革兰氏阳性球菌-Zhengzhou-060310

革兰氏阳性球菌诊治策略

阳性球菌的耐药和治疗问题

Po-Ren Hsueh (薛博仁)National Taiwan University Hospital

革兰氏阳性球菌诊治策略

臺灣大學醫學院附設醫院

革兰氏阳性球菌诊治策略

醫院規模一般病床

特殊病床

其他

一般病床 精神病床 加護病床 燒傷病床 觀察病床 嬰兒病床 急診觀察病床 其他觀察病床 安寧病床 手術恢復床 嬰兒床 血液透析床 呼吸照護中心 精神科日間照護急性

1975 68 261 14 48 140 6 17 53 20 52 15 160

總計

2829

革兰氏阳性球菌诊治策略

革兰氏阳性球菌诊治策略

革兰氏阳性球菌诊治策略

Bacteria: A Colorful World

S aureus

S pneumoniae

H influenzae

P aeruginosa

K pneumoniae

C neoformans

Nocardia

M tuberbulosis

Staphylococcus

Aspiration pneumonia

P jirovecii

Aspergillus

革兰氏阳性球菌诊治策略

革兰氏阳性球菌诊治策略

Resistance Problems in Gram-Positive InfectionsCategory Infections CAP Community infections Major pathogens S. pneumoniae S. aureus SSTI UTI HAP SSTI Nosocomial infections S.aureus Enterococci S.aureus S.aureus Antibiotics with resistance problems Macrolide, penicillin, MDR Methicillin (CA-MRSA) Methicillin (CA-MRSA) Vancomycin (VRE) Methicillin, vancomycin Methicillin, vancomycin

SSTIUTI

EnterococciEnterococci

Vancomycin (VRE)Vancomycin (VRE)

IAI

Enterococci

Vancomycin (VRE)

革兰氏阳性球菌诊治策略

Trends of Penicillin and Erythromycin Resistance Disk Method, S. pneumoniae, NTUH, 1984-2009100 90 80No. of isolates Penicillin-nonsusceptible Erythromycin-resistant400 350 300

% of isolates

70 60 50 40 30100 250 200 150

20 1085 86 87 88 89 90 91 92 93 94 95 96 97 98 1984 99 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

50 0

0

No. of isolates

革兰氏阳性球菌诊治策略

革兰氏阳性球菌诊治策略

Annual Death Rates in the United States Selected Infectious DiseasesNo. of patients died20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0MRSA infection (2005) AIDS (2004) Viral hepatitis (2002)

19,000 15,798

5793

662Tuberculosis (2004)

0SARS (all) Avian influenza (all)

0

Boucher HW and Corey GR. Clin Infect Dis 2008;46:S344-9.

革兰氏阳性球菌诊治策略

Prevalence of MRSA in China%100 80.3 80 60 40 20 0Shanghai (71) Beijing (364) Shenyang Hangzhou Guangzhou Wuhan Others Total (798) (70) (70) (31) (62) (100) Wang H et al. Diagn Microbiol Infect Dis 2008;62:226-9.

798 isolates, 2005, 12 Cities, ChinaCHINET 2007 58% (1963/3384) Mohnarin 2006~2007 56.1%

55.5

50

47.1

45.2 35.5

50.5 37

革兰氏阳性球菌诊治策略

Community-acquired MRSA in AsiaANSORP Surveillance in Asia-2005-6 %50 40.5 40 30 20 10 0Taiwan Sri Lanka Philippines VietNam Korea India

38.8 30.1 28.2 20.5 13.8 8.4 6.9China

Hong Kong

Hsueh PR, Song JH et al. ANSORP 2006

革兰氏阳性球菌诊治策略

Community-acquired S. aureus Bacteremia

2001-2006, NTUH, 215 Episodes0.5 0.45 0.4 0.35 0.3 0.25 0.2 0.15 0.1 0.05 0CaMSSA (/1000 ED visits) CaMRSA (/1000 ED visits)CaMRSA: increase 32%/yr CaMSSA: stable0.352 0.33 0.289 0.254 0.276 0.331

0.009

0.029

0.066

0.057

0.049

0.091

2001

2002

2003

2004

2005

2006

Wang JL, Hsueh PR et al. Clin Infect Dis 2008;46:799-806.

革兰氏阳性球菌诊治策略

MRSA Causing Nosocomial Infections NTUH, 1986-2009 %500 100 MRSA MSSA % of MRSA 80 60 40 20 01986 88 90 92 94 96 98 2000 2002 2004 2006 2008 2009

No. of s

trains

400 300 200 100 0

革兰氏阳性球菌诊治策略

MRSA Bacteremia at ED 2001-2006, NTUH, 177 Episodes%80 70 60 50 40 30 20 10 0

Rate (%) Mortality (%)

76.3

Overall mortality 59 (33.3%)52.4 33.3

11.9

14.3

11.9

Community-onset (n=21)

Healthcareassociated (n=135)

Hospital-onset (n=21)

Liao CH, Hsueh PR et al. Int J Antimicrob Agents 2008;32:326-32.

革兰氏阳性球菌诊治策略

MRSA Bacteremia at ED 2001-2006, NTUH, 177 Episodes%60 50 40 30 20 10 0

Rate (%)

Mortality (%)

Overall mortality 59 (33.3%)51.4

36.7 35.4

31.1

36.4 23.2

41.5

39.5 21.5 19.8

DM (n=65)

IVC use (n=55)

Stroke (n=41)

Heart Dis (n=38)

Active malignancy (n=35)

Liao CH, Hsueh PR et al. Int J Antimicrob Agents 2008;32:326-32.

革兰氏阳性球菌诊治策略

MRSA Bacteremia at ED 2001-2006, NTUH, 177 Episodes %80 70 60 50 40 30 20 10 0BS I

Rate (%)

Mortality (%)66.7

Overall mortality 59 (33.3%)50 41.7

32.5 22.6 20.9 21.6 15.3

37 20 13.6 9 6.3 6.8 5.6 5.1

33.3

1.1

(n =4 0)

So fttis su

ca rd iti s

Pr im

Pn eu

an d

En do

on e

Liao CH, Hsueh PR et al. Int J Antimicrob Agents 2008;32:326-32.

Sh un

B

to

rv

as cu la r( n= 9) B ili ar y (n =2 )

ar y

ia

jo in t

C

m on

R

U

TI (n =1 0)

)

(n =2 7)

(n =2 4)

(n =1 6)

(n =3 7

e

(n =1 2

)

革兰氏阳性球菌诊治策略

Nosocomial Pneumonia due to MRSA

Sputum and blood: MRSA

革兰氏阳性球菌诊治策略

革兰氏阳性球菌诊治策略