假体周围感染参考课件.ppt

1、PJI术后，如何使用抗生素？浙江中医药大学附属第一医院童培建2017.09.031 关节假体周围感染（Periprosthetic joint infection，PJI），发生于关节置换术后，以膝关节（2%）、髋关节（0.45-0.57%）多见。Two-stage Revision for Periprosthetic Hip and Knee Joint Infections.The open orthropaedics journal.2017 Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic H

2、ip and Knee Joint Infections.The Open Orthopaedics Journal,201622023-1-6 存在于假体相通的窦道 受累人工关节部位2处组织或关节液样本中分离出同一病原体 以下4条满足3条或以上 ESR或CRP水平升高 滑膜或关节液白细胞升高 滑膜或关节液中性粒细胞百分比升高 组织或关节液单次细菌培养阳性*Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty:Current Concepts.JAAOS-D-15-00017,2016 32023-1-6红肿热痛，切口

3、不愈合红肿热痛，切口不愈合急性急性慢性慢性PJI夜间痛，休息痛夜间痛，休息痛窦道形成窦道形成脓液流出脓液流出 Two-stage Revision for Periprosthetic Hip and Knee Joint Infections.The open orthropaedics journal.2017 Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint Infections.The Open Orthopaedics Journal,201642023-

4、1-6*初次人工全膝关节置换术后假体周围感染的病原菌分布及药敏分析.Chinese Journal of Reparative and Reconstructive Surgery.2014、类感染 金黄色葡萄球菌 类感染 凝固酶隐性葡萄球菌屎肠球菌革兰阳性杆菌大肠埃希菌阴沟肠杆菌真菌分支杆菌链球菌沙门菌鲍曼不动杆菌铜绿假单胞菌金黄色葡萄球菌凝固酶阴性葡萄球菌52023-1-6 病原体 基质 多糖聚合物 蛋白 DNA Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint

5、 Infections.The Open Orthopaedics Journal,2016 The role of microbial biofilms in prosthetic joint infections A review.Acta Orthopaedica 2015 普遍存在 难以清除62023-1-6抗生素抗生素抗体抗体生物膜内生物膜内容物聚集容物聚集生物膜生物膜DNADNA片段片段骨骨 科科 内内 植植 物物细菌细菌吞噬细胞吞噬细胞Correlation between in vivo&in vitro efficacy of antimicrobial agent agai

6、nst foreign body infection,Rev Infect Dis.江荣林院长授课摘录江荣林院长授课摘录72023-1-6 Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint Infections.The Open Orthopaedics Journal,2016 The role of microbial biofilms in prosthetic joint infections A review.Acta Orthopaedica 20158

7、2023-1-6 早期感染：24个月*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.根据术后PJI发生的时间，可分为早期感染、迟发感染、晚期感染。行清创术是否行清创术视具体情况而定92023-1-6*Executive summary of management of prosthetic joint inf

8、ections.Clinical practice guidelines by the Spanish Society of InfectiousDiseases and Clinical Microbiology(SEIMC).Enferm Infecc Microbiol Clin.2017.102023-1-6 适应症 感染症状、体征持续时间3周以内的术后早期早期深部感染或急性急性血源性感染 无假体松动假体松动或感染感染的影像学改变 软组织条件好，无大量疤痕无大量疤痕或窦道窦道形成 经血或组织培养，病原体明确且对药物敏感敏感 开放清创推荐，关节镜清创慎重！术后抗生素治疗方案 静脉用药4-

9、6周 后续口服给药7-14天 治疗期间监测白细胞及CRP The management of an infected total knee arthroplasty.Bone Joint J,2015 An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.清创术+抗生素+假体保留（DAIR）如条件允许，早期感染推荐行

10、清创术+抗生素+假体保留（debridement,antibiotics,implant retention）DAIR。112023-1-6 第一阶段 假体取出 关节内假体完全取出 彻底清创 抗生素骨水泥垫片置入 长期抗生素治疗 第二阶段 假体再植入（或关节融合/切除成形）抗生素骨水泥垫片取出 彻底清创 假体再植入 抗生素治疗 Two-stage Revision for Periprosthetic Hip and Knee Joint Infections.Open Orthop J.2016 Two stage revision hip arthroplasty in periprost

11、hetic joint infection.Comparison study:with or without the use of a spacer.Int Orthop.2017假体取出术 术后抗生素治疗方案术后抗生素治疗方案 静脉用药静脉用药4-6周周 间歇期停抗生素间歇期停抗生素2-8周周 治疗期间监测治疗期间监测ESR及及CRP 血及组织培养病原体是否阳性血及组织培养病原体是否阳性静脉用药静脉用药5-7天天122023-1-6 适应症 病原体明确 长期使用的口服抗生素无毒性作用 患者可行长期随访 术后抗生素治疗方案 清创术在抗生素使用之前，术后静脉使用抗生素至少7天 病原体诊断明确，选

12、择敏感抗生素 除特殊病例，不建议联合使用抗生素或加用利福平 因毒性作用，不宜使用利奈唑胺 推荐使用内酰胺酶抑制剂或低剂量复方新诺明 不建议长期使用抗生素假体保留+抗生素压制（SAT）适当清创，保留假体，不试图清除感染无法缓解因假体松动无法缓解因假体松动或不稳引起的疼痛或不稳引起的疼痛*Executive summary of management of prosthetic joint infections.Clinical practice guidelines by the Spanish Society of InfectiousDiseases and Clinical Microbi

13、ology(SEIMC).Enferm Infecc Microbiol Clin.2017.132023-1-6革兰阳性球菌感染革兰阴性杆菌感染其它感染多重感染培养阴性的感染142023-1-6 常见病原菌 葡萄球菌 链球菌*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.用药推荐 氟喹诺酮类左氧氟沙星（75

14、0mg/24h）环丙沙星（500-750mg/12h）利福平+利奈唑胺（10mg/kg/24h）复方新诺明（20mg/kg/day）达托霉素+利福平（10mg/kg/day）万古霉素（15 mg/kg/12h）152023-1-6 常见病原菌 铜绿假单胞菌*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.用药推

15、荐 内酰胺酶抑制剂+环丙沙星/氨基糖苷类 清创术+氟喹诺酮类左氧氟沙星（750mg/24h）环丙沙星（500-750mg/12h）碳青霉烯类162023-1-6 真菌 念珠菌：假体取出+清创+伏立康唑/两性霉素B Fungal Periprosthetic Joint Infection after Total Knee Arthroplasty.J Med Assoc Thai 2014.Management of Resistant,Atypical and Culture-negative Periprosthetic Joint Infections after Hipand Knee

16、 Arthroplasty.Open Orthop J.2016.分枝杆菌 非结核分支杆菌（抗痨治疗9个月）异烟肼+利福平+吡嗪酰胺或/和乙胺丁醇三/四联治疗，2个月 异烟肼+利福平二联治疗，4-7个月 偶然分支杆菌/龟分支杆菌（根据培养及药敏结果选择敏感抗生素）静脉用药6周 口服用药3-6个月172023-1-6 高危因素 年龄65岁 伴有严重基础疾病 术后引流 手术切口开裂 常见病原体 金黄色葡萄球菌 肠球菌 需氧G-杆菌（铜绿）广谱抗生素联合应用内酰胺酶抑制剂氨基糖苷类利奈唑胺或达托霉素 The management of an infected total knee arthropla

17、sty.Bone Joint J,2015 An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.182023-1-6培养阴性的原因1.取样备前使用抗生素2.培养基选取不当3.培养时间过短（2周）抗生素使用原则 覆盖范围足够广 革兰阳性菌 革兰阴性菌 耐药菌（MASA）厌氧菌 使用时间足够长 至少2周 监测WBC及C

18、RP 联合用药 The management of an infected total knee arthroplasty.Bone Joint J,2015 An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.192023-1-6病原体病原体静脉用药静脉用药备选方案备选方案后续口服用药后续口服用药新青新青敏感葡萄

19、球菌敏感葡萄球菌新青新青或氯唑西林或氯唑西林或头孢唑林或头孢唑林万古霉素或替考拉宁万古霉素或替考拉宁或达托霉素或或达托霉素或利奈唑胺利奈唑胺左氧氟沙星左氧氟沙星+利福平利福平克林霉素克林霉素/复方新诺明复方新诺明夫西地酸或夫西地酸或利奈唑胺利奈唑胺耐新青耐新青葡萄球菌葡萄球菌万古霉素万古霉素达托霉素或达托霉素或替考拉宁或替考拉宁或利奈唑胺利奈唑胺克林霉素克林霉素/复方新诺明复方新诺明夫西地酸或夫西地酸或利奈唑胺利奈唑胺青霉素敏感肠球菌青霉素敏感肠球菌青霉素青霉素G或氨苄西林或氨苄西林万古霉素万古霉素/替考拉宁替考拉宁或或利奈唑胺利奈唑胺，或，或氨苄西林氨苄西林+头孢曲松头孢曲松利奈唑胺利奈唑胺

20、氨苄西林氨苄西林耐青霉素肠球菌耐青霉素肠球菌万古霉素万古霉素替考拉宁或替考拉宁或利奈唑胺利奈唑胺利奈唑胺利奈唑胺-溶血性链球菌溶血性链球菌青霉素青霉素G或头孢曲松或头孢曲松万古霉素或替考拉宁或万古霉素或替考拉宁或利利奈唑胺奈唑胺阿莫西林或阿莫西林或利奈唑胺利奈唑胺一般肠内杆菌一般肠内杆菌环丙沙星环丙沙星厄他培南厄他培南环丙沙星环丙沙星或头孢类或头孢类/复方新诺明复方新诺明某些特殊肠内杆菌某些特殊肠内杆菌环丙沙星环丙沙星厄他培南或头孢吡肟厄他培南或头孢吡肟环丙沙星环丙沙星铜绿假单胞菌铜绿假单胞菌头孢他啶头孢他啶/环丙沙星环丙沙星美罗培南美罗培南/环丙沙星环丙沙星环丙沙星环丙沙星厌氧菌厌氧菌阿莫西

21、林克拉维酸或哌拉阿莫西林克拉维酸或哌拉西林他唑巴坦或碳青霉烯西林他唑巴坦或碳青霉烯克林霉素克林霉素/甲硝唑甲硝唑克林霉素克林霉素/甲硝唑甲硝唑清创术+抗生素+假体保留药物推荐*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.202023-1-6 G+所致的PJI，后续口服用药推荐利奈唑胺。212023-1-6抗

22、生素抗生素药物含量药物含量最大血药浓度最大血药浓度（mg/ml）半衰期（小时）半衰期（小时）每日剂量每日剂量青霉素G3g130-2350.5-0.6720-24万单位，q4h或持续阿莫西林2/0.2g110/141.0-1.52g/8h氟氯西林1g130-2101.0-1.52g/4h头孢唑林1g1881.5-2.02g/8h头孢曲松1g2008.02g/24h头孢他啶1g902.0-2.52g/8h头孢吡肟1g1631.02g/8h利奈唑胺0.6g21.24.260.6g/12h美罗培南0.5g521.02g/8h万古霉素-4.0-6.015 mg/kg/12h替考拉宁400mg7050-7

23、010-12 mg/kg/day达托霉素350mg1408-96-10 mg/kg/day环丙沙星400mg4.64400 mg/12h常用抗生素剂量及用法*An update on surgical and antimicrobial therapy for acute periprosthetic joint infection:new challenges for the present and the future.Expert Rev Anti Infect Ther.2015.222023-1-6 1.PJI明确病原体，根据培养及药敏结果选择合适的抗生素 2.手术+抗生素联合治疗，单纯抗生素治疗效果不佳 3.术后抗生素覆盖范围足够广，时间足够长，必要时多种抗生素或利福平联合用药（SAT除外）。232023-1-624