CRBSI导管感染概述

Device 设备(catheter导管 ) Related Infection 相关感染,Agenda议程,What are the Devices.装置Epidemiology.流行病学Pathogenesis.发病机理Diagnosis.诊断Treatment.处置Prevention.预防,Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM), 2007 Elsevier,艾斯维尔-传染病,Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM), 2007 Elsevier,Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM), 2007 Elsevier,Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM), 2007 Elsevier,Device (catheter ) Related Infection装置(导管)相关感染,美国医院内部相关设施感染数据(每1000套-天),导尿管引发感染,呼吸器引发肺炎,中心管引发血液感染,感染形式,ICU类型,PICU儿科,MICU内科,SICU外科重症监护,发病率和死亡率周报,重症室类型,中心静脉管相关的血液感染,冠动脉,心脏检查,内/外科主要技术,神经外科,高风险婴幼儿,小儿科,外科,创伤科,烧伤科,呼吸科,Nonvalvular Cardiovascular DeviceRelated Infections,Circulation. 2003;108:2015-2031.,AHA Scientific Statement:,非瓣膜心血管装置相关感染,美国心脏协会,Downloaded from: Infectious Diseases (on 16 November 2007 12:04 PM), 2007 Elsevier,Device( catheter related )infections,导管引发感染,IF YOU REMEMBER ONE THING是否记得一件事,PLEASE WASH YOUR HANDS请洗手!,Alcohol Based Hand Sanitizers醇基手消毒,Recommended by CDC based on strong experimental,clinical, epidemiologic and microbiologic data 美国疾控中心强力以实验、临床、流行病学和微生物数据为基础推荐Antimicrobial superiority抗菌剂优势Greater microbicidal effect 强力灭菌Prolonged residual effect 效力持久Ease of use and application使用简单,Agenda议程,What are the Devices.Epidemiology.流行病学Pathogenesis.Diagnosis.Treatment.Prevention.,Epidemiology流行病学,In the United States, the use of central venous catheters is associated with an estimated 80,000 CRBI( or 250 000 Bactremia and Fungemia) that result in 28,000 deaths among ICU patients. These infections may result in $2 billion in annual health care expenditures. 在美国,中心静脉管的使用导致大约80,000CRBI(导管相关血流感染)(或者250,000菌血症和真菌血症),这个结果导致在ICU患者中28000人死亡.这导致护理中心每年的费用超过20亿美元.,Types of catheter导管类型,Peripheral IV静脉辅助设备Multiple Lumen central lines多腔主线PICC穿刺中心静脉导管(外周导管)Chemotherapy port化疗端口Quinton catheter昆顿透析导管Swan Ganze catheter斯旺甘兹式导管Others其他,Agenda,What are the Devices.Epidemiology.Pathogenesis.发病机理Diagnosis.Treatment.Prevention.,皮肤微生物感染,The major cause of infection during the first weeks of indwelling time is from skin microorganisms.主要原因是皮肤留置微生物导致的最初几周的感染Rannem, et. al., 1990Maki, et. al., 1991Maki (review), 1994 Widmer (review), 1997,MECHANISM Of INFECTION感染机理,Operator操作员Skin flora 皮肤菌丛Contamination of catheter hub and Lumen.导管接口和内腔污染Contamination of Infusate.输液污染,医院感染的内源和外源,菌丛,环境,静脉输液装置导致污染,病人飞沫,地板或水污染,交叉感染,间接接触,其他病人,直接接触,工作人员,Risk factors风险因子,Loss of skin integrity. 皮肤完整性缺失Severity of underlying illness. 潜在疾病严重性Thrombogenicity.凝血活性Number of catheter lumens.导管腔数量Availability of IV team Arch Intern Med. 1998;158:473. 静脉注射团队的可能性 Location of catheter 导管定位Complications of femoral and subclavian venous catheterization in critically ill patients: A randomized controlled trial. JAMA. 2001;286:700 Duration of placement (more or less than 72 hrs)(大于或低于72小时)处置时间Emergent placement elective紧急处置选择Nursing staffing variables (nurse-to-patient ratio)护理人员变动(护士-患者比例),Infusate related Infections输液相关感染,Primary (i.e. no source site identified) nosocomial bacteremia caused by psychrophilic (cold-growing) organisms, such as non-aeruginosa pseudomonads, Achromobacter, Flavobacterium, Enterobacter, Serratia, Salmonella or Yersinia spp., 最重要的是(也就是无法确认来源)由嗜冷菌(温度降低)导致的菌血症.比如假单胞菌,无色杆菌,黄杆菌,肠杆菌,沙雷氏菌,沙门氏菌或耶尔森菌等.,Agenda,What are the Devices.Epidemiology.Pathogenesis.Diagnosis.诊断Treatment.Prevention.,When to suspect可疑情况,Local cellulites.局部发炎Bactremia without source.无源菌血症Clinically septic without source.临床无源败血Non functioning catheter.无效导管Positive tip culture.细菌培养阳性反应Pus at insertion site. 插入点有脓Shivering during the use of catheter (Quinton昆顿).使用导管期间颤抖,Definitions定义,Catheter Colonization导管细菌定植: Considered significant growth if 15 cfu of organism is isolated from catheter segment , or more 1000 cfu/ml is isolated from the lumen or hub, in the absence of clinical infection. 如果被分离导管段微生物生长 15 cfu ,或者来自导管段内腔或端部的微生物生长1000 cfu/ml ,而无临床症状,具有重要意义.Catheter Related Blood Stream Infection CR-BSI.导管相关的血流感染Phlebitis静脉炎: induration or erythema, warmth, and pain or tenderness around catheter exit site.硬块或红斑,发热和疼痛或导管周围压痛,Definitions定义,Tunnel infection隧道感染: tenderness, erythema, and/or induration 2 cm from the catheter exit site, along the subcutaneous tract of a tunneled catheter (e.g., Hickman or Broviac catheter). 沿着导管通道有压痛,红斑和导管出口段大于2CM硬块,2. Exit-site infection出口感染 : erythema, induration, and/or tenderness within 2 cm of the catheter exit site; may be associated with other signs and symptoms of infection, such as fever or pus emerging from the exit site, with or without concomitant bloodstream infection 红斑,硬块,或导管出口2CM内压疼,或者有其它感染症状关联,比如出口处发烧,脓,是否伴随血流感染?,静脉输液港相关感染,纤维碎片,隔膜,Groeger, J. S. et. al. Ann Intern Med 1993;119:1168-1174,Microbiologic Isolates: First Device-related Bacteremia or Fungemia,分离微生物:初次使用设备相关的菌血症和真菌血症,微生物,How To Diagnose?如何诊断?,A positive result of semiquantitative Culture 半定量培养阳性结果( 15 CFU per catheter segment) Maki D, et al NEJM 1977;296:1305 or quantitative ( 102 CFU per catheter segment) catheter culture, whereby the same organism isolated from a catheter segment and a peripheral blood sampleSimultaneous quantitative cultures of blood samples with a ratio of 5:1 (CVC vs. peripheral)同步血液定量培养,5:1(导管血和外周血菌落比) Differential time to positivity 阳性时间差:positive result of culture from a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood) 导管血比外周血阳性出现时间至少早2H,Remember.记得,If You put a central line in a patient with documented Bacteremia, then later next day somebody may obtain a blood culture from both the central line and from periphery, a positive blood culture from both sites, does not mean that the central lien is the source.如果置入导管的病人有菌血症记录,那么第二天某人就要做中心管和外周管的血液培养,双方的血液培养为阳性,也不意味导管时细菌源.,Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Issam Raad, Dennis Maki血管内导管相关感染在诊断预防管理的进展,穿刺感染疾病,A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter WithdrawalCID 2007 march ;44:820-826留置导管的导管血流感染诊断研究,半定量表面培养,差量血液培养,阳性差时,措施,敏感性,特性,精确,A Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007,Conclusions结论.CR-BSI can be assessed without catheter withdrawal in patients without neutropenia or blood disorders who have catheters inserted for a short time and are hospitalized in the intensive care unit. Because of ease of performance, low cost, and wide availability, we recommend combining semiquantitative superficial cultures and peripheral vein blood cultures to screen for CR-BSI, leaving differential quantitative blood cultures as a confirmatory and more specific technique. CR-BSI可能被确定,在病人没有撤出导管的情况下,并且他没有嗜中性白血球减少和血液疾病,他在医院监护室短时间插入导管.由于性能好,成本低,可用性强,我们推荐使用结合半定量技术表面培养和外周静脉血管排查,然后采用差别定量血培养作为验证技术.确定CR-BSI,Agenda,What are the Devices.Epidemiology.Pathogenesis.Diagnosis.Treatment.处置Prevention.,Treating the garbage!废物处理,A central line is removed and it is growing less than 15 CFU.中心管被移除,且微生物成长少于15CFUPatient is not septic and blood Culture is negative.病人无败血症且血液培养为阴性 No indication to treat the infected or colonized central line, which is in the garbage.无迹象表明要对垃圾桶里的中心管或细菌处理,Coagulase Negative Staphylococci凝固酶阴性葡萄球菌,CVC can be retained, if necessary, in patients with uncomplicated, catheter-related, bloodstream infection.如有必要,中心静脉管能够保留,且病人无并发症和关联导管血流感染 If the CVC is retained, patients should be treated with systemic antibiotic therapy for 7 days.如果CVC被保留,病人应该采用7天全身抗生素处置Treatment failure is a clear indication for removal of the catheter .处置失败的清晰迹象是移除导管,Staphylococcus Aureus葡萄球菌,REMOVE the central line . 移除中心线Systemic antibiotics for minimal 14 days. 最少14天的全身抗生素治疗Failure to clear bactremia within 72 hours Or patient with high risk for endovascualr infection or having prosthesis may be indicative for longer 3-6 weeks of treatment. 72小时内清理大肠杆菌失败,或者高风险病人血管内感染或者假体处置超过36周TTE or TEE are strongly advised.大力推荐胸超声心动图或食管超声心动图Blood Culture should be repeated during therapy and1-2 weeks after completion of therapy, looking for relapses.治疗期间重复做血液培养,并且在治疗结束后的12周也要进行,索取报告单.,Staphylococcus Aureus Relapse葡萄球菌复发,WARNING警告,Gram Negative Organisms革兰氏阴性菌,IF gram negative organism were the cause of CR-BSI, then central line should be removed, unless other sources can be found.如果革兰氏阴性菌是CR-BSI的原因,那么中心管应该被移除,除非找到其他感染源.Antimicrobial should be given for 7-10 days. 抗生素治疗710天,Fungal Infection真菌感染,Remove the central line and give anti-fungal for 14 days , from the day of the last negative culture.移除中心线,持续14天抗菌治疗,最后一天做阴性培养It is advisable to repeat the culture at the end of therapy, to document clearance of the Fungemia. 在治疗后期重复进行培养是必要的,排除真菌血症Some authorities advise funduscopical examination. 一些权威人士建议眼底镜检查,Septic Thrombosis败血血栓,Remove the Central line移除中心线Systemic antibiotics for 4-6 weeks or more46周或更多时间的全身抗生素治疗Remove the infected vein if patient clinically not improving如果病人临床症状没有改变,移除被感染血管Systemic anticoagulation is also highly recommended.强力推荐全身抗凝血治疗,Downloaded from: Infectious Diseases (on 16 November 2007 12:26 PM), 2007 Elsevier,Downloaded from: Infectious Diseases (on 16 November 2007 12:26 PM), 2007 Elsevier,Treatment Of local Infections局部感染处理,Antibiotics for 7 days or less + Removal of central line, as far as patient does NOT have bactremia .移除中心管至少7天抗生素治疗,直至病人没有菌血症Do NOT change over Guide wire if patient has local infection.如果病人局部感染,不要改变线规Antimicrobial Therapy WITHOUT catheter removal is also an option , provided the patient does not have systemic signs and symptoms of infection. it is IMPERATIVE that patient should be closely monitored.在病人没有全身感染的症状和体征的情况下,导管移除后也要进行抗菌治疗.重要的是病人要被全程监控.Tunnel or Pocket infection catheter MUST be removed. 通道或者囊状感染导管必须被移除,Do NOT think of treating local infection with local antibiotics ointment不要采用局部抗生素药膏来处理局部感染,CVC中心静脉管或ID直入装置相关的菌血症,复杂,不复杂,Agenda,What are the Devices.Epidemiology.Pathogenesis.Diagnosis.Treatment.Prevention.预防,If you remember one thing : WASH YOUR HANDS是否记得洗手?,Alcohol based hand hygiene solutions乙醇基手部卫生溶液,Quick: 5- 15 seconds,Easy to use,Very effective antisepsis due to bactericidal properties of alcohol,高效,快速,简便,Hand washing : 洗手Historical Perspectives回顾历史,1846,IgnazSemmelweis postulated that the puerperal fever was caused by cadaverous particles transmitted from the autopsy suite to the obstetrics 1846年,赛麦尔维斯提出孕妇产后发烧是医生们离开解剖室进入产科病房把“尸体颗粒(cadaverous particles)”带给了产妇导致的.1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient examination in the clinic. 1847年他要求学生和医生在诊所里对每个病人检查时用含氯消毒剂清洁手部,Center For Disease control (CDC) guidelinesCDC疾病控制中心规范,预防导管相关感染规范,CDC RECCOMENDATIONCDC推荐,预防血管内装置相关血流感染推荐规程,一般方法,体外诊断试剂,监控,英国BSI的ivdr体外诊断试剂法规的ICU,CVC相关标准,CDC RECCOMENDATIONCDC推荐,无菌技术,插入,IVD插入和维护前手部卫生,非中心IVD插入和维护期间衣物清洁和手套消毒,CVC期间使用最大面积遮蔽预防措施,皮肤杀菌,无菌纱布或聚氨酯半透膜包裹导管插入端,在插入或移植前不使用抗生素杀菌,Cutaneous Antisepsis and Topical Anti-Infectives 皮肤消毒和抵御局部感染,Maki and Band prospectively studied three regimens of catheter care:导管事故处理方式 (1) application of polymyxin-neomycin-bacitracin ointment at insertion and every 48 hours,每48小时用新霉素软膏衬垫 (2) application of iodophor ointment at insertion and every 48 hours, or每48小时用含碘消毒剂衬垫 (3) no ointment.无软膏 In their study of 827 random catheter insertions, there were no differences in either catheter-acquired sepsis (two cases in each group) or local inflammation (38.9% vs. 41.9% vs. 41.7% percent, respectively). The only difference noted was in semiquantitative cultures of catheter tips. Am J Med. 1981;70:739.,Using Chlorhexidine 0.5%使用0.5%的洗必泰,A meta-analysis determined that chlorhexidine gluconate significantly reduces the incidence of bacteremia in patients with central venous catheters compared to povidone-iodine for insertion-site skin disinfection.一元分析确定洗必泰相对于碘液衬垫皮肤消毒显著降低了中心静脉管病人的菌血症Chaiyakunapruk et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med. 2002;136:792.,Chlorhexidine Skin Antisepsis洗必泰皮肤消毒,Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol. 70%异丙醇里加2%洗必泰用于皮肤抗菌Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad.捏住安瓶的两翼 握住填充器,直到溶液浸透爪垫Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. 逆向挤压海绵,使用洗必泰溶液由后向前摩擦,至少30秒,不要抹去液体.Allow antiseptic solution time to dry completely before puncturing the site ( 2 minutes).确认穿刺位置前抗菌溶液完全干燥时间(约2分钟),The inanimate environment is a reservoir of pathogens无生命环境是致病菌储藏库, Contaminated surfaces increase cross-transmission Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.,X represents a positive Enterococcus culture,The pathogens are ubiquitous,X代表阳性球菌培养,病原体无处不在,污染表面增加了交叉感染,Compliance with hand washing手部清洗对比,Berhe M, Edmond MB, G Bearman in AJIC 33;1 February 2005, 55-57,Majority of respondents reported excellent compliance with IC practices,Alcohol based hand hygiene solutions乙醇手部卫生溶液,Quick: 5- 15 seconds,Easy to use,Very effective antisepsis due to bactericidal properties of alcohol,An intervention to decrease catheter-related bloodstream infections in the ICU.ICU中降低导管相关性血流感染的措施 N Engl J Med Pronovost P, et al: 355(26):2725-2732, 2006,(1) hand washing, 洗手(2) use of full-barrier precautions during placement of catheters, 布置导管时完全屏蔽预防(3) cleansing of the skin with chlorhex