导管相关血流感染.ppt

导管相关性血行性感染(CRBSI)诊断、治疗与预防,北京协和医院MICU江伟,CRBSI:流行病学,美国ICU每年发生16,000例CRBSI病死率18%(035%)每年死亡5004,000例每例CRBSI医疗费用$28,690-$56,000每年医疗费用$60,000,000460,000,000,CDC.MMWR2002;HeiselmanJAMA1994;DimickArchSurg2001,CRBSI:中国vs.全球数据,TaoL,HuB,RosenthalVD,etal.Device-associatedinfectionratesin398intensivecareunitsinShanghai,China:InternationalNosocomialInfectionControlConsortium(INICC)findings.IntJInfectDis2011;15:e774-e780,中国CRBSI数据:致病菌(n=845),TaoL,HuB,RosenthalVD,etal.Device-associatedinfectionratesin398intensivecareunitsinShanghai,China:InternationalNosocomialInfectionControlConsortium(INICC)findings.IntJInfectDis2011;15:e774-e780,CRBSI:ChangingEpidemiology,MarcosM,SorianoA,InurrietaA,etal.Changingepidemiologyofcentralvenouscatheter-relatedbloodstreaminfections:increasingprevalenceofGram-negativepathogens.JAntimicrobChemother2011;66:2119-2125,CRBSI:发病机制,CRBSI:微生物学诊断方法,RaadI,HannaH,MakiD.Intravascularcatheter-relatedinfections:advancesindiagnosis,prevention,andmanagement.LancetInfectDis2007;7:645-657,CRBSI:腔外感染的临床表现,全身表现发热白细胞增多插管局部表现炎症表现不敏感（多数导管感染并无插管局部炎症表现）不特异（出现相应表现亦无需拔除导管）提示导管感染的症状和体征插管部位脓性分泌物插管部位蜂窝织炎超过4mm,CRBSI:腔外感染的实验室诊断,滚动平板技术（Maki法）*将导管尖端放置在含有5%羊血的Columbia琼脂培养基的平皿上将导管尖端在平皿表面前后滚动至少34次15CFU/plate外周血培养阳性且与导管尖端培养一致,GuembeM,Martin-RabadanP,EchenagusiaA,etal.Howshouldlong-termtunneledcentralvenouscathetersbemanagedinmicrobiologylaboratoriesinordertoprovideanaccuratediagnosisofcolonization?JClinMicrobiol2012;50:1003-1007,*evenforlong-termtunneledcentralvenouscatheters,withdetectionof94.9%ofcathetercolonization,CRBSI:插管部位消毒,MakiDG,RingerM,AlvaradoCJ.Prospectiverandomisedtrialofpovidone-iodine,alcohol,andchlorexidineforpreventionofinfectionassociatedwithcentralvenousandarterialcatheters.Lancet1991;338:339-343,CRBSI:敷料选择,SafdarN,OHoroJC,GhufranA,etal.Chlorhexidine-impregnateddressingforpreventionofcatheter-relatedbloodstreaminfection:ameta-analysis.CritCareMed2014,含氯己啶敷料可能具有一定优势,CRBSI:腔内感染的临床表现,全身表现发热白细胞增多插管局部表现无其他表现血培养革兰阴性杆菌?,CRBSI:微生物学诊断方法,RaadI,HannaH,MakiD.Intravascularcatheter-relatedinfections:advancesindiagnosis,prevention,andmanagement.LancetInfectDis2007;7:645-657,CRBSI的DTP:应当从几个腔留取血标本?,对于伴随CRBSI的中心静脉导管，约有40%仅有一个导管腔有细菌显著定植随机选择一个导管腔留取血标本进行培养，得到阴性结果的概率为66%总体上看，随机选择从一个导管腔留取血标本培养60%的概率检测到定植,DobbinsBM,CattonJA,KiteP,etal.Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed2003;31:1688-1690,CRBSI的DTP:需要留取多少外周血标本?,GuembeM,Rodriguez-CreixemsM,Sanchez-CarrilloC,etal.Differentialtimetopositivity(DTTP)forthediagnosisofcatheter-relatedbloodstreaminfection:doweneedtoobtainoneormoreperipheralveinbloodcultures?EurJClinMicrobiolInfectDis2011Oct21Epubaheadofprint,当根据DTP方法确诊CLABSI时，仅留取一个（套）外周血培养并不会明显遗漏CLABSI病例,CRBSI的诊断,RaadI,HannaH,MakiD.Intravascularcatheter-relatedinfections:advancesindiagnosis,prevention,andmanagement.LancetInfectDis2007;7:645-657,CRBSI初始治疗,OGradyNP,ChertowDS.Managingbloodstreaminfectionsinpatientswhohaveshort-termcentralvenouscatheters.CleveClinJMed2011;78:10-17,临床怀疑短期留置中心静脉导管相关性血行性感染,重症患者,轻中症患者（无低血压或器官功能衰竭）,拔除导管至少留取2套血培养，其中至少1套来自外周静脉开始经验性抗生素治疗请感染科医生会诊,有危险因素*,无危险因素,拔除导管至少留取2套血培养，其中至少1套来自外周静脉开始经验性抗生素治疗,如仍需要导管可保留至少留取2套血培养，其中至少1套来自外周静脉开始经验性抗生素治疗,*例如免疫功能抑制，血管内异物，严重全身性感染表现，插管部位感染表现，确诊菌血症或真菌血症,CRBSI的治疗:拔除导管的实际感染率,MerrerJ,DeJongheB,GolliotF,etal.Complicationsoffemoralandsubclavianvenouscatheterizationincriticallyillpatients:arandomizedcontrolledtrial.JAMA2001;286:700-707.LeonC,Alvarez-LermaF,Ruiz-SantanaS,etal.Antisepticchamber-containinghubreducescentralvenouscatheter-relatedinfection:aprospective,randomizedstudy.CritCareMed2003;31:1318-1324.RanucciM,IsgroG,GiomarelliPP,etal.Impactofoligoncentralvenouscathetersoncathetercolonizationandcatheter-relatedbloodstreaminfection.CritCareMed2003;31:52-59.DobbinsBM,CattonJA,KiteP,etal.Eachlumenisapotentialsourceofcentralvenouscatheter-relatedbloodstreaminfection.CritCareMed2003;31:1688-1690.DarouicheRO,RaadII,HeardSO,etal.Acomparisonoftwoantimicrobial-impregnatedcentralvenouscatheters.CatheterStudyGroup.NEnglJMed1999;340:1-8.,CRBSI的治疗:拔管vs.不拔管,RijndersBJ,PeetermansWE,VerwaestC,etal.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed2004;30:1073-1080,怀疑CRBSI并计划更换中心静脉导管,试验组,标准治疗组,拔除导管,留取2套血培养,保留导管继续观察5天,感染表现缓解,不拔除导管,感染表现持续,拔除导管,血培养阳性，或血流动力学不稳定,CRBSI的治疗:拔管vs.不拔管,RijndersBJ,PeetermansWE,VerwaestC,etal.WatchfulwaitingversusimmediatecatheterremovalinICUpatientswithsuspectedcatheter-relatedinfection:arandomizedtrial.IntensiveCareMed2004;30:1073-1080,CRBSI的治疗:拔管vs.不拔管,DeliberatoRO,MarraAR,CorreaTD,etal.CatheterRelatedBloodstreamInfection(CR-BSI)inICUPatients:MakingtheDecisiontoRemoveorNottoRemovetheCentralVenousCatheter.PLoSONE2012;7:e32687,CRBSI的初始治疗,OGradyNP,ChertowDS.Managingbloodstreaminfectionsinpatientswhohaveshort-termcentralvenouscatheters.CleveClinJMed2011;78:10-17,CRBSI的预防,医护协作管理比技术更重要,预防CRBSI的质量改进计划,BlotK,BergsJ,VogelaersD,etal.Preventionofcentralline-associatedbloodstreaminfectionsthroughqualityimprovementinterventions:asystematicreviewandmeta-analysis.ClinInfectDis2014,CRBSI的预防：CentralLineBundle,洗手放置导管过程中采用最大限度的隔离措施使用氯己啶消毒皮肤如有可能，避免股静脉置管拔除不必要的导管,CRBSI的预防:Cent