2017年IDSA感染性腹泻诊治指南

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曲霉菌病诊治指南IDSA_2017年新版

IDSA：2016 新版曲霉菌病诊治指南原创2016-07-06步步非烟感染时间曲霉菌病是感染曲霉菌引起的一种真菌病，可累及皮肤、黏膜、眼、鼻、支气管、肺、胃肠道、神经系统、骨骼等多器官系统，严重者导致败血症，病例呈世界性分布。

病原体曲霉菌属丝状真菌，是一种常见的条件致病性真菌，广泛分布于自然界，其感染者并不少见。

时隔 8 年，美国感染病学会（IDSA）就曲霉菌病临床关注的热点问题，总结现有不同类型曲霉菌病相关证据，于近期发布了新版曲霉菌病诊治指南，替代 2008 旧版指南，旨在为临床医生诊治管理此病提供参考。

该 2016 新版指南于近期发表在 Clinical Infectious Diseases 杂志上。

现将主要内容简述如下。

流行病学与感染风险因素1. 易感者如何预防曲霉菌病？何为易感人群？（1）应将住院的异体造血干细胞移植（HSCT）接受者安置在受保护的环境中，以减少霉菌暴露机会（强烈推荐；证据级别低）。

（2）也应给予其他严重免疫功能低下的、易发生侵袭性曲霉菌病（IA）的高危患者相应防护措施，如急性白血病正在接受诱导/再诱导化疗方案治疗者（强烈推荐；证据级别低）。

（3）若住院无法提供防护病房的条件，推荐此类患者入住单独病房，且病房远离施工场地，也不允许将绿植或鲜花带入病房（强烈推荐；证据级别低）。

（4）建议对 IA 高危门诊患者采取合理防护措施，以减少霉菌暴露机会，包括避免园艺、施肥劳作或密切接触装修或施工场地（强烈推荐；证据级别低）。

（5）白血病诊疗中心与移植中心应当定期监测侵袭性霉菌感染。

若发现霉菌感染率超过基线水平，或者非高危人群发生侵袭性霉菌感染，应当立即对医源性感染情况进行评估（强烈推荐；证据级别低）。

曲霉菌病的诊治2. 如何确立侵袭性曲霉菌病的诊断？（6）在临床实验室推广使用分子生物学诊断技术以前，推荐采集足量组织和体液样本同时送检组织病理学/细胞学检查与真菌培养。

如果分离培养得到非典型菌株或考虑存在耐药，可采用分子生物学实验方法进行菌种鉴定（强烈推荐；证据级别低）。

2016版IDSA曲霉病指南（全文）

2016版IDSA曲霉病指南（全文）翻译说明：本指南由昆明总医院血液科组织翻译，原文第1～11页的推荐汇总部分、方法学部分均省略，从原文第12页开始翻译。

以下内容为历次推送汇总：感染的流行病学和危险因素I. 如何保护高度易感患者，使其免于曲霉感染？哪些患者高度易感？•什么是曲霉的暴露源，如何减少暴露？环境监测是否有用？•哪些获得性或遗传性免疫缺陷会增加曲霉感染风险？诊断II.如何确诊侵袭性曲霉病？•如何确诊曲霉感染？这些方法对曲霉病的管理有何影响？•对临床标本做核酸检测的价值如何？•该如何将半乳甘露聚糖（GM）和1-3-beta-D-葡聚糖（G试验）检测应用于曲霉病的诊断？•肺曲霉病的影像学诊断方法是什么？•支气管镜在侵袭性肺曲霉病诊断中起什么作用？III. 用于侵袭性曲霉病的治疗和预防的抗真菌药物及其药理学如何？药敏检测的价值？•两性霉素B•棘白菌素三唑类•三唑类的药理学（伊曲康唑、伏立康唑、泊沙康唑、艾莎康唑）•三唑类药物相互作用（含表2：在曲霉病治疗中常见的药物相互作用）和治疗药物监测（含表3:在曲霉病治疗中TDM有用的临床场景）•对联合使用抗真菌药物的临床前和实验室评价•抗真菌药敏应该何时做？药敏的结果应该如何解读并影响治疗决策？IV. 侵袭性曲霉病治疗•侵袭性肺曲霉病（IPA）应如何治疗（含表1：曲霉病治疗推荐）•辅助措施和免疫调节：在侵袭性曲霉病治疗中何时应该考虑停用免疫抑制剂或增加集落刺激因子或粒细胞输注、重组干扰素(rIFN-γ)、手术？•侵袭性曲霉病的患者何时继续化疗或移植是安全的？•难治性和进展性曲霉病的治疗方法（挽救治疗）有哪些？•如何使用生物标记物对患者治疗反应进行评估••儿童患者的曲霉病应如何治疗••移植和非移植患者的气道曲霉病应如何治疗？与侵袭性肺曲霉病治疗有何不同？[腐生型TBA、支气管中心性肉芽肿、侵袭性TBA、肺移植患者的TBA]肺外曲霉•如何治疗中枢神经系统曲霉病？•手术对治疗副鼻窦曲霉病的作用？•曲霉性心内膜炎，心包炎，心肌炎如何治疗？•曲霉菌致骨髓炎和化脓性关节炎的治疗推荐是什么？•皮肤曲霉病、曲霉腹膜炎•食道、胃肠、肝脏、肾脏曲霉••曲霉耳内感染、角膜炎、眼内炎•非移植人群曲霉菌支气管炎如何诊断和治疗？V. 预防方案、突破性感染的管理•哪些患者应该预防曲霉？•GVHD患者的预防方案•肺移植患者的抗真菌预防推荐是什么？•非肺的实体器官移植患者如何预防真菌？•突破性曲霉病的管理VI. 什么时候患者需要接受经验性治疗？•对异基因HSCT和AML治疗中的患者而言，经验性和抢先治疗策略是什么••肺移植患者的疑似侵袭性肺曲霉病的管理和其他免疫抑制患者有哪些不同？VII.慢性曲霉病、变态反应症状或非侵袭性症状应如何管理？•慢性空洞型肺曲霉如何诊治？•肺曲霉球的治疗选择是什么？•哮喘和囊性纤维化患者中发生的过敏性支气管肺曲霉病(ABPA)如何辨别和治疗？•由曲霉菌所致的过敏性真菌性鼻及鼻窦炎（AFRS）的治疗方法---------全文完毕-------------。

成人艰难梭菌感染临床实践指南_美国卫生保健流行病学会与感染病学会2010年更新

６．检测无症状患者和治愈患者的粪便没有临床意义，除非进行流行病学研究，否则不予推荐。
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中国感染与化疗杂志２０１１年１１月２０日第１１卷第６期Ｃｈｉｎ
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７．粪便培养艰难梭菌是最灵敏的检测方法，而且为流行病学研究所必需。８．有经验的实验室能够在粪便培养之后再进行细菌的鉴定及毒素监测（例如，产毒菌株培养）增加该方法的灵敏度和特异度。因此尽管粪便培养耗时过长，临床实用性差，但可用作为评价其他检测方法时的标准。９．酶免疫法测定艰难梭菌Ａ毒素和Ｂ毒素速度快，但灵敏度较细胞毒素检测法低，因此是诊断试验的次佳选择。１０．临床实践中毒素检测最为重要，但灵敏度低阻碍了其应用。二步法有可能解决这个问题：先用酶免疫法检测谷氨酸脱氢酶（ｇｌｕｔａｍａｔｅ
收稿日期：２０１１０１—２１
万方数据
自１９９５年美国卫生保健流行病学会（ＳＨＥＡ）确定了艰难梭菌是急性感染性腹泻的主要病原之一以来，艰难梭菌感染（Ｃｌｏｓｔｒｉｄｉｕｍｄｉｆｆｉｃｉｌｅ
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基于良好的证据与临床经验，由美国ＳＨＥＡ和美国传染病学会（ＩＤｓＡ）共同组成的专家委员会制定。一、流行病学监测ＣＤＩ最少需要收集哪些数据并报告。１．为了提高医疗机构之间ＣＤＩ的可比性，监测时使用标准化病例定义：①卫生保健机构发病，卫生保健相关ＣＤＩ；②社区发病，卫生保健相关ＣＤＩ；③ 社区发病，社区相关ＣＤＩ。２．至少需要对住院患者医院内发病，卫生保健相关的ＣＤＩ进行监测，监测项目包括ＣＤＩ的暴发流行以及患者的安全性。３．以病例数／１００００住院天数的方式报告卫生保健机构相关ＣＤＩ的发病率。４．如果ＣＤＩ发病率高于其他机构或出现暴发流行，需要按照患者所处病房或环境进行分层分析，以便于有目的地实施感染控制措施。二、诊断ＣＤＩ的实验室诊断。５．除非怀疑肠梗阻由艰难梭菌所致，否则仅对腹泻患者的（不成形）粪便进行艰难梭菌或其毒素的

IDSA 隐球菌指南-中文

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IDSA医院感染预防指南2014年

IDSA医院感染预防指南2014➢关键点据美国CDC估计，10-20位住院患者中就有1位会发生医院感染。

➢基本原则加强医务人员培训；确保操作者经过专业培训。

定期考核医务人员操作规范依从性。

对病人及家属进行宣教。

进行风险评估。

认真评估必要性，尽量使用低风险操作、技术或装置。

尽快移除相关装置。

使用医院批准的操作规范及核对清单。

经常进行手卫生。

不要开放无菌、密闭系统，开放后应及时更换。

记录过程指标、个体操作过程（individual performing procedure）、操作开始及结束日期和时间。

对所有必要因素进行主动、持续监控，并反馈给所有相关人员。

采用自动化数据采集系统。

启动抗菌药物管理项目。

➢预防策略导管相关性血流感染（CLABSI）的预防策略✓预防和监测CLABSI的基本策略*（适用于所有急性病医院）置管前对医务人员进行中央导管置管、护理及维护过程中CLABSI预防策略的培训（A-II）。

置管中置管时使用核对清单（checklist）以确保感染预防策略的依从性（B-II）。

置管前或导管维护前进行手卫生（B-II）。

成人置管时应尽量避开股静脉（A-I）。

使用全套的静脉穿刺和导管车或包（B-II）。

置管时采用最大化无菌屏障（A-I）。

对于2月龄以上的患者，使用含氯己定的消毒剂进行皮肤准备（A-I）。

置管后在连接导管前，对导管的交换器，无针连接器以及注射端口进行消毒（B-II）。

移除不必要的导管（A-II）。

对于成人和儿童使用的非隧道式中央导管，每5-7天更换透明敷料，并使用洗必泰消毒，如果透明敷料出现脏污、松散或潮湿，增加频率；每2天更换纱布敷料，如果敷料出现脏污、松散或潮湿，增加频率（A-I）。

不用于输注血液，血液制品或脂质的导管更换时间间隔不应超过96 小时（A-II）。

进行CLABSI监测（B-II）。

对血液透析导管穿刺位点使用抗菌软膏（A-I）。

✓预防CLABSI的特殊策略**进行CLABSI风险评估。

2017IDSA：感染性腹泻诊治指南

2017IDSA：感染性腹泻诊治指南2017 年 10 月，美国感染病学会（IDSA）发布了感染性腹泻的诊断和管理指南，指南针对成人和儿童疑似以及确诊感染性腹泻患者的诊断和管理提出指导建议。

本文截取其中的诊断、经验性治疗、目标治疗、支持治疗、辅助治疗进行了整理翻译。

指南根据GRADE 将证据等级分为高、中、低三个级别，意见推荐等级分为强推荐和弱推荐两个级别。

诊断当患者出现腹泻时，首先应考虑哪些病原菌感染，哪些诊断试验有助于明确病原菌并用于疾病暴发调查？•当患者出现腹泻伴发热、血便或粘液样便、严重腹部压痛绞痛或脓毒血症时，应行粪便样本检测沙门菌、志贺菌、弯曲杆菌、耶尔森菌、艰难梭菌和 STEC（强推荐，中等级）；艰难梭菌感染时，患者较少出现血便，STEC 应行粪便培养并检测抗原O157，O157 阴性STEC 应行志贺毒素及其基因型检测（强推荐，低等级）；山梨醇-MacConkey 琼脂或其它显色培养基被推荐用于STEC 培养和抗原O157:H7 检测；志贺毒素检测有助于其它 STEC 血清型鉴别（强推荐，中等级）。

•年龄＜3个月的新生儿、有败血症表现、怀疑肠源性发热、有全身感染表现、免疫缺陷患者、溶血性贫血患者、有肠源性发热流行地区旅游史并出现不明原因发热或有该人群接触史患者推荐做血培养（强推荐，中等级）。

•有症状患者早期鉴别诊断时应进行粪便检测，重点检测沙门菌、志贺菌、弯曲菌、耶尔森菌和艰难梭菌（强推荐，低等级）。

a 持续腹痛患者应检测小肠结肠炎耶尔森菌，尤其是学龄儿童出现右下腹类阑尾炎样疼痛，可伴有肠系膜淋巴结炎。

发热患者有耶尔森菌流行病学暴露风险也需检测，包括婴幼儿直接或间接食用生的或未煮熟猪肉食品。

b 当患者出现大量淘米水洋便、有咸水暴露史、食用生的或未煮熟的贝壳类水生生物或是腹泻出现前三天内有霍乱地区旅游史时，应粪便检测弧菌。

•无论腹泻患者是否伴有发热血便或粘液样便，或其它疾病加重或腹泻暴发流行特征，都应考虑是否存在细菌、病毒或其它寄生病原体感染。

艰难梭菌感染性腹泻

其他毒力因子
第五页，共二十五页。
1、初级胆汁酸促进芽孢的萌发；胆汁酸盐类似物治疗前景 2、TcdA 〔肠毒素〕and TcdB〔细胞毒素〕；细胞信号传导通路、炎症介质、中性粒细胞的浸润破坏肠上皮细胞形成 “假膜〞 3、 binary toxin 破坏细胞骨架 4、体液免疫(miǎnyì) 5、复发：机体免疫反响，NAP1/BI/027 菌株感染，肠道菌群破坏有关OUTLINE
院内感染： 82%患者为无病症携带者，其中21%的患者粪便中检出艰难梭菌；携带者为传播源，与同期住院患者相比，开展(fāzhǎn)为CDI的风险反而更低，可能与无毒菌群感染后机体的免疫反响有关。
近期研究显示，爆发性艰难梭菌感染与NAP1/BI/027 流行株相关，该菌株有两个亚型，分别为FQR1 and FQR2。
艰难梭菌感染 (jiānnán)
Clostridium difficile Infection
第一页，共二十五页。
定义(dìngyì)
Clostridium difficile infection (CDI) is acute diarrhea and colitis that is most often preceded by antimicrobial use and is caused by an anaerobic sporeforming, toxinproducing bacterium.
儿童艰难梭菌感染的诊断具有争议性，尤其2岁以前患儿；1岁内儿童携带艰难梭菌的比例较高，艰难梭菌的检测意义不大；3岁以后儿童的感染率与危险因素与成人相同，但CDI的发病率较成人低。
四．危险因素
抗生素使用1月内是艰难梭菌感染的高风险时期，其风险在2-3月后

感染性腹泻诊治指南

感染性腹泻诊治指南疾病简介：感染性腹泻(Infectious diarrhea)是指各种急性、慢性的细菌、病毒、真菌、寄生虫感染引起肠道炎症所致的腹泻。

我们也把除霍乱、细菌性和阿米巴性痢疾、伤寒和副伤寒以外的感染性腹泻，称为感染性腹泻，为狭义上的感染性腹泻，为《中华人民共和国传染病防治法》中规定的丙类传染病。

病因感染性腹泻的原因有很多，也有感染性和非感染性的腹泻，如果是感染性慢性感染，有细菌感染，有比较特殊的像结核杆菌(N/med tuberculosis bacili)的感染，也可能造成慢性腹泻，当然其他的慢性感染也可以。

还有一些是非感染一类的，对于慢性腹泻来讲，跟急性腹泻比较起来非感染的更多见，非感染一大类叫慢性炎症性肠病，包括溃疡性结肠炎和克罗恩病，另外还有经常服某种药物引起的慢性腹泻，另外还有老年人的缺血性腹泻，一般是急性的，也有慢性缺血性质的，少见一些。

还有肿瘤，有些肿瘤也可以引起。

再有一个是吸收不良，还有一类是肠易激综合症，有些达不到这个标准，但是也属于功能性的。

还有全身疾病也可以引起慢性腹泻，尿毒症等等，慢性腹泻很复杂，病因很多，一旦有慢性腹泻的症状最好不要掉以轻心，到医院来看看，首先查明原因是什么。

感染性腹泻不明原因只是暂时查不出原因，但是一定是有原因的，这需要通过系统的诊断。

常规检查查不出来的，有些特殊检查能查出来。

在诊断的时候，我们一步一步地从最常规的检查查起，不会一下子全面地所有检查一块儿上，根据病人的临床表现，他最可能的是什么，先做那个检查，除外以后再考虑其他的。

明确是什么原因引起的疾病，才能根据病因做针对性的治疗。

临床表现腹泻，大便每日≥3次，粪便的性状异常，可为稀便、水样便, 亦可为粘液便、脓血便可伴有恶心、呕吐、食欲不振、发热及全身不适等病情严重者，大量丢失水分引起脱水、电解质紊乱甚至休克1、分泌性腹泻(Secretory diarrhea)导致的腹泻病人多不伴有发热，粪便性状为稀便或水样便，粪便的显微镜检查多无细胞，或可见少许红、白细胞属于此类腹泻的除霍乱外，还有肠产毒性大肠杆菌肠炎、致泻性弧菌肠炎、非O1/非O139霍乱弧菌肠炎、轮状病毒肠炎、隐孢子虫肠炎，以及常以食物中毒形式出现的腊样芽胞杆菌腹泻，金黄色葡萄球菌腹泻等2、炎症性腹泻(Inflammatory diarrhea)病原体侵袭上皮细胞，引起炎症而致的腹泻常伴有发热，粪便多为粘液便或粘液血便，粪便的显微镜检查见有较多的红、白细胞属于此类感染性腹泻的除细菌性痢疾外，还有侵袭性大肠杆菌肠炎、肠出血性大肠杆菌肠炎、弯曲菌肠炎、小肠结肠炎耶尔森氏菌肠炎等。

成人急性感染性腹泻诊疗专家共识

(四)特殊的感染性腹泻病
• 2．医院获得性腹泻：以腹泻为主要症状的医院感染的主要致病菌为大肠埃希菌、金黄色葡萄球菌、肠球菌和铜绿假单胞菌，其次为白念珠菌、变形杆菌属、克雷伯菌属、沙门菌属等。这些病原菌多为多重耐药菌，主要来自于交叉感染或肠道内源性感染。
(四)特殊的感染性腹泻病
• 3．免疫缺陷相关腹泻：先天性和获得性免疫缺陷人群容易发生感染性腹泻，且不易治愈，易发展为慢性腹泻，如HIV感染相关腹泻和老年人群的腹泻等。
(一)临床诊断
• ⑤脱水、电解质紊乱和酸碱失衡：成人急性感染性腹泻病一般无严重的脱水症状。一旦出现严重脱水表现，多提示病情严重，或有基础疾病，或未及时就诊、未及时有效补液。较长时间高热又未得到液体的及时补充，也可导致或加重水电解质紊乱。感染性腹泻从肠道失去的液体多为等渗液体；如果伴有剧烈呕吐，则可出现低氯、低钾性碱中毒；严重脱水、休克未得到及时纠正可引起代谢性酸中毒。
• 近期旅行史是诊断感染性腹泻的重要线索，尤其是从卫生条件较好的发达地区前往欠发达地区旅行。
(一)临床诊断
• 2．临床表现：成人急性感染性腹泻病，不仅临床表现多样、病情轻重不一，而且致病病原体种类繁多。
• ①潜伏期：急性感染性腹泻病的潜伏期不一，细菌感染所致腹泻，从感染到腹泻症状出现，数小时至数天不等，而细菌毒素所致腹泻潜伏期较短。先于腹泻的前驱症状有发热、不适和恶心等。
• 皮肤是否干燥和皮肤弹性试验，是否无泪、眼球凹陷，脉搏次数，是否有体位性低血压或低血压，体质量下降程度，以及意识状况。
• 据此将脱水分型如下： • ①无脱水。意识正常，无眼球凹陷，皮肤弹性好，无口干。 • ②轻度脱水。脉搏加快，烦躁，眼球凹陷，皮肤弹性差，

2016 IDSA 指南：曲霉病的诊断和管理

2016 IDSA 指南：曲霉病的诊断和管理（一）2016-08-102016年6月，美国感染病学会(IDSA)发布了曲霉病的诊断和管理指南2016更新版，指南主要内容涉及：流行病学和感染危险因素，曲霉病的诊断，曲霉菌侵入性综合征，曲霉菌感染肺外疾病表现，侵袭性曲霉病的预防，曲霉菌感染的突破性管理，曲霉菌感染慢性和腐生症状，曲霉菌过敏等。

现小编将主要推荐意见翻译如下：感染的流行病学和风险因素Ⅰ如何保护易感人群避免曲霉菌（IA）感染，哪些患者最易感曲霉菌？推荐1、院内异源造血干细胞移植接受者应处于保护环境中，以减少曲霉菌暴露（强推荐；低质量证据）。

2、这些保护措施应合理应用于IA风险增加的其它高度免疫抑制的患者，如接受诱导/再诱导治疗的急性白血病患者（强推荐；低质量证据）。

3、若医院内保护环境不可行，推荐患者入住私人房间，不与施工现场相连，不允许将植物或花带入患者房间（强推荐；低质量证据）。

4、建议合理预防，以降低IA高风险患者的曲霉菌暴露风险，包括避免园艺、施工或装修（强推荐；低质量证据）。

5、白血病和移植中心应对侵袭性感染患者进行常规监测。

非高危患者的基线处发病率增加或发生侵袭性感染时，应及时评估在医院的来源（强推荐；低质量证据）。

曲霉病的诊断Ⅱ如何确诊侵袭性曲霉病？6、在分子诊断工具未广泛用于临床实验室以前，建议提交足够的组织和液体标本，以同时进行组织病理学/细胞学和病原体培养检查。

在分离到非典型病原体或担心耐药时，应使用分子诊断方法进行病原体鉴别（强推荐；低质量证据）。

核酸检测在临床样本检测中的价值是什么？7、利用血液的聚合酶链反应（PCR）进行IA诊断尚未达成一致。

8、由于研究正继续，建议临床医生基于病例进行个体化治疗时，仔细选择PCR检测。

临床医生应了解特异性检测的方法和性能特点，并能解读结果。

使用PCR时，诊断结果应结合其它检测结果和临床背景（强推荐；低质量证据）。

半乳甘露聚糖和（1→3）-β-D-葡聚糖应如何用于曲霉病的诊断？9、用于某些患者亚群时（血液恶性肿瘤，造血干细胞移植患者），推荐血清和BAL半乳甘露聚糖（GM）作为成人和儿童患者诊断IA的精确标志物（强推荐；低质量证据）。

呼和浩特地区腹泻患者艰难梭菌检测方法比较、临床分离株的毒素特征及药物敏感性分析

. 1288 .中国抗生素杂志2020年12月第45卷第12期文章编号：1001-8689(2020)12-1288-05呼和浩特地区腹泻患者艰难梭菌检测方法比较、临床分离株的毒素特征及药物敏感性分析郭素芳王俊瑞王艳艳申慧敏吕莹莹韩艳秋*(内蒙古医科大学附属医院检验科，呼和浩特 010050)摘要：目的了解呼和浩特地区艰难梭菌腹泻患者临床分离株的毒素特征及艰难梭菌药物敏感性，为艰难梭菌治疗和防控提供参考数据。

方法收集2018年7月至2019年6月间本院疑似艰难梭菌感染的252例腹泻患者的粪便标本。

同一样本分别检测：粪便艰难梭菌培养和鉴定、VIDAS酶联荧光法粪便直接检测艰难梭菌毒素A/B(CDAB)和艰难梭菌谷氨酸脱氢酶(GDH)。

培养获得的艰难梭菌进行PCR扩增毒素基因和二元毒素基因(tcdA、tcdB、cdtA、cdtB)，以明确是否为产毒菌株；琼脂稀释法测定艰难梭菌对抗菌药物的敏感性。

结果艰难梭菌毒素A/B(CDAB)阳性7例，灰区5例；谷氨酸脱氢酶(GDH)阳性39例；培养出艰难梭菌37株；PCR扩增毒素基因检测30株为产毒株，毒素基因tcdA(-)/tcdB(+)型3株，tcdA(+)/tcdB(+)型27株，二元毒素基因检测均为阴性；克林霉素、头孢西丁耐药率较高，分别为100%和97.3%，莫西沙星耐药率54.1%。

万古霉素、甲硝唑无耐药株检出。

结论 GDH法具有较好的灵敏性，可作为艰难梭菌感染的筛查；CDAB检测特异性较高，但敏感性较低；毒素基因检测有较高的敏感性和特异性，tcdA(+)/tcdB(+)型艰难梭菌为我院主要流行株；96.7%的临床感染患者为I级；克林霉素、莫西沙星耐药率较高，需限制使用；全部菌株对甲硝唑、万古霉素敏感，可以经验用药。

关键词：艰难梭菌；厌氧培养法；毒素基因tcdA/B；药敏试验中图分类号：R9 文献标志码：ACompartion of detection methods of Clostridium difficile in patients with diarrhea in hohhot and analysis of toxin characteristics and drug sensitivity of clinical isolatesGuo Su-fang, Wang Jun-rui, Wang Yan-yan, Shen Hui-min, Lu Ying-ying and Han Yan-qiu(Clinical Laboratory, Affiliated Hospital of Inner Mongolian Medical University, Hohhot 010050)Abstract Objective To understand the toxin characteristics of clinical isolates of Clostridium difficile diarrhea in Hohhot and the drug sensitivity of Clostridium difficile, and provide reference data for Clostridium difficile treatment and prevention. Method Collecting stool specimens from 252 patients with diarrhea suspected of Clostridium difficile infections from July 2018 to June 2019. The same sample was tested separately: Culture and identification of Clostridium difficile, and VIDAS ELISA for direct detection of Clostridium difficile toxin A/B (CDAB) and Clostirdium difficile glutamate dehydrogenase (GDH). The obtained Clostridium difficile was cultured for PCR amplification of the toxin gene and the binary toxin genes (tcdA, tcdB, cdtA, and cdtB) to determine whether it was a toxigenic strain. Determination of the sensitivity of Clostridium difficile to antibiotics by the agar dilution method. Results Clostridium difficile toxin A/B (CDAB) was positive in seven cases, and with gray areas in five cases;收稿日期：2020-01-02基金项目：内蒙古自然科学基金面上项目(No. 2018MS080)作者简介：郭素芳，生于1965年，女，学士，副主任技师，主要从事临床微生物检验和细菌耐药性监测，E-mail:***************** *通讯作者，E-mail:****************. 1289 .艰难梭菌(Clostridium difficile, CD)是一种专性厌氧、革兰染色阳性的粗大芽孢杆菌。

成人急性感染性腹泻诊疗流程

成人急性感染性腹泻诊疗流程感染性腹泻是值得关注的全球性公共卫生问题，当前我国感染性腹泻患者数量呈现出上升趋势。

急性腹泻定义为：每天排便≥3次，总量超过250 g，持续时间不超过2周的腹泻。

本文对急性感染性腹泻的病原学特点及诊治流程进行了综述。

一、病原学引起感染性腹泻的病原体包括细菌、病毒、寄生虫和真菌等。

1. 细菌感染•大肠埃希菌：即大肠杆菌，是一种条件致病菌。

与人类腹泻有关的主要有以下5类：产肠毒素性大肠埃希菌（ETEC）、肠侵袭性大肠埃希菌（EIEC）、肠出血性大肠埃希菌（EHEC）、肠致病性大肠埃希菌（EPEC）和肠黏附性大肠埃希菌（EAEC）。

•霍乱：霍乱病原包括古典型霍乱弧菌、埃尔托型霍乱弧菌及O139霍乱弧菌。

霍乱弧菌污染水和食物而引起本病传播，患者和携带者为传染源。

霍乱弧菌感染后，可导致患者出现剧烈腹泻、失水以及呕吐等相关症状，其死亡率非常高。

•细菌性痢疾：由痢疾杆菌（肠杆菌科的志贺菌属）引起的急性肠道传染病，简称菌痢。

志贺菌可分为4个血清群，A群（痢疾志贺菌）、B群（福氏志贺菌）、C群（鲍氏志贺菌）和D群（宋内志贺菌）。

•弯曲菌：是人兽共患菌，主要通过未彻底煮熟的鸡肉、被交叉污染的蔬菜、牛奶和水传播。

弯曲菌感染后腹泻常为脓血便，部分患者会发生严重的并发症，如吉兰-巴雷综合征、反应性关节炎和肠易激综合征（IBS）。

•耶尔森菌：该菌广泛分布于自然界，能产生耐热性肠毒素，进食被该菌污染的食物可引起肠炎。

长时间冷藏的食品食用前如不彻底加热，有结肠炎耶尔森菌感染的危险。

2.病毒感染•B组轮状病毒：轮状病毒是最常见的腹泻病毒，一般在夏秋冬季流行，主要通过粪-口途径传播。

该病毒分为7个组，只有A、B、C组能感染人。

A组主要感染6个月到2岁的婴幼儿；B组轮状病毒感染多为成人，腹泻绝大多数为水样便；C组病毒主要侵犯儿童。

•诺如病毒：又被称为诺瓦克病毒，是杯状病毒中的一类。

全年均有发病，以冬季较多。

2010年IDSA复杂腹腔感染诊治指南

Diagnosis and Management of ComplicatedIntra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Societyand the Infectious Diseases Society of AmericaJoseph S.Solomkin,1John E.Mazuski,2John S.Bradley,3Keith A.Rodvold,7,8Ellie J.C.Goldstein,5Ellen J.Baron,6 Patrick J.O’Neill,9Anthony W.Chow,16E.Patchen Dellinger,10Soumitra R.Eachempati,11Sherwood Gorbach,12 Mary Hilﬁker,4Addison K.May,13Avery B.Nathens,17Robert G.Sawyer,14and John G.Bartlett151Department of Surgery,the University of Cincinnati College of Medicine,Cincinnati,Ohio;2Department of Surgery,Washington University School of Medicine,Saint Louis,Missouri;Departments of3Pediatric Infectious Diseases and4Surgery,Rady Children’s Hospital of San Diego,San Diego,5R.M.Alden Research Laboratory,David Geffen School of Medicine at UCLA,Los Angeles,6Department of Pathology,Stanford University School of Medicine,Palo Alto,California;Departments of7Pharmacy Practice and8Medicine,University of Illinois at Chicago,Chicago;9Department of Surgery,The Trauma Center at Maricopa Medical Center,Phoenix,Arizona;10Department of Surgery,University of Washington, Seattle;11Department of Surgery,Cornell Medical Center,New York,New York;12Department of Medicine,Tufts University School of Medicine, Boston,Massachusetts;13Department of Surgery,Vanderbilt University Medical Center,Nashville,Tennessee;14Department of Surgery,University of Virginia,Charlottesville;15Department of Medicine,Johns Hopkins University School of Medicine,Baltimore,Maryland;and16Department of Medicine,University of British Columbia,Vancouver,British Columbia,and17St Michael’s Hospital,Toronto,Ontario,CanadaEvidence-based guidelines for managing patients with intra-abdominal infection were prepared by an Expert Panel of the Surgical Infection Society and the Infectious Diseases Society of America.These updated guidelines replace those previously published in2002and2003.The guidelines are intended for treating patients who either have these infections or may be at risk for them.New information,based on publications from the period2003–2008,is incorporated into this guideline document.The panel has also added recommendations for managing intra-abdominal infection in children,particularly where such management differs from that of adults;for appendicitis in patients of all ages;and for necrotizing enterocolitis in neonates.EXECUTIVE SUMMARYThe2009update of the guidelines contains evidence-based recommendations for the initial diagnosis and sub-sequent management of adult and pediatric patients with complicated and uncomplicated intra-abdominal infec-tion.The multifaceted nature of these infections has led to collaboration and endorsement of these recommen-dations by the following organizations:American Society for Microbiology,American Society of Health-SystemReceived7October2009;accepted9October2009;electronically published 23December2009.Reprints or correspondence:Dr Joseph S.Solomkin,Dept of Surgery,University of Cincinnati College of Medicine,231Albert B.Sabin Way,Cincinnati OH45267-0558(joseph.solomkin@).Clinical Infectious Diseases2010;50:133–64ᮊ2009by the Infectious Diseases Society of America.All rights reserved. 1058-4838/2010/5002-0001$15.00DOI:10.1086/649554Pharmacists,Pediatric Infectious Diseases Society,andSociety of Infectious Diseases Pharmacists.These guidelines make therapeutic recommendationson the basis of the severity of infection,which is deﬁnedfor these guidelines as a composite of patient age,phys-iologic derangements,and background medical con-ditions.These values are captured by severity scoringsystems,but for the individual patient,clinical judg-ment is at least as accurate as a numerical score[1–4].“High risk”is intended to describe patients with a rangeThis guideline might be updated periodically.To be sure you have the mostrecent version,check the Web site of the journal(http://www.journals.uchicago.edu/page/cid/IDSAguidelines.html).It is important to realize that guidelines cannot always account for individualvariation among patients.They are not intended to supplant physician judgmentwith respect to particular patients or special clinical situations.The InfectiousDiseases Society of America considers adherence to these guidelines to bevoluntary,with the ultimate determination regarding their application to be madeby the physician in the light of each patient’s individual circumstances.by guest on March 8, 2015/Downloaded fromTable 1.Clinical Factors Predicting Failure of Source Control for Intra-abdominal InfectionDelay in the initial intervention (124h)High severity of illness (APACHE II score у15)Advanced ageComorbidity and degree of organ dysfunctionLow albumin levelPoor nutritional statusDegree of peritoneal involvement or diffuse peritonitis Inability to achieve adequate debridement or control of drainagePresence of malignancyNOTE.APACHE,Acute Physiology and Chronic Health Evaluation.of reasons for increased rates of treatment failure in addition to a higher severity of infection,particularly patients with an anatomically unfavorable infection or a health care–associatedinfection [5](Table 1).Initial Diagnostic Evaluation 1.Routine history,physical examination,and laboratory studies will identify most patients with suspected intra-abdom-inal infection for whom further evaluation and management is warranted (A-II).2.For selected patients with unreliable physical examination ﬁndings,such as those with an obtunded mental status or spinal cord injury or those immunosuppressed by disease or therapy,intra-abdominal infection should be considered if the patient presents with evidence of infection from an undetermined source (B-III).3.Further diagnostic imaging is unnecessary in patients with obvious signs of diffuse peritonitis and in whom immediate surgical intervention is to be performed (B-III).4.In adult patients not undergoing immediate laparotomy,computed tomography (CT)scan is the imaging modality of choice to determine the presence of an intra-abdominal infec-tion and its source (A-II).Fluid Resuscitation 5.Patients should undergo rapid restoration of intravascular volume and additional measures as needed to promote phys-iological stability (A-II).6.For patients with septic shock,such resuscitation should begin immediately when hypotension is identiﬁed (A-II).7.For patients without evidence of volume depletion,in-travenous ﬂuid therapy should begin when the diagnosis of intra-abdominal infection is ﬁrst suspected (B-III).Timing of Initiation of Antimicrobial Therapy 8.Antimicrobial therapy should be initiated once a patient receives a diagnosis of an intra-abdominal infection or once such an infection is considered likely.For patients with septic shock,antibiotics should be administered as soon as possible(A-III).9.For patients without septic shock,antimicrobial therapy should be started in the emergency department (B-III).10.Satisfactory antimicrobial drug levels should be main-tained during a source control intervention,which may ne-cessitate additional administration of antimicrobials just before initiation of the procedure (A-I).Elements of Appropriate Intervention 11.An appropriate source control procedure to drain in-fected foci,control ongoing peritoneal contamination by di-version or resection,and restore anatomic and physiological function to the extent feasible is recommended for nearly all patients with intra-abdominal infection (B-II).12.Patients with diffuse peritonitis should undergo an emer-gency surgical procedure as soon as is possible,even if ongoing measures to restore physiologic stability need to be continuedduring the procedure (B-II).13.Where feasible,percutaneous drainage of abscesses and other well-localized ﬂuid collections is preferable to surgical drainage (B-II).14.For hemodynamically stable patients without evidenceof acute organ failure,an urgent approach should be taken.Intervention may be delayed for as long as 24h if appropriate antimicrobial therapy is given and careful clinical monitoring is provided (B-II).15.In patients with severe peritonitis,mandatory or sched-uled relaparotomy is not recommended in the absence of in-testinal discontinuity,abdominal fascial loss that prevents ab-dominal wall closure,or intra-abdominal hypertension (A-II).16.Highly selected patients with minimal physiological de-rangement and a well-circumscribed focus of infection,suchas a periappendiceal or pericolonic phlegmon,may be treatedwith antimicrobial therapy alone without a source control pro-cedure,provided that very close clinical follow-up is possible (B-II).Microbiologic Evaluation17.Blood cultures do not provide additional clinically rel-evant information for patients with community-acquired intra-abdominal infection and are therefore not routinely recom-mended for such patients (B-III).18.If a patient appears clinically toxic or is immunocom-promised,knowledge of bacteremia may be helpful in deter-mining duration of antimicrobial therapy (B-III).19.For community-acquired infections,there is no provenvalue in obtaining a routine Gram stain of the infected material (C-III).by guest on March 8, 2015/Downloaded fromTable2.Agents and Regimens that May Be Used for the Initial Empiric Treatment of Extra-biliary Complicated Intra-abdominal InfectionRegimen Community-acquired infectionin pediatric patientsCommunity-acquired infection in adultsMild-to-moderate severity:perforated or abscessed appendicitisand other infections ofmild-to-moderate severityHigh risk or severity:severe physiologic disturbance,advanced age,or immunocompromised stateSingle agent Ertapenem,meropenem,imipenem-cilastatin,ticarcillin-clavulanate,andpiperacillin-tazobactam Cefoxitin,ertapenem,moxiﬂoxacin,tigecycline,and ticarcillin-clavulanicacidImipenem-cilastatin,meropenem,dori-penem,and piperacillin-tazobactamCombination Ceftriaxone,cefotaxime,cefepime,orceftazidime,each in combination withmetronidazole;gentamicin or tobra-mycin,each in combination with met-ronidazole or clindamycin,and with orwithout ampicillin Cefazolin,cefuroxime,ceftriaxone,cefotaxime,ciproﬂoxacin,or levoﬂox-acin,each in combination withmetronidazole aCefepime,ceftazidime,ciproﬂoxacin,orlevoﬂoxacin,each in combinationwith metronidazole aa Because of increasing resistance of Escherichia coli toﬂuoroquinolones,local population susceptibility proﬁles and,if available,isolate susceptibility should be reviewed.20.For health care–associated infections,Gram stains may help deﬁne the presence of yeast(C-III).21.Routine aerobic and anaerobic cultures from lower-risk patients with community-acquired infection are considered op-tional in the individual patient but may be of value in detecting epidemiological changes in the resistance patterns of pathogens associated with community-acquired intra-abdominal infection and in guiding follow-up oral therapy(B-II).22.If there is signiﬁcant resistance(ie,resistance in10%–20%of isolates)of a common community isolate(eg,Esche-richia coli)to an antimicrobial regimen in widespread local use, routine culture and susceptibility studies should be obtained for perforated appendicitis and other community-acquired in-tra-abdominal infections(B-III).23.Anaerobic cultures are not necessary for patients with community-acquired intra-abdominal infection if empiric an-timicrobial therapy active against common anaerobic pathogens is provided(B-III).24.For higher-risk patients,cultures from the site of infec-tion should be routinely obtained,particularly in patients with prior antibiotic exposure,who are more likely than other pa-tients to harbor resistant pathogens(A-II).25.The specimen collected from the intra-abdominal focus of infection should be representative of the material associated with the clinical infection(B-III).26.Cultures should be performed from1specimen,pro-vided it is of sufﬁcient volume(at least1mL ofﬂuid or tissue, preferably more)and is transported to the laboratory in an appropriate transport system.For optimal recovery of aerobic bacteria,1–10mL ofﬂuid should be inoculated directly into an aerobic blood culture bottle.In addition,0.5mL ofﬂuid should be sent to the laboratory for Gram stain and,if indi-cated,fungal cultures.If anaerobic cultures are requested,at least0.5mL ofﬂuid or0.5g of tissue should be transportedin an anaerobic transport tube.Alternately,for recovery of anaerobic bacteria,1–10mL ofﬂuid can be inoculated directlyinto an anaerobic blood culture bottle(A-I).27.Susceptibility testing for Pseudomonas,Proteus,Acine-tobacter,Staphylococcus aureus,and predominant Enterobac-teriaceae,as determined by moderate-to-heavy growth,shouldbe performed,because these species are more likely than othersto yield resistant organisms(A-III).RECOMMENDED ANTIMICROBIAL REGIMENSThe antimicrobials and combinations of antimicrobials de-tailed in Tables2–4are considered adequate for empiric treat-ment of community-and health care–associated intra-abdom-inal infection as indicated.Community-Acquired Infection of Mild-to-Moderate Sever-ity in Adults28.Antibiotics used for empiric treatment of community-acquired intra-abdominal infection should be active againstenteric gram-negative aerobic and facultative bacilli and entericgram-positive streptococci(A-I).29.Coverage for obligate anaerobic bacilli should be pro-vided for distal small bowel,appendiceal,and colon-derivedinfection and for more proximal gastrointestinal perforationsin the presence of obstruction or paralytic ileus(A-I).30.For adult patients with mild-to-moderate community-acquired infection,the use of ticarcillin-clavulanate,cefoxitin, ertapenem,moxiﬂoxacin,or tigecycline as single-agent therapyor combinations of metronidazole with cefazolin,cefuroxime, ceftriaxone,cefotaxime,levoﬂoxacin,or ciproﬂoxacin are pref-erable to regimens with substantial anti-Pseudomonal activity(Table2)(A-I).by guest on March 8, 2015/Downloaded fromTable3.Recommendations for Empiric Antimicrobial Therapy for Health Care–Associated Complicated Intra-abdominal InfectionOrganisms seen in health care–associated infection at the local institutionRegimenCarbapenem a Piperacillin-tazobactamCeftazidime or cefepime,each with metronidazole Aminoglycoside Vancomycin!20%Resistant Pseudomonas aeruginosa,ESBL-producing Enterobacteriaceae,Acinetobacter,or other MDR GNBRecommended Recommended Recommended Not recommended Not recommendedESBL-producing Enterobacteriaceae Recommended Recommended Not recommended Recommended Not recommended P.aeruginosa120%resistant toceftazidimeRecommended Recommended Not recommended Recommended Not recommendedMRSA Not recommended Not recommended Not recommended Not recommended Recommended NOTE.ESBL,extended-spectrum b-lactamase;GNB,gram-negative bacilli;MDR,multidrug resistant;MRSA,methicillin-resistant Staphylococcus aureus.“Recommended”indicates that the listed agent or class is recommended for empiric use,before culture and susceptibility data are available,at institutions that encounter these isolates from other health care–associated infections.These may be unit-or hospital-speciﬁc.a Imipenem-cilastatin,meropenem,or doripenem31.Ampicillin-sulbactam is not recommended for use be-cause of high rates of resistance to this agent among com-munity-acquired E.coli(B-II).32.Cefotetan and clindamycin are not recommended for use because of increasing prevalence of resistance to these agents among the Bacteroides fragilis group(B-II).33.Because of the availability of less toxic agents demon-strated to be at least equally effective,aminoglycosides are not recommended for routine use in adults with community-acquired intra-abdominal infection(B-II).34.Empiric coverage of Enterococcus is not necessary in pa-tients with community-acquired intra-abdominal infection (A-I).35.Empiric antifungal therapy for Candida is not recom-mended for adult and pediatric patients with community-acquired intra-abdominal infection(B-II).36.The use of agents listed as appropriate for higher-severity community-acquired infection and health care–associated in-fection is not recommended for patients with mild-to-moderate community-acquired infection,because such regimens may carry a greater risk of toxicity and facilitate acquisition of more-resistant organisms(B-II).37.For those patients with intra-abdominal infection of mild-to-moderate severity,including acute diverticulitis and various forms of appendicitis,who will not undergo a source control procedure,regimens listed for treatment of mild-to-moderate–severity infection are recommended,with a possi-bility of early oral therapy(B-III).High-Risk Community-Acquired Infection in Adults38.The empiric use of antimicrobial regimens with broad-spectrum activity against gram-negative organisms,including meropenem,imipenem-cilastatin,doripenem,piperacillin-tazobactam,ciproﬂoxacin or levoﬂoxacin in combination with metronidazole,or ceftazidime or cefepime in combination with metronidazole,is recommended for patients with high-severity community-acquired intra-abdominal infection,as deﬁned byAPACHE II scores115or other variables listed in Table1(Table2)(A-I).39.Quinolone-resistant E.coli have become common insome communities,and quinolones should not be used unlesshospital surveys indicate190%susceptibility of E.coli to quin-olones(A-II).40.Aztreonam plus metronidazole is an alternative,but ad-dition of an agent effective against gram-positive cocci is rec-ommended(B-III).41.In adults,routine use of an aminoglycoside or anothersecond agent effective against gram-negative facultative andaerobic bacilli is not recommended in the absence of evidencethat the patient is likely to harbor resistant organisms thatrequire such therapy(A-I).42.Empiric use of agents effective against enterococci is rec-ommended(B-II).e of agents effective against methicillin-resistant S.au-reus(MRSA)or yeast is not recommended in the absence ofevidence of infection due to such organisms(B-III).44.In these high-risk patients,antimicrobial regimensshould be adjusted according to culture and susceptibility re-ports to ensure activity against the predominant pathogens iso-lated in culture(A-III).Health Care–Associated Infection in Adults45.Empiric antibiotic therapy for health care–associated in-tra-abdominal infection should be driven by local microbio-logic results(A-II).46.To achieve empiric coverage of likely pathogens,mul-tidrug regimens that include agents with expanded spectra ofactivity against gram-negative aerobic and facultative bacillimay be needed.These agents include meropenem,imipenem-cilastatin,doripenem,piperacillin-tazobactam,or ceftazidimeby guest on March 8, 2015/Downloaded fromTable4.Agents and Regimens that May Be Used for the Initial Empiric Treatment of Biliary Infection in AdultsInfection RegimenCommunity-acquired acute cholecystitis of mild-to-moderate severity Cefazolin,cefuroxime,or ceftriaxoneCommunity-acquired acute cholecystitis of severe physiologic disturbance, advanced age,or immunocompromised state Imipenem-cilastatin,meropenem,doripenem,piperacillin-tazobactam, ciproﬂoxacin,levoﬂoxacin,or cefepime,each in combination with metronidazole aAcute cholangitis following bilio-enteric anastamosis of any severity Imipenem-cilastatin,meropenem,doripenem,piperacillin-tazobactam,ciproﬂoxacin,levoﬂoxacin,or cefepime,each in combination withmetronidazole aHealth care–associated biliary infection of any severity Imipenem-cilastatin,meropenem,doripenem,piperacillin-tazobactam,ciproﬂoxacin,levoﬂoxacin,or cefepime,each in combination with metroni-dazole,vancomycin added to each regimen aa Because of increasing resistance of Escherichia coli toﬂuoroquinolones,local population susceptibility proﬁles and,if available,isolate susceptibility should be reviewed.or cefepime in combination with metronidazole.Aminogly-cosides or colistin may be required(Table3)(B-III).47.Broad-spectrum antimicrobial therapy should be tai-lored when culture and susceptibility reports become available, to reduce the number and spectra of administered agents(B-III).Antifungal Therapy48.Antifungal therapy for patients with severe community-acquired or health care–associated infection is recommended if Candida is grown from intra-abdominal cultures(B-II). 49.Fluconazole is an appropriate choice for treatment if Candida albicans is isolated(B-II).50.Forﬂuconazole-resistant Candida species,therapy with an echinocandin(caspofungin,micafungin,or anidulafungin) is appropriate(B-III).51.For the critically ill patient,initial therapy with an echi-nocandin instead of a triazole is recommended(B-III).52.Because of toxicity,amphotericin B is not recommended as initial therapy(B-II).53.In neonates,empiric antifungal therapy should be started if Candida is suspected.If C.albicans is isolated,ﬂuconazole is an appropriate choice(B-II).Anti-enterococcal Therapy54.Antimicrobial therapy for enterococci should be given when enterococci are recovered from patients with health care–associated infection(B-III).55.Empiric anti-enterococcal therapy is recommended for patients with health care–associated intra-abdominal infection, particularly those with postoperative infection,those who have previously received cephalosporins or other antimicrobial agents selecting for Enterococcus species,immunocompromised patients,and those with valvular heart disease or prosthetic intravascular materials(B-II).56.Initial empiric anti-enterococcal therapy should be di-rected against Enterococcus faecalis.Antibiotics that can poten-tially be used against this organism,on the basis of susceptibilitytesting of the individual isolate,include ampicillin,piperacillin-tazobactam,and vancomycin(B-III).57.Empiric therapy directed against vancomycin-resistant Enterococcus faecium is not recommended unless the patient isat very high risk for an infection due to this organism,suchas a liver transplant recipient with an intra-abdominal infection originating in the hepatobiliary tree or a patient known to becolonized with vancomycin-resistant E.faecium(B-III).Anti-MRSA Therapy58.Empiric antimicrobial coverage directed against MRSAshould be provided to patients with health care–associated in-tra-abdominal infection who are known to be colonized withthe organism or who are at risk of having an infection due tothis organism because of prior treatment failure and signiﬁcantantibiotic exposure(B-II).59.Vancomycin is recommended for treatment of suspectedor proven intra-abdominal infection due to MRSA(A-III). Cholecystitis and Cholangitis in Adults60.Ultrasonography is theﬁrst imaging technique used for suspected acute cholecystitis or cholangitis(A-I).61.Patients with suspected infection and either acute cho-lecystitis or cholangitis should receive antimicrobial therapy,as recommended in Table4,although anaerobic therapy is notindicated unless a biliary-enteric anastamosis is present(B-II).62.Patients undergoing cholecystectomy for acute chole-cystitis should have antimicrobial therapy discontinued within24h unless there is evidence of infection outside the wall ofthe gallbladder(B-II).63.For community-acquired biliary infection,antimicrobialactivity against enterococci is not required,because the path-ogenicity of enterococci has not been demonstrated.For se-lected immunosuppressed patients,particularly those with he-by guest on March 8, 2015/Downloaded fromTable5.Initial Intravenous Pediatric Dosages of Antibiotics for Treatment of Com-plicated Intra-abdominal InfectionAntibiotic,age range Dosage a Frequency of dosing Amikacin b15–22.5mg/kg/day Every8–24h Ampicillin sodium c200mg/kg/day Every6h Ampicillin-sulbactam c200mg/kg/day of ampicillin component Every6h Aztreonam c90–120mg/kg/day Every6–8h Cefepime c100mg/kg/day Every12h Cefotaxime c150–200mg/kg/day Every6–8h Cefotetan c40–80mg/kg/day Every12h Cefoxitin c160mg/kg/day Every4–6h Ceftazidime c150mg/kg/day Every8h Ceftriaxone c50–75mg/kg/day Every12–24h Cefuroxime c150mg/kg/day Every6–8hCiproﬂoxacin20-30mg/kg/day Every12h Clindamycin20–40mg/kg/day Every6–8h Ertapenem3months to12years15mg/kg twice daily(not to exceed1g/day)Every12hу13years1g/day Every24h Gentamicin b3–7.5mg/kg/day Every2–4h Imipenem-cilastatin c60–100mg/kg/day Every6h Meropenem c60mg/kg/day Every8h Metronidazole30–40mg/kg/day Every8h Piperacillin-tazobactam c200–300mg/kg/day of piperacillin component Every6–8h Ticarcillin-clavulanate c200–300mg/kg/day of ticarcillin component Every4–6h Tobramycin b 3.0–7.5mg/kg/day Every8–24h Vancomycin b40mg/kg/day as1h infusion Every6–8ha Dosages are based on normal renal and hepatic function.Dose in mg/kg should be based on total body weight.Further information on pediatric dosing can be obtained elsewhere[186–188].b Antibiotic serum concentrations and renal function should be monitored.c b-Lactam antibiotic dosages should be maximized if undrained intra-abdominal abscesses may be present.patic transplantation,enterococcal infection may be signiﬁcant and require treatment(B-III).Pediatric Infection64.Routine use of broad-spectrum agents is not indicated for all children with fever and abdominal pain for whom there is a low suspicion of complicated appendicitis or other acute intra-abdominal infection(B-III).65.Selection of speciﬁc antimicrobial therapy for pediatric patients with complicated intra-abdominal infection should be based on considerations of the origin of infection(community vs health care),severity of illness,and safety of the antimicrobial agents in speciﬁc pediatric age groups(A-II).66.Acceptable broad-spectrum antimicrobial regimens for pediatric patients with complicated intra-abdominal infection include an aminoglycoside-based regimen,a carbapenem(im-ipenem,meropenem,or ertapenem),a b-lactam/b-lactamase–inhibitor combination(piperacillin-tazobactam or ticarcillin-clavulanate),or an advanced-generation cephalosporin(cefo-taxime,ceftriaxone,ceftazidime,or cefepime)with metroni-dazole(Tables2and5)(B-II).67.For children with severe reactions to b-lactam antibi-otics,ciproﬂoxacin plus metronidazole or an aminoglycoside-based regimen are recommended(B-III).68.Necrotizing enterocolitis in neonates is managed withﬂuid resuscitation,intravenous broad-spectrum antibiotics (potentially including antifungal agents),and bowel decom-pression.Urgent or emergent operative intervention,consistingof either laparotomy or percutaneous drainage,should be per-formed when there is evidence of bowel perforation.Intra-operative Gram stains and cultures should be obtained(B-III).69.Broad-spectrum antibiotics that may be useful in neo-nates with this condition include ampicillin,gentamicin,and metronidazole;ampicillin,cefotaxime,and metronidazole;or meropenem.Vancomycin may be used instead of ampicillinfor suspected MRSA or ampicillin-resistant enterococcal infec-tion.Fluconazole or amphotericin B should be used if the Gramstain or cultures of specimens obtained at operation are con-sistent with a fungal infection(B-II).Pharmacokinetic Considerations70.Empiric therapy of patients with complicated intra-abdominal infection requires the use of antibiotics at optimalby guest on March 8, 2015/Downloaded from。

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感染性腹泻经验性治疗
32，免疫功能减退患者，病情严重或伴有血性腹泻时可行经验性抗菌治疗（强推荐，低等级）。 33，与血性腹泻患者接触的无症状人群，不推荐行经验性抗菌治疗，但应建议患者采取合理的预防和控制措施（强推荐，中等级）。
感染性腹泻经验性治疗
34，有脓毒血症临床表现并疑为肠源性发热患者，推荐在留取血、尿和粪便标本后，予以广谱抗菌药物行经验性治疗（强推荐，低等级）；得到药敏试验结果后，应使用窄谱抗菌药（强推荐，高等级）；若临床疑似肠源性发热患者暂不能隔离，经验性抗菌治疗药物选择应结合症状发生地易感病原体谱（弱推荐，低等级）。
感染性腹泻经验性治疗
31，成年患者经验性抗菌治疗可使用喹诺酮类药物，如环丙沙星或阿奇霉素，具体用药方案需结合当地易感病原体和患者旅行史（强推荐，中等级）；儿童经验性治疗可使用阿奇霉素，年龄＜3个月或有中枢神经系统侵犯时，推荐使用三代头孢，具体用药方案需结合易感病原体和患者旅行史（强推荐，中等级）。
诊断
VI. 何时进行艰难梭菌诊断试验？
推荐意见： 18，年龄＞2周岁、腹泻并已使用抗菌药物患者和医疗保健相关腹泻患者，应行艰难梭菌检查试验（弱推荐，高等级）；不明原因和无已知风险因素的持续腹泻患者需行艰难梭菌检查（弱推荐，低等级）；单一腹泻患者粪便样本建议行毒素和产毒型艰难梭菌毒株检测（强推荐，低等级）。多样本送检并未增加其检出率。
诊断
V. 当怀疑患者为肠源性发热和菌血症时，需行哪些诊断试验？
推荐意见： 17，首先可考虑行血液和粪便样本多元分子诊断，当疑为肠源性发热或腹泻合并菌血症时，应行病原体培养检查（强推荐，中等级）；骨髓（对已使用抗菌药患者）、粪便、十二指肠液和尿液培养对肠源性发热具有较好诊断价值（弱推荐，中等级）；血清学检测不推荐用于诊断肠源性发热（强推荐，中等级）。
诊断
VIII. 急性腹泻患者粪便中白细胞、乳铁蛋白和钙卫蛋白有何临床意义？
推荐意见： 20，粪便白细胞和乳铁蛋白检测并不推荐用于急性感染性腹泻病因检测（强推荐，中等级）。目前尚无足够证据证明粪便钙卫蛋白对急性感染性腹泻患者具有诊断价值。
诊断
IX. 哪些情况下推荐使用影像学、生化学或血清学试验等非微生物检查方法？
诊断
13，大多数非复杂旅行者腹泻患者无需进行诊断试验，除非治疗需要。持续腹泻超过14天的旅行者腹泻患者需考虑是否为肠道寄生虫感染（强推荐，中等级）；旅行者腹泻患者应在抗菌治疗的前8-12周内行艰难梭菌检查试验，还需评估是否伴发肠道疾病，如炎症性肠病和感染后肠易激综合征（强推荐，中等级）。
诊断
14，多种病原体核酸扩增检测结果解释需考虑是否具有临床意义，因该检测方法检测的是DNA，而不是活体生物（强推荐，低等级）。 15，所有细菌病原体非培养诊断试验阳性的标本，应按照公共卫生报告规则单独送检，在临床检验实验室或公共卫生实验室培养，以确保类似微生物感染的疫情监测和调查（强推荐，低等级）；若药敏试验结果会影响患者护理和公共卫生决策，也应行微生物培养检测（强推荐，低等级）。 16，肠道疾病爆发时期的患者标本，需在公共卫生部门指导下行肠道病原体检测（强推荐，低等级）。
感染性腹泻经验性治疗
35，疑为O157 阳性STEC或产2型志贺毒素(或毒素基因型未知)STEC感染时，不推荐行经验性治疗（强推荐，中等级）；其它非产2型志贺毒素STEC（通常为O157阴性STEC）感染患者是否行抗菌治疗具有争议，目前尚无足够证据证实抗菌治疗可使其获益还是增加疾病风险（强推荐，低等级）。
推荐意见: 21，血清学检查并不推荐用于感染性腹泻或肠源性腹泻发热的病因学检查（强推荐，低等级）；对感染后HUS患者，粪便培养产志贺毒素微生物阴性时，可行血清学检测明确病因（弱推荐，低等级）。 22，外周血白细胞分类计数和血清学检测不推荐用于腹泻病因学检查（强推荐，低等级），但有其本身临床意义（弱推荐，低等级）。
诊断
X.实验室确诊特异性病原体感染性腹泻患者，治疗后有改善或无明显改善仍存在持续性腹泻，应行哪些后续检查？
推荐意见： 26，大多数治疗后腹泻缓解患者，不推荐行后续检查（强推荐，中等级）；肠道伤寒沙门菌、副伤寒沙门菌、STEC、志贺菌和非伤寒沙门菌等病原菌感染患者，粪便样本由当地公共卫生机构收集培养并分析，以将结果返回至幼儿托管机构、公司或社会群体活动组织机构（强推荐，中等级）；临床从业者应积极配合当地公共卫生组织，有关检查结果备案上报的有关规定（强推荐，高等级）。
诊断
9，年龄＜3个月的新生儿、有败血症表现、怀疑肠源性发热、有全身感染表现、免疫缺陷患者、溶血性贫血患者、有肠源性发热流行地区旅游史并出现不明原因发热或有该人群接触史患者推荐做血培养（强推荐，中等级）。 10，有症状患者早期鉴别诊断时应进行粪便检测，重点检测沙门菌、志贺菌、弯曲菌、耶尔森菌和艰难梭菌（强推荐，低等级）。
诊断
25，影像学检查（如超声、CT、MRI）被推荐用于大动脉炎、霉菌性动脉瘤、腹膜炎、腹腔游离气体、中毒性巨结肠诊断。侵袭性肠道沙门菌或耶尔森菌感染的老年患者合并血管外感染时，如足疗程抗生素治疗后仍有持续发热和败血症表现，以及有潜在动脉粥样硬化风险或新发胸、背、腹部疼痛，也推荐行影像学检查（弱推荐，低等级）。
流行病学特征
II. 发热或血性腹泻患者，哪些临床、人口统计学或流行病学特征具有诊疗意义？
推荐意见： 3，发热或血性腹泻患者，应检测是否为肠道病原体感染，包括沙门菌、志贺菌和弯曲菌等（强推荐，低等级）。 4，当发热患者有病原体流行地旅游史、食用有相应暴露史患者提供的食物、有肠沙门菌肠亚种伤寒血清型（Salmonella enterica subspecies enterica serovar Typhi）（下文简称伤寒沙门菌）和肠沙门菌肠亚种副伤寒血清型（Salmonella enterica subspecies enterica serovar Paratyphi）（下文简称副伤寒沙门菌）实验室暴露史，无论其是否合并腹泻，均需考虑肠源性发热（强推荐，中等级）。
诊断
a 持续腹痛患者应检测小肠结肠炎耶尔森菌，尤其是学龄儿童出现右下腹类阑尾炎样疼痛，可伴有肠系膜淋巴结炎。发热患者有耶尔森菌流行病学暴露风险也需检测，包括婴幼儿直接或间接食用生的或未煮熟猪肉食品。 b 当患者出现大量淘米水洋便、有咸水暴露史、食用生的或未煮熟的贝壳类水生生物或是腹泻出现前三天内有霍乱地区旅游史时，应粪便检测弧菌。
流行病学特征
III. 哪些临床表现、人口统计学或流行病学特征与病情恶化和并发症发生相关？
推荐意见： 5，应评估急性腹泻患者脱水程度，因脱水会使危及生命的疾病和死亡风险增加，尤其对年轻和老年患者（强推荐，高等级）。
流行病学特征
6，当临床病史和流行病学史提示疑为产志贺毒素病原菌感染时，应行粪便样本检测志贺毒素或其编码基因，并进一步区分O157:H7大肠埃希菌和其它产志贺毒素大肠埃希菌（Shiga toxin–producing E. coli ，STEC）（强推荐，中等级）；如实验室条件允许，建议检测志贺毒素分型（1型或2型），有助于患者后期诊治（弱推荐，中等级）；痢疾志贺菌1型或其它少见产志贺毒素病原菌可引起溶血性尿毒症综合征（hemolytic uremic syndrome ，HUS)，特别是有跨境旅游史或密切接触该人群患者（强推荐，中等级）。 7，临床医生需认真观察患者与肠道感染相关感染后和肠外临床表现（强推荐，中等级）。
诊断
27，初治无效患者，可再行临床和实验室检查，并重点考虑乳糖不耐症等非感染性腹泻（弱推荐，低等级）。 28，腹泻症状持续14天以上且病因不明患者，可考虑炎症性肠病和肠易激综合征等引起的非感染性腹泻（强推荐，中等级）。
29，症状持续患者，推荐行再次评估其水电解质平衡、营养状况，以及抗菌治疗的最佳剂量和疗程（强推荐，高等级）。
2017 IDSA 感染性腹泻诊治指南
本指南根据GRADE将证据等级分为高、中、低三个级别，意见推荐等级分为强推荐和弱推荐两个级别。
流行病学特征
I. 哪些临床、人口统计学或流行病学特征对腹泻患者具有诊疗意义？
推荐意见： 1，应尽可能全面了解患者疾病暴露史和临床特征，包括其它类似疾病史（强推荐，中等级）。 2，儿童看护机构、长期病患护理机构、饮食服务机构或水上娱乐项目相关机构如游泳池工作的人员，如出现腹泻症状，应严格遵守当地相关部门疫情报告和感染控制建议（强推荐，高等级）。
诊断
IV. 当患者出现腹泻时，首先应考虑哪些病原菌感染，哪些诊断试验有助于明确病原菌并用于疾病暴发调查？
推荐意见： 8，当患者出现腹泻伴发热、血便或粘液样便、严重腹部压痛绞痛或脓毒血症时，应行粪便样本检测沙门菌、志贺菌、弯曲杆菌、耶尔森菌、艰难梭菌和STEC（强推荐，中等级）；艰难梭菌感染时，患者较少出现血便，STEC应行粪便培养并检测抗原O157，O157阴性STEC应行志贺毒素及其基因型检测（强推荐，低等级）；山梨醇-MacConkey琼脂或其它显色培养基被推荐用于STEC培养和抗原O157:H7检测；志贺毒素检测有助于其它STEC血清型鉴别（强推荐，中等级）。
诊断
11，无论腹泻患者是否伴有发热血便或粘液样便，或其它疾病加重或腹泻暴发流行特征，都应考虑是否存在细菌、病毒或其它寄生病原体感染。检查方法选择需综合考虑患者症状和流行病学风险，最好与当地公共卫生部门协调（强推荐，中等级）。
诊断
12，腹泻合并免疫缺陷患者推荐行粪便培养、病毒和寄生虫检测，以扩大疾病鉴别诊断范围，尤其是中重度原发和继发性免疫缺陷（强推荐，中等级）。获得性免疫缺陷综合征患者（acquired immune deficiency syndrome，AIDS)出现持续性腹泻应检测隐孢子虫（Cryptosporidium）、环孢子虫（Cyclospora）、囊等孢球虫（Cystoisospora）、微孢子虫（microsporidia,）、鸟型分支杆菌复合群（Mycobacterium avium complex）和巨细胞病毒（强推荐，中等级）。