三型腹膜炎JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007第8頁/共35頁P(yáng)rimarybacterialperitonitis指腹腔沒有破口的自發(fā)性腹膜炎更多見于嬰幼兒、肝硬化及免疫抑制的病人第9頁/共35頁Secondarybacterialperitonitis繼發(fā)性腹膜炎是腸源細(xì)菌通過胃腸道穿孔泄漏入腹腔導(dǎo)致的感染炎癥Itmaybecommunity-acquiredorhealthcare–associated.第10頁/共35頁Tertiaryperitonitis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第11頁/共35頁社區(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第12頁/共35頁醫(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，還有念珠菌第13頁/共35頁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,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005第14頁/共35頁腹腔感染常見致病菌胃、十二指腸、近端小腸與膽道：革蘭陰性或陽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、腸球菌亦常見第15頁/共35頁P(yáng)athogensassociatedwithperitonitisJOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74?supplement4august2007第16頁/共35頁cIAI綜合治療策略液體復(fù)蘇、感染源控制(ie,surgicaldebridement,drainage,andrepair)、適當(dāng)系統(tǒng)地抗感染是cIAI治療成功的主要部分沒有感染源的控制，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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007第17頁/共35頁cIAI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)耐藥第18頁/共35頁社區(qū)獲得性腹腔感染應(yīng)選擇對(duì)腸源性革蘭氏陰性專性或兼性需氧菌有效或針對(duì)β-內(nèi)酰胺類敏感革蘭氏陽性球菌源于遠(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)獲得性腹腔感染無益高危病人選擇廣譜抗生素JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007第19頁/共35頁

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005第20頁/共35頁cIAI危險(xiǎn)分層JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfectionsCLEVELANDCLINICJOURNALOFMEDICINEVOLUME74?SUPPLEMENT4AUGUST2007第21頁/共35頁High-severityIAIAdvancedage;poornutrition;lowserumalbumin;pre-existingdisorders,suchassignifcantcardiovasculardisease;higherAcutePhysiologyAndChronicHealthEvaluationIIscores(≥15);inadequatesourcecontrolduringtheinitialoperativeprocedure;resistantnosocomialmicroorganisms;immunosuppressionresultingfrommedicaltherapyfortransplantation,cancer,orinfammatorydisease;orotheracute/chronicdiseasesofdiffcult-to-defneimmunosuppressionIDSofTaiwan;TaiwanSurgicalSocietyofGastroenterology,etal,Guidelinesforantimicrobialtherapyofintra-abdominalinfectionsinadults,JMicrobiolImmunolInfect.2008;41:279-281第22頁/共35頁氨基糖苷類氨基糖苷類不推薦作為社區(qū)獲得性腹腔感染的常規(guī)治療(A-1)氨基糖苷類根據(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的治療應(yīng)該個(gè)體化(A-1)第23頁/共35頁抗厭氧菌藥物藥物敏感試驗(yàn)提示Bacteroidesfragilis對(duì)下列藥物普遍耐藥clindamycin,cefotetan,cefoxitin,andquinolones

上述藥物不能單藥治療B.fragilis第24頁/共35頁第三型及醫(yī)院獲得性腹腔感染耐藥菌感染更常見病原體類似于其他院內(nèi)感染治療基于局部常見院感菌種及耐藥情況院內(nèi)感染考慮覆蓋腸球菌是合適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JOHNA.WEIGELT,MD,Empirictreatmentoptionsinthemanagementofcomplicatedintra-abdominalinfections,clevelandclinicjournalofmedicinevolume74?supplement4august2007MAZUSKIJE,Antimicrobialtreatmentforintra-abdominalinfections.ExpertOpinPharmacother.2007Dec;8(17):2933-45第25頁/共35頁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,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005第26頁/共35頁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-infectivetherapyforCandidashouldbewithhelduntiltheinfectingspeciesisidenti?ed(C-3).

10版有較大修正分離到白念則選擇氟康唑(B-2)氟康唑耐藥的念珠菌可選擇amphotericinB,caspofungin,orvoriconazole(B-3).腎功能不全選擇后二者(A-1).

IDSA,theSurgicalInfectionSociety,theAmericanSocietyforMicrobiology,andtheSocietyofInfectiousDiseasePharmacists,GuidelinesfortheSelectionofAntiinfectiveAgentsforComplicatedIntra-abdominalInfections，CID2003,37:997–1005第27頁/共35頁何時(shí)開始抗感染治療應(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)即開始抗生素治療抗感染的目標(biāo)是清除感染病原體、減少復(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，其腎毒性會(huì)因腎灌注不足而加重第28頁/共35頁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(Level1)以及胃腸穿孔24h內(nèi)修補(bǔ)的病人(Level3)不認(rèn)為已經(jīng)合并IAI，僅需給予24h或更短的預(yù)防用藥炎癥病灶能夠完全移除的病人如沒有穿孔的急性或壞疽性闌尾炎或膽囊炎，或者沒有發(fā)生穿孔或腹膜炎的腸梗阻或腸壞死，也僅需給予24h或更短的預(yù)防用藥(Level2)已經(jīng)合并廣泛IAI的上述病人應(yīng)該給予超過24h的抗感染治療(Level3).theTherapeuticAgentsCommitteeoftheSurgicalInfectionSociety,TheSurgicalInfectionSocietyGuidelinesonAntimicrobialTherapyforIntra-AbdominalInfections:AnExecutiveSummary,SURGICALINFECTIONSVolume3,Number3,2002第29頁/共35頁81.Theadministrationofprophylacticantibioticstopatientswithseverenecrotizingpancreatitispriortothediagnosisofinfectionisnotrecommended(A-I).DiagnosisandManagementofComplicatedIntra-abdominalInfectioninAdultsandChildren:GuidelinesbytheSurgicalInfectionSocietyandtheInfectiousDiseasesSocietyofAmerica；Clinical

InfectiousDiseases2010;50:133–64第30頁/共35頁抗感染療程大多數(shù)IAI的抗感染治療不應(yīng)該超過5(Level2)to7days(Level3).抗感染療程可基于術(shù)中介入時(shí)發(fā)現(xiàn)的情況(Level3).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(Level2).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，而非簡單延長抗感染時(shí)間(Level3).感染源不能充分控制時(shí)，延長抗感染時(shí)間或許管用(Level3).theTherapeuticAge