血管移植物感染抗微生物药物治疗策略及合理选择  

Treatment strategies and reasonable selection of antimicrobial drugs for vascular graft infections

作　　者：陈璋璋 陈灿 岳嘉宁 吕迁洲 李晓宇 CHEN Zhang-zhang;CHEN Can;YUE Jia-ning(Department of Pharmacy,Zhongshan Hospital,Fudan University,Shanghai 200032,China;不详)

机构地区：[1]复旦大学附属中山医院药剂科,上海200032 [2]复旦大学附属中山医院血管外科,上海200032

出　　处：《中国实用外科杂志》2024年第12期1358-1362,共5页Chinese Journal of Practical Surgery

基　　金：上海市卫生健康委员会临床研究专项(No.202240293);上海市医院协会抗菌药物科学化标杆管理项目(No.2023LCYS001_S02)。

摘　　要：血管移植物感染(VGI)是血管移植术后少见但严重的并发症,其发生风险与移植物位置、材料、病原微生物的种类和耐药性,以及病人的年龄和合并症等因素相关。主要病原体包括凝固酶阴性葡萄球菌、金黄色葡萄球菌、肠球菌等革兰阳性菌,以及革兰阴性菌、厌氧菌和真菌等。VGI的诊治依赖于及时采样明确病原体,并进行有效的抗微生物药物治疗和外科处理。抗微生物药物治疗是VGI管理的核心,需综合考虑病原体类型、感染部位、病人基础情况及药物的生物膜穿透性等因素。经验性治疗通常广泛覆盖革兰阳性和阴性菌,并使用能够穿透生物膜的抗微生物药物;目标性治疗则根据明确的病原体选择窄谱药物,如青霉素类、万古霉素及利福平等。对于耐药菌株,如产超广谱β内酰胺酶肠杆菌目细菌或碳青霉烯类耐药菌,可用碳青霉烯类或新型β酰胺类酶抑制剂复方制剂。针对生物膜相关感染,可联合使用利福平、氟喹诺酮类等药物提高治疗效果。药代动力学/药效学(PK/PD)指导下制定的治疗方案可优化抗感染疗效,常根据药物浓度与时间关系,选择浓度依赖性或时间依赖性药物。抗感染治疗的疗程视感染严重程度、病原体特性、临床随访结果而定,通常为4~6周,必要时延长至3~6个月甚至终身。移植物的彻底清创与替换对改善VGI预后至关重要。对于无法完全去除感染的病例,建议进行长期抗感染治疗,并定期评估其有效性及不良反应。通过及时、充分的抗微生物药物治疗,以及精准的外科干预,可显著降低VGI相关死亡率并延长无感染生存期。Vascular graft infection(VGI) is a rare but severe complication following vascular graft surgery.Its risk factors are associated with graft location,material,type,and resistance of pathogenic microorganisms,as well as the patient's age and comorbidities.The primary pathogens include Grampositive bacteria such as coagulase-negative staphylococci,Staphylococcus aureus,and enterococci,as well as Gramnegative bacteria,anaerobes,and fungi.The diagnosis and management of VGI rely on timely pathogen identification through sampling,followed by effective antimicrobial therapy and surgical intervention.Antimicrobial therapy is central to VGI management,requiring consideration of pathogen type,infection site,patient's baseline characteristics,and the biofilm-penetration properties of the drugs.Empirical therapy generally includes broad-spectrum coverage of Gram-positive and Gram-negative bacteria,using biofilm-penetrating agents.Targeted therapy,guided by pathogen identification,involves the use of narrow-spectrum agents such as penicillin,vancomycin,and rifampin.For resistant strains,such as extended-spectrum beta-lactamase-producing Enterobacterales or carbapenem-resistant bacteria,carbapenems or new β-lactamase inhibitor compounds can be used.In biofilm-associated infections,rifampin or fluoroquinolones can be combined to enhance efficacy.Therapeutic regimens guided by pharmacokinetic/pharmacodynamic(PK/PD) principles can optimize antimicrobial efficacy,with drug selection tailored to concentration-or time-dependent properties according to the relationship between drug concentration and time.The duration of antimicrobial therapy depends on the severity of infection,pathogen characteristics,and clinical follow-up outcomes,typically lasting 4-6 weeks,with extensions to 3-6months or even lifelong treatment when necessary.Complete debridement and graft replacement are critical for improving VGI outcomes.In cases where complete eradication of infection is not feasible,long-term antimicrobial therapy is recommended,with regul

关 键 词：血管移植物感染 抗微生物药物治疗 生物膜 抗微生物药物耐药性 药代动力学 病原体 清创术 感染控制 

分 类 号：R6[医药卫生—外科学]