《激素在细菌性脑膜炎中的应用优秀课件.ppt》由会员分享，可在线阅读，更多相关《激素在细菌性脑膜炎中的应用优秀课件.ppt（29页珍藏版）》请在taowenge.com淘文阁网|工程机械CAD图纸|机械工程制图|CAD装配图下载|SolidWorks_CaTia_CAD_UG_PROE_设计图分享下载上搜索。
1、激素在细菌性脑膜炎中的应用第1页，本讲稿共29页臨床問題臨床問題P(patient):Becterial meningitisI (intervention):SteroidC(comparison):PlaceboO(outcome):Efficacy第2页，本讲稿共29页背景說明背景說明Steroid 在臨床上已被廣泛地應用，它具有抗炎、止痛及減緩異常血腦障壁之微血管的通透，以及降低顱內壓等作用。治療細菌性腦膜炎，雖然有著抗生素的介入治療，但卻仍具高死亡率，且造成嚴重的後遺症，不僅是一個衝擊，也是我們要去突破的瓶頸。第3页，本讲稿共29页背景說明背景說明感染性疾病有著強烈的地域性特色，在西
2、方國家細菌性腦膜炎最常見到的致病菌是鏈球菌(Streptococcus Pneumoniae)、李斯特菌(Listeria monocytogenes)，或是奈瑟氏菌(Neisseria meningitids)；我國則是鏈球菌(Streptococcus Pneumoniae)和取而代之的克雷伯氏菌(Klebsiella Pneumoniae)為主。至於Steroid針對Bacterial meningitis的使用，目前仍受爭議，至今尚無定論，但在有些病人身上是可以加速改善症狀，但對於減少後遺症則很難說。第4页，本讲稿共29页期待目標期待目標提供有用的文獻資料，期待進一步釐清Steroid
3、 使用於Bacterial meningitis的角色及療效。第5页，本讲稿共29页搜尋步驟搜尋步驟-1Cochrane Library：Key Word：Combine bacterial meningitis AND steroid Found：【Reviews：1篇】【DARE：1篇】【CENTRAL：7篇】Combine bacterial meningitis AND dexamethasone Found：【Reviews：1篇】【DARE：3篇】【CENTRAL：23篇】第6页，本讲稿共29页搜尋步驟搜尋步驟-2EBMR-ACP Journal ClubKey Word：Comb
4、ine bacterial meningitis AND steroid Found：0篇篇 Combine bacterial meningitis AND dexamethasone Found：2篇篇第7页，本讲稿共29页搜尋步驟搜尋步驟-3NGC（National Guideline Clearinghouse）Key Word：Combine bacterial meningitis AND steroid Found：1篇篇 Combine bacterial meningitis AND dexamethasone Found：1篇篇第8页，本讲稿共29页搜尋步驟搜尋步驟-4Pu
5、bMedKey Word：Combine bacterial meningitis AND steroid Found：9篇篇 Combine bacterial meningitis AND dexamethasone Found：8篇篇 第9页，本讲稿共29页搜尋步驟搜尋步驟-5MEDLINEKey Word：Combine bacterial meningitis AND steroid Found：10篇篇 Combine bacterial meningitis AND dexamethasone Found：8篇篇第10页，本讲稿共29页搜尋步驟搜尋步驟-6EBM ONLINEKe
6、y Word：Combine bacterial meningitis AND steroid Found：2篇篇Combine bacterial meningitis AND dexamethasone Found：2篇篇第11页，本讲稿共29页結果摘要結果摘要Eighteen studies involving 1853 people were included.Overall,adjuvant corticosteroids were associated with lower case fatality(relativerisk(RR)0.76,95%condence interva
7、ls(CI)0.59 to 0.98)and lower rates of both severe hearing loss(RR 0.36,95%CI 0.22 to 0.60)and long-term neurological sequelae(RR 0.66,95%CI 0.44 to 0.99).In children,corticosteroids reduced severe hearing loss in bacterial meningitis caused by Haemophilus influenzae(RR 0.31,95%CI 0.15 to 0.62),as we
8、ll as in meningitis caused by other bacteria than H.influenzae(RR 0.42,95%CI 0.20 to 0.89).van de Beek D,de Gans J,McIntyre P,Prasad K.Corticosteroids for acute bacterial meningitis.The Cochrane Database of Systematic Reviews 2003,Issue 3.第12页，本讲稿共29页結果摘要結果摘要In adults,there was a reduction in case-f
9、atality(RR 0.38,95%CI 0.18 to 0.78),however there were few data.Adverse events were not increased signicantly with the use of corticosteroids.Adjuvant corticosteroids are benecial in the treatment of children with acute bacterial meningitis.The limited data available in adults shows a trend in favou
10、r of adjuvant corticosteroids but a denite recommendation must await more studies.van de Beek D,de Gans J,McIntyre P,Prasad K.Corticosteroids for acute bacterial meningitis.The Cochrane Database of Systematic Reviews 2003,Issue 3.第13页，本讲稿共29页結果摘要結果摘要7 RCTs（848 pt in total）：）：1.In Haemophilus influen
11、zae type b meningitis,dexamethasone reduced severe hearing loss.(pooled OR0.31,95%CI:0.14,0.69)2.In pneumoccal meningitis,the pooled odds ratio for severe hearing loss was 0.52.(95%CI:0.17,1.46)3.Limiting dexamethasone therapy to 2 days may be optimal.第14页，本讲稿共29页結果摘要結果摘要7 RCTs（848 pt in total）：）：4.
12、The available evidence on adjunctive dexamethasone therapy confirms benefit for Haemophilus influenzae type b meningitis and,if commenced with or before parenteral antibiotics,suggests benefit for pneumoccal meningitis in childhood.P B McIntyre,C S Berkey,S M King,U B Schaad,T Kilpi,G Y Kanra,C M Pe
13、rez.Dexamethasone as adjunctive therapy in bacterial meningitis:a meta-analysis of randomized clinical trials since 1988(Structured abstract).The Cochrane Database of Systematic DARE.2000 第15页，本讲稿共29页結果摘要結果摘要1 RCT（301 pt）:1.Early treatment with dexamethasone improves the outcome in adults with acute
14、 bacterial meningitis and does not increase the risk of G-I bleeding.1 double blind placebo control study(40 pt):1.Dexamethasone was given in dose of 0.6mg/kg/day in divided dose,for first 4 days of therapy.2.First dose of dexamethasone was given 15 minutes prior to first dose dose of ceftriaxone.3.
15、Neurological complications and hearing loss were more common and severe in placebo group as compared to the dexamethasone group(p0.05).第16页，本讲稿共29页結果摘要結果摘要1 Controlled Clinical Trial(68 pt):1.Dexamethasone was given in dose of 0.6mg/kg/day in divided dose,for first 4 days of therapy.2.Mortality was
16、lower in the group treated with dexamethasone but the difference was not statistically significant.3.Dexamethasone should be administered to all adultes patients with acute bacterial meningitis.第17页，本讲稿共29页NeonatesAt present,there are insufficient data to make a recommendation on the use of adjuncti
17、ve dexamethasone in neonates with bacterial meningitis.(C-I)結果摘要結果摘要第18页，本讲稿共29页結果摘要結果摘要Infants and Children1.Despite some variability in result of published trials,the Practice Guideline Committee believes the available evidence supports the use of adjunctive dexamethasone in infants and children w
18、ith H.influenzae type b meningitis.(A-I)2.Dexamethasone should be initiated 10-20 min prior to,or at least concomitant with,the first antimicrobial dose,at 0.15 mg/kg every 6 h for 2-4 days.第19页，本讲稿共29页結果摘要結果摘要Infants and Children3.Adjunctive dexamethasone should not be given to infants and children
19、 who have already received antimicrobial therapy,because administration of dexamethasone in this circumstance is unlikely to improve patient outcome.(A-I)4.In infants and children with pneumococcal meningitis,there is controversy concerning the use of adjunctive dexamethasone therapy.(C-II)第20页，本讲稿共
20、29页結果摘要結果摘要Adults1.The Practice Guideline Committee recommends use of dexamethasone(0.15 mg/kg every 6 h for 2-4 days with the first dose administered 10-20 min before,or at least concomitant with,the first dose of antimicrobial therapy)in adults with suspected or proven pneumococcal meningitis.(A-I
21、)2.Some experts would only administer adjunctive dexamethasone if the patient had moderate-to-severe disease(Glasgow Coma Scale score 11).第21页，本讲稿共29页結果摘要結果摘要Adults3.However,the Practice Guideline Committee thinks that adjunctive dexamethasone should be initiated in all adult patients with suspected
22、 or proven pneumococcal meningitis,because assessment of the score may delay initiation of appropriate therapy.4.Dexamethasone should only be continued if the CSF Gram stain reveals gram-positive diplococci,or if blood or CSF cultures are positive for S.pneumoniae.第22页，本讲稿共29页結果摘要結果摘要Adults4.Adjunct
23、ive dexamethasone should not be given to adult patients who have already received antimicrobial therapy,because administration of dexamethasone in this circumstance is unlikely to improve patient outcome.(A-I)5.The data are inadequate to recommend adjunctive dexamethasone to adults with meningitis c
24、aused by other bacterial pathogens,although some authorities would initiate dexamethasone in all adults,because the etiology of meningitis is not always ascertained at initial evaluation.(B-III)第23页，本讲稿共29页結果摘要結果摘要Pneumococcal Meningitis1.The Practice Guideline Committee recommends that adjunctive d
25、examethasone be administered to all adult patients with pneumococcal meningitis,even if the isolate is subsequently found to be highly resistant to penicillin and cephalosporins(B-III).2.Careful observation and follow-up are critical to determine whether dexamethasone is associated with adverse clin
26、ical outcome.第24页，本讲稿共29页結果摘要結果摘要Pneumococcal Meningitis 3.For data on outcome in patients with meningitis caused by resistant pneumococcal isolates,case reports and small case series may help ascertain whether dexamethasone is harmful to these patients.4.Furthermore,in patients with suspected pneum
27、ococcal meningitis who receive adjunctive dexamethasone,addition of rifampin to the empirical combination of vancomycin plus a third-generation cephalosporin may be reasonable pending culture results and in vitro susceptibility testing(B-III).第25页，本讲稿共29页後記後記The available evidence supports the use o
28、f adjunctive dexamethasone in infants and children with H.influenzae type b meningitis.(0.15 mg/kg every 6 h for 2-4 days)Dexamethasone in adults with the adjunctive dexamethasone be administered to all adult patients with suspected or proven pneumococcal meningitis.(0.15 mg/kg every 6 h for 2-4 day
29、s)第26页，本讲稿共29页後記後記For children and adults with acute bacterial meningitis,adjuvant dexamethasone therapy reduces mortality,hearing loss,and long term neurological sequelae.In patients with acute bacterial meningitis,adjunctuve treatment with dexamethasone was more effective than placebo in improving
30、 disability and reducing death.第27页，本讲稿共29页後記後記Dexamethasone should now be considered the standard of care,provided that it is initiated before or at the same as antibiotics.Adjunctive dexamethasone should not be given to infants,children and adult patients who have already received antimicrobial therapy,because administration of dexamethasone in this circumstance is unlikely to improve patient outcome.第28页，本讲稿共29页Thanks for your attention第29页，本讲稿共29页