临床常见病原体检测英文版2011.ppt

临床常见病原体检测临床常见病原体检测 Examination of clinical common pathogens呼吸内科呼吸内科 熊维宁熊维宁Department of Respiratory MedicineXiong, Weining1目的目的Objectiven确定感染的发生和性质，及早明确诊断；确定感染的发生和性质，及早明确诊断；nDetermine the occuring and nature of infection, and make diagnosis early;n尽早选择适当的治疗方案；尽早选择适当的治疗方案；nSelect the appropriate treatment as soon as possible;n采取有效的预防措施，防止感染可能广泛传播所采取有效的预防措施，防止感染可能广泛传播所造成的危害造成的危害nTake effective prevention measures to prevent infection to cause widespread damage. 2基本程序基本程序Basic Proceduresn正确采集和运送标本；正确采集和运送标本；nCorrect collection and transportation of specimensn初步诊断：直接镜检，免疫学和分子生物学检测；初步诊断：直接镜检，免疫学和分子生物学检测；nInitial diagnosis: direct microscopy, immunology and molecular biology examination;n确定诊断：病原体的分离、鉴定及药敏实验，报告结确定诊断：病原体的分离、鉴定及药敏实验，报告结果；果；nDetermined diagnosis: pathogen isolation, identification and sensitivity test, reporting results;n合理用药合理用药nAppropriate drug use3第一节第一节Section One标本的采集运送、实验室评价标本的采集运送、实验室评价和检查方法和检查方法Transportation and collection of specimen, laboratory evaluation and examination methods4一、标本采集和运送一、标本采集和运送One. Collection and transportation of Specimen 5基本原则基本原则Basic principlesn根据病史与临床表现确定标本采集的时间、部位、种类和数量，尽量根据病史与临床表现确定标本采集的时间、部位、种类和数量，尽量采集病变明显部位标本；采集病变明显部位标本；nAccording to history and clinical manifestations to determine the collection time, location, type and quantity of specimens, collect specimens at significant parts of lesions; n无菌操作，防止污染；无菌操作，防止污染；nUse aseptic technique to prevent contamination; n采取适宜的方式进行储存，尽快送检；采取适宜的方式进行储存，尽快送检；nAppropriate way to store, as soon as possible for examination;n要视所有标本为传染品，高度危险性的标本要有明显标识，急症或危要视所有标本为传染品，高度危险性的标本要有明显标识，急症或危重患者标本要特别注明。

重患者标本要特别注明nTo view all the specimens for infectious, high risk specimens should be clearly marked, acute or critically ill patient specimens should be specified.6（一）血液（一）血液(One) Bloodn适应症：疑为菌血症、败血症或脓毒血症的病人；适应症：疑为菌血症、败血症或脓毒血症的病人；nIndications: suspected bacteremia, sepsis or sepsis patients; n一般在抗生素使用前，于发热初期或高峰期采血；已用过抗菌药物治疗者，一般在抗生素使用前，于发热初期或高峰期采血；已用过抗菌药物治疗者，在下次用药前采集；在下次用药前采集；nIn general, prior to use of antibiotics, in the early or peak heat, to collect blood; if antibiotic treatment has been used, collect blood before the next administration;n以无菌法由肘静脉穿刺，一般成人采血量每次以无菌法由肘静脉穿刺，一般成人采血量每次10~20ml，婴儿和儿童，婴儿和儿童1-5ml ，在床边接种；，在床边接种；nPuncture cubital vein by a sterile method, in general, 10 ~ 20ml blood per time for adult, 1-5ml for infants and children, and inoculate at the bedside;n注明抗生素使用情况，选择合适类型的培养瓶；注明抗生素使用情况，选择合适类型的培养瓶；nIndicate the use of antibiotics, select the appropriate type of culture flask;n24小时内在不同部位采血小时内在不同部位采血3次可提高阳性率。

次可提高阳性率nCollecting blood at different parts 3 times within 24 hours can increase the positive rate.7血液标本的采集方法血液标本的采集方法Collection method of blood samples8（二）尿液（二）尿液(Two) Urinen无菌采集中段尿；无菌采集中段尿；nSterile collection of mid-portion urine;n如考虑厌氧菌感染，采取膀如考虑厌氧菌感染，采取膀胱穿刺法采集标本，无菌厌胱穿刺法采集标本，无菌厌氧小瓶运送；氧小瓶运送；nIf consideration of anaerobic infections, apply bladder puncture to collect specimens, transport them with sterile anaerobic vial;n排尿困难者考虑导尿采集标排尿困难者考虑导尿采集标本本nApply catheterization to collect specimens for dysuria patients.9（三）粪便（三）粪便(Three) Stooln挑取脓、血或粘液部分于清洁容器中送检；挑取脓、血或粘液部分于清洁容器中送检；nPick pus, blood or mucus from stoll into clean containers for examination;n排便困难者或婴儿采用直肠拭子采集，置于有保存液的试管内送检；排便困难者或婴儿采用直肠拭子采集，置于有保存液的试管内送检；nApply rectal swab for infants or difficult defecation, place it with preservation solution in the test tube for examination; n怀疑霍乱弧菌感染引起的腹泻，将标本置于碱性蛋白胨水或卡怀疑霍乱弧菌感染引起的腹泻，将标本置于碱性蛋白胨水或卡-布布（（Cary-Blair）运送培养液送检；）运送培养液送检；nSuspected infections caused by Vibrio cholerae, the specimens were placed in alkaline peptone water or card - cloth (Cary-Blair) transport medium for examination;n传染性腹泻应连续送检传染性腹泻应连续送检3次。

次nContinuous examination 3 times for infectious diarrhea.10（四）呼吸道标本（四）呼吸道标本(Four) Respiratory specimensn类型：鼻咽拭子，痰和经气类型：鼻咽拭子，痰和经气管采集的标本；管采集的标本；nTypes: nasopharyngeal swab, sputum, and specimens collected through trachealn上呼吸道存在正常菌群，在上呼吸道存在正常菌群，在采集标本与结果分析时应予采集标本与结果分析时应予考虑考虑nThere is normal flora in upper respiratory tract, the specimens collection and results analysis should be considered.11（五）脑脊液与其他无菌体液（五）脑脊液与其他无菌体液(Five) Cerebrospinal fluid and other sterile body fluidsn脑脊液应立即保温送检或床边接种；脑脊液应立即保温送检或床边接种；nCSF should be transported immediately with insulation or cultured bedside；；n胸腔积液、腹腔积液和心包积液等应采集较大胸腔积液、腹腔积液和心包积液等应采集较大量标本送检，离心后再接种培养。

量标本送检，离心后再接种培养nPleural effusion, ascites and pericardial effusion with a large volume should be collected, centrifugated and then cultured.12（六）眼、耳部标本（六）眼、耳部标本(Six) Eye, ear specimensn拭子采样nSwab samples13（七）泌尿生殖道标本（七）泌尿生殖道标本(Seven) Urogenital specimensn男性：无菌采集尿道口分泌物或前列腺液男性：无菌采集尿道口分泌物或前列腺液；nMale: urethra or prostatic fluid secretions with sterile collection; n女性：无菌采集阴道或宫颈分泌物女性：无菌采集阴道或宫颈分泌物nFemale: vaginal or cervical secretions collected aseptically.14（八）创伤、组织和脓肿标本（八）创伤、组织和脓肿标本(Eight) Trauma, organization, and abscess specimensn对损伤范围较大的创伤，从不同部位采集多份标本；对损伤范围较大的创伤，从不同部位采集多份标本；nOn a wider range of trauma injuries, specimens collected from many different parts; n采集部位应首先清除污物、消毒皮肤；采集部位应首先清除污物、消毒皮肤；nFirstly remove dirt, disinfect the skin around collection site;n标本较少则需加入无菌生理盐水以防干燥；标本较少则需加入无菌生理盐水以防干燥；nFewer samples must be added to sterile saline to prevent drying;n开放性脓肿及脓性分泌物：用无菌棉纤采取脓液或病灶深部分泌物；开放性脓肿及脓性分泌物：用无菌棉纤采取脓液或病灶深部分泌物；nOpen abscess and purulent secretions: collect deep discharge pus or lesions with sterile cotton fibers; n封闭性脓肿用注射器抽取；封闭性脓肿用注射器抽取；nCollect specimen in closed abscess with a syringe;n怀疑厌氧菌感染，应隔绝空气采集。

怀疑厌氧菌感染，应隔绝空气采集nSuspected anaerobic infections, collection should be isolated from air.15（九）血清(Nine) Serumn用于检测特异性抗体；nFor the detection of specific antibodies;n血液自然凝固后吸取血清，灭活补体nDraw serum after natural coagulation of blood, then inactivate complement.16二、标本的实验室质量评估标准Two. Standard of laboratory quality assessment of specimens17检验申请单的基本内容检验申请单的基本内容The basic content of an application for examinationnThe patient,s name and hospital number.nAge and sex.nCollection date and time.nSuspected diagnosis.nExact nature and source of the specimen.nImmunization history and antimicrobial therapy.nObjective.nSigned by physician.18标本接收和拒收准则标本接收和拒收准则Reception and rejection criteria for specimensn1 The information on the label does not exist or not match the information on the requisition;n2 Delay in delivery of the specimens;n3 The specimen is leaking; n4 The specimen has been transported at the improper temperature or in improper medium.19n5 Contaminated samples;n6 The quantity of specimen is insufficient for testing;n7 Duplicate submission of specimens (except blood cultures);n8 The transportation of specimens of severe infectious diseases should comply with the relevant rules.20三、检查方法三、检查方法Three. Examination methods 21（一）直接显微镜检查（一）直接显微镜检查(One) Direct microscopic examinationn不染色标本检查法：用于观察病原体的生不染色标本检查法：用于观察病原体的生长、形态与运动等特性；长、形态与运动等特性；nNot stained specimen test method: to observe the growth, shape and motion characteristics of pathogens;n评价：部分病原体可借此初步诊断。

评价：部分病原体可借此初步诊断nEvaluation: for some pathogens, the initial diagnosis can be taken.22n染色标本检查法：观察细菌的形态、染染色标本检查法：观察细菌的形态、染色性或观察宿主细胞内包涵体的特征；色性或观察宿主细胞内包涵体的特征；nStained specimen test method: to observe bacterial morphology, staining or observe the characteristics of the inclusion bodies in host cell; n评价：为临床初步诊断提供依据评价：为临床初步诊断提供依据nEvaluation: available basis for the preliminary clinical diagnosis.23革兰氏（染色）阳性球菌革兰氏（染色）阳性球菌Gram (staining)-positive cocci革兰氏（染色）阴性杆菌革兰氏（染色）阴性杆菌Gram (staining)-negative bacilli24抗酸染色阳性杆菌（抗酸杆菌）抗酸染色阳性杆菌（抗酸杆菌）Acid-fast stain-positive bacilli (Acid-fast bacilli)25（二）病原体特异性抗原检查（二）病原体特异性抗原检查(Two) Pathogen-specific antigen testn免疫荧光技术免疫荧光技术nImmunofluorescence techniquen酶联免疫技术酶联免疫技术nELISAn化学发光技术化学发光技术nChemiluminescence technologyn乳胶凝集试验乳胶凝集试验nLatex agglutination testn对流免疫电泳对流免疫电泳nCounter immuno electrophoresisn蛋白质芯片蛋白质芯片nProtein chips26病原体特异性抗原检测结果评价病原体特异性抗原检测结果评价Evaluation of pathogen-specific antigen test resultsn如果能排除交叉抗原的影响，病原体抗原检如果能排除交叉抗原的影响，病原体抗原检测可明确感染的病原体。

测可明确感染的病原体nIf the impact of cross-antigen can be excluded, pathogen antigen test could clear the infection of pathogens.27（三）病原体核酸检查（三）病原体核酸检查(Three) Pathogen nucleic acid testn聚合酶链式反应：扩增病原体微生物特异的聚合酶链式反应：扩增病原体微生物特异的DNA或或 RNA片段；片段；nPolymerase chain reaction (PCR): amplify the specific fragments of DNA or RNA of microbial pathogens;n实时荧光定量实时荧光定量PCR技术；技术；nReal-time PCR; n核酸探针杂交技术：通过已知序列的探针与标本中核酸探针杂交技术：通过已知序列的探针与标本中的病原体的核苷酸杂交，用以了解病原体的有无的病原体的核苷酸杂交，用以了解病原体的有无；nNucleic acid probe hybridization: hybridization between the known sequence of the probe and the nucleotide of pathogens in the samples, to explore whether pathogens exist;n基因芯片技术。

基因芯片技术nGene chip or DNA microarray.28病原体核酸检查结果评价病原体核酸检查结果评价Evaluation of pathogen DNA test resultsn是检测病原体微生物最灵敏的方法，但具有一是检测病原体微生物最灵敏的方法，但具有一定的假阳性与假阴性；定的假阳性与假阴性；nis the most sensitive detection method for microbial pathogens, but has some false positive and false negative;n阳性只表明存在某种病原体的核酸，是否正被阳性只表明存在某种病原体的核酸，是否正被感染应结合临床具体分析感染应结合临床具体分析nis the only show that the existence of a positive pathogen nucleic acid, whether being infected should be combined with clinical specific analysis.29（四）病原体的分离培养与鉴定（四）病原体的分离培养与鉴定(Four) Isolation, culture and identification of pathogens1 细菌感染性疾病病原体的分细菌感染性疾病病原体的分离培养离培养1 Isolation and culture the pathogens of bacterial infections n明确感染病原体；明确感染病原体；nClear the pathogens;n为临床提供体外抗微生物药为临床提供体外抗微生物药物敏感试验结果。

物敏感试验结果nProvide vitro test results of anti-microbial drug sensitivity for clinical.302 不能人工培养的病原体感染性疾病2 Not cultivated pathogens of infectious diseasen将标本接种易感动物、鸡胚或行细胞培养nSpecimens were inoculated into susceptible animals, eggs or cell lines.31（五）血清学实验（五）血清学实验(Five) Serological testn特异性特异性 IgM可作为感染性疾病的早期诊可作为感染性疾病的早期诊断指标，且可区分原发与复发感染；断指标，且可区分原发与复发感染；nSpecific IgM can be indicator of early diagnosis for infectious diseases and can distinguish between primary and recurrent infections;n特异性特异性 IgG，尤其双份血清的滴度呈，尤其双份血清的滴度呈4倍或倍或4倍以上升高，考虑现症感染。

倍以上升高，考虑现症感染nFor IgG, the titer of double serum higher 4 times or more than 4 times, current pathogen infection should be considered.32第二节第二节 病原体耐药性检测病原体耐药性检测Section two Detection of pathogen drug resistance 33n抗生素压力nAntibiotic pressure34一、耐药性及其发生机制一、耐药性及其发生机制One. Drug resistance and its mechanism 35（一）耐药病原体（一）耐药病原体(One) Drug resistant pathogensn革兰氏阴性杆菌：革兰氏阴性杆菌：ß -内酰胺酶、超广谱内酰胺酶、超广谱ß -内酰胺酶内酰胺酶(ESBL)、、ⅠⅠ类类ß -内酰胺酶、多重耐药等；内酰胺酶、多重耐药等；nGram-negative bacillus: ß - lactamase, extended spectrum ß - lactamase (ESBL), ⅠⅠ type ß - lactamases, multidrug resistance, etc.;n革兰氏阳性球菌：耐甲氧西林葡萄球菌革兰氏阳性球菌：耐甲氧西林葡萄球菌(MRS)、耐青霉素、耐青霉素肺炎链球菌肺炎链球菌(PRSP)、耐万古霉素肠球菌、耐万古霉素肠球菌(VRE)、高耐氨基、高耐氨基糖苷类抗生素肠球菌。

糖苷类抗生素肠球菌nGram-positive coccus: methicillin-resistant Staphylococcus (MRS), penicillin-resistant Streptococcus pneumoniae (PRSP), vancomycin-resistant enterococcus (VRE), enterococcus with high resistance to aminoglycoside antibiotics.36（二）耐药机制（二）耐药机制(Two) Drug resistance mechanismn1 细菌水平和垂直传播耐药基因的整合子系统；n1 Horizontal and vertical transmission of bacterial drug resistance genes through integrons;n2 产生灭活抗生素的水解酶和钝化酶, 如ESBLs， AmpC ß -内酰胺酶，碳青霉烯酶，氨基糖苷类钝化酶；n2 proteolytic enzyme and inactive enzyme produced for inactivation of antibiotics, such as ESBLs, AmpC ß – lactamase, carbapenemase, aminoglycoside inactive enzyme; 37n3 细菌抗生素作用靶位的改变；n3 Changes in the bacterial antibiotics target；n4 细菌膜外排泵出系统；n4 Bacterial membrane efflux pump system；n5 细菌生物膜的形成。

n5 Bacterial biofilm (BF) formation.38二、检查项目、结果和临二、检查项目、结果和临床应用床应用examination projects, results and clinical application39（一）药物敏感试验（一）药物敏感试验Drug sensitivity testn 抗微生物药物敏感试验抗微生物药物敏感试验(antimicrobial susceptibility test, AST)对敏感性不对敏感性不能预测的临床分离菌株进行药敏试验，能预测的临床分离菌株进行药敏试验，以指导临床选择治疗药物以指导临床选择治疗药物 nAST can not be predicted on the sensitivity of clinical isolates for susceptibility testing to guide clinical treatment of drug40目的目的Objectiven临床分离菌株，如不能对抗生素敏感性进行预测，必须常规进行临床分离菌株，如不能对抗生素敏感性进行预测，必须常规进行药敏试验药敏试验。

nClinical isolates, if they can not predict the sensitivity to antibiotics should be routine susceptibility testingn临床治疗效果差而考虑调整抗菌药物时临床治疗效果差而考虑调整抗菌药物时nPoor clinical treatment to consider adjusting the antimicrobial drugs.n了解细菌耐药的流行病学情况了解细菌耐药的流行病学情况nUnderstand the epidemiology of bacterial resistance.n评价新抗菌药物的抗菌谱和抗菌活性等评价新抗菌药物的抗菌谱和抗菌活性等nEvaluation of new antibiotics and antibacterial activity of antibacterial spectrum.41方法方法Methodsn1 K-B纸片琼脂扩散法（纸片琼脂扩散法（Kirby-Bauer disc agar diffusion method））42参照参照NCCLS标准标准NCCLS standard referencen敏感（敏感（susceptible，，S）：表示测试菌能被测定药物常规剂量给药后在）：表示测试菌能被测定药物常规剂量给药后在体内达到的血药浓度所抑制或杀灭体内达到的血药浓度所抑制或杀灭。

nBacteria can be determined that the test drugs in the body after administration of conventional doses to achieve plasma concentrations inhibit or kill.n耐药（耐药（resistant，，R）：表示测试菌不能被测定药物常规剂量给药后在）：表示测试菌不能被测定药物常规剂量给药后在体内达到的血药浓度所抑制或杀灭，治疗无效体内达到的血药浓度所抑制或杀灭，治疗无效nTest bacteria that can not be measured after administration of conventional dose of drug in the body to the plasma concentrations inhibit or kill, the treatment ineffective.n中介中介 (intermediate，，I) : 该范围作为敏感与耐药之间的缓冲区，避免该范围作为敏感与耐药之间的缓冲区，避免由于微小技术误差影响实验结果。

由于微小技术误差影响实验结果nThe range as a buffer between sensitive and resistant to avoid the impact of the small technical error results.43n2 稀释法（稀释法（Dilution test）） 最低抑菌浓度（最低抑菌浓度（MIC）：能够抑制检测菌肉眼可见）：能够抑制检测菌肉眼可见生长的最低药物浓度称为测定药物对检测菌的最低抑菌生长的最低药物浓度称为测定药物对检测菌的最低抑菌浓度 Minimum inhibitory concentration (MIC): Detection of bacteria able to inhibit visible growth of the minimum drug concentration determination of drugs on the detection of bacteria known as the minimum inhibitory concentration.n3 E试验法（试验法（E test））n4 耐药筛选试验耐药筛选试验Drug screening testn5 折点敏感试验折点敏感试验Sensitive turning point test44（二）耐药菌监测试验（二）耐药菌监测试验Resistant to monitor testn由于细菌存在一种或几种耐药机制，造成了细由于细菌存在一种或几种耐药机制，造成了细菌的多重耐药性。

单一的药敏试验已不能完全菌的多重耐药性单一的药敏试验已不能完全表示细菌的耐药性，必须进行一些特殊的耐药表示细菌的耐药性，必须进行一些特殊的耐药性监测试验性监测试验 Because there is one or several bacterial resistance mechanisms, resulting in multiple drug resistance of bacteria. Single susceptibility test can not fully express the drug resistance of bacteria to be resistant to some special monitoring tests.451. 耐甲氧西林的葡萄球菌（耐甲氧西林的葡萄球菌（methecillin resistance staphylococcus，，MRS））n1μg甲氧西林甲氧西林(苯唑青霉素苯唑青霉素)纸片纸片的抑菌圈直径的抑菌圈直径≤10mm，或，或MIC≥4μg/ml的金黄色葡萄球的金黄色葡萄球菌菌, 1μg苯唑青霉素纸片的抑菌苯唑青霉素纸片的抑菌圈直径圈直径≤17mm，或的凝固酶阴，或的凝固酶阴性葡萄球菌称耐甲氧西林葡萄球性葡萄球菌称耐甲氧西林葡萄球菌菌。

n1μg of methicillin (oxacillin) paper of the inhibition zone diameter ≤ 10mm, or MIC ≥ 4μg/ml Staphylococcus aureus, 1μg oxacillin disk inhibition zone diameter ≤ 17mm, or MIC ≥ 0.5μg / ml of coagulase-negative methicillin-resistant Staphylococcus aureus, said46临床意义临床意义 Clinical significancen对所有对所有β-内酰胺类药物均无效内酰胺类药物均无效,并对氨基糖苷并对氨基糖苷类、大环内酯类、克林霉素和四环素等抗生素类、大环内酯类、克林霉素和四环素等抗生素多重耐药治疗首选药物为万古霉素多重耐药治疗首选药物为万古霉素 For all β-lactam drugs are ineffective, and aminoglycosides, macrolides, clindamycin and tetracycline antibiotics such as multi-drug resistant. The preferred drug for the treatment of vancomycin.472. 氨基糖苷类抗生素高耐药肠球菌氨基糖苷类抗生素高耐药肠球菌High-resistant enterococci aminoglycosidesn对氨基糖苷类和青霉素等作用于细胞壁对氨基糖苷类和青霉素等作用于细胞壁的等抗生素联用无效。

的等抗生素联用无效 The role of aminoglycosides and penicillin and other antibiotics in the cell wall combined with null and void.483. 耐青霉素的肺炎链球菌耐青霉素的肺炎链球菌Penicillin-resistant Streptococcus pneumoniaen定义：定义：1μg苯唑青霉素纸片的苯唑青霉素纸片的抑菌圈直径抑菌圈直径<19mm且且MIC>2μg/ml应视为耐青霉应视为耐青霉素肺炎链球菌（素肺炎链球菌（penicillin resistant streptococcus pneumonia，，PRSP）nDefinition:1μg oxacillin disk inhibition zone diameter <19mm and MIC> 2μg/ml should be regarded as penicillin-resistant Streptococcus pneumoniae 49临床意义临床意义Clinical significancenPRSP对氨苄西林、对氨苄西林、 氨苄西林氨苄西林/舒巴坦、舒巴坦、 头孢头孢唑啉的临床治疗疗效很差，治疗时参考药敏结唑啉的临床治疗疗效很差，治疗时参考药敏结果选择药物，经验治疗重症感染时，可用头孢果选择药物，经验治疗重症感染时，可用头孢曲松或头孢噻肟联合万古霉素用药。

曲松或头孢噻肟联合万古霉素用药nPRSP to ampicillin, ampicillin / sulbactam, cefazolin poor clinical efficacy of the treatment drug of choice when drug susceptibility results for reference, experience the treatment of severe infection, can be combined ceftriaxone or cefotaxime to vancomycin therapy.504. β-内酰胺酶的检测内酰胺酶的检测 β-lactamase detectionnβ-内酰胺酶：可水解内酰胺酶：可水解β-内酰胺类抗生素内酰胺类抗生素β-lactamases: hydrolyzed β-lactam antibiotics.n临床意义：（临床意义：（1）流感嗜血杆菌、淋病奈瑟菌以及卡拉莫拉菌等阳）流感嗜血杆菌、淋病奈瑟菌以及卡拉莫拉菌等阳性，表示对青霉素、氨苄西林以及阿莫西林耐药性，表示对青霉素、氨苄西林以及阿莫西林耐药。

2）葡萄球菌）葡萄球菌属以及肠球菌属等，阳性表示对青霉素、氨基组青霉素、羧基组青属以及肠球菌属等，阳性表示对青霉素、氨基组青霉素、羧基组青霉素以及脲基组青霉素耐药霉素以及脲基组青霉素耐药 Clinical significance: (1), Haemophilus influenzae, Neisseria gonorrhoeae, and karaoke-positive microorganisms in Mora, said to penicillin, ampicillin and amoxicillin resistance. (2) such as Staphylococcus and Enterococcus, the positive that penicillin, penicillin amino group, carboxyl group of penicillin and penicillin-resistant urea-based group.515. 产超广谱产超广谱β-内酰胺酶内酰胺酶(extend spectrum β-lactamase, ESBL)的肠杆菌科细菌的肠杆菌科细菌Producing ESBL Enterobacteriaceaen超广谱超广谱β-内酰胺酶是由质粒介导内酰胺酶是由质粒介导的的β- 内酰胺酶，可水解青霉素类、内酰胺酶，可水解青霉素类、头孢菌素和氨曲南，主要在大肠埃头孢菌素和氨曲南，主要在大肠埃希菌和克雷伯菌属等肠杆菌科细菌希菌和克雷伯菌属等肠杆菌科细菌中产生。

中产生 Extended spectrum β-lactamase mediated by plasmid β-lactamases, can be hydrolyzed penicillins, cephalosporins and aztreonam, mainly in Escherichia coli and Klebsiella species and other Enterobacteriaceae Generated.52临床意义临床意义Clinical significancen产产ESBL细菌，不论体外药物敏感试验结细菌，不论体外药物敏感试验结果如何，对青霉素类、头孢菌素类和氨果如何，对青霉素类、头孢菌素类和氨曲南治疗均无效曲南治疗均无效nESBL producing bacteria, regardless of the outcome of in vitro drug sensitivity tests, to penicillin, cephalosporins and aztreonam treatment were ineffective.536. 耐万古霉素的肠球菌耐万古霉素的肠球菌Vancomycin resistant enterococcin定义定义: 对对30μg万古霉素纸片万古霉素纸片抑菌圈直径抑菌圈直径≤19mm，， 或或MIC≥32μg/ml应视为耐万应视为耐万古霉素肠球菌古霉素肠球菌（（vancomycin resistant enterococcus，，VRE）。

n Definition: paper 30μg vancomycin inhibition zone diameter ≤ 19mm, or MIC ≥ 32μg/ml should be considered as VRE.54临床意义临床意义Clinical significancen耐万古霉素肠球菌目前尚无有效的治疗方法，但是对青霉素敏感耐万古霉素肠球菌目前尚无有效的治疗方法，但是对青霉素敏感的的VRE可用青霉素和庆大霉素联合治疗，若对青霉素耐药而不是可用青霉素和庆大霉素联合治疗，若对青霉素耐药而不是高水平耐氨基糖苷类可用白霉素和庆大霉素另外氯霉素、红霉高水平耐氨基糖苷类可用白霉素和庆大霉素另外氯霉素、红霉素、四环素（或多西环素、或米诺环素）及利福平可用于素、四环素（或多西环素、或米诺环素）及利福平可用于VRE株nVancomycin resistant enterococci is currently no effective treatment, but the VRE to penicillin-sensitive penicillin and gentamicin combination therapy can be used, if not the high-level resistance to penicillin-resistant available aminoglycosides neomycin and celebrate great white Adriamycin. Addition of chloramphenicol, erythromycin and tetracycline (or doxycycline, or minocycline) and rifampin can be used for VRE strains.55（三）病原菌耐药基因的检测（三）病原菌耐药基因的检测Detection of pathogen resistance genesn更早更早Earlier n确证确证Confirmedn准确准确Accuraten金标准金标准Gold standard56第三节第三节 临床感染常见病原体检查临床感染常见病原体检查Check the common pathogens of clinical infection 57n感染性疾病感染性疾病指各种生物性病原体（病原微生物、寄生虫）寄生人体所引起的传染性感染疾病和非传染性感染疾病。

Refers to a variety of infectious diseases, biological pathogens (pathogens, parasites) caused by human infectious parasitic diseases and non-communicable diseases.58 一、流行病学和临床类型一、流行病学和临床类型Epidemiology and clinical types59（一）流行病学（一）流行病学Epidemiologyn新传染病陆续被发现，老传染病死灰复燃新传染病陆续被发现，老传染病死灰复燃nBeen discovered new infectious diseases, the resurgence of old diseasesn多重耐药株多重耐药株nMulti-drug resistant strainsn新医疗技术的开展新医疗技术的开展nThe launching of new medical technologies60（二）临床类型（二）临床类型Clinical typesn临床常见病原体为：细菌、真菌、病毒、临床常见病原体为：细菌、真菌、病毒、支原体、衣原体、螺旋体、立克次体以支原体、衣原体、螺旋体、立克次体以及寄生虫等。

及寄生虫等nCommon clinical pathogens: bacteria, fungi, viruses, mycoplasma, chlamydia, spirochetes, rickettsia, and parasites.61 二、检查项目和临床应用二、检查项目和临床应用 inspection items and clinical applications 62（一）细菌感染检查项目的选择（一）细菌感染检查项目的选择The selection of checking projects on bacterial infectionn普通细菌：常采用直接镜检、分离培养与鉴定、抗原检测普通细菌：常采用直接镜检、分离培养与鉴定、抗原检测nCommon bacteria: direct microscopic examination is often used, Isolation and identification of antigen.n病原体抗体检测病原体抗体检测nAntibody detection of pathogens n难培养或培养要求高的细菌：综合运用免疫学或分子生物学检测，难培养或培养要求高的细菌：综合运用免疫学或分子生物学检测，如结核分枝杆菌感染以及幽门螺杆菌感染等。

如结核分枝杆菌感染以及幽门螺杆菌感染等nDifficult for high culture or bacterial culture: the integrated use of immunology or molecular biology, such as Mycobacterium tuberculosis and Helicobacter pylori infection.n细菌培养是最重要的确诊方法细菌培养是最重要的确诊方法nBacterial culture is the most important diagnostic method.63（二）实验结果分析和临床应用（二）实验结果分析和临床应用Analysis and clinical application of experimental resultsn显微镜检查或分离培养的阴性结果不能完全排除感染；显微镜检查或分离培养的阴性结果不能完全排除感染；nMicroscopy or isolation and culture of negative results can not be completely ruled out infectionn共同抗原引起的交叉反应；共同抗原引起的交叉反应；nAntigenic cross-reactivity caused by the commonn核酸检测的假阳性；核酸检测的假阳性；nFalse-positive nucleic acid detectionn血清学的动态检测。

血清学的动态检测nDynamic detection of serological64第六节第六节 医院感染常见病原体检测医院感染常见病原体检测Detection of common pathogens of nosocomial infection 65n医院感染（医院感染（nosocomial infection）：又称医院获得性感染）：又称医院获得性感染（（hospital acquired infection），指患者在入院时不存在，也），指患者在入院时不存在，也不处于潜伏期，而在医院内发生的感染，包括医院内获得的而在不处于潜伏期，而在医院内发生的感染，包括医院内获得的而在出院后发病的感染广义的医院感染对象不仅指住院患者，还包出院后发病的感染广义的医院感染对象不仅指住院患者，还包括门诊病人、医院职工、探视人员与陪护人员等括门诊病人、医院职工、探视人员与陪护人员等nNosocomial infection (nosocomial infection): also known as hospital-acquired infection (hospital acquired infection), that does not exist on admission of patients, nor in the incubation period, while in the hospital infections occurred, including the hospital after discharge from hospital acquired disease in Infection. Generalized infection, not only by means of hospital inpatients, including outpatient, hospital staff, visiting officers and escort personnel.66 一、流行病学和临床类型一、流行病学和临床类型Epidemiology and clinical types67 （一）流行病学（一）流行病学Epidemiology681.病原学病原学Pathogenn细菌是最常见的病原体。

细菌是最常见的病原体 nBacterial is the most common pathogens.n变化趋势：革兰氏阴性杆菌比例在增加，革兰氏阳性变化趋势：革兰氏阴性杆菌比例在增加，革兰氏阳性球菌比例在减少球菌比例在减少nTrend: increasing the proportion of Gram-negative bacteria, Gram-positive cocci ratio decreased.n罕见细菌变成流行株：阴沟肠杆菌、洋葱假单孢菌，罕见细菌变成流行株：阴沟肠杆菌、洋葱假单孢菌，军团菌等军团菌等nStrains of bacteria become rare: Enterobacter cloacae, Pseudomonas onion, Army monocytogenesn其它：病毒、真菌等其它：病毒、真菌等nOther: viruses, fungi, etc 692. 感染源感染源Source of infectionn住院病人、医院职工、探视人员、陪伴人住院病人、医院职工、探视人员、陪伴人员；员；nPatients, hospital staff, visiting staff, his companion;n医院环境、未彻底消毒的医疗器械、血液医院环境、未彻底消毒的医疗器械、血液制品等。

制品等nHospital environment, without thorough disinfection of medical devices, blood products, etc.70高危人群高危人群High-risk groupsn慢性疾病患者，如肿瘤、糖尿病以及肝硬化患者等慢性疾病患者，如肿瘤、糖尿病以及肝硬化患者等nPatients with chronic diseases such as cancer, diabetes and liver cirrhosis, etc.n免疫抑制剂及激素的使用者免疫抑制剂及激素的使用者nImmunosuppressive drugs and hormone usersn化疗及放疗患者化疗及放疗患者nChemotherapy and radiotherapy in patientsn手术及麻醉患者手术及麻醉患者nSurgery and anesthesia in patientsn使用介入性诊断与治疗的患者使用介入性诊断与治疗的患者nUse of interventional diagnosis and treatment of patientsn广谱抗生素使用者广谱抗生素使用者nBroad-spectrum antibiotic users71（二）常见临床类型（二）常见临床类型Common clinical typesn1 下呼吸道感染：最常见下呼吸道感染：最常见nLower respiratory tract infection: the most commonn2 尿路感染尿路感染nUrinary Tract Infection n3 手术切口感染：外源性和内源性手术切口感染：外源性和内源性nSurgical wound infection: exogenous and endogenousn4 胃肠道感染胃肠道感染nGastrointestinal infectionsn5 血液感染血液感染nBlood infectionn6 皮肤和软组织感染皮肤和软组织感染nSkin and soft tissue infections72 二、检查项目和临床应用二、检查项目和临床应用inspection items and clinical applications 73 （一）医院感染病原体检查项（一）医院感染病原体检查项目和临床应用目和临床应用inspection items and clinical applications for Hospital Infection74n基本原则与病原体感染类似，但更应注意正常基本原则与病原体感染类似，但更应注意正常菌群的污染以及条件致病菌在医院感染中的地菌群的污染以及条件致病菌在医院感染中的地位。

位 Similar to the basic principles and pathogen infection, but more should pay attention to the pollution of the normal flora and opportunistic pathogens in the hospital infection status.751.标本采集和送检基本原则标本采集和送检基本原则The basic principles of specimen collection and submissionn及时采集标本及时采集标本nCollect specimens in a timely mannern严格无菌操作严格无菌操作nStrict asepticn立即送出立即送出nImmediately sentn在抗菌药物使用前在抗菌药物使用前nBefore the use of antibioticsn合适的容器合适的容器nAppropriate containern注明来源和目的注明来源和目的nIndicate the source and destinationn定量或半定量培养定量或半定量培养nQuantitative or semi-quantitative culturen分级报告和限时报告分级报告和限时报告nReports and limit grading report762. 涂片镜检涂片镜检Smear microscopyn痰标本痰标本 nSputum773. 分离培养鉴定法分离培养鉴定法Isolation and culture identification methodn尿路感染尿路感染nUrinary Tract Infectionn手术切口感染手术切口感染nSurgical wound infectionn大便培养大便培养nStool culturen血培养血培养nBlood culture78 （二）医院环境中细菌污染的监（二）医院环境中细菌污染的监测和消毒灭菌效果的监测测和消毒灭菌效果的监测Bacterial contamination in the hospital environment monitoring and the monitoring of sterilization results79n定期对医院环境进行病原体监测：空气、物体定期对医院环境进行病原体监测：空气、物体表面、医务人员手部；表面、医务人员手部；nRegular monitoring of pathogens in hospital environment: air, surface, the medical staff of hand;n定期对医疗器械的消毒效果进行监测：高压蒸定期对医疗器械的消毒效果进行监测：高压蒸气、紫外线、化学消毒剂。

气、紫外线、化学消毒剂nRegular disinfection of medical devices to monitor: high-pressure steam, UV light, chemical disinfectants.80Thanks！81。