2008 30% 2008 2008 2004 813 386 07-346-8339 E-mail srwann@vghks.gov.tw 66
30% 2008 1 2008 2008 Intensive Care Med (2008)34:17-60 67
2 3 C activated protein C 4 5,6 65% JAMA 1995;273(2):117-23 Circulation, 1970;41:989-1001 30% 3% 1C 68
70% 90-95% 7 10 8 9 2004 14.6% 11.7% 70.3% 29.7% 3.7% 15.8% Escherichia coli 30.8% Klebsiella pneumoniae 16.6% Staphylococcus aureus 15.4% Streptococcus spp. 8.6% 80% gentamicin cefazolin gentamicin 90% 28 extended spectrum lactamase, ESBL 17 9 89% 11% carbapenem amikacin 71% 1C 7.6% 10 1D 1B 1D Crit Care Med 2006;34:1589-1596 69
communityacquired infection hospital-acquired infection health-care associated infection 1B 11 12 vancomycin amikacin superinfection Candida spp.clostridium difficile vancomycin-resistant enterococcus, VRE 1C combination therapy Pseudomonas aeruginosa 13 2D 14 2D 3 5 2D de-escalation therapy 7 10 1D 1D 15 70
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SURVIVING SEPSIS CAMPAIGN 2008: INFECTION ISSUE Shue-Ren Wann Abstract There is a continuum of clinical events from infection to systemic inflammatory response syndrome (SIRS) to severe sepsis to septic shock. The rates of morbidity, bacteremia and mortality increase over time. In this era of modern critical care, the mortality rate of septic shock remains relatively high. Approximately 30% of patients with septic shock die, and sepsis remains to be the main cause of death in critically ill patients. To effectively manage septicemia and thus lower the mortality rate of patients with sepsis, the issues of infectious diseases should be tackled seriously. The 2008 Surviving Sepsis Campaign Guideline for the "infection issues" were divided into 3 categories - the infection diagnosis, antibiotic therapy and source control. The diagnosis of infection (sepsis) is influenced mainly by 2 important factors - the determination of the pathogen causing the disease and the evaluation of the severity of the patient. The former provides the basis of the selection of antibiotic agents while the latter confers an assessment of the hemodynamic status of the patient. The measurement of serum lactate levels, coagulation profiles and mixed venous oxygen saturation could provide quantitation of the severity of the sepsis. Appropriate and timely administration of antibiotic agents is one of the most crucial factors in the management of the patient. Antibiotic agents should be given within one hour after a patient presents with severe sepsis or septic shock. Microbiologic cultures should be done prior to the administration of the antibiotic agents. The selection of empiric antibiotic agent is done after obtaining a detailed clinical history and meticulous physical examination along with laboratory, radiologic and invasive diagnostic procedures. Administration of a broad-spectrum antibiotic agent in the absence of adequate drainage and debridement may lead to prolongation of antibiotic treatment and the inevitable emergence of bacterial resistance. In this article, we concisely introduce infection and sepsis, the evaluation of an infected patient, the analysis of bacteremia of adult patients in the emergency department of Kaohsiung Veterans General Hospital in 2004, the principles of antibiotic usage, aggressive eradication of the source of infection and the control of emerging resistant pathogens. Key words: Sepsis, Septic shock, Antibiotic therapy, Source control Correspondence: Dr. Shue-Ren Wann Emergency Medicine Division, Kaohsiung Veterans General Hospital, No.386, Ta-Chung 1st Rd., Kaohsiung City 813, Taiwan Phone: 886-7-346-8339; E-mail: srwann@vghks.gov.tw 73