血培养在感染性疾病诊断中的意义.ppt

《血培养在感染性疾病诊断中的意义.ppt》由会员分享，可在线阅读，更多相关《血培养在感染性疾病诊断中的意义.ppt（74页珍藏版）》请在得力文库 - 分享文档赚钱的网站上搜索。

1、血培养在感染性疾病血培养在感染性疾病诊断中的意义诊断中的意义A Free sample background from Slide 2血培养的目的及意义血培养的目的及意义n n1 1 败血症唯一的确诊手段败血症唯一的确诊手段n n2 2 协助感染性疾病的诊断协助感染性疾病的诊断n n3 3 判断预后判断预后n n4 4 指导治疗指导治疗“Laboratory must use an efficient blood culture Laboratory must use an efficient blood culture system that rapidly detects maximum

2、number of a system that rapidly detects maximum number of a wide variety of bacteria and fungi.”wide variety of bacteria and fungi.”实验室必须运用有效的血培养系统快速并且最大限度地检测实验室必须运用有效的血培养系统快速并且最大限度地检测实验室必须运用有效的血培养系统快速并且最大限度地检测实验室必须运用有效的血培养系统快速并且最大限度地检测出细菌和真菌。出细菌和真菌。出细菌和真菌。出细菌和真菌。CalvinStrandCalvinStrand Bloodstream

3、 Infections Bloodstream InfectionsA Free sample background from Slide 3菌血症和真菌血症-直接威胁生命的感染性疾病直接威胁生命的感染性疾病n n阳性的血培养报告应被视为潜在的医疗紧急状态阳性的血培养报告应被视为潜在的医疗紧急状态警报。警报。发展为败血症的比率高达发展为败血症的比率高达40%90%40%90%。n n血培养阳性的患者应尽可能快地给予适当的抗感血培养阳性的患者应尽可能快地给予适当的抗感染治疗。染治疗。A Free sample background from Slide 4一过性菌血症（Transient bac

4、teremia）n n对感染组织的处理：如对感染组织的处理：如 脓肿、疖、蜂窝组织炎脓肿、疖、蜂窝组织炎n n污染粘膜表面的创伤性操作：如污染粘膜表面的创伤性操作：如 牙齿修复、膀胱镜检、尿道扩张术牙齿修复、膀胱镜检、尿道扩张术 各种插管各种插管 引产，结肠镜检查引产，结肠镜检查n n污染的外科手术：如污染的外科手术：如 经尿道的前列腺切除经尿道的前列腺切除 阴道子宫切除术阴道子宫切除术 烧伤感染清创术烧伤感染清创术n n在全身或局部感染的早期：如在全身或局部感染的早期：如 脑膜炎、肺炎、脑膜炎、肺炎、化脓性关节炎、骨髓炎、腹膜炎、胆囊炎、小肠化脓性关节炎、骨髓炎、腹膜炎、胆囊炎、小肠结肠炎、

5、外伤感染结肠炎、外伤感染菌血症的类型菌血症的类型A Free sample background from Slide 5间歇性菌血症（Intermittent bacteremia）n各种脓肿：如如腹腔、骨盆、肾周、肝脏、前列腺 （脓肿是不明发热常见的原因）n血管外局部感染n螺旋体病菌血症的类型菌血症的类型A Free sample background from Slide 6持续性菌血症（Continuous bacteremia）n n 感染性心内膜炎n n感染性动脉瘤n n血栓性静脉炎n n其它血管内膜感染n n伤寒热，波浪热最初几周 菌血症的类型菌血症的类型A Free sampl

6、e background from Slide 7提高局部感染血培养送检率提高局部感染血培养送检率菌血症与感染菌血症与感染数据摘自CUMITECH干扰因素最少，阳性结果可靠，具有明确的指导意义干扰因素最少，阳性结果可靠，具有明确的指导意义合理使用抗生素合理使用抗生素A Free sample background from Slide 8不同系统感染引发菌血症死亡率不同系统感染引发菌血症死亡率心内膜炎和呼吸系统感染在已知部位菌血症心内膜炎和呼吸系统感染在已知部位菌血症感染中感染中,死亡率最高死亡率最高,超过超过30%Derek C.Angus et al,Crit Care Med 2001

7、Vol.29,Nov.1303-1310A Free sample background from Slide 9败血症败血症败血症败血症:定义一个疾病的定义一个疾病的定义一个疾病的定义一个疾病的连续统一体连续统一体连续统一体连续统一体 Sepsis:DefiningaDiseaseContinuumSepsis:DefiningaDiseaseContinuumn n下列由非特异性损伤引起的临床表现，患下列由非特异性损伤引起的临床表现，患者至少出现其中者至少出现其中2 2种以上种以上:体温体温 38 38o oC or 36C or 36o oC C 心率心率 90 90 次次/分分 呼吸呼

8、吸 20 20次次/分分 白细胞计数白细胞计数 12,000/12,000/mmmm3 3 或或 4,000/4,000/mmmm3 3 或或 10%10%未成熟中性粒细胞未成熟中性粒细胞n nA clinical response arisingA clinical response arisingfrom a nonspecific insult,including from a nonspecific insult,including 2 of 2 of the following:the following:Temperature 38Temperature 38o oC or 36C

9、 or 36o oC C HR 90 beats/minHR 90 beats/min Respirations 20/minRespirations 20/min WBC count 12,000/mmWBC count 12,000/mm3 3 oror 4,000/4,000/mmmm3 3 or 10%immature or 10%immature neutrophilsneutrophilsSIRS=SIRS=全身炎性反应综合征全身炎性反应综合征.Bone et al.Bone et al.Chest.Chest.1992;101:1644.1992;101:1644.败血症Seps

10、is全身炎性反应全身炎性反应综合征综合征SIRS感染感染/损伤损伤Infection/Infection/TraumaTrauma重度败血症重度败血症Severe Sepsisn nSIRS SIRS 伴随一疑似或伴随一疑似或确认的确认的 感染性病程感染性病程n nSIRS with a SIRS with a presumed or presumed or confirmed infectious confirmed infectious processprocessSIRS=systemic inflammatory response syndrome.SIRS=systemic infl

11、ammatory response syndrome.A Free sample background from Slide 10重度重度重度重度败血症败血症败血症败血症SevereSevereSepsisSepsisSIRSIR（全身炎性反应综合征）、败血症与重度败全身炎性反应综合征）、败血症与重度败全身炎性反应综合征）、败血症与重度败全身炎性反应综合征）、败血症与重度败血症的关系血症的关系血症的关系血症的关系 RelationshipBetweenSIRS,RelationshipBetweenSIRS,SepsisandSevereSepsisSepsisandSevereSepsisB

12、one RC,et al.Chest 1992;101:1644-55.外伤Trauma感染感染Infection败血症败血症Sepsis其他Other胰腺炎Pancreatitis烧伤BurnsSIRSA Free sample background from Slide 11败血症的常见临床表现败血症的常见临床表现CommonClinicalManifestationsofSepsisn n发烧发烧n n心动过速心动过速n n呼吸急促呼吸急促 和和/或或 换气换气过度过度n n白细胞增多白细胞增多n n“核左移核左移”n n神智异常神智异常n n血凝异常血凝异常n nFeverFevern

13、 nTachycardiaTachycardian nTachypneaTachypnea&/or&/or HyperventilationHyperventilationn nLeukocytosisLeukocytosisn n“Shift to the LeftShift to the Left”n nAlteration in Mental StatusAlteration in Mental Statusn nCoagulation AbnormalitiesCoagulation AbnormalitiesA Free sample background from Slide 12

14、脓毒症流行病学脓毒症流行病学n n血流感染（血流感染（BSIBSI）是导致患病率和病死率的主要原因之一）是导致患病率和病死率的主要原因之一 在致死的主导因素中居第十位在致死的主导因素中居第十位 非冠脉意外的非冠脉意外的ICUICU（重症监护病房）中最多见的致死因素重症监护病房）中最多见的致死因素 器官功能障碍的常见诱因器官功能障碍的常见诱因n n由细菌引发的败血症，全球每年发生大约由细菌引发的败血症，全球每年发生大约 18001800万病例万病例 美国：确诊病例美国：确诊病例130130万万 欧洲和日本：确诊病例欧洲和日本：确诊病例190190万万n n 死亡率死亡率,留院时间留院时间,治疗费

15、用治疗费用 住院时间延长住院时间延长7 7 到到 25 25 天天 每年治疗费用：每年治疗费用：167167亿美金美国亿美金美国 6767亿美金欧洲亿美金欧洲？亿美金中国？亿美金中国1.DMarch2003report3.MedtapInternational2.CritCareMed2001;29:1303-104.SocietyforCriticalCareMedicine(pressrelease2004)A Free sample background from Slide 13一项中国一项中国severesepsis的流行的流行病学调查病学调查n n中国中国6 6省省7 7市市101

16、0所大型医院有关外科所大型医院有关外科ICUICU中严重脓毒症中严重脓毒症（Severe SepsisSevere Sepsis）的流行病学调查）的流行病学调查n n北大一附院北大一附院n n武汉同济协和医院武汉同济协和医院n n武汉大学中南医院武汉大学中南医院n n湘雅大学附属湘雅医院湘雅大学附属湘雅医院n n南方医院南方医院n n青岛大学附属医院青岛大学附属医院n n浙江大学一附院浙江大学一附院n n浙江大学附属邵逸夫医院浙江大学附属邵逸夫医院n n宁波大学附属李惠利医院宁波大学附属李惠利医院n n温州医学院一附院温州医学院一附院A Free sample background from

17、Slide 14EpidemiologyofseveresepsisincriticallyEpidemiologyofseveresepsisincriticallyillsurgicalpatientsintenuniversityillsurgicalpatientsintenuniversityhospitalsinChina*.hospitalsinChina*.n nClinical Investigations Critical Care Medicine.35(11):2538-2546,November 2007.Clinical Investigations Critica

18、l Care Medicine.35(11):2538-2546,November 2007.Cheng,Baoli etcCheng,Baoli etc【Abstract:Abstract:】n nObjectives:Objectives:n n To determine the occurrence rate,outcomes,and the characteristics of severe sepsis in surgical To determine the occurrence rate,outcomes,and the characteristics of severe sep

19、sis in surgical intensive care units in multiple medical centers within China and to assess the cost and resource use intensive care units in multiple medical centers within China and to assess the cost and resource use of severe sepsis in China.of severe sepsis in China.n nDesignandSetting:Designan

20、dSetting:Prospective,observational study of surgical intensive care unit patients at ten university hospitals in six provinces Prospective,observational study of surgical intensive care unit patients at ten university hospitals in six provinces in China.in China.Patients:All adult admissions in stud

21、ied intensive care units from December 1,2004,to November 30,2005.Patients:All adult admissions in studied intensive care units from December 1,2004,to November 30,2005.Interventions:None.Interventions:None.n nMeasurementsandMainResults:MeasurementsandMainResults:The criteria of severe sepsis were b

22、ased on the American College of Chest Physicians/Society of Critical Care The criteria of severe sepsis were based on the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definition.Analysis of data from 3,665 intensive care unit admissions identified Medic

23、ine Consensus Conference definition.Analysis of data from 3,665 intensive care unit admissions identified 318(8.68%)cases of severe sepsis,64.8%of which were men.The median age(interquartile range)of patients 318(8.68%)cases of severe sepsis,64.8%of which were men.The median age(interquartile range)

24、of patients with severe sepsis was 64(47-74)yrs.Microbes had been isolated from 228(71.7%)patients,including 171 with severe sepsis was 64(47-74)yrs.Microbes had been isolated from 228(71.7%)patients,including 171(53.8%)with Gram-negative bacteria and 146(45.9%)with Gram-positive bacteria.A total of

25、 90(22.0%)patients(53.8%)with Gram-negative bacteria and 146(45.9%)with Gram-positive bacteria.A total of 90(22.0%)patients had invasive fungal infection,20(6.3%)of which had fungemia.The abdomen was the most common site of had invasive fungal infection,20(6.3%)of which had fungemia.The abdomen was

26、the most common site of infections(72.3%),followed by lung(52.8%).The overall hospital mortality of severe sepsis was 48.7%.Risk infections(72.3%),followed by lung(52.8%).The overall hospital mortality of severe sepsis was 48.7%.Risk factors for hospital mortality included age,chronic comorbidity of

27、 malignant neoplasm,Gram-positive bacterial factors for hospital mortality included age,chronic comorbidity of malignant neoplasm,Gram-positive bacterial infection,invasive fungal infection,admission Acute Physiology Score,and admission Sequential Organ Failure infection,invasive fungal infection,ad

28、mission Acute Physiology Score,and admission Sequential Organ Failure Assessment score of respiratory dysfunction and cardiovascular dysfunction.The median Therapeutic Assessment score of respiratory dysfunction and cardiovascular dysfunction.The median Therapeutic Intervention Scoring System-28 sco

29、re was 43(38-49).The mean hospital cost was$11,390 per patient and$502 Intervention Scoring System-28 score was 43(38-49).The mean hospital cost was$11,390 per patient and$502 per patient per day.per patient per day.n nConclusions:Conclusions:Severe sepsis is a common,expensive,and frequently fatal

30、syndrome in critically ill surgical patients in China.Severe sepsis is a common,expensive,and frequently fatal syndrome in critically ill surgical patients in China.Other than the microbiological patterns,the incidence,mortality,and major characteristics of severe sepsis in Other than the microbiolo

31、gical patterns,the incidence,mortality,and major characteristics of severe sepsis in Chinese surgical intensive care units are close to those documented in developed countries.Chinese surgical intensive care units are close to those documented in developed countries.A Free sample background from Sli

32、de 15一项中国一项中国severesepsis的流行病学调查的流行病学调查Dec1,2004Nov30,2005A Free sample background from Slide 16一项中国一项中国severesepsis的流行病学调查的流行病学调查Dec1,2004Nov30,2005A Free sample background from Slide 17一项中国一项中国一项中国一项中国severesepsisseveresepsis的流行病学调查的流行病学调查的流行病学调查的流行病学调查Dec1,2004Nov30,2005Dec1,2004Nov30,2005n n文章还提

33、供了在中国外科文章还提供了在中国外科文章还提供了在中国外科文章还提供了在中国外科ICUICU中这些中这些中这些中这些sepsissepsis患者的消费水平：平均费用每人每天患者的消费水平：平均费用每人每天患者的消费水平：平均费用每人每天患者的消费水平：平均费用每人每天$502$502$401$401（存活者的费用显著高于死亡者：（存活者的费用显著高于死亡者：（存活者的费用显著高于死亡者：（存活者的费用显著高于死亡者：$812$431$812$431vs.vs.$301$155$301$155,p0.001,p0.001），总），总），总），总住院费每人住院费每人住院费每人住院费每人$11,39

34、0$11,455$11,390$11,455（存活者与死（存活者与死（存活者与死（存活者与死亡者无差别，因为存活者住院时间长亡者无差别，因为存活者住院时间长亡者无差别，因为存活者住院时间长亡者无差别，因为存活者住院时间长!）。）。）。）。n n按照汇率按照汇率按照汇率按照汇率6.86.8计算，国外每位患者的费用和国计算，国外每位患者的费用和国计算，国外每位患者的费用和国计算，国外每位患者的费用和国内的科室已相差无几。内的科室已相差无几。内的科室已相差无几。内的科室已相差无几。A Free sample background from Slide 18内内 容容n n如何提高血培养的阳性率 n

35、n治疗感染而不是污染n n血培养质量控制A Free sample background from Slide 19血培养的原则和流程血培养的原则和流程A Free sample background from Slide 20影响血培养病原菌检出率的影响血培养病原菌检出率的主要因素主要因素n血量及血液与肉汤比例n采血时间n培养条件和周期n监测频率和转种A Free sample background from Slide 21血量及血液与肉汤比例血量及血液与肉汤比例A Free sample background from Slide 22对于对于成年患者成年患者，每份标本推荐的采血量为每份

36、标本推荐的采血量为20-20-30ml30ml（分别注入（分别注入2 2个培养瓶个培养瓶/管内）因为研究显示管内）因为研究显示细菌检出率和血量成正比细菌检出率和血量成正比（2-30ml2-30ml采血量间）采血量间）对于对于婴幼儿患者婴幼儿患者，采血量不超过患者总血量的采血量不超过患者总血量的1 1.在此前提下，增加采血量也会增加阳性率在此前提下，增加采血量也会增加阳性率采血量采血量（p5p5）A Free sample background from Slide 23A Free sample background from Slide 24A Free sample background

37、from Slide 25需氧血培养瓶和厌氧血培养瓶需氧血培养瓶和厌氧血培养瓶n nIn In this this study,study,use use of of paired paired aerobic/anaerobic aerobic/anaerobic blood blood culture culture bottles bottles yielded yielded more more staphylococci,staphylococci,members members of of the the family family EnterobacteriaceaeEntero

38、bacteriaceae,and and anaerobes anaerobes when when compared compared to to paired paired aerobic blood culture bottles.aerobic blood culture bottles.50 50 n nit it is is recommended recommended that that routine routine blood blood cultures cultures include include paired paired aerobic/anaerobic bl

39、ood culture bottles.aerobic/anaerobic blood culture bottles.50-52 50-52 n nWhen When less less than than the the recommended recommended volume volume of of blood blood is is drawn drawn for for culture,culture,the the blood blood should should be be inoculated inoculated into into the the aerobic a

40、erobic vial vial first;first;any any remaining blood should then be inoculated into the anaerobic vial.remaining blood should then be inoculated into the anaerobic vial.这些研究中，使用“配对需氧/厌氧血培养瓶”比用“两个需氧血培养瓶”复现出更多的金葡、肠杆菌科细菌和厌氧菌。50 推荐常规血培养包括配对的需氧推荐常规血培养包括配对的需氧/厌氧血培养瓶。厌氧血培养瓶。50-52 当抽得的血少于推荐血量时，应该首首先先接接种种需需氧

41、氧瓶瓶；剩余血液接种厌氧瓶。A Free sample background from Slide 26AnaerobicBottlesareStillImportantinBloodCultureSetsP.Khanna,P.CollignonP.Khanna,P.Collignon，EuropeanJournalofClinicalEuropeanJournalofClinicalMicrobiology&InfectiousDiseasesMicrobiology&InfectiousDiseasesVolume20,Number3Volume20,Number3A Free sampl

42、e background from Slide 27Clinicalvalueofanaerobicbloodculture:aretrospectiveClinicalvalueofanaerobicbloodculture:aretrospectiveanalysisofpositivepatientepisodesanalysisofpositivepatientepisodesPeterAJamesPeterAJames，KhalidMKhalidMAl-ShafiAl-Shafi，J.Clin.Pathol.J.Clin.Pathol.2000;53;231-2332000;53;2

43、31-233A Free sample background from Slide 28AnaerobicBloodCulturesUsefulintheICU?n nDespite these observations,there is Despite these observations,there is unwillingness in the medical community to unwillingness in the medical community to alter the current practice of obtaining alter the current pr

44、actice of obtaining anaerobic blood cultures.anaerobic blood cultures.The most The most compelling reason for this reluctance is compelling reason for this reluctance is that most clinically significant aerobic that most clinically significant aerobic bacterial pathogens are facultative bacterial pa

45、thogens are facultative anaerobes.Continuing the practice of anaerobes.Continuing the practice of obtaining both aerobic and anaerobic obtaining both aerobic and anaerobic blood cultures,therefore,in effect doubles blood cultures,therefore,in effect doubles the volume of blood cultured and may,the v

46、olume of blood cultured and may,thereby,increase the isolation of these thereby,increase the isolation of these facultative organisms.facultative organisms.Moreover,there are Moreover,there are some pathogenic organisms that are some pathogenic organisms that are classified as facultative anaerobes

47、that classified as facultative anaerobes that grow more quickly in anaerobic grow more quickly in anaerobic conditions.Thus,blood cultures for these conditions.Thus,blood cultures for these organisms may be positive earlier or only organisms may be positive earlier or only positive in the anaerobic

48、blood culture positive in the anaerobic blood culture bottle.bottle.Ryland P.Byrd,Jr,MD,FCCPThomas M.Roy,MD,FCCPEast Tennessee State UniversityJohnson City,TN尽管有一些医疗单位仍不情愿进行厌氧血培养。可是又不得不承认绝大多数需氧的不得不承认绝大多数需氧的致病菌都是兼性厌氧菌。坚致病菌都是兼性厌氧菌。坚持需氧加厌氧的双瓶培养，持需氧加厌氧的双瓶培养，不仅可以获得双倍的血培养不仅可以获得双倍的血培养血量，还可以增加这些兼性血量，还可以增加这些

49、兼性厌氧菌的检出率。更何况，厌氧菌的检出率。更何况，一些兼性厌氧菌在厌氧环境一些兼性厌氧菌在厌氧环境中得以更快的生长出来。因中得以更快的生长出来。因此，这些细菌的血培养可能此，这些细菌的血培养可能在厌氧瓶中更早报告阳性或在厌氧瓶中更早报告阳性或者只在厌氧瓶中生长。者只在厌氧瓶中生长。A Free sample background from Slide 29血培养组合的累积敏感性血培养组合的累积敏感性Weinsteinetal.DetectionofBloodstreamInfectionsinAdults:Weinsteinetal.DetectionofBloodstreamInfecti

50、onsinAdults:HowManyBloodCulturesAreNeededHowManyBloodCulturesAreNeededJClinMicrobiol.JClinMicrobiol.2007;45:3546-35482007;45:3546-3548A Free sample background from Slide 30推荐的血培养组合的数量推荐的血培养组合的数量A Free sample background from Slide 31血液和肉汤的比例（血液和肉汤的比例（p8）推荐的比例是1：51：10A Free sample background from Slid