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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2017.09.03,什么是PJI,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. 2017Biofilm and the Role of Antibiotics in the Treatment of Peripro
2、sthetic Hip and Knee Joint Infections. The Open Orthopaedics Journal, 2016,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,PJI诊断标准（AAOS标准）,* Principles of Antibiotic Prophylaxis in Total Joint Arthroplasty: Current Concepts. JAAOS-D-15-00017,2016,
3、PJI临床表现,红肿热痛，切口不愈合,急性,慢性,PJI,Two-stage Revision for Periprosthetic Hip and Knee Joint Infections. The open orthropaedics journal. 2017Biofilm and the Role of Antibiotics in the Treatment of Periprosthetic Hip and Knee Joint Infections. The Open Orthopaedics Journal, 2016,PJI常见病原菌,*初次人工全膝关节置换术后假体周围感染
4、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,病原菌主要来源于血液及皮肤,生物膜-PJI药物治疗的关键,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 Infections. The Open Orthopaedics Journal, 2016The role of microb
5、ial biofilms in prosthetic joint infections A review. Acta Orthopaedica 2015,普遍存在难以清除,抗生素,抗体,生物膜内容物聚集,生物膜,DNA片段,骨 科 内 植 物,细菌,吞噬细胞,Correlation between in vivo & in vitro efficacy of antimicrobial agent against foreign body infection, Rev Infect Dis.,江荣林院长授课摘录,Biofilm and the Role of Antibiotics i
6、n the Treatment of Periprosthetic Hip and Knee Joint Infections. The Open Orthopaedics Journal, 2016The role of microbial biofilms in prosthetic joint infections A review. Acta Orthopaedica 2015,PJI分期,早期感染：24个月,* An update on surgical and antimicrobial therapy for acute periprosthetic joint infectio
7、n: 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,* Executive summary of management of prosthetic joint infections.Clinical practice guidelines by the Spanish Society of InfectiousDiseases and Clinical Microbiology
8、 (SEIMC). Enferm Infecc Microbiol Clin. 2017.,PJI 2017年SIMIC治疗指南,适应症感染症状、体征持续时间3周以内的术后早期深部感染或急性血源性感染无假体松动或感染的影像学改变软组织条件好，无大量疤痕或窦道形成经血或组织培养，病原体明确且对药物敏感开放清创推荐，关节镜清创慎重！,术后抗生素治疗方案静脉用药4-6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, 2015An update on surgic
9、al 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，早期感染推荐行清创术+抗生素+假体保留（debridement, antibiotics, implant retention）DAIR。,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
10、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. 2016Two stage revision hip arthroplasty in periprosthetic 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静脉用药4-6周间歇期停抗生素2-8周
11、治疗期间监测ESR及CRP血及组织培养病原体是否阳性,静脉用药5-7天,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或不稳引起的疼痛,* Executive summary of management of prosthetic joint infections
12、.Clinical practice guidelines by the Spanish Society of InfectiousDiseases and Clinical Microbiology (SEIMC). Enferm Infecc Microbiol Clin. 2017.,治疗PJI抗生素选择,革兰阳性球菌感染,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 presen
13、t and the future. Expert Rev Anti Infect Ther. 2015.,用药推荐氟喹诺酮类左氧氟沙星（750mg/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）,革兰阴性杆菌感染,常见病原菌铜绿假单胞菌,* An update on surgical and antimicrobial therapy for acute periprosthetic joint infection: new challe
14、nges for the present and the future. Expert Rev Anti Infect Ther. 2015.,用药推荐内酰胺酶抑制剂+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,其它感染,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 a
15、nd Culture-negativePeriprostheticJointInfections afterHipand KneeArthroplasty. 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,多重感染,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）,The management of an infected
16、 total knee arthroplasty. Bone Joint J, 2015An 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.,培养阴性的感染,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）
17、厌氧菌使用时间足够长至少2周监测WBC及CRP联合用药,The management of an infected total knee arthroplasty. Bone Joint J, 2015An 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+假体保留药物推荐,* An updat
18、e on surgical and antimicrobial therapy for acute periprosthetic joint infection: new challenges for the present and the future. Expert Rev Anti Infect Ther. 2015.,G+所致的PJI，后续口服用药推荐利奈唑胺。,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.,总结,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）。,谢谢,