1 / 22

抗生素的降阶梯治疗

抗生素的降阶梯治疗. 吴东 北京协和医院内科. 人类的历史是与感染抗争的历史. 抗生素：新纪元还是旧轮回？. Sir Alexander Fleming ( 1881.8.6 – 1955.3.11) isolated the antibiotic substance penicillin from the fungus Penicillium notatum in 1928, for which he was rewarded the Nobel Prize in Physiology or Medicine in 1945. 过度使用抗生素的危害.

quant
Download Presentation

抗生素的降阶梯治疗

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 抗生素的降阶梯治疗 吴东 北京协和医院内科

  2. 人类的历史是与感染抗争的历史

  3. 抗生素：新纪元还是旧轮回？ Sir Alexander Fleming ( 1881.8.6 – 1955.3.11) isolated the antibiotic substance penicillin from the fungus Penicillium notatum in 1928, for which he was rewarded the Nobel Prize in Physiology or Medicine in 1945.

  4. 过度使用抗生素的危害 By constantly killing off the good guys as collateral damage, antibiotic-resistant bacteria that now have no competition for growth. Tactically, you may be winning many health battles, but you will lose the war. — Laurance Johnston

  5. 耐药性与使用抗生素有关

  6. 应用抗生素时机与感染病死率 Crit Care Med, 2006, 34: 1589-1596

  7. 中重度感染的迅速处理 初步评估 复苏 继续评估 1个小时之内 相关检查 病原学标本 抗生素

  8. 早期充分治疗的重要性 ( VAP ) • 在得到细菌学资料前进行早期充分治疗，可以改善病死率。适当的抗生素治疗一旦延误，不能改善预后 • 即使BAL得到准确病原学资料，仍不能影响预后 * * 病死率% * P<0.01 Chest, 1997,111: 676-685.

  9. 早期充分治疗的重要性 ( ESBL阳性菌 ) 7/14 OR = 4.701 P = 0.016 14/71 Intensive Care Med, 2002, 28: 1718-1723

  10. 经验性和针对性抗生素

  11. 抗生素的治疗用量 北京协和医院抗生素用量 • -内酰胺类占所有抗生素消耗量的51.8% • 最常应用的经验性抗生素: • 亚胺培南 甲硝唑 • 三代头孢 氟康唑 • 万古霉素 喹诺酮

  12. 指南意见 2008战胜全身性感染指南 Crit Care Med, 2008, 36: 296-327

  13. 经验性抗生素应该如何选择

  14. 经验性抗生素应该如何选择

  15. 病例 • ♂, 57岁, 39.5℃×5天, 呼吸困难, 黄痰, 右上腹痛. • PMH: DM未控制. • T 39.8℃, HR 112, R 28, BP 125/70. 右下肺罗音. • 132 125 98 210 17.2 86 23.3 38 2.8 16 12.6 • 痰培养和血培养已送. • CT: 双肺多发浸润影，有空洞，肝内多发低密度灶. • ABG ( NC 5L/min ) : 7.24 / 28 / 65 / 15.8

  16. 病例

  17. 病例 • 重症CAP; I 型呼衰; 肝脓肿; 酮症酸中毒； • 泰能 0.5 Q8h; 补液, 补钾, 降糖； • T 38.2℃, HR 98, R 20, BP 135/75； • 痰培养及血培养均 ( - )； • 因病原未明，予经皮肺穿。

  18. 病例

  19. 病例 • 明确诊为播散性奴卡菌病； • 将泰能 0.5 Q8h降阶梯为TMP/SMZ 3# tid； • 病情逐步好转，随诊CT病灶明显吸收。

  20. 病例

  21. 病例

  22. 小结 • 降阶梯治疗对象: 有器官功能障碍的中重度感染; • 正确的早期经验性抗生素是改善预后的关键; • 经验性抗生素的选择需考虑感染和宿主因素; • 在使用抗生素之前留取培养, 争取为后期治疗提供坚实的资料; • 及时降阶梯治疗可能有助于控制抗生素使用, 减少耐药.

More Related