围手术期抗菌药物的使用ppt课件.ppt

围手手术期抗感染期抗感染药物物应用用 1.历史上的今天史上的今天1945年年8月月17日日溥溥仪被被苏军俘俘获1949年年8月月17日日,解放解放军攻占福州攻占福州2.1958年年8月月17日日北戴河会北戴河会议掀起全民大掀起全民大炼钢铁运运动3.1968年年8月月17日日尼日利尼日利亚内内战导致致饥荒灾荒灾难 4.1998年年8月月17日日克林克林顿承承认和莱温斯基有不正当关系和莱温斯基有不正当关系5.Question1、如何使用是合理使用抗菌药物？2、强调合理应用抗菌药物的意义何在？2010年年8月月17日日我我们一起一起讨论。6.合理合理使用抗菌药物即：在安全安全的前提下确保有效有效7.是否是否进行抗感染治行抗感染治疗？（是感染性疾病？（是感染性疾病吗）用哪一用哪一类抗感染抗感染药物？（是物？（是细菌、真菌或其他病原体感染）菌、真菌或其他病原体感染）用哪一种抗菌用哪一种抗菌药物？（是什么物？（是什么细菌引起的感染）菌引起的感染）细菌菌对所所选药物敏感物敏感吗？（近期当地耐？（近期当地耐药性性监测结果如何）果如何）用用药剂量足量足够吗？每天一次？每天一次还是分次是分次给药？（？（药物物PK/PD）静脉用静脉用药还是口服治是口服治疗？（？（药物的生物利用度）物的生物利用度）药物能达到感染部位物能达到感染部位吗？（盆腔、？（盆腔、宫颈粘液粘液药物的物的组织浓度）度）病人的身体状况能承受病人的身体状况能承受这种种药物物吗？（肝？（肝肾功能等副作用）功能等副作用）没有更便宜但效果仍良好的没有更便宜但效果仍良好的药物？（物？（药物物经济学分析）学分析）用用1周就停周就停药感染会复感染会复发吗？（用？（用药疗程程问题）会引起二重感染会引起二重感染吗？（？（对正常菌群的影响）正常菌群的影响）会出会出现耐耐药菌菌吗？（防？（防细菌耐菌耐药突突变浓度）度）临床上最困床上最困难的用的用药决策决策 抗感染治抗感染治疗选择8.细菌菌 患者患者毒性毒性药代代动力学力学药效效动力学力学防御功能防御功能感染感染耐耐药抗菌治抗菌治疗三角三角抗菌抗菌药物物9.我国每年由于我国每年由于药品使用不当品使用不当药品不良反品不良反应造成的死亡人数造成的死亡人数在在20-50万人，而其中抗菌万人，而其中抗菌药物占物占40%。耐耐药菌菌株株的的增增加加，这也也是是造造成成我我国国抗抗菌菌药物物使使用用剂量量越越来来越大、一些炎症疾病治越大、一些炎症疾病治疗困困难的重要原因之一的重要原因之一。而与耐而与耐药菌株增加迅速相菌株增加迅速相对应的残酷事的残酷事实是研究一种新的是研究一种新的抗菌抗菌药所需的所需的时间的漫的漫长，医学科研工作者在最好的研究，医学科研工作者在最好的研究条件下开条件下开发一种新的抗菌一种新的抗菌药需要需要10年的年的时间。10.NDM-1,the newly discovered superbug gene 11.12.主要主要细菌病原菌的菌病原菌的发现年代疾病细菌名称 发现人1873 麻风病 麻风分枝杆菌 汉森（Hansen,G.A.）1877 炭疽病炭疽芽孢杆菌 科赫（Koch,R.）1880 伤寒伤寒沙门氏菌 艾博斯（Eberth,C.J.）1882 结核病结核分枝杆菌 科赫（Koch,R.）1883 霍乱霍乱弧菌 科赫（Koch,R.）1884 破伤风破伤风梭菌尼可奈尔（Nicolaier,A.）1886 肺炎肺炎链球菌 佛兰克尔（Franenkel,A.）1887 脑膜炎脑膜炎奈瑟氏菌 威克塞保（Weichselbaum）1888 食物中毒肠炎沙门氏菌 格尔特内（Gaertner）1894 鼠疫鼠疫耶尔森氏菌北里（Kitasato,S.）耶尔森（Yersin）1898 痢疾痢疾志贺氏菌志贺(Shiga,K)13.科赫定理：科赫定理：首先一种病原微生物必定存在于患病首先一种病原微生物必定存在于患病动物物中。中。其次其次这种病原微生物必能从寄生主体分离种病原微生物必能从寄生主体分离到，并能到，并能获得得纯培养。培养。还有分离到的有分离到的纯培养物接种到敏感培养物接种到敏感动物身物身上，必然出上，必然出现特有的疾病症状特有的疾病症状。14.抗菌素的抗菌素的发展展简史史Alexander FlemingPenicillin 1928Nobel Prize,194515.不久的将来，青霉素不久的将来，青霉素就将在世界普及。缺乏就将在世界普及。缺乏药品知品知识的患者很容易会减的患者很容易会减少少剂量，不足以量，不足以杀灭他体他体内的所有内的所有细菌，从而使菌菌，从而使菌种种产生抗生抗药性性16.抗菌素的抗菌素的发展展简史史Gerhard Johannes Paul DomagkSulfonamides 1935 Nobel Prize,193917.抗菌素的抗菌素的发展展简史史Selman Abraham WaksmanNobel Prize,1952streptomycin 194418.大大规模模筛选抗菌素的抗菌素的时代到来代到来此后在短短的一二十年间，相继发现了金霉素(1947),氯霉素(1948)、土霉素(1950)、制霉菌素(1950)、红霉素(1952)、卡那霉素(1958)等从此，抗菌素研究进入了有目的、有计划、系统化的阶段进入60年代后，人们从微生物中寻找新的抗菌素的速度明显放慢，取而代之的是半合成抗菌素的出现抗菌素的抗菌素的发展展简史史19.20.Penicillin1941Methicillin1959vancomycin1958linezolid2000PCase producing SA 1944MRSA 1961VRE 1986Palumbi,S.R.,Science,293:1786-90,2001.VRSA 2002LRE 199921.抗菌抗菌药物的物的选择性性压力力Selective Pressure of Antibotics22.提提 纲手手术部位感染部位感染(s surgical urgical s site ite i infectionnfection，SSI)SSI)定定义及及诊断断标准准 手手术切口分切口分类手手术部位感染的部位感染的细菌学菌学预防性防性应用抗菌用抗菌药物的适物的适应症症预防性防性药物的物的选择及使用方法及使用方法23.Epidemiology of SSIsthird most frequently reported NI1416%among hospitalised patients38%among surgical patientsData from the United States Centersfor Disease Control National Nosocomial InfectionsSurveillance(CDC NNIS)system24.Impact of SSIs on healthcare resourcesa case control study involving 215 matched pairs of patients with and without SSIsRelative Risk:Death 2.2(95%CI:1.1-4.5)Readmission 5.5(95%CI:4.0-7.7)ICU treatment 1.6(95%CI:1.3-2.0)The median duration of hospitalisation:11 days VS 6 days.the median extra duration attributable to SSIs was 6.5 days(95%CI:5-8).Infect Control Hosp Epidemiol 1999;20:725 730.25.提提 纲手手术部位感染部位感染(surgical site infection(surgical site infection，SSI)SSI)定定义及及诊断断标准准 手手术切口分切口分类手手术部位感染的部位感染的细菌学菌学预防性防性应用抗菌用抗菌药物的适物的适应症症预防性防性药物的物的选择及使用方法及使用方法26.are defined as infections occurring up to 30 days after surgery(or up to one year after surgery in patients receiving implants)and affecting either the incision or deep tissue at the operation site.definitionSurgical Site Infections(SSIs)27.Types of SSI28.SSI诊断断标准准切口浅部感染切口浅部感染:(1)具有下列症状之一：疼痛或压痛，局部红、肿、热；(2)切口浅层有脓性分泌物；(3)切口浅层分泌物培养出致病菌；29.SSI诊断断标准准切口深部感染切口深部感染-累及切口深部筋膜及肌层的感染 (1)从切口深部流出脓液；(2)切口深部自行裂开或由医师主动打开，细菌培养阳性且具备下列症状体征之一：体温38，局部疼痛或压痛；(3)临床或经手术或病理组织学或影像学诊断发现切口深部有脓肿：30.SSI诊断断标准准器官腔隙感染器官腔隙感染:(1)放置于器官腔隙的引流管有脓性引流物；(2)器官腔隙的液体或组织培养有致病菌；(3)经手术或病理组织学或影像学诊断器官腔隙有脓肿；31.提提 纲手手术部位感染部位感染(surgical site infection(surgical site infection，SSI)SSI)定定义及及诊断断标准准 手手术切口分切口分类手手术部位感染的部位感染的细菌学菌学预防性防性应用抗菌用抗菌药物的适物的适应症症预防性防性药物的物的选择及使用方法及使用方法32.手手术切口的分切口的分类I类清清洁切口切口II类可能可能污染的切口染的切口III类污染切口染切口将手将手术切口分切口分为三三类：II类III类IV 既往既往33.手手术切口的分切口的分类分分类标准准I I类（清（清洁）切口）切口 手手术未未进入炎症区，未入炎症区，未进入呼吸道、及泌入呼吸道、及泌尿生殖道，以及尿生殖道，以及闭合性合性创伤手手术符合上述符合上述条件者条件者 IIII类（清（清洁污染）切口染）切口 手手术进入呼吸道、及泌尿生殖道但无明入呼吸道、及泌尿生殖道但无明显污染，例如无感染且染，例如无感染且顺利完成的胆道、胃利完成的胆道、胃肠道、阴道、口咽部手道、阴道、口咽部手术 IIIIII类（污染）切口染）切口 新新鲜开放性开放性创伤手手术：手：手术进入急性炎症入急性炎症但未化但未化脓区域；胃区域；胃肠道内容物有明道内容物有明显溢出溢出污染；无菌技染；无菌技术有明有明显缺陷（如缺陷（如紧急开胸急开胸心心脏按按压）者）者IVIV类（严重重污染染-感染）切口感染）切口 有失活有失活组织的的陈旧旧创伤手手术；已有；已有临床感床感染或染或脏器穿孔的手器穿孔的手术 34.甲状腺腺瘤切除甲状腺腺瘤切除术乳腺乳腺纤维腺瘤切除腺瘤切除术无人工植入物的腹股沟疝修无人工植入物的腹股沟疝修补术经阴道子阴道子宫切除切除术扁桃体切除扁桃体切除术35.按上述方法分按上述方法分类，不同切口感染率有，不同切口感染率有显著不同著不同清清洁切口感染切口感染发生率生率为1 1，清清洁污染切口染切口为7 7，污染切口染切口为2020，严重重污染感染切口染感染切口为4040 确切分确切分类一般在手一般在手术后作出，但外科医生在后作出，但外科医生在术前前应进行行预测，作，作为决定是否决定是否须要要预防性使用抗生素的防性使用抗生素的重要依据重要依据。36.提提 纲手手术部位感染部位感染(surgical site infection(surgical site infection，SSI)SSI)定定义及及诊断断标准准 手手术切口分切口分类手手术部位感染的部位感染的细菌学菌学预防性防性应用抗菌用抗菌药物的适物的适应症症预防性防性药物的物的选择及使用方法及使用方法37.各各类手手术最易引起最易引起SSISSI的病原菌的病原菌手手术最可能的病原菌最可能的病原菌心心脏手手术金黄色葡萄球菌、凝固金黄色葡萄球菌、凝固酶阴性葡萄球菌阴性葡萄球菌神神经外科手外科手术金黄色葡萄球菌、凝固金黄色葡萄球菌、凝固酶阴性葡萄球菌阴性葡萄球菌血管外科手血管外科手术金黄色葡萄球菌、凝固金黄色葡萄球菌、凝固酶阴性葡萄球菌阴性葡萄球菌乳房手乳房手术金黄色葡萄球菌、凝固金黄色葡萄球菌、凝固酶阴性葡萄球菌阴性葡萄球菌头颈外科手外科手术金黄色葡萄球菌、凝固金黄色葡萄球菌、凝固酶阴性葡萄球菌阴性葡萄球菌腹外疝外科腹外疝外科金黄色葡萄球菌金黄色葡萄球菌、凝固、凝固酶阴性葡萄球菌阴性葡萄球菌胃十二指胃十二指肠手手术革革兰阴性杆菌，阴性杆菌，链球菌、口咽部球菌、口咽部厌氧菌氧菌(如消化如消化链球菌球菌)胆道手胆道手术革革兰阴性杆菌，阴性杆菌，厌氧菌氧菌(如脆弱如脆弱类杆菌）杆菌）阑尾手尾手术革革兰阴性杆菌，阴性杆菌，厌氧菌氧菌(如脆弱如脆弱类杆菌）杆菌）结、直、直肠手手术革革兰阴性杆菌，阴性杆菌，厌氧菌氧菌(如脆弱如脆弱类杆菌）杆菌）泌尿外科手泌尿外科手术革革兰阴性杆菌阴性杆菌妇产科手科手术革革兰阴性杆菌，阴性杆菌，肠球菌、球菌、B族族链球菌，球菌，厌氧菌氧菌38.手手术最可能的病原菌最可能的病原菌经口咽部粘膜切口的大手口咽部粘膜切口的大手术金黄色葡萄球菌，金黄色葡萄球菌，链球菌、口咽部球菌、口咽部厌氧菌（如消化氧菌（如消化链球球菌）菌）胸胸外外科科手手术（食食管管、肺肺）金金黄黄色色葡葡萄萄球球菌菌、凝凝固固酶阴阴性性葡葡萄萄球球菌菌、肺肺炎炎链球球菌菌，革革兰阴性杆菌阴性杆菌矫形外科手形外科手术(包括用螺包括用螺钉、钢板、金属关板、金属关节置置换)金黄色葡萄球菌、凝固金黄色葡萄球菌、凝固酶阴性葡萄阴性葡萄球菌球菌、革、革兰阴性杆菌阴性杆菌各各类手手术最易引起最易引起SSISSI的病原菌的病原菌39.手手术部位感染的部位感染的细菌学菌学最常最常见的病原菌的病原菌：葡萄球菌(金黄色葡萄球菌和凝固酶阴性葡萄球菌)，其次：其次：肠道杆菌科细菌(大肠杆菌、肠杆菌属、克雷伯菌属等)。SSI的病原菌可以是内源性或外源性的，大多数是内源性的。即来自病人本身的皮肤、粘膜及空腔脏器内的细菌。皮肤携带的致病菌多数是革兰阳性球菌，但在会阴及腹股沟区，皮肤常被粪便污染而带有革兰阴性杆菌及厌氧菌。手术切开胃肠道、胆道、泌尿道、女性生殖道时，典型的SSI致病菌是革兰阴性肠道杆菌，在结直肠和阴道还有厌氧菌(主要是脆弱类杆菌)，它们是这些部位器官腔隙感染的主要病原菌。在任何部位，手在任何部位，手术切口感染大多由葡萄球菌引起。切口感染大多由葡萄球菌引起。40.S.aureus41.42.43.44.45.46.47.48.E.faecalis49.50.51.52.53.宿州眼球事件宿州眼球事件2005年年12月月11日，宿州市立医院，日，宿州市立医院，为10名患者名患者做白内障手做白内障手术。结果果10名患者均出名患者均出现感染情况，感染情况，其中其中9人的人的单眼眼球被摘除。眼眼球被摘除。54.55.P.aeruginosa56.57.提提 纲手手术部位感染部位感染(surgical site infection(surgical site infection，SSI)SSI)定定义及及诊断断标准准 手手术切口分切口分类手手术部位感染的部位感染的细菌学菌学预防性防性应用抗菌用抗菌药物的适物的适应症症预防性防性药物的物的选择及使用方法及使用方法58.如何可以减少如何可以减少围手手术期的感染？期的感染？59.Patient-relatedandprocedure-relatedfactorsthatmayinfluencetheriskofsurgicalsiteinfectionsPatient-relatedProcedure-relatedageDurationofsurgicalscrubNutritionalstatusSkinantisepsisdiabetesPreoperativeshavingsmokingPreoperativeskinpreparationobesityDurationofoperationCoexistentinfectionataremotebodysiteAntimicrobialprophylaxisColonisationwithmicro-organisms(staphylococcus aureus)OperatingroomventilationInadequatesterilisationofsurgicalinstrumentsForeignmaterialinthesurgicalsiteSurgicaldrainsSurgicaltechniquepoorhaemostasisAlteredimmuneresponsefailuretoobliteratedeadspaceLengthofpreoperativehospitalstayTissuetrauma60.容易容易导致手致手术部位感染的危部位感染的危险因素（因素（1 1）病人因素病人因素 高高龄、营养不良、糖尿病、肥胖、吸烟、免疫低下、其他部养不良、糖尿病、肥胖、吸烟、免疫低下、其他部位有感染灶、已有不正常的位有感染灶、已有不正常的细菌（如鼻孔葡萄球菌定植）、菌（如鼻孔葡萄球菌定植）、低氧血症低氧血症61.术前前处理理 术前住院前住院时间过长、用剃刀剃毛、剃毛、用剃刀剃毛、剃毛过早、手早、手术野野卫生状生状况差（况差（术前未很好沐浴）、前未很好沐浴）、对有指征者未用抗生素有指征者未用抗生素预防防容易容易导致手致手术部位感染的危部位感染的危险因素（因素（2 2）62.手手术情况情况 手手术时间长(3h)(3h)、术中中发生明生明显污染、置入人工材料、染、置入人工材料、组织创伤大、止血不大、止血不彻底、局部底、局部积血血积液、存在死腔和液、存在死腔和/或失或失活活组织、留置引流、留置引流、术中低血中低血压、大量、大量输血、刷手不血、刷手不彻底、底、消毒液使用不良、器械敷料消毒液使用不良、器械敷料灭菌不菌不彻底底容易容易导致手致手术部位感染的危部位感染的危险因素（因素（3）63.PreoperativePreoperativePreparation of the patient(1)Where possible,identify and treat remote infections,and postpone surgery until such infections have resolved(1A)(2)Do not remove hair around the operation site,unless it will interfere with the operation(1A)(3)If hair is removed,this should be done immediately before the operation,preferably with clippers(1A)(4)Adequately control blood glucose in diabetic patients,and avoid perioperative hyperglycaemia(1B)(5)Encourage tobacco cessation(1B)(6)Do not withhold necessary blood products as a means of preventing SSIs(1B)(7)Require patients to shower or bathe with an antiseptic agent on at least the night before the operation(1B)(8)Thoroughly wash and clean around the incision site to remove gross contamination before performing antiseptic skinpreparation(1B)(9)Use an appropriate antiseptic for skin preparation(1B)Hand/forearm antisepsis for surgical team members(1)Keep nails short and do not wear artificial nails(1B)(2)Perform preoperative surgical scrub for at least 2 5 min using an appropriate antiseptic.Scrub hands and forearmsup to the elbows(1B)(3)After performing the surgical scrub,keep hands up and away from the body(elbows flexed).Dry hands with a steriletowel and don sterile gown and gloves(1B)Management of infected or colonised surgical personnel(1)Educate and encourage surgical personnel who have signs and symptoms of transmissible infectious illness to reportconditions promptly to their supervisors and occupation health service(1B)(2)Develop well-defined policies concerning patient care responsibilities when personnel have potentially transmissibleinfectious conditions(1B)(3)Obtain appropriate cultures from,and exclude from duty,surgical personnel with draining skin lesions until infectionhas been ruled out or resolved(1B)(4)Do not routinely exclude personnel who are colonised with organisms such as S.aureus or Group A streptococci unlesssuch personnel have been linked epidemiologically to dissemination of the organism in the healthcare setting(1B)Antimicrobial prophylaxis(1)Administer antimicrobial prophylaxis only when indicated and select agent according to efficacy against most commonpathogens associated with a specific procedure(1A)(2)Administer initial dose intravenously,timed so that bactericidal concentrations are established in serum and tissueswhen incision is made.Maintain therapeutic concentrations in serum and tissue throughout the procedure until atmost a few hours after wound closure in the operating theatre(1A)(3)Before elective colorectal operations,mechanically prepare the colon by use of enemas and cathartic agents.Administer non-absorbable oral antimicrobial agents in divided doses on the day before the operation(1A)(4)For high-risk caesarean section,administer prophylaxis immediately after the umbilical cord is clamped(1A)(5)Do not routinely use vancomycin for antimicrobial prophylaxis(1B)64.IntraoperativeIntraoperativeVentilation(1)Maintain positive pressure in the operating theatre with respect to corridors and adjacent areas(1B)(2)Maintain at least 15 air changes per hour,of which three should be fresh air(1B)(3)Filter all air,recirculated and fresh,through appropriate filters(1B)(4)Introduce all air at the ceiling,and exhaust near the floor(1B)(5)Do not use UV radiation in the operating theatre to prevent SSI(1B)(6)Keep operating theatre doors closed except as needed for passage of equipment,personnel,and the patient(1B)Cleaning and disinfection of environmental surfaces(1)When visible soiling or contamination with blood or other body fluids of surfaces or equipment occurs during an operation,clean affected areas with disinfectant before the next operation(1B)(2)Do not perform special cleaning or closing of operating theatres after contaminated or dirty operations(1B)(3)Do not use tacky mats at the entrance to the operating suite or theatre for infection control(1B)Microbiological sampling(1)Do not perform routine environmental sampling of the operating theatre.Perform microbiological sampling of operating theatre environmental surfaces or air only as part of an epidemiological investigation(1B)Sterilisation of surgical instruments(1)Sterilise all surgical instruments according to published guidelines(1B)(2)Perform flash sterilisation only for patient care instruments that will be used immediately(e.g.to reprocess a dropped instrument).Do not use flash sterilisation for reasons of convenience,as an alternative to purchasing additional instrument sets,or to save time(1B)Surgical attire and drapes(1)Wear a surgical mask that fully covers the mouth and nose when entering the operating theatre if an operation is about to begin or already under way,or if sterile instruments are exposed.Wear the mask throughout the operation(1B)(2)Wear a cap or hood to cover fully the hair on the head and face when entering the operating theatre(1B)(3)Do not wear shoe covers for the prevention of SSI(1B)(4)Wear sterile gloves if a surgical team member.Put on gloves after donning surgical gown(1B)(5)Use surgical gowns and drapes that are effective barriers when wet(i.e.materials that resist liquid penetration)(1B)(6)Change scrub suits that are visibly soiled,contaminated and/or penetrated by blood or other potentially infectious materials(1B)Asepsis and surgical technique(1)Adhere to principles of asepsis when placing intravascular devices or when administering intravenous drugs(1A)(2)Handle tissue gently,maintain effective haemostasis,minimise devitalised tissue and foreign bodies(e.g.sutures,charred tissue,necrotic debris),and eradicate dead space at the surgical site(1B)(3)Use delayed primary skin closure or leave incision open to heal by second intention if the surgical site is considered to be heavily contaminated(1B)(4)If drainage is necessary,use a closed suction drain.Place drain through a separate incision distant from the operative incision.Remove drain as soon as possible(1B)65.PostoperativeincisioncarePostoperativeincisioncare(1)Protect an incision that has been closed primarily with a sterile dressing for 24 48 h postoperatively(1B)(2)Wash hands before and after changing dressings and any contact with the surgical site(1B)SurveillanceSurveillance(1)Use CDC definitions of SSI without modification for identifying SSI among surgical inpatients and outpatients(1B)(2)For inpatient case-finding(including readmissions),use direct prospective observation,indirect prospectivedetection,or a combination of direct and indirect methods for the duration of hospitalisation(1B)(3)For outpatient case-finding,use a method that accommodates available resources and data needs(1B)(4)For each patient undergoing an operation chosen for surveillance,record those variables shown to be associatedwith increased SSI risk(e.g.surgical wound class,duration of operation,etc.)(1B)(5)Periodically calculate operation-specific SSI rates stratified by variables shown to be associated with increased SSI risk(e.g.NNIS risk index)(1B)(6)Report appropriately stratified,operation-specific,SSI rates to surgical team members.The optimum frequency and format for comparisons of SSI rates will be determined by stratified case-load rates and the objectives of localcontinuous quality improvement initiatives(1B)66.应用抗菌用抗菌药物物预防外科手防外科手术部位部位感染作用是肯定的。