318.2 🩺 國考版

318.2.1 高頻考點

318.2.1.1 Categories

  • HAP: ≥ 48 h after admission
  • VAP: ≥ 48 h after intubation
  • HCAP RETIRED (2016)

318.2.1.2 MDR Risk Factors

  • Recent IV antibiotics 90 days
  • Septic shock at presentation
  • ARDS preceding
  • Hospitalization ≥ 5 days prior
  • MRSA / Pseudomonas colonization
  • Acute RRT prior

318.2.1.3 Common Pathogens

  • Pseudomonas (top in VAP)
  • MRSA + MSSA
  • Acinetobacter
  • Klebsiella (ESBL/CRE)
  • E. coli
  • Stenotrophomonas

318.2.1.4 Empiric Therapy

  • Single anti-Pseudomonas (low MDR risk)
  • Double anti-Pseudomonas (high MDR risk)
  • Add MRSA cover (vanc / linezolid)

318.2.1.5 Antibiotic Choices

  • Pseudomonas: pip-tazo, cefepime, meropenem, ceftazidime
  • MRSA: vancomycin, linezolid (NOT daptomycin)
  • Acinetobacter: sulbactam, colistin, tigecycline, cefiderocol
  • ESBL: meropenem
  • CRE: ceftaz-avibactam, meropenem-vaborbactam, imipenem-relebactam, cefiderocol
  • Stenotrophomonas: TMP-SMX

318.2.1.6 Duration

  • 7 days for most (PneumA)
  • 14 days for MDR / complicated

318.2.1.7 VAP Prevention Bundle

  • HOB elevation 30-45°
  • SAT/SBT daily
  • Oral hygiene
  • Subglottic suction
  • Hand hygiene
  • Early mobilization

318.2.1.8 Key Trials

  • PneumA (2003): 8 vs 15 days — equivalent
  • ASPECT-NP: ceftolozane-tazo for HAP/VAP
  • APEKS-NP: cefiderocol with mortality signal
  • RESTORE-IMI: imipenem-relebactam for CRE
  • TANGO: meropenem-vaborbactam for CRE

318.2.1.9 MRSA Pneumonia

  • Vancomycin trough 15-20
  • Linezolid alternative (especially renal)
  • NOT daptomycin (inactivated by surfactant)

318.2.2 易混淆比范

Type Onset Common Pathogens Duration
CAP (Ch316) Outside hospital or < 48 h S. pneumoniae, atypicals, viral 5-7 d
HAP ≥ 48 h post-admission Pseudomonas, MRSA, GNR 7-14 d
VAP ≥ 48 h post-intubation Pseudomonas, MRSA, GNR 7-14 d

318.2.3 Special Topics

318.2.3.1 Antibiotic Stewardship in HAP/VAP

  • De-escalation per cultures within 48-72 hr
  • Procalcitonin-guided shortening
  • 7-day duration sufficient for most
  • Local antibiogram knowledge

318.2.3.2 Hospital Antibiogram

  • Local resistance patterns
  • Drives empiric choices
  • MRSA prevalence > 10-20% triggers cover
  • Pseudomonas + MDR rates regional