IDSA2010复杂腹腔感染诊治指南解读
复杂性腹腔感染-关注外科问题
初始恰当经验性使用抗生素
约40%的腹膜炎发展为腹部sepsis
联合抗需氧菌和厌氧 菌治疗降低了病死率 和残余脓肿的发生率
针对IAI危重患者
初始恰当抗生素应用
hit hard and hit early
目标性更换抗生素
降阶梯治疗→靶向
Plotkin l: Epidemiology of abdominal sepsis. vestn Khir Im I I aya DA, Nathens AB. Surg Infect 2003;4:355–362.
Microbiologic evaluation
Solomkin,et al. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. CID 2010;50 (1) :133-164.
复杂性IAI的初始经验性抗生素治疗 —HA-IAI (2010 IDSA与SIS指南)
Solomkin,et al. Diagnosis and Management of Complicated Intra-abdominal Infection in Adults and Children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. CID 2010:50 (1) :133-164.
2010版美国腹腔感染指南更新内容介绍(最终版)
•
氟喹诺酮（环丙沙星或左氧氟沙星） +甲硝唑
2003版与2010版指南推荐用药区别：
• 轻-中度cIAI： • 2010年新版指南不再推荐使用氨苄西林/舒巴坦治疗
• 2010年新版指南增加了莫西沙星、替加环素及头孢西丁单药 治疗方案
• 重度cIAI：
• 2010年新版指南不再推荐头孢曲松等三代头孢治疗重度腹腔 感染
外科常用抗菌药物日费用比较
常用抗菌药物
拜复乐
（莫西沙星） 舒普深 （头孢哌酮/舒巴坦） 特治星 （哌拉西林/他唑巴坦） 泰能 （亚胺培南/西司他丁）
日治疗费用*
2010年IDSA腹腔感染指南推荐意见
333元
单药治疗轻中度腹腔感染一线用药
452－678元
未通过美国FDA批准上市，国外指南 无推荐意见 重症腹腔感染单药治疗
388－776元
428－856元
重症腹腔感染单药治疗
*按照MIMS说明书用法用量及价格
谢 谢！
科室会短信有奖问答
1、2010年IDSA《复杂腹腔感染抗菌药物选用指南》中推荐拜复乐®作为_____。 A、治疗重度腹腔感染的单一用药 B、治疗轻中度腹腔感染的联合用药
C、单药治疗轻中度腹腔感染的一线用药
2010年IDSA cIAI 指南为何不推荐氨苄西林/舒巴坦？
• G-菌耐药呈显著增加趋势(尤其是对氨苄西林/舒巴坦耐药的大肠埃希菌)
2010年IDSA cIAI 指南为何不推荐头孢曲松等三代头孢？
• 大量研究显示，头孢曲松对产ESBL的大肠杆菌/肺炎克雷伯菌无效
•
美国临床实验室标准化委员会(CLSI)严格规定，产 ESBL酶细菌即使体
外药敏对头孢菌素（头孢噻肟、头孢他啶、头孢哌酮、头孢曲松等）敏 感，临床上也必须报告耐药
最新感染性疾病指南解读
第二就是强调了生命复苏也就是液体复苏。液体复苏要快速补充血容量并且监测需要的参数，如果病人已经发生了感染性休克，在 6 个小时内遵从一个早期目标性的治疗，即便是没有液体缺失的证据也应该补充液体，因为这样的病人丢失比较多， 他会出现发热、呼吸急促、呼吸性碱中毒。同样也特别强调回顾性对照的一些研究数据，比如化脓性阑尾炎的病人将从给予液体的治疗当中获益，即便没有感染性休克的表现，具体复苏实际上是按照了严重感染和感染中毒性休克的国际性指南的要求，先给 5000 到 1000 毫升的晶体液或者 300 到 500 毫升的胶体液，在 30 分钟的时间里输入，根据病人的反映或者承受能力决定是否再重复给药。
在指南当中也特别摘录了前面提到的严重感染和感染性休克指南当中的 EGDT 的一个要求，也就是早期目标性的液体复苏治疗的要求，最初 6 小时内达到目标。这样的目标就是中心静脉压在 8 到 12mmHg ，平均动脉压大于等于 65mmHg ，尿量超过 0.5ml 每公斤体重每小时，中心静脉、上腔静脉的氧饱和度≥ 70% ，或者是混合静脉氧饱和度≥ 60% ，那么在这个复苏的过程当中如果发现下面的情况需做一些调整，比如 CVP 已经达标，但静脉的氧饱和度没有达到 65% ，上腔静脉的氧饱和度没有达到 70% ，这种情况下可以考虑输注浓缩的红细胞，使红细胞压积能够≥ 30% ，同时输入多巴酚丁胺来达到上述目的，多巴酚丁胺的最大剂量是 20 微克每公斤体重每分钟。
复杂腹腔感染诊治方法(cIAIs)
处理
1 原发病灶的局部处理； 2 抗感染药物的使用； 3 复苏及脏器功能支持。
复杂腹腔感染诊治方法（ cIAIs ）
复杂腹腔感染诊治方法（ cIAIs ）
SIAI的临床特点
• 进行性脏器功能障碍 • 持续性腹腔或腹膜后广泛感染 • 大多起病急、发展快、变化多、病情重 • 死亡率高达5%-50% • 常表现为弥漫性腹膜炎、多发性腹腔或腹
膜后脓肿，如： 重症胰腺炎合并腹腔感染 空腔脏器穿孔/破裂与吻合口瘘合并感染
复杂腹腔感染诊治方法（ cIAIs ）
– 体温、心率、WBC、呼吸率
• CARS期 （代偿性抗炎症反应）：
– HLA-DR表达持续降低 – CD8>CD4, TH1 TH2
• MARS期（混合性拮抗物反应综合征）:
复杂腹腔感染诊治方法（ cIAIs ）
感染源控制措施
复杂腹腔感染诊治方法（ cIAIs ）
IAI感染源控制原则
• 尽早介入的原则 • 损伤控制的原则 • 控制、去除感染源
at least 2 of the followings： SIRS plus Documented Infection
•T >38°or < 37°C
•P >90 beats/ min
Severe Sepsis
Sepsis plus organ failure
•RR > 20 breaths/min
复杂腹腔感染诊治方法（ cIAIs ）
复杂腹腔感染cIAI的疾病概述和抗感染治疗课件
文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。
脓肿
文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。
腹腔脓肿的危害严重
• 腹腔脓肿可分为膈下脓肿、盆腔脓肿、肠间隙脓肿灯 • 一般继发于急性腹膜炎或腹腔内手术，原发性感染少见
• I/II期患者通常不会出现严重脓 毒症/感染性休克，且可以安全 进行肠内治疗、抗生素静脉输 注和经皮引流治疗较大脓肿
Moore FA,et al.World J Emerg Surg.2013 Dec 26;8(1):55.
• III/IV期患者可能存在感染性休克， 若在手术时仍存在，应在有限条件 下接受DCL(损伤控制剖腹手术)
Ramakrishnaiah VP,et al.Trop Gastroenterol.2012 Oct-Dec;33(4):275-81.
文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。
消化性溃疡穿孔的诊治
诊断
基于病史及临床检查进行诊断
• 间歇性腹痛或胃食管反流史 • 已知消化性溃疡并且治疗不
Moore FA,et al.World J Emerg Surg.2013 Dec 26;8(1):55.
文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。
乙状结肠憩室炎穿孔的诊治
治疗
• 治疗决策的制定主要基于：
− 疾病的进展阶段 − 患者的合并症 − ቤተ መጻሕፍቲ ባይዱ毒症严重程度
充分，或伴随持续症状和/ 或疼痛突然恶化 • 近期检查证实
不同类型复杂腹腔感染的疾病概述与抗感染治疗--FINAL
Moore FA,et al.World J Emerg Surg.2013 Dec 26;8(1):55.
乙状结肠憩室炎穿孔的诊治
治疗 • 治疗决策的制定主要基于：
− 疾病的进展阶段
− 患者的合并症
− 脓毒症严重程度
•
I/II期患者通常不会出现严重脓 毒症/感染性休克，且可以安全 进行肠内治疗、抗生素静脉输 注和经皮引流治疗较大脓肿
实验室检查 • 往往为非特异性， 但白细胞升高，代 谢性酸中毒和血清 淀粉酶升高可能与 穿孔有关
影像学
• X线 • CT：大大提高了 穿孔检测的能力 和准确性
Di Saverio S,et al.World J Emerg Surg.2014 Aug 3;9:45.
消化性溃疡穿孔的诊治
治疗 若溃疡通过粘连网膜等自行封闭，则在患者无 腹膜炎或严重脓毒症情况下可进行非手术治疗
9
9
8
北美研究：一项前瞻性、双盲、随机、III期对照研究，研究纳入2000年10月23日至2003年4月22日美 国，加拿大，以色列71个调查中心681例患者，其中莫西沙星组 339例，莫西沙星400mg qd，序贯治 疗，疗程5-14天；对照组342例，哌拉西林/他唑巴坦静脉给药(3.0/0.375g qid)后口服阿莫西林/克拉维酸 (800/114mg bid)，疗程5-14天
若溃疡有仍有渗漏，需要手术
• 消化性溃疡穿孔非手术治疗成功与否的最重要因素是溃疡是否封闭，可通过 胃肠造影术来鉴别
乙状结肠憩室炎穿孔诊治
诊断 基于病史、体格检查、 常规实验室检查进行诊断 • 腹痛，通常位于左下象限 • 可到达右下腹，类似阑尾炎 影像学 • CT：对于确诊有较高的敏感性 和特异性
复杂性腹腔感染的抗菌治疗(指南解读))
张文宏 复旦大学附属华山医院感染科
・１３５・
复杂性腹腔感染的分类（感染获得地点区分）
・社区获得性腹腔感染
一感染发生于社区，如化脓性阑尾炎，结肠憩室穿孔 一多为革兰阴性菌、厌氧菌，较少耐药 一多为轻中度腹腔感染 一如有脏器功能不全、免疫抑制的病人则归为重度腹腔感染
－１３７・
・１３８・
・１３９・
・１４０・
・医院获得性腹腔感染
一多为术后感染，如肠吻合口瘘并腹腔感染 一可合并休克、脏器功能损害，多为重度腹腔感染 一可为革兰阴性杆菌、肠球菌或条件致病菌，多为耐药菌。如 ＥＳＢＬ的大肠杆菌，阴沟肠ｓ Ｄｉｓｅａｓｅｓ．２０１０．ＳＯ：１３３－１６４
・１３６・
腹腔感染诊断一影像学
影像学检查
・Ｂ超：优点一便于床旁检查，引导脓肿的穿
刺引流 缺点一受腹腔内肠袢积气的影响 ・ＣＴ．－优点一了解感染灶的部位、毗邻脏器 的相关变化，甚至肠壁的炎症水肿，膈上 膈下的积液积气 缺点一重症病人病人转运不便
ＯＩｎＩ口Ｉ加把删啦Ｏｂａａｓｅｓ．２０１０．５仉１３３－１６４
初始复苏治疗
ｍｅｎｓｉｖｅ Ｃａｒｃ Ｍｅｄ １２０１３１ ３９：１６５－２２８
复杂腹腔感染(cIAI) 的疾病概述与抗感染治疗
脓肿
腹腔脓肿的危害严重
• 腹腔脓肿可分为膈下脓肿、盆腔脓肿、肠间隙脓肿灯 • 一般继发于急性腹膜炎或腹腔内手术，原发性感染少见
未早期引流 抗菌药物选择不当 用药不及时
多器官衰竭
危害
Ramakrishnaiah VP,et al.Trop Gastroenterol.202X Oct-Dec;33(4):275-81.
消化性溃疡穿孔的诊治
诊断
基于病史及临床检查进行诊断
• 间歇性腹痛或胃食管反流史 • 已知消化性溃疡并且治疗不
充分，或伴随持续症状和/ 或疼痛突然恶化 • 近期检查证实
肠间脓肿
如非手术治疗无效或发生肠梗阻时，考 虑剖腹探查并行引流术
陈孝平主编,外科学.人民卫生出版社.北京.2010年第2版.
腹腔脓肿常见病原体： 肠杆菌科和脆弱拟杆菌（厌氧菌）
复杂腹腔感染的疾病类型
复杂腹腔感染
胃十二指肠穿孔(24h内未能接受手术者) 外伤性小肠结肠破裂(12h内未能接受手术者) 非外伤性小肠结肠穿孔 阑尾炎穿孔引起的化脓性腹膜炎或阑尾周围脓肿 胆囊炎并发穿孔或脓肿 腹腔脓肿 腹部手术后腹腔内感染等
1. https:///ucm/groups/fdagov-public/@fdagov-drugs-gen/documents/document/ucm321390.pdf 2. 黎沾良,等.中国感染与化疗杂志,2009,9(2):97-98.
脓毒症
病死率可高达20%
1. 陈孝平主编,外科学.人民卫生出版社.北京.2010年第2版. 2. 田可歌,等.中华医院感染学杂志.2007.17(1)42-44.
复杂腹腔感染
连续药敏监测结果显示，腹腔感染主要致病菌对亚胺培 南敏感性高
产ESBL大肠杆菌和肺炎克雷伯杆菌的耐药菌株不断增加， 但对亚胺培南耐药率并未明显增加，对亚胺培南仍保持 较高敏感性
复杂性腹腔感染 (IAIs)
抗感染药物选用指南——美国感染病学会(IDSA)推荐
亚胺培南在复杂性腹腔 感染的应用
内容
概念 复杂腹腔感染常见病原菌 起始充分治疗的诊治策略 亚胺培南在腹腔感染的优势和安全性
概念
复杂性腹腔感染(complicated intraabdominal infections)
感染致病菌不仅累及空腔脏器，还穿透原发受累 的器官进入腹腔，引起腹膜炎或腹腔脓肿
Weigelt JA, et al. Cleveland Clinical Journal of Medicine, 2007, 30 (suppl. 4): s29-37.
复杂性腹腔感染(IAIs)的微生物 学特点
混合杆菌感染为特征
– 以肠杆菌科为主，大肠杆菌感染占多数
非发酵菌和厌氧菌感染比例增加
1.Journal of Antimicrobial Agents 11(1999)107-113 2.Arch Surg.1997;132:1294-1302. 3.Antimicrobial Chemotherapy(1995)35,139-148 4.Scand J Infect Dis 29:503-508,1997. 5.Drugs exptl clin res xxv(6) 243-252(1999) 6.Scand J Infect Dis 28:513-518(1996)
AmpC -
2010版美国腹腔感染指南更新内容介绍课件
复杂性腹腔感染(cIAI)分类
• 社区获得性感染 胃或十二指肠穿孔
小肠或结肠穿孔
阑尾穿孔或阑尾周围脓肿
医源性感染
腹部手术后腹腔内感染
新版指南经验治疗用药建议
在北美人群中证实拜复乐单药每日1次治疗复杂腹腔 感染与哌拉西林/他唑巴坦每日4次效果相当 对亚太人群进行的最大规模的腹腔感染RCT研究，结果 证实拜复乐单药治疗复杂腹腔感染与头孢曲松联合甲 硝唑疗效相当 拜复乐针剂在欧洲、拉丁美洲和南美洲的多中心研究，
北美研究
Dragon研究
AIDA研究
再一次验证了拜复乐单药=联合方案（头孢曲松＋ 甲硝唑）
（亚胺培南/西司他丁）
*按照MIMS说明书用法用量及价格
谢 谢！
环丙沙星或左氧氟沙星 + 甲硝唑
2010版与2003版指南推荐用药区别：
• 轻-中度社区获得性cIAI： • 2010版指南不再推荐使用氨苄西林/舒巴坦治疗
• 2010版指南新加了莫西沙星、替加环素及头孢西丁等单药治 疗方案
• 重度社区获得性cIAI：
• 2010版指南不再推荐头孢曲松、头孢噻肟和头孢唑肟等三代 头孢菌素治疗
2010版美国感染病学会(IDSA)
复杂腹腔感染(cIAI)指南
更新内容介绍
2010年1月《临床感染病杂志》 成人及儿童复杂性腹腔感染诊断与治疗指南
复杂性腹腔感染(cIAI)定义
• 复杂性腹腔感染（Complicated intra-abdominal infection, cIAI）
感染自空腔脏器扩展至腹膜腔内，形成腹膜炎或者脓肿的一类疾
复杂性腹腔感染的抗生素指南
复杂性腹腔感染的抗菌素选用指南（作者略）内容概要该指南由美国感染病协会、外科感染协会、美国微生物协会和感染性疾病药剂师协会共同制订，根据循证医学研究结果提出关于成年患者复杂性腹腔感染如何选择抗生素的建议。
复杂性腹腔感染是指感染由空腔脏器向腹腔扩散，伴有脓肿形成或腹膜炎。
指南还论述了开始抗生素治疗的时机、何时应行何种培养、如何根据培养结果调整抗生素治疗方案以及疗程长短。
病原体：此类感染的病原体以及相应应选择的抗生素因感染地点而不同，分为社区获得性和医院获得性两种。
医院获得性腹腔感染最常见于择期或急诊腹腔内手术的并发症，是由特定手术部位、特定医院和医疗单元的院内病原体引起。
对于社区获得性感染，胃肠道穿孔的部位（胃、十二指肠、空肠、回肠、阑尾或结肠）决定了感染病原体。
近端小肠以远的感染常由兼性需氧和需氧的革兰氏阴性菌引起；近端回肠以远的感染还可由各种厌氧菌引起。
微生物学检测：由于常用抗厌氧菌治疗方案对于治疗社区获得性感染很有效，因此仅限于在针对兼性需氧和需氧性革兰氏阴性杆菌进行鉴定和药敏试验时才需要留取标本进行微生物检测。
由于药敏试验显示脆弱拟杆菌类菌株对克林霉素、头孢替坦、头孢西丁和喹诺酮类药物有明确的耐药性，因此对于有可能存在脆弱拟杆菌感染的情况下，应该避免经验性单用上述药物。
推荐的治疗方案：这些感染可应用各种单药或多药治疗方案。
表1中所列抗生素及其联合应用方案适用于社区获得性腹腔感染的治疗。
没有证据表明哪一种方案更好或较差。
虽然表中所列药物大多已经有前瞻性临床试验在研究，但许多这样的试验存在严重的设计缺陷。
因此治疗建议部分是根据抗生素体内活性。
社区获得性感染：对于轻至中度的社区获得性感染，优先选用窄谱和院内不常用的抗生素，如氨苄西林/舒巴坦、头孢唑啉或头孢呋辛与甲硝唑联用、替卡西林/克拉维酸、厄他培南以及喹诺酮类与甲硝唑联用，而不是选用广谱抗革兰氏阴性菌和/或毒性较大的抗生素。
在选用特定抗生素治疗方案时，经济花费是需考虑的重要因素。
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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7. 如果经验治疗可覆盖常见厌氧菌, 社区获得性腹腔内感 染的患者无需进行厌氧培养( BIII)
8. 对于高危患者, 应常规对感染部位进行培养。尤其是先 前使用过抗菌药的患者, 发生耐药菌感染的可能性更大 ( AII)
6. 一般情况很好, 感染部位局限的患者, 如阑 尾或结肠周围蜂窝织炎, 可仅予抗感染治疗, 而不进行外科干预, 但必须密切监测病情变 化( BII)
六、病II)
2. 如果患者有中毒症状, 或存在免疫抑制, 菌 血症的结果有助于决定抗感染治疗的疗程 ( BIII)
药物( BIII) 7. 高危患者, 需要根据培养和药敏结果, 对抗
菌治疗方案进行调整, 以覆盖分离培养获得 的优势病原菌( AIII)
(三)、成人医疗保健相关感染
1. 医疗保健相关腹腔内感染的经验治疗需要根据 当地微生物学资料制订( AII)
2. 为覆盖所有可能的病原菌, 经验治疗选用广谱 抗革兰阴性需氧和兼性厌氧杆菌抗菌药的联合 治疗。广谱抗革兰阴性需氧和兼性厌氧杆菌的 药物有美罗培南、亚胺培南-西司他丁、多尼 培南、哌拉西林-他唑巴坦、头孢他啶或头孢 吡肟联合甲硝唑。可能需要使用氨基糖苷类抗 生素或黏菌素, 见表( BIII)
(一)、成人轻中度社区获得性感染
1. 社区获得性腹腔内感染的经验治疗, 需要覆盖肠道 革兰阴性需氧菌和兼性厌氧菌以及肠道革兰阳性链 球菌( AI)
2. 小肠末端、阑尾和结肠感染, 机械性或麻痹性肠梗 阻所致胃肠道穿孔, 需要覆盖专性厌氧菌( AI)
3. 对于成人轻中度社区获得性感染, 使用替卡西林-克 拉维酸、头孢西丁、厄他培南、莫西沙星、替加环 素单药治疗, 或甲硝唑联合头孢唑林、头孢呋辛、 头孢曲松、头孢噻肟、左氧氟沙星、环丙沙星的方 案比具有抗假单胞菌作用的方案更好( AI) , 见表
±氨苄西林
a 由于大肠埃希菌对氟喹诺酮类药物耐药持续上升, 需要结合当地耐药情况, 如果可以, 参考分离病原菌的药敏结果
(一)、成人轻中度社区获得性感染
4. 不推荐使用氨苄西林-舒巴坦, 因为社区获得 性感染的大肠埃希菌对其耐药率较高( B II)
5. 不推荐使用头孢替坦和克林霉素, 因为脆弱 拟杆菌组细菌对其耐药率呈逐步上升趋势 ( BII)
复杂 腹腔感染
非复杂 腹腔感染
分类
社区获得性轻度腹腔感染 社区获得性中度腹腔感染 社区获得性重度腹腔感染 卫生保健相关的腹腔感染
分类
二、初步诊断
1. 根据病史、体格检查、实验室检查可以对大 部分疑似腹腔内感染的患者作出诊断( AII)
2. 对于体格检查结果不可靠的患者, 如精神状 态迟钝、脊髓损伤、治疗或疾病所致免疫抑 制状态,如果怀疑感染但部位不明确, 需怀疑 腹腔内感染( BIII)
3. 获得培养和药敏结果后, 调整抗菌治疗方案, 减少抗菌药的数量或改用窄谱抗菌药( BIII)
医疗保健相关复杂性腹腔内感染抗菌药物经验治疗方案
医疗保健相关感染
常见病原菌
碳青霉 烯类a
耐药铜绿假单胞菌, 产 ESBLs 肠杆菌科细菌, 不 动杆菌, 或其他多重耐药 革兰阴性菌均< 20%
推荐
产ESBLs 肠杆菌科细菌 推荐
五、适当的干预措施
1. 建议对于所有的腹腔内感染患者, 采取恰当 的措施引流感染灶, 以防止感染在腹腔扩散, 最大程度的恢复患者的解剖及生理功能( BII)
2. 弥漫性腹膜炎的患者, 即使生命体征不稳定, 也应在稳定生命体征治疗的同时, 尽快外科 急诊手术( BII) ，如果可行, 推荐通过经皮 穿刺引流感染灶, 而非外科手术( BII)
APACH E: 急性生理学和慢性健康状况评估
胆道外复杂性腹腔内感染初始抗菌药物经验治疗方案
成人社区获得性感染
方案
儿童社区获得性感染 轻中度: 阑尾炎穿 高危或重症: 严重生 孔或阑尾脓肿形成 理紊乱、高龄或免疫 及其他轻中度感染 抑制状态
单药治疗 厄他培南、美罗培南、头孢西丁、厄他培 亚胺培南-西司他丁、 南、莫西沙星、替 替卡西林-克拉维酸 加环素和替卡西林 和哌拉西林-他唑巴 - 克拉维酸 坦
胆道外复杂性腹腔内感染初始抗菌药物经验治疗方案
成人社区获得性感染
方案
儿童社区获得性感染 轻中度: 阑尾炎穿 高危或重症: 严重生 孔或阑尾脓肿形成 理紊乱、高龄或免疫 及其他轻中度感染 抑制状态
单药治疗 厄他培南、美罗培南、头孢西丁、厄他培 亚胺培南-西司他丁、 南、莫西沙星、替 替卡西林-克拉维酸 加环素和替卡西林 和哌拉西林-他唑巴 - 克拉维酸 坦
IDSA2010复杂腹腔感染 诊治指南解读
哈医大一院 ICU
金松根
等级
推荐强度 A级 B级 C级 证据质量 I级
II级
III级
推荐强度和证据质量
证据类型
良好的证据支持推荐 中度的证据支持推荐 微弱的证据支持推荐
证据源于至少1 项合理设计的随机对照临床试 验结果 证据源于至少1 项设计良好的非随机临床试验; 队列研究或病例对照研 究( 最好多于1 个中 心) ; 多时间序列研究; 或非对照研究的戏剧 性结果 证据源于专家的临床经验, 描述性研究, 或专 家委员会的报告
6. 由于有很多低毒性的抗菌药疗效与氨基糖苷 类相同, 所以成人社区获得性腹腔内感染不 推荐常规使用氨基糖苷类抗生素( BII) 。
7. 社区获得性腹腔内感染的经验性治疗无需覆 盖肠球菌属( AI)
(一)、成人轻中度社区获得性感染
8. 成人和儿童社区获得性腹腔内感染患者无需 进行经验性抗念珠菌治疗( BII)
3. 社区获得性感染, 没有必要常规对感染组织 进行革兰染色涂片检查( CIII)
4. 医疗保健相关感染( health care associatedinfect ions) , 革兰染色涂片对 诊断真菌感染有帮助( CIII)
六、病原学检测
5. 社区获得性感染的低危患者不需常规进行需氧和厌氧培 养, 但对于了解社区获得性腹腔内感染病原学及耐药性 的变迁, 以及对序贯口服治疗药物的选择有帮助( BII)
9. 推荐将用于重症社区获得性感染及医疗保健 相关感染的药物不宜用于轻中度社区获得性 感染患者, 因为这些药物毒性较大, 并且易 诱导病原菌耐药( BII)
10.对于轻中度腹腔内感染的患者, 包括急性憩 室炎和不同类型的阑尾炎, 不需外科手术治 疗, 建议按轻中度感染方案治疗, 并可考虑 早期改为口服药( BIII)
3. 血流动力学稳定, 无急性器官功能衰竭的患 者, 应紧急处理。在恰当的抗感染治疗及临 床密切监测的情况下, 最长可以推迟24 h 再 进行外科干预( BII)
五、适当的干预措施
5. 重症腹膜炎的患者, 如无肠不连贯 ( intestinaldisco nt inuity) , 腹壁筋膜 缺失无法关腹( abdominalfascial loss that prevent s abdominal w all closure) ,或腹腔内高压( int ra abdominalhy pertension) , 则不推荐急诊 或择期再次剖腹探查( AII)
±氨苄西林
a 由于大肠埃希菌对氟喹诺酮类药物耐药持续上升, 需要结合当地耐药情况, 如果可以, 参考分离病原菌的药敏结果
(二)、高危成人社区获得性感染
4. 成人患者如果没有耐药菌定植的证据, 没有 必要常规使用氨基糖苷类抗生素或加用另一 种抗兼性厌氧和需氧革兰阴性杆菌的药物 ( AI)
5. 建议经验性治疗覆盖肠球菌属( BII) 。 6. 没有依据时, 不推荐使用抗MRSA 或抗真菌的
3. 有明显弥漫性腹膜炎症状和即将手术的患者, 无需进行诊断性影像学检查( BIII)
4. 不能立即进行剖腹探查的成人患者, 应作CT 扫描以明确是否有腹腔内感染及其来源( AII)
三、补液支持治疗
1. 迅速补充患者的血容量, 并采取其他措施 保持生命体征稳定( AII)
2. 对于感染性休克的患者, 一旦发现低血压, 立刻补充血容量( AII)
内容
一
定义、分类
二
初步诊断
三
液体支持治疗
四
开始抗感染治疗时间
五
适当干预措施
六
病原学检测
七
抗菌药物治疗
一、定义
复杂腹腔感染
• 是原发感染灶穿透空腔脏器，进入腹膜腔， 伴有脓肿形成和腹膜炎的感染
非复杂腹腔感染
• 原发感染灶局限于胃肠道壁内的感染
不足之处
急性穿孔性阑尾炎 （死亡率0.5%～2%）
艰难梭状芽孢杆菌引起的结肠炎 （20%～30%）
11. 如果培养结果示假单胞菌属、变形杆菌属、不动杆菌属、 金葡菌和其他肠杆菌科细菌中度或大量生长, 需要进行 药敏试验, 因为这些细菌更易发生耐药( AIII)
七、抗菌药物治疗
(一)、成人轻中度社区获得性感染 (二)、高危成人社区获得性感染 (三)、成人医疗保健相关感染 (四)、抗真菌治疗 (五)、抗肠球菌治疗 (六)、抗MRSA 治疗 (七)、成人胆囊炎和胆道感染 (八)、药动学建议 (九)、用微生物学结果指导治疗 (十)、成人复杂性腹腔内感染的疗程 (十一)、疑似治疗失败的处理
亚胺培南-西司他丁、 美罗培南、多尼培南 和哌拉西林-他唑巴 坦
联合治疗 头孢曲松、头孢噻肟、头孢唑林、头孢呋 头孢吡肟、头孢他啶、
头孢吡肟、头孢他啶，辛、头孢曲松、头 环丙沙星、左氧氟
联合甲硝唑；
孢噻肟、环丙沙星、沙星，
庆大霉素或妥布霉素 左氧氟沙星，
联合甲硝唑a
+ 甲硝唑或克林霉素 联合甲硝唑a