病原学检查结果解读

•
A category used for isolates for which only a susceptible interpretive criterion has been designated because of the absence or rare occurrence of resistant strains.Isolates for which the antimicrobial agent MICs are above or zone diameters below the value indicated for the susceptible breakpoint shoule be reported as nonsusceptible.
2.
Antibiotics kill bacteria causint the illness, as well as good bacteia protecting the body from intection.
3.
The drug-resistant bacteria are now allowde to grow and take over.
50-150mg qd 首剂6mg/kg q12h 第二天起4mg/kg q12h
•
The “intermediate” category includes isolates with antimicrobial agent MICs that approach usually attainable and tissue levels,and for which response rates may be lower than for susceptible isolates.The intermediate category implies clinical efficacy in body sites where the drugs are physiologically concentrated(eg,quinolones and β-lactams in urine) or when a higher than normal dosage of a drug can be uncontrolled,technical factors from causing major discrepancies in interpretations,especially for drugs with narrow pharmacotoxicity margins.
MIC介于敏感和耐药折点之间，敏感性低于敏感株 在大剂量（β内酰胺类）或生理浓缩情况（喹诺酮和β内酰胺类在尿中） 使用有效 缓冲区
•
The “resistant” category implies that isolates are not inhibited by the usually achievable concentrations of the agent with normal dosage schedules,and/or that demonstrate MICs or zone diameters that fall in the range where specific microbial resistance mechanisms(eg, β-lactamases) are likely,and clinical efficacy of the agent against the isolate has not been reliably shown in treatment studies.
细菌
对苯唑西林耐药 的葡萄球菌 肠球菌 沙门菌、志贺菌 李斯特菌 鼠疫耶尔森菌 克柔假丝酵母
不能报告为敏感的抗生素
所有的碳青酶烯类、头孢菌素类及其他β-内酰 胺类。例如阿莫西林/克拉维酸、哌拉西林/他 唑巴坦和亚胺培南 氨基糖苷类（高浓度除外）、头孢菌素类、克 林霉素和磺胺甲恶唑/甲氧特啶 一代、二代头孢菌素和氨基糖苷类 头孢菌素 β-内酰胺类抗生素 氟康唑
静脉内抗生素
氨卡西林 青霉素G 曝拉西林 阿莫西林克拉维酸 氨卡西林舒巴坦 2-4g q8h 400u q8h 2-3g q8h 1.2g q8h 1.5g q8h
成人常用剂量
替卡西林克拉维酸
哌拉西林他唑巴坦 头孢噻污 头孢拉定 头孢美他唑 头孢呋辛 头孢哌酮舒巴坦 头孢噻污
3.2g q8h
4.5g q8h 1-2g q8h 1-2g q8h 1-2g q8h 1-5g q8h 3g q8h 2g q8h
Urgent Threats
Clostridium difficile Carbapenem-resistant Enterobacteriaceae(CRE) Drug-resistant Neisseria gonorrhoeae
Serious Threats
Multidrug-resistant Acinetobacter Drug-resistant Campylobacter Fluconazole-resistant Candida(a fungus) Extended spectrum β-lactamase producing Enterobacteriaceae(ESBLs) Vancomycin-resistant Enterococcus(VRE) Multidrug-resistant Pseudomonas aeruginosa Drug-resistant Non-typhoidal Salomnella Drug-resistant Salmonella Typhi Drug-resistant Shigella Methicillin-resistant Staphylococcus aureus(MRSA) Drug-resistant Streptococcus pneumoniae Drug-resistant tuberculosis
ESBL Confirmatory Test
E test for ESBL Detection
E.coli: 粉红
Kleb：蓝绿
变形：褐色
Test Results Penicillin Oxacillin(cefoxitin)
Predicts
Susceptible to: All penicillins Β-lac/β-lactamase inhibitor combos Cephems Carbapenems Resistant to: Penicillinase-labile penicillins Susceptible to: Penicillinase-stable penicillins Β-lac/β-lactamase inhibitor combos Cephems Carbapenems Resistant to: All β-lactams(except cephems with anti-MRSA activity,e.g.,ceftaroline)
“Warning”:The following antimicrobial agent/organism combinations may appear active in vitro,but are not effective clinically and should not be reported as susceptible. Antimicrobial Agents That Must Not Be Reported as Suceptible 1st-and 2nd-generation cephalosporins,cephamycins,and aminoglycosides Penicillins, β-lactam/β-lactamase inhibitor combinations,antistaphylococcal cephems(except cephalosporins with anti-MRSA activity), and carbapenems Aminoglycosides(except high concentrations),cephalosporins,clindamycin,and trimethoprim-sulfamethoxazole
倪语星
上海交通大学医学院附属瑞金医院 教授 博士生导师 现任： 检验医学系 副主任
临床微生物科 主任
医院感染控制管理科 主任 兼任： 卫生部医院感染标准委员会会 委员 卫生部抗菌药物合理应用专家小组 委员
卫生部医院感染质控中心
委员
中华预防医学会医院感染分会，常委 中国医院协会医院感染管理专委会，常委 上海微生物学会临床微生物专科委员会，主任委员
Concerning Threats
Vancomycin-resistant Staphylococcus aureus(VRSA) Erythromycin-resistant Group A Streptococcus Clindamycin-resistant Group B Streptococcus
Enterococcus faecium
（屎肠球菌）
Staphylococcus aureus
（金黄色葡萄球菌）
Klebsiella pneumoniae
（肺炎克雷伯菌）
Acinetobacter baumannii
（鲍氏不动杆菌）
Pseudomonas aeruginosa
（铜绿假单胞菌）
Enterobacter species
（肠杆菌）
18
16
16 14 10
14 12
10
86Βιβλιοθήκη 7542
0
今天不采取行动， 明天就无药可用！
2011年4月7日 世界卫生日

缺少研究 没有承诺 检测薄弱 药性质量低下 药物使用不合理 缺乏感染控制
1.
Lots of germs. A few are drug resistant.
上海抗感染和化疗学会，副主任委员
上海检验学会，顾问 中国感染化疗杂志副主编
病原学检查与 抗菌药物临床应用
上海交通大学医学院附属瑞金医院
倪语星
2014.4.30日内瓦
全世界面临严重的公共卫生威胁！
提供了迄今关于抗菌药物耐药的最 全面情况，数据来自 114 个国家，显示 所有地区都发现存在抗菌药物耐药。
4.
Some bacteria give their drug-resistance to other bacteria,causing more problesm.
预防感染 耐药性监测 抗菌药物管理
诊断和治疗
误区：找到细菌就一定有临床意义
临床意义低的标本
• 痰、咽拭子
（HI，SP除外）
临床意义中等的标本
头孢曲松
亚胺培南 美罗培南 万古霉素 利奈唑氨 达托霉素 伊取康唑
1-2g qd
0.5g q6h 1g q8h 1g q12h 600mg q12h 8-8mg/kg qd 第1,2天治疗方法：200mg，q12h 第3天起：200mg，qd
卡泊芬净
米卡芬净 伏立康唑
首剂70mg qd 第二天起50mg qd
• 尿 • 脓 • 伤口分泌物 • 血 • 脑脊液 • 胸腹水 • 无菌体液
• 粪便、肛拭子
（ADCD除外）
相同的部位，不同细菌检出的意义不同 SP，HI与AB SA与SCN
相同的细菌，不同部位检出的意义不同 从痰中检出与血中检出
抗菌谱：经验治疗 耐药趋势
Definition
• An infection due to the strain may be appropriately treated with the dosage of antimicrobial agent recommended for that type of infection and infecting species, unless otherwise contraindicated
Location
Organism
Table 2A
Salmonella spp.,Shigella spp.
Table 2C
Oxacillin-resistant Stapylococcus spp.
Table 2D
Enterococcus spp.
LGA251
MSSA
ESBL Confirmatory Test