導(dǎo)管相關(guān)血流感染

1、導(dǎo)管相關(guān)性血行性感染(CRBSI)診斷、治療與預(yù)防北京協(xié)和醫(yī)院MICU江偉CRBSI: 流行病學(xué) 美國ICU每年發(fā)生16,000例CRBSI 病死率18% (0 35%) 每年死亡500 4,000例 每例CRBSI醫(yī)療費(fèi)用$28,690 - $56,000 每年醫(yī)療費(fèi)用$60,000,000 460,000,000CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001CRBSI: 中國 vs. 全球數(shù)據(jù)INICC中國上海中國上海 2004-2009總體均值總體均值(95%CI)INICC 2004-2009總體均值總體均值(95%

2、CI)US NHSN 2006-2008總體均值總體均值(95%CI)內(nèi)科ICUCLABSI4.3 (3.7 5.0)14.7 (13.8 15.6)1.9 (1.8 2.0)外科ICUCLABSI3.5 (3.2 3.7)5.0 (4.7 5.4)2.3 (2.2 2.4)兒科ICUCLABSI3.5 (2.7 4.4)10.7 (9.9 11.5)3.0 (2.8 3.2)Tao L, Hu B, Rosenthal VD, et al. Device-associated infection rates in 398 intensive care units in Shanghai, C

3、hina: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis 2011; 15: e774-e780中國CRBSI數(shù)據(jù): 致病菌(n = 845)15.9%14.1% 14.0%12.3%10.1%6.9%5.1%5.1%3.3%1.9%1.7%1.7%1.3%0.6%0.5%3.3%0%5%10%15%20%金黃色葡萄球菌其他葡萄球菌念珠菌屬鮑曼不動桿菌大腸埃希氏菌肺炎克雷伯菌銅綠假單胞菌糞腸球菌腸桿菌屬窄食單胞菌屎腸球菌鏈球菌屬其他假單胞菌變形桿菌屬黃桿菌屬其他病

4、原體Tao L, Hu B, Rosenthal VD, et al. Device-associated infection rates in 398 intensive care units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis 2011; 15: e774-e780CRBSI: Changing EpidemiologyMarcos M, Soriano A, Inurrieta A, et al. Chang

5、ing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens. J Antimicrob Chemother 2011; 66: 2119-2125CRBSI: 發(fā)病機(jī)制CRBSI: 微生物學(xué)診斷方法診斷標(biāo)準(zhǔn)診斷標(biāo)準(zhǔn)敏感性敏感性特異性特異性缺點(diǎn)缺點(diǎn)無需拔除無需拔除CVC的方法的方法同時定量血培養(yǎng)經(jīng)CVC留取血培養(yǎng)菌落計數(shù)相當(dāng)于外周血培養(yǎng)菌落計數(shù)的5倍或更多93%97-100%耗費(fèi)人力，價格昂貴血培養(yǎng)陽性時間差

6、經(jīng)CVC留取血培養(yǎng)報警時間較外周血培養(yǎng)報警時間提前 2小時89-90%72-87%若經(jīng)CVC輸注抗生素，結(jié)果難以解釋經(jīng)CVC留取定量血培養(yǎng)經(jīng)CVC留取定量血培養(yǎng) 100 CFU/ml81-86%85-96%無法鑒別CRBSI和菌血癥吖啶橙白細(xì)胞離心涂片發(fā)現(xiàn)任何細(xì)菌87%94%未得到廣泛應(yīng)用腔內(nèi)毛刷定量培養(yǎng) 100 CFU/ml95%84%可能導(dǎo)致菌血癥，心律失?；蛩ㄈ枰纬枰纬鼵VC的方法的方法CVC尖端半定量培養(yǎng)，滾動平板導(dǎo)管尖端 15 CFU/ml45-84%85%無法培養(yǎng)腔內(nèi)細(xì)菌CVC定量培養(yǎng)：離心，混旋，超聲振蕩導(dǎo)管尖端 103 CFU/ml82-83%89-97%臨界值尚不明確

7、CVC革蘭染色和吖啶橙染色鏡檢直接看到微生物84-100%97-100%耗費(fèi)人力，缺乏實用性Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis 2007; 7: 645-657CRBSI: 腔外感染的臨床表現(xiàn) 全身表現(xiàn) 發(fā)熱 白細(xì)胞增多 插管局部表現(xiàn) 炎癥表現(xiàn) 不敏感（多數(shù)導(dǎo)管感染并無插管局部炎癥表現(xiàn)） 不特異（出現(xiàn)相應(yīng)表現(xiàn)亦無需拔除導(dǎo)管） 提示導(dǎo)管感染的癥狀和體征 插管部位

8、膿性分泌物 插管部位蜂窩織炎超過4 mmCRBSI: 腔外感染的實驗室診斷 滾動平板技術(shù)（Maki法）*將導(dǎo)管尖端放置在含有5%羊血的Columbia瓊脂培養(yǎng)基的平皿上將導(dǎo)管尖端在平皿表面前后滾動至少3 4次 15 CFU/plate 外周血培養(yǎng)陽性且與導(dǎo)管尖端培養(yǎng)一致Guembe M, Martin-Rabadan P, Echenagusia A, et al. How should long-term tunneled central venous catheters be managed in microbiology laboratories in order to provide

9、an accurate diagnosis of colonization? J Clin Microbiol 2012; 50: 1003-1007*even for long-term tunneled central venous catheters, with detection of 94.9% of catheter colonizationCRBSI: 插管部位消毒10%碘仿碘仿(n = 227)70%乙醇乙醇(n = 227)2%氯己啶氯己啶(n = 214)中心靜脈插管(n = 77)(n = 32)(n = 67)局部感染(%)15 (19.5)5 (15.6)4 (5.9

10、)菌血癥(%)5 (6.5)2 (6.3)1 (1.5)動脈導(dǎo)管(n = 150)(n = 195)(n = 147)局部感染(%)6 (4.0)6 (3.1)1 (0.7)菌血癥(%)1 (0.7)1 (0.5)0總計(n = 227)(n = 227)(n = 214)局部感染(%)21 (9.3)11 (7.4)5 (2.3)菌血癥(%)6 (2.6)3 (2.3)1 (0.5)Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorexidine

11、 for prevention of infection associated with central venous and arterial catheters. Lancet 1991; 338: 339-343CRBSI: 敷料選擇Safdar N, OHoro JC, Ghufran A, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med 2014含氯己啶敷料可能具有一定優(yōu)勢

12、CRBSI: 腔內(nèi)感染的臨床表現(xiàn) 全身表現(xiàn) 發(fā)熱 白細(xì)胞增多 插管局部表現(xiàn) 無 其他表現(xiàn) 血培養(yǎng)革蘭陰性桿菌?CRBSI: 微生物學(xué)診斷方法診斷標(biāo)準(zhǔn)診斷標(biāo)準(zhǔn)敏感性敏感性特異性特異性缺點(diǎn)缺點(diǎn)無需拔除CVC的方法同時定量血培養(yǎng)經(jīng)CVC留取血培養(yǎng)菌落計數(shù)相當(dāng)于外周血培養(yǎng)菌落計數(shù)的5倍或更多93%97-100%耗費(fèi)人力，價格昂貴血培養(yǎng)陽性時間差經(jīng)CVC留取血培養(yǎng)報警時間較外周血培養(yǎng)報警時間提前 2小時89-90%72-87%若經(jīng)CVC輸注抗生素，結(jié)果難以解釋經(jīng)CVC留取定量血培養(yǎng)經(jīng)CVC留取定量血培養(yǎng) 100 CFU/ml81-86%85-96%無法鑒別CRBSI和菌血癥吖啶橙白細(xì)胞離心涂片發(fā)現(xiàn)任何細(xì)

13、菌87%94%未得到廣泛應(yīng)用腔內(nèi)毛刷定量培養(yǎng) 100 CFU/ml95%84%可能導(dǎo)致菌血癥，心律失?；蛩ㄈ枰纬鼵VC的方法CVC尖端半定量培養(yǎng)，滾動平板導(dǎo)管尖端 15 CFU/ml45-84%85%無法培養(yǎng)腔內(nèi)細(xì)菌CVC定量培養(yǎng)：離心，混旋，超聲振蕩導(dǎo)管尖端 103 CFU/ml82-83%89-97%臨界值尚不明確CVC革蘭染色和吖啶橙染色鏡檢直接看到微生物84-100%97-100%耗費(fèi)人力，缺乏實用性Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, p

14、revention, and management. Lancet Infect Dis 2007; 7: 645-657CRBSI的DTP: 應(yīng)當(dāng)從幾個腔留取血標(biāo)本? 對于伴隨CRBSI的中心靜脈導(dǎo)管，約有40%僅有一個導(dǎo)管腔有細(xì)菌顯著定植 隨機(jī)選擇一個導(dǎo)管腔留取血標(biāo)本進(jìn)行培養(yǎng)，得到陰性結(jié)果的概率為66% 總體上看，隨機(jī)選擇從一個導(dǎo)管腔留取血標(biāo)本培養(yǎng) 60%的概率檢測到定植Dobbins BM, Catton JA, Kite P, et al. Each lumen is a potential source of central venous catheter-related blood

15、stream infection. Crit Care Med 2003; 31: 1688-1690CRBSI的DTP: 需要留取多少外周血標(biāo)本?外周血培養(yǎng)數(shù)外周血培養(yǎng)數(shù)留取兩個血培養(yǎng)的留取兩個血培養(yǎng)的CRBSI(n = 49)留取三個血培養(yǎng)的留取三個血培養(yǎng)的CRBSI(n = 11)合計合計(n = 60)一個91.9%(83.7 98.0%)90.9%(72.7 100.0%)91.7%兩個100%96.9%(81.8 100.0%)99.5%Guembe M, Rodriguez-Creixems M, Sanchez-Carrillo C, et al. Differential t

16、ime to positivity (DTTP) for the diagnosis of catheter-related bloodstream infection: do we need to obtain one or more peripheral vein blood cultures? Eur J Clin Microbiol Infect Dis 2011 Oct 21 Epub ahead of print當(dāng)根據(jù)DTP方法確診CLABSI時，僅留取一個（套）外周血培養(yǎng)并不會明顯遺漏CLABSI病例CRBSI的診斷Raad I, Hanna H, Maki D. Intrava

17、scular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis 2007; 7: 645-657CRBSI初始治療OGrady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med 2011; 78: 10-17臨床懷疑短期留置中心靜脈導(dǎo)管相關(guān)性血行性感染重癥患

18、者輕中癥患者（無低血壓或器官功能衰竭）拔除導(dǎo)管至少留取2套血培養(yǎng)，其中至少1套來自外周靜脈開始經(jīng)驗性抗生素治療請感染科醫(yī)生會診有危險因素*無危險因素拔除導(dǎo)管至少留取2套血培養(yǎng)，其中至少1套來自外周靜脈開始經(jīng)驗性抗生素治療如仍需要導(dǎo)管可保留至少留取2套血培養(yǎng)，其中至少1套來自外周靜脈開始經(jīng)驗性抗生素治療*例如免疫功能抑制，血管內(nèi)異物，嚴(yán)重全身性感染表現(xiàn)，插管部位感染表現(xiàn)，確診菌血癥或真菌血癥CRBSI的治療: 拔除導(dǎo)管的實際感染率52%50%29%22%9%0%10%20%30%40%50%60%Merrer J, et alLeon C, et alRanucci M, et alDobbin

19、s BM, et alDarouiche RO, et alMerrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001; 286: 700-707. Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub

20、reduces central venous catheter-related infection: a prospective, randomized study. Crit Care Med 2003; 31: 1318-1324. Ranucci M, Isgro G, Giomarelli PP, et al. Impact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection. Crit Care Med 2003; 31: 52-5

21、9. Dobbins BM, Catton JA, Kite P, et al. Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Med 2003; 31: 1688-1690. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group.

22、 N Engl J Med 1999; 340: 1-8.CRBSI的治療: 拔管 vs. 不拔管Rijnders BJ, Peetermans WE, Verwaest C, et al. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med 2004; 30: 1073-1080懷疑CRBSI并計劃更換中心靜脈導(dǎo)管試驗組標(biāo)準(zhǔn)治療組拔除導(dǎo)管留取2套血培

23、養(yǎng)保留導(dǎo)管繼續(xù)觀察5天感染表現(xiàn)緩解不拔除導(dǎo)管感染表現(xiàn)持續(xù)拔除導(dǎo)管血培養(yǎng)陽性，或血流動力學(xué)不穩(wěn)定CRBSI的治療: 拔管 vs. 不拔管標(biāo)準(zhǔn)治療標(biāo)準(zhǔn)治療密切觀察密切觀察p更換中心靜脈導(dǎo)管38/3816/42 0.2總住院日4234 0.2ICU病死率10/328/32 0.2Rijnders BJ, Peetermans WE, Verwaest C, et al. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a rand

24、omized trial. Intensive Care Med 2004; 30: 1073-1080CRBSI的治療: 拔管 vs. 不拔管標(biāo)準(zhǔn)治療標(biāo)準(zhǔn)治療(n = 37)保守治療保守治療(n = 16)p年齡66.8 20.159.3 16.60.2男性17 (45%)11 (68%)0.127胃腸外營養(yǎng)13 (35%)8 (50%)0.31菌血癥時APACHE II15.4 4.615.4 4.40.99菌血癥時SOFA7.0 4.47.1 3.40.94頸內(nèi)靜脈33 (89%)16 (100%)雙腔導(dǎo)管29 (78%)9 (56%)導(dǎo)管留置天數(shù)17.09.214.86.80.35菌血

25、癥前住院日25 (3-245)24.5 (9-143)0.69最初24小時充分治療15 (40%)7 (44%)0.828ICU病死率17 (46%)12 (75%)0.051住院病死率21 (57%)12 (75%)0.208Deliberato RO, Marra AR, Correa TD, et al. Catheter Related Bloodstream Infection (CR-BSI) in ICU Patients: Making the Decision to Remove or Not to Remove the Central Venous Catheter. PL

26、oS ONE 2012; 7: e32687CRBSI的初始治療OGrady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med 2011; 78: 10-17CRBSI的預(yù)防 醫(yī)護(hù)協(xié)作 管理比技術(shù)更重要預(yù)防CRBSI的質(zhì)量改進(jìn)計劃質(zhì)量改進(jìn)干預(yù)措施質(zhì)量改進(jìn)干預(yù)措施定義與舉例定義與舉例教育(n = 33)通過講座傳遞有關(guān)CLABSI的理論知識（針對CLABSI流行病學(xué)或預(yù)防措施進(jìn)行每月定期或單次講座；帶有

27、課前與課后考試的教學(xué)模塊）培訓(xùn)(n = 4)與CVC護(hù)理及留置相關(guān)的實際技能培訓(xùn)（通過模擬人進(jìn)行無菌操作留置CVC的個人培訓(xùn)）反饋(n = 20)向ICU醫(yī)務(wù)人員報告CLABSI發(fā)生率或感染預(yù)防措施依從性（每月在員工會議上報告感染率；改進(jìn)預(yù)防措施依從性或CLABSI發(fā)生率的招貼畫）臨床提醒(n = 15)有關(guān)適當(dāng)臨床操作的提醒以改進(jìn)預(yù)防措施的知曉率或?qū)嵤ㄓ嘘P(guān)手衛(wèi)生或CLABSI發(fā)生率的招貼畫；每日提醒每位患者的CVC是否可以停用；CVC上貼紙或佩戴徽章提醒正確操作的重要性；信息一覽表，流程圖或每日目標(biāo)清單）集束化措施(n = 11)包括至少2項IHI留置或保留CVC期間的預(yù)防措施（包括2-5項IHI建議的集束化措施；不包括旨在提高依從性的質(zhì)量改進(jìn)措施的集束化措施）清單(n = 18)有關(guān)集束化預(yù)防措施的清單以提高循證感染預(yù)防措施的依從性（CVC置管過程中包括2-5項IHI建議的清單以提高集束化措施的依從性）授權(quán)終止操作(