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三、临床病情的判定 PowerPoint PPT Presentation


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三、临床病情的判定. 发热(  38  C )或低温(  36  C ) 寒战 白细胞增多(计数大于 10 , 000  10 9 /L ,特别有 “ 核 左移 ” 未成熟的或杆状核的白细胞) 粒细胞减少(成熟的多核白细胞 <1000  10 9 /L ) 血小板减少 皮肤粘膜出血 昏迷 ,休克 多器官衰竭 CRP 升高. 患者,男性, 58 岁, 因右上腹不适一周伴发热五天 (头孢呋辛 4 天)

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三、临床病情的判定

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5526182

38C36C

10000109/L

<1000109/L

CRP


5526182

58

4

16.2 *10E9/L, N(92%)

CRP218mg/L

ESBLs


5526182


5526182

G

G


5526182

  • SSI

    • SSI15%

    • SSI35%~40%

  • 20064423 -1594-1596


    5526182

    • 3010

    • 39

    • 2.310E9/LCRP65mg/L


    5526182

    • 47

    • 2008.3.26


    5526182

    • 2008.3.21


    5526182

    • WBC 0.7510E9/LL16Hb 103g/LPLT 1110E9/LESR 55mm/h

    • TB/DB 41.8/21.5umol/LAlb 33.8g/LALT/AST 172/146IU/L

    • CRP 19.34mg/L

    • 40mg QD10u

    • 39-40


    5526182

    • T37.4 R20/min P108/min BP114/65mmHg,6cmNS


    5526182

    2008.3.26-2008.4.1


    2008 4 2 2008 4 8

    2008.4.2-2008.4.8


    2008 4 9 2008 4 15

    2008.4.9-2008.4.15


    2008 4 16 2008 4 22

    2008.4.16-2008.4.22


    5526182

    • 3.26-4.2

    • 4.3

    • 2008.4.112*3cm1.0*1.0cm2008.4.142

    • 2008.4.15

    • 2008.4.18


    5526182

    • WBC, N%, PLT, CRP, NAP

    • 2008.3.27 2.1 58.9 30.0 19.3 300

    • 2008.4.1 1.6 59.8 113.0 2.6

    • 2008.4.7 3.7 77.8 131 2.17

    • 2008.4.11 5.6 87.5 89 6.01

    • 2008.4.14 4.0 83.2 41 26.6 200

    • 2008.4.18 1.9 46.1 96 8.69

    • 2008.4.22 2.9 50.8 223 3.6 18


    5526182

    • 3.28NAPTCR/IgH

    • B0.7*0.3cm1.0*0.3cm

    • B


    5526182

    • 4.2NAP88

    • 4.11


    5526182

    • 2008.4.12B

    • 4.18NAP3


    5526182

    • 4.22CD3+,CD5+,CD7-,CD20-,CD43+,CD79-,CD68-.

    • T


    5526182

    LCACD20 ,CD79a

    B

    B


    5526182

    1

    2

    3


    5526182

    Rello et al.

    Alvarez-Lerma

    Ibrahim et al.

    Luna et al.

    Garnacho-Montero et al.

    Valls et al.

    0

    20

    40

    60

    80

    100

    Mortality (%)

    • Rello et al. Am J Respir Crit Care Med 1997;156:196200; Alvarez-Lerma. Intensive Care Med 1996;22:387394; Ibrahim et al. Chest 2000;118:146155; Luna et al. Chest 1997;111:676685

    • Garnacho-Montero et al. Crit Care Med 2003;31:27422751; Valls et al. Chest 2003;123:16151624


    5526182

    (/)


    5526182

    Christain Gram(1884)


    5526182

    • G+coccus

    • G+

    • G+bacillus

    • G

    • G-coccus

    • G-

    • G-bacillus


    5526182

    • +

      Staphylococcus aureus

      Escherichia Coil

    • ETECEIECEHECEPEC

    • ABCGD


    5526182

    3

    • :

    • :36 :

    • :2007-11-23


    5526182

    • 10820

    • 108


    5526182

    • 2007322331CT:


    5526182


    5526182

    CT


    5526182

    1

    WBC 11.8109/LN 81.0

    WBC+

    CRP 74.4mg/LESR 45mm/h

    2008.6.22


    5526182

    2008.6.27

    39.5

    39.5

    2008.7.9


    5526182

    • 15mg BID15mg10mg

    • 1


    5526182

    • T38.9P98/R 20/BP109/74mmHg


    5526182

    • 1.

    • 2.


    5526182

    • CRP

    0.5 q8h

    4.0 q8h


    5526182

    • CRP+ASO+RFESRPPD

    • ANAAMAANCA

    • B


    5526182

    7.9

    • WBC 13.6109/LN 89.3

    • CRP6.02mg/L

    • ESR29mm/h


    5526182

    7.10

    230mmH2O


    5526182

    2008.7.10

    • 0.5 q8h0.5 q12h

    • 20125ml q8h

    • 15mg10mg


    5526182

    1


    5526182

    7.14

    30mmH2O


    Crp 7 15

    CRP7.15


    5526182

    • CT:

    • BCT


    5526182

    2


    5526182

    7.18

    150mmH2O


    5526182

    • 0.6 q6h


    5526182

    7.21

    • WBC 6.4109/LN 81.4

    • CRP2.84mg/L

    • ESR20mm/h


    5526182

    2-3

    WHY?


    5526182

    7.23

    120mmH2O


    5526182


    5526182

    7.25

    • WBC 14.2109/LN 89.3

    • CRP16.1mg/L

    • ESR22mm/h


    Mri 7 25

    MRI7.25


    5526182

    • 0.5 qd

    • 7.27CT


    5526182

    7.28

    • 23


    5526182


    5526182

    VP H2S

    +

    +

    -

    -

    -

    -

    -+

    +

    -

    -

    -

    +

    -

    +

    -

    +

    +

    +-

    +

    +

    -

    -

    -

    +

    -

    -

    +

    +

    -

    -

    -

    -

    +

    +

    -+

    -

    -

    -

    +

    +-

    +

    -

    +-

    +

    -

    V

    -+

    +-


    5526182

    -

    • -(ESBLs)

    • (AmpC)

    • ( 2f)


    Esbls

    ESBLs


    China 7 centre survey resistance community

    China : 7-Centre survey% resistance(community)

    Ling et al AAC 2006, 50, 374


    5526182

    58

    4

    16.2 *10E9/L, N(92%)

    CRP218mg/L


    32 1994 2004 nprs esbls

    32 1994-2004NPRSESBLs


    5526182

    ESBL prevalence in China

    %

    year

    Wang H, Chen M. Diagnos Microbiol Infect Dis, 2005, 51, 201-208, NPRS data

    CMS data, 10 hospitals in ChinaSEANIR, 15 hospitals in China.


    2007 chinet esbl

    2007CHINETESBL


    2007 12 3462 esbl

    2007123462ESBL%


    5526182

    2007121362ESBL%


    Esbls1

    ESBLs

    1.

    2.

    3.

    4. 85%50%


    Esbls2

    ESBLs

    Clinical Infectious Diseases 2003; 39:317


    Esbls3

    ESBLs

    • 30 Thirty-day mortality rates

      • 12.9% (8 of 62)

      • 10.3% (3 of 29

      • 26.9% (7 of 26)

      • 26.9% (7 of 26)

    ESBLs

    Bloodstream Infections Due to Extended-Spectrum

    Beta-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae:

    Risk Factors for Mortality and Treatment Outcome, with Special

    Emphasis on Antimicrobial Therapy. AAC. 2004, 48,(12),p. 45744581


    Esbls4

    ESBLs

    Bloodstream Infections Due to Extended-Spectrum

    Beta-Lactamase-Producing Escherichia coli and Klebsiella pneumoniae:

    Risk Factors for Mortality and Treatment Outcome, with Special

    Emphasis on Antimicrobial Therapy. AAC. 2004, 48,(12),p. 45744581


    5526182

    G-


    5526182

    1%2-5

    6596

    2596

    2094

    1583

    1592()

    10100(B)

    801004

    301005

    651003

    251003

    151003

    201005

    1. Gorvach SL, j Antimicrob Chemother 31:67-78,1993 2. Neu HC, E ur J Surg: 7-18, 1994.

    3. Jones RN, Challenges Infect Dis 1:1-6, 1993 4. Jones RN, Diagn Microbiol Infect Dis 12:489-494, 1989

    5.Von Rosenstiel N-A et al, Anti-infect Drugs Chemother 14:187-199


    5526182

    G-


    5526182


    5526182

    PCR

    • PCRTEM-1SHVCTX-M-1CTX-M-9OXA-48VIM OXA-10KPC-1

    • DNAPCRTEMSHVKPC

    • KPC

    • PCRTEM-1SHV-12KPC-2


    5526182


    5526182

    . 2004


    5526182


    5526182

    2007


    5526182


    5526182

    PFGE(1)


    2007 12 3988

    2007123988%


    5526182

    • /


    5526182

    CRAB

    ?


    5526182

    (A.baumanii pneumonia)

    http://www.acinetobacter.org/map/map.htm


    5526182

    1994-2004(1874)

    (%)


    Mdr ab

    MDR-AB

    http://www.acinetobacter.org/


    5526182

    (A.baumanii ) -----21MRSA

    Jawad et al. JCM 1996;34:2881-87; Jawad et al. JCM 1998;36:1938-41


    2007 12 3157

    2007123157%


    5526182

    • :

      MDRXDRPDR

    • CRPPCT

    • PK/PD


    5526182


    5526182

    • T()

    • ()


    5526182


    5526182

    FDA

    ABCDX


    5526182

    (FDA)


    5526182


    5526182


    5526182


    5526182

    • ()()


    5526182


    5526182

    1.

    ()B

    • 3.TDM()

      4.()


    5526182


    5526182

    • ()


    5526182

    (140)(kg)

    ------------------------------------- =(,ml/min)

    (mg/dl) 72

    () 0.85


    5526182

    • 5-8ml/min


    5526182


    5526182

    (1)


    5526182

    (2)


    5526182

    *

    B

    *


    5526182


    5526182

    • 35/102000

    • 25%30%


    5526182

    • B

    • A


    5526182


    5526182


    5526182

      • 57

      • 1014

      • 4

      • 46


    5526182


    5526182


    5526182


    5526182


    5526182


    5526182


    5526182


    5526182


    5526182


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