Intens Care Med:感染性疾病----我从来不相信的10个普遍真相

2018-07-14 吴燕妮 译 重症医学

感染性疾病领域给我们带来了许多惊喜。即使在现代医学时代,疾病生物学和管理的发展的观点仍不时地挑战我们(图1)。各个科学领域知识的整合,开辟了一个令人兴奋的局面,动摇了我们在医学院或临床医学实践中习得的信念。表1列出了在某些医学进化因素的影响下形成的10个选定主题。


东莞东华医院ICU 吴燕妮译

感染性疾病领域给我们带来了许多惊喜。即使在现代医学时代,疾病生物学和管理的发展的观点仍不时地挑战我们(图1)。各个科学领域知识的整合,开辟了一个令人兴奋的局面,动摇了我们在医学院或临床医学实践中习得的信念。表1列出了在某些医学进化因素的影响下形成的10个选定主题。


大多数报告一致报道肺炎链球菌是社区获得性肺炎的主要病因。然而,最近的一项进行灵敏分子检验的研究,分析了病毒的流行是导致需要住院的严重肺炎的原因,并提示了鼻病毒是最普遍的微生物。目前的管理应包括在严重发作时使用复合PCR技术,和抗病毒治疗(西多福韦)或强化免疫球蛋白可能成为新的治疗方法。

几十年来,一直需要至少48-72小时才获得鉴定和随后的药敏试验的信息。在常规诊断微生物学中引入基质辅助激光解析-电离-飞行时间质谱法(MALDI-TOF MS)后,6小时即可识别血液培养中的细菌,具有重要的临床效益。进一步的研究应该包括快速诊断测试,可在床边即时识别耐药表型。

强烈建议避免使用已经在体外测试显示耐药的抗生素。然而,对于某些耐碳青霉烯类肺炎克雷伯菌感染,没有替代的或被证明是成功的治疗选择,建议基于碳青霉烯类的最小抑菌浓度(MICs)审核治疗。对于MICS在4-8 mcg/ml之间,甚至高达16 mcg/ml的分离菌株,最近的报道建议,当与敏感药物(如替加霉素、多粘菌素或磷霉素)联合使用时,高剂量和延长输注碳青霉烯是一个很好的选择。最近的报道还建议使用双碳青霉烯类化合物,联合厄他培南-美罗培南,可有效治疗产碳青霉烯酶的肺炎克雷伯菌感染。

传统上,随机对照试验的脓毒症的辅助治疗并没有考虑个性化处方的需要。最近一些报告表明,在一些患者分组中,治疗的反应是非常不同的。进一步的研究应该纳入ESCMID对于脓毒症个性化管理的建议书的推荐的更新建议和观点中。

使用洗必泰的口腔护理是许多预防呼吸机相关肺炎的护理集束的基石。然而,最近的证据表明口腔洗必泰护理可能会增加整体医院人群的死亡风险。在非心脏手术患者中,也没有明显减少呼吸机相关肺炎(VAP)的风险,引发了对常规使用洗必泰的的重新考虑。

继药物的指示,如在囊性纤维化患者中使用氨曲南或妥布霉素,雾化给药以治疗/预防呼吸道感染,许多重症监护医师以雾化的形式在机械通气患者身上使用这些药物,以治疗呼吸机相关的气管支气管炎或肺炎。直到最近认为,这种治疗措施会潜在增加多重耐药假单胞菌或不动杆菌的感染。观察性研究显示潜在的疗效,很少有不良事件的报道。然而,重点关注在机械通气时,发现证据不足。这些研究报告了支气管痉挛、低氧血症和其他呼吸道并发症的重大风险。因此,ESCMID建议书中考虑疗效证据弱而呼吸道不良事件风险不可忽视。需要使用网膜雾化器和实施标准化的研究协议。进一步的研究应以预定的临床结果为终点。

最近对鲍曼不动杆菌VAP的一项研究报告指出,添加负载剂量的多粘菌素E并不能改善预定的结果,但与肾毒性有关。其他作者一致认为,治疗严重的MDR感染时,肾毒性的风险系由于多粘菌素/多粘菌素E的治疗范围较低。此外,最近一项关于多重耐药假单胞菌肺炎的研究未能证实,由高度耐碳青霉烯 (MIC50 16 mg/l)菌株引起的肺炎的机械通气患者队列中,使用多粘菌素E(或阿米卡星)可改善死亡率。这些患者应该接受替代药物,如头孢洛扎-他唑巴坦,并需要新的抗菌药物。临床中越来越多报道,在抗生素暴露下由多粘菌素E敏感菌株进化至耐药菌株,序列研究支持显示在选择压力下发生高频突变。

DALI研究是欧洲重症监护单元(ICU)网络组织的一项多中心观察研究,该研究表明,许多暴露于标签剂量的头孢菌素的患者,其血浆水平不理想,低于PK/PD目标。这部分是由于机械通气和脓毒性休克引起的分布容积增加。因此最近建议,个性化的剂量,以更高的剂量形式、延长输液,甚至持续输注(对时间依赖的药物)。流感的流行使呼吸道病毒的诊断技术得到更好的应用,目前大多数ICU都采用了这种技术。因此,许多以前被诊断为原因不明的重症肺炎已经被识别。与此同时,在这些病人身上使用奥司他韦已成为标准治疗,而在2009年流感流行之前不太可能。低CD4/CD 18和血小板减少的患者分组,与进一步病发侵袭性肺曲霉菌病有关。建议在严重淋巴细胞减少的患者中,应用泊沙康唑抢先治疗,并且应该在进一步的随机临床试验中评估其疗效。

埃博拉病毒病(EVD)的管理受到暴发国家的资源匮乏的传统限制。西非过去的流行爆发与一些患者被遣返到欧洲或继发感染的病例有关。这些病人在设备良好的ICU中进行管理。因此,存活患者显示出更好的复苏策略;肺水肿和急性呼吸窘迫综合征具有相关性。

原始出处:

Jordi Rello, et al.Infectious diseases: the 10 common truths I never believed.Intensive Care Medicine (2018)

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    2018-07-15 131****1460

    学习了受益匪浅

    0

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    2018-07-15 张新亮1853311252142e2fm

    好文献学习了

    0

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    2018-07-14 1e0f8808m18(暂无匿称)

    学习了.谢谢分享!

    0

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    2018-07-14 惠映实验室

    学习了.谢谢分享.

    0

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