2017/11/14 Bijie 1 HAP and VAP: diagnosis, severity assessment and antimicrobial therapy 医院内肺炎和呼吸机相关肺炎 诊断、严重程度评估和抗感染治疗 复旦大学附属中山医院 Zhongshan Hospital of Fudan University 胡必杰 Bijie HU Hospital-Acquired Pneumonia (HAP): Definitions HAP: Arises 48 hours or more after hospital admission Is not incubating at the time of admission Ventilator-associated pneumonia (VAP): Arises 48-72 hours or more after endotracheal intubation Healthcare-associated pneumonia (HCAP): Arises within 90 days of having been admitted to an acute care facility & pt. has resided in a nursing home or LTCF (American Thoracic Society/IDSA. Am J Respir Crit Care Med 2005;171:388-416) ical pneumonia这个词 使用“医疗相关感染”(health care–associated infection)或缩写为HAI,ial(医院内的)一词 医院获得性肺炎也改用医疗相关肺炎(health care–associated pneumonia),英文缩写仍为HAP,ical pneumonia一词 2017/11/14 Bijie 3 Hospital Location & Relative Frequency of HAP & VAP HAP 14% ICU HAP % Non-ICU HAP % VAP 86% Non-ICU HAP ICU HAP VAP ICU HAP HAP ICU (Kumpf G et al. J Clin Epidemiol 1998;54:495-502) (Lizioli A et al. J Hosp Infect 2003;54:141-148) (Richards MJ et al. Crit Care Med 1999;27:887-892) 2017/11/14 Bijie 5 Diagnosis 诊断 Non-invasive Strategy for Diagnosing HAP/VAP Clinical approach New lung infiltrate new onset fever, leukocytosis or purulent sputum non-quantitative bacterial analysis of endotracheal aspirate Drawback – relatively non-specific for HAP Heyland et al. demonstrated adequacy of clinical criteria for VAP diagnosis in RCT (BAL with quantitation vs. non-quantitative endotracheal aspirate): no difference in 28 d mortality or LOS in ICU or hospital (ATS, Am J Respir Crit Care Med 1996;153:1711-1725) (Helling TS, Van Way C, Krantz S, et al. Am J Surg 1996;171:570-575) (Hubmayr RD et al ATS Consensus Statement Intensive Care Med 2002;28:1521-1536) (Canadian Critical Care Trials Group. NEJM 2006;355:2619-2630) 2017/11/14 Bijie 7 肺部感染临床诊断困难: “类肺炎” 充血性心衰,肺栓塞 急性肺损伤与ARDS 过敏性肺炎,嗜酸细胞浸润性肺炎
