导管相关性感染完整版

概述,i什么时候怎么进行导管培养和血培养II导管相关感染的一般处理III短期外周静脉相关的感染处理特别之处。iV非隧道式中心静脉导管和动脉导管，导管相关性感染处理的特别之处V长期CVC或者置入物，和血滤管路相比，他们相关的感染感染处理的特别之处VI 儿童导管相关感染的特别之处,2017/12/21,2009导管相关性感染指南摘要张柳,VII 需要导管透析的患者，怀疑导管感染如何处理VIII，什么是抗生素局部封闭治疗，怎么应用于导管相关感染的患者IX有病原特异的治疗推荐么X如何处理化脓性感染的血栓性静脉炎XI持续血流感染和感染性心内膜炎怎么处理CII怎么预测和处理可能的爆发性导管相关性感染（CRBSI）,纲要,诊断：经导管培养概况1-6短期导管和动脉导管7-8长期导管9-10诊断：血培养11-21导管相关感染的一般处理22-38,一般推荐,1. Catheter cultures should be done when a catheter is removedbecause of suspected CRBSI; catheter cultures shouldnot be obtained routinely (A-II).2. Qualitative broth culture of catheter tips is not recommended(A-II).3. For CVCs, culture the catheter tip, not the subcutaneoussegment (B-III).4. For cultures of an anti-infective catheter tip, use specificinhibitors in the culture media (A-II).5. Growth of 115 cfu from a 5-cm segment of the cathetertip by semiquantitative (roll-plate) culture or growth of 1102cfu from a catheter by quantitative (sonication) broth culturereflects catheter colonization (A-I).6. When catheter-related infection is suspected and there isa catheter exit site exudate, swab the drainage to obtain samplesfor culture and Gram staining (B-III).,一般推荐,1. 疑似导管相关性血流感染（catheter-related bloodstream infection，CRBSI）而拔除导管时，应对该导管进行培养；导管培养不应该成为常规检查项目（A-II）。2. 不推荐对导管末端进行肉汤定性培养（A-II）。3. 对于中心静脉导管（central venous catheters，CVCs），应培养其末端，而不应该培养皮下段（B-III）。4. 如果培养含有抗感染药物的导管末端，应该在培养基中添加特定抑制剂（A-II）。5. 5cm长的导管末端进行半定量（平皿滚动法，roll-plate）培养，如果生长15个菌落形成单位（colony-forming units，cfu）；或者对其进行定量（超声法）肉汤培养，生长100 cfu，均可认为该菌在导管上有定植（A-I）。6. 疑似导管相关性感染，并且导管置入部位有渗出物，推荐使用无菌拭子蘸取渗出物进行革兰染色和培养（B-III）。,General,Short-term catheters, including arterial catheters7. For short-term catheter tip cultures, the roll plate techniqueis recommended for routine clinical microbiological analysis(A-II).8. For suspected pulmonary artery catheter-related infection,culture the introducer tip (A-II).Long-term catheters9. Semiquantitative growth of !15 cfus/plate of the samemicrobe from both the insertion site culture and catheter hubculture strongly suggests that the catheter is not the source ofa bloodstream infection (A-II).10. If a venous access subcutaneous port is removed becauseof suspected CRBSI, send the port to the microbiology laboratoryfor qualitative culture of the,短期导管（包括动脉导管）7. 对于短期导管末端的培养，推荐使用平皿滚动法进行常规的临床微生物学分析（A-II）。8. 疑似肺动脉导管相关感染时，应该培养引导器末端（the introducer tip）（A-II）。长期留置导管9. 导管插入端和接口部位（the catheter hub）培养出相同微生物，如果都0.5%），不建议使用聚维酮碘（povidone-iodine）；消毒液要充分接触皮肤，干燥时间要足够，以减少血液培养的污染机会（A-I）。14. 如果经导管抽取血液标本，则需要对接口处（the catheter hub）进行消毒，建议用酒精或碘酊或酒精氯己定（0.5%），消毒液要充分接触皮肤，干燥时间要足够，以减少血液培养的污染机会（A-I）。15. 疑似CRBSI时应该在抗微生物治疗前留取配对血液标本，即从导管和外周静脉各抽取血液标本进行培养，并且在培养瓶上做好标记，以标明抽取位置（A-II）。16. 无法从外周静脉抽取血液时，推荐从不同catheter lumen中抽取两瓶或两瓶以上标本（B-III）。尚不清楚此时是否应该从所有catheter lumen内抽取标本（C-III）。17. 确诊CRBSI的条件：至少一个经皮血液培养和导管末端培养培养出同种微生物，或者两份血液培养（一份经导管接口（the catheter hub），另一份经外周静脉）的结果满足CRBSI的定量血液培养诊断标准或差异报警时间（differential time to positivity，DTP）诊断标准（A-II）。此外，如果从两处catheter lumen取出的血液标本进行定量培养，其中一份的培养结果是另一份结果的三倍或三倍以上，则应该考虑可能存在CRBSI（B-II）。此时符合DTP诊断标准的血液培养结果的解释尚无定论（C-III）。18. 定量血液培养时，导管血液培养结果是静脉血液培养结果的三倍或三倍以上可以确诊CRBSI（A-II）。19. 对于DTP，导管血液培养阳性报警时间比静脉血液培养阳性报警时间早2小时或以上可以确诊CRBSI（A-II）。20. 定量血液培养和/或DTP标本留取应该在启动抗微生物治疗前进行，且每瓶中的血液标本量应该相同（A-II）。21. 尚无用以推荐CRBSI抗微生物治疗停止后常规进行血液培养的充分证据（C-III）。,General Management of Catheter-Related Infection,22. When denoting duration of antimicrobial therapy, day 1 is the first day on which negative blood culture results areobtained (C-III).23. Vancomycin is recommended for empirical therapy in heath care settings with an elevated prevalence of methicillinresistant Staphylococcus aureus (MRSA); for institutions in which the preponderance of MRSA isolates have vancomycin minimum inhibitory concentration (MIC) values 12 mg/mL, alternative agents, such as daptomycin, should be used (A-II).24. Linezolid should not be used for empirical therapy (i.e., for patients suspected but not proven to have CRBSI) (A-I).25. Empirical coverage for gram-negative bacilli should be based on local antimicrobial susceptibility data and the severity of disease (e.g., a fourth-generation cephalosporin, carbapenem, or b-lactam/b-lactamase combination, with or without an aminoglycoside) (A-II).26. Empirical combination antibiotic coverage for multidrug- resistant (MDR) gram-negative bacilli, such as Pseudomonas aeruginosa, should be used when CRBSI is suspected in neutropenic patients, severely ill patients with sepsis, or patients known to be colonized with such pathogens, until the culture and susceptibility data are available and de-escalation of the antibiotic regimen can be done (A-II).27. In addition to coverage for gram-positive pathogens, empirical therapy for suspected CRBSI involving femoral catheters in critically ill patients should include coverage for gram-negative bacilli and Candida species (A-II).28. Empirical therapy for suspected catheter-related candidemia should be used for septic patients with any of the following risk factors: total parenteral nutrition, prolonged use of broad-spectrum antibiotics, hematologic malignancy, receipt of bone marrow or solid-organ transplant, femoral catheterization, or colonization due to Candida species at multiple sites (B-II).,General Management of Catheter-Related Infection,29. For empirical treatment of suspected catheter-related candidemia, use an echinocandin or, in selected patients, fluconazole (A-II). Fluconazole can be used for patients without azole exposure in the previous 3 months and in health care settings where the risk of Candida krusei or Candida glabrata infection is very low (A-III).30. Antibiotic lock therapy should be used for catheter salvage (B-II); however, if antibiotic lock therapy cannot be used in this situation, systemic antibiotics should be administered through the colonized catheter (C-III).31. Four to 6 weeks of antibiotic therapy should be administered to patients with persistent fungemia or bacteremia after catheter removal (i.e., occurring 172 h after catheter removal) (A-II for S. aureus infection; C-III for infection due to other pathogens), to patients who are found to have infective endocarditis or suppurative thrombophlebitis, and to pediatric patients with osteomyelitis; 68 weeks of therapy should be used for the treatment of osteomyelitis in adults (figures 2 and 3) (A-II).32. Long-term catheters should be removed from patients with CRBSI associated with any of the following conditions: severe sepsis; suppurative thrombophlebitis; endocarditis; bloodstream infection that continues despite 172 h of antimicrobial therapy to which the infecting microbes are susceptible; or infections due to S. aureus, P. aeruginosa, fungi, or mycobacteria (A-II). Short-term catheters should be removed from patients with CRBSI due to gram-negative bacilli, S. aureus, enterococci, fungi, and mycobacteria (A-II).33. For patients with CRBSI for whom catheter salvage is attempted, additional blood cultures should be obtained, and the catheter should be removed if blood culture results (e.g., 2 sets of blood cultures obtained on a given day; 1 set of blood cultures is acceptable for neonates) remain positive when blood samples are obtained 72 h after the initiation of appropriate therapy (B-II).34. For long-term and short-term CRBSI due to less virulent microbes that are difficult to eradicate (e.g., Bacillus species, Micrococcus species, or Propionibacteria), catheters should generally be removed after blood culture contamination is ruled out on the basis of multiple positive culture results, with at least 1 blood culture sample drawn from a peripheral vein (B-III).,General Management of Catheter-Related Infection,35. In uncomplicated CRBSI involving long-term catheters due to pathogens other than S. aureus, P. aeruginosa, Bacillus species, Micrococcus species, Propionibacteria, fungi, or mycobacteria, because of the limited access sites in many patients who require long-term intravascular access for survival (e.g., patients undergoing hemodialysis or with short-gut syndrome), treatment should be attempted without catheter removal, with use of both systemic and antimicrobial lock therapy (B-II).36. After a positive blood culture result is reported that may represent CRBSI, automated standardized treatment advice can be formulated to improve compliance with Infectious Diseases Society of America (IDSA) guidelines (B-II).37. Urokinase and other thrombolytic agents are not recommended as adjunctive therapy for patients with CRBSI (B-I).38. If a catheterized patient has a single positive blood culture that grows coagulase-negative Staphylococcus species, then additional cultures of blood samples obtained through the suspected catheter and from a peripheral vein should be performed before the initiation of antimicrobial therapy and/or catheter removal to be certain that the patient has true bloodstream infection and that the catheter is the likely source (A-II).,导管相关性感染的一般处置措施,22. 抗微生物治疗持续时间的第一天，指的是获得阴性血液培养结果的第一天（C-III）。23. 医疗机构中耐甲氧西林金黄色葡萄球菌（methicillin-resistant Staphylococcus aureus，MRSA）流行率升高时，推荐使用万古霉素作为经验治疗药物；对于MRSA分离株中MIC2mg/ml者为主的医疗机构，应该使用替代药物，如达托霉素（daptomycin）（A-II）。24.不推荐使用利奈唑酮（Linezolid）作为经验治疗药物（即对于疑似而非确诊的CRBSI患者不推荐使用）（A-I）。25. 应基于当地的抗微生物药物敏感性数据和疾病的严重程度在经验治疗时覆盖革兰阴性杆菌（如：一种四代头孢菌素，碳氢霉烯类，或-内酰胺类/-内酰胺酶抑制剂联合制剂，伴或不伴一种氨基糖苷类）（A-II）。26. 下列患者疑似CRBSI时，应该使用经验性联合治疗以覆盖多重耐药（multidrug-resistant，MDR）的革兰阴性杆菌如铜绿假单胞菌。这些患者包括中性粒细胞减少的患者，患有脓毒症的重症患者，已知有该类病原体定植的患者。得到培养和敏感性数据后进行抗生素的降阶梯治疗（de-escalation of the antibiotic regimen）（A-II）。,导管相关性感染的一般处置措施,27. 危重患者疑似有累及股动脉导管的CRBSI时，治疗除了要覆盖革兰阳性病原外，还应覆盖革兰阴性杆菌和假丝酵母菌属菌种（A-II）。28. 疑似导管相关假丝酵母菌血症时经验治疗应该用于有如下危险因素的脓毒症患者：完全胃肠外营养，广谱抗生素的长期使用，血液系统恶性肿瘤，接受骨髓移植或器官移植，股动脉插管，或者多部位存在假丝酵母菌的定植（B-II）。29. 疑似导管相关假丝酵母菌血症的经验治疗应该使用棘白菌素，特定患者可以使用氟康唑（A-II）。氟康唑可以用于治疗前三个月内没有使用过唑类药物（azole），并且所在的医疗机构克柔假丝酵母菌和光滑假丝酵母菌感染危险性很低的患者（A-III）。,导管相关性感染的一般处置措施,30. 应该使用抗生素栓疗法（Antibiotic lock therapy）进行导管补救（B-II）；如果不能使用抗生素栓疗法，应当通过该定植导管进行系统性抗生素给药（C-III）。31. 对感染性心内膜炎患者、化脓性血栓性静脉炎患者、有骨髓炎的儿科患者，如果拔除导管后仍有持续性真菌血症或细菌血症（即拔除后超过72小时仍有菌血症），应该给予4到6周的抗微生物治疗（金黄色葡萄球菌感染A-II，其他病原体感染C-III）；对成人骨髓炎患者，需要治疗6到8周（图2和3）（A-II）。32. 伴有下列情况的CRBSI患者均应拔除长期导管：严重脓毒症，化脓性血栓性静脉炎，感染性心内膜炎，致病病原体经敏感抗微生物药物治疗72小时以上仍有血流感染，或者金黄色葡萄球菌、铜绿假单胞菌、真菌以及分枝杆菌引起的感染（A-II）。革兰阴性杆菌、金黄色葡萄球菌、肠球菌、真菌和分枝杆菌引起的短期导管CRBSI，应拔除该导管（A-II）。33. 对于尝试进行导管补救的CRBSI患者，应再进行血液培养，如果启动正确治疗72小时后该血液培养（即每天成人取两套血液培养，新生儿一套可以接受）结果仍为阳性，需要拔除导管（B-II）。,导管相关性感染的一般处置措施,34. 如果长期导管CRBSI或短期导管CRBSI由毒力较弱却难以根除的微生物（如芽孢杆菌属菌种、微球菌属菌种、丙酸杆菌属菌种）导致，如果基于多套血液培养阳性（其中至少一套取自外周静脉）从而排除了血液培养污染的可能，一般来讲需要拔除导管（B-III）。35. 对于累及长期导管的非复杂性CRBSI，并且病原不是金黄色葡萄球菌、铜绿假单胞菌、芽孢杆菌属菌种、微球菌属菌种、丙酸杆菌属菌种、真菌或分枝杆菌，如果生存必须的长期血管内插管（如血液透析患者、短肠综合征患者）的置入位点有限，可以尝试不拔除导管，同时进行系统性抗微生物药物治疗和抗微生物栓疗法（B-II）。36. 对于可能提示CRBSI的阳性血液培养结果，为提高对美国感染性疾病学会（Infectious Diseases Society of America，IDSA）指南的依从性，可以使用自动化的标准治疗措施（B-II）。37. 不推荐尿激酶和其他溶栓剂作为CRBSI患者的辅助治疗（B-I）。38. 如果有插管的患者有单个血液培养阳性并且是血浆凝固酶阴性葡萄球菌生长，则需要在启动抗微生物治疗和/或拔除导管前再分别从被怀疑的导管和外周静脉抽取血液进行培养，以确定该感染是否是真的血流感染，而该导管是否是可能的感染源（A-II）。,0.WHAT ARE THE UNIQUE ASPECTS OF TREATING PATIENTS WHO HAVE SHORTTERMPERIPHERAL VENOUS CATHETERS?短期外周静脉相关的感染处理特别之处,39. Peripheral intravenous catheters with associated pain,induration, erythema, or exudate should be removed (A-I).外周静脉局部疼痛、不能忍受、脓肿、渗出的应拔除40. Any exudate at the insertion site should be submitted for Gram staining, routine culture, and additional culture for fungi and acid-fast organisms, as indicated, when assessing immunocompromised patients (A-II).穿刺点渗出应行革兰染色涂片、常规培养，免疫缺陷病人应真菌培养和抗酸培养,1.WHAT ARE THE UNIQUE ASPECTS OF TREATING PATIENTS WITH NONTUNNELEDCVCS AND ARTERIAL CATHETERS?非隧道式中心静脉导管和动脉导管，导管相关性感染处理的特别之处,41. For patients who are hospitalized in the intensive care unit with a new onset of fever but without severe sepsis or evidence of bloodstream infection, obtain blood samples for culture from the nontunneled CVC, the arterial catheter (if present), and percutaneously, instead of performing routine catheter removal (B-II). Consider culture of samples obtained from the insertion site and catheter hubs, if available, as noted above (A-II).ICU患者新发发热，无severe sepsis或血流感染证据，如果是非隧道式导管，可不拔除导管，而是行血培养+动脉导管（如果存在）血培养。如果可以，考虑行插入点和导管hub的采样培养42. The CVC and arterial catheter, if present, should be removed and cultured if the patient has unexplained sepsis or erythema overlying the catheter insertion site or purulence at the catheter insertion site (B-II).如果患者有不能解释的sepsis或导管穿刺部位的红肿43. For patients with unexplained fever, if blood culture results are positive, the CVC or arterial catheter was exchanged over a guidewire, and the catheter tip has significant growth, then the catheter should be removed and a new catheter placed in a new site (B-II).,2.WHAT ARE THE UNIQUE ASPECTS OF TREATING PATIENTS WITH LONG-TERM CVCS OR IMPLANTED CATHETER-RELATED INFECTIONS THAT ARE NOT ASSOCIATED WITH HEMODIALYSIS CATHETERS? 非透析导管的长期CVC或者植入物患者，怀疑导管感染如何处理,44. Patients with tunnel infection or port abscess require removal of the catheter, incision and drainage if indicated, and 710 days of antibiotic therapy (A-II) in the absence of concomitant bacteremia or candidemia. 隧道或者导管口脓肿，拔除导管、切开引流，7-10天抗生素45. For patients with suspected exit site infection, obtain cultures of any drainage from the exit site and blood cultures(A-II). 可疑出口感染，出口引流物培养和血培养46. Uncomplicated exit site infections (i.e., those without systemic signs of infection, positive blood culture results, or purulence) should be managed with topical antimicrobial agents on the basis of the exit site culture results (e.g., mupirocin ointment for S. aureus infection and ketoconazole or lotrimin ointment for Candida infection) (B-III).不复杂的出口处感染（没有全身症状的感染，血培养阳性或化脓），需要给予出口处培养结果的局部抗生素治疗（金葡需要局部用莫匹罗星软膏，白念用酮康唑或克霉唑软膏）,WHAT ARE THE UNIQUE ASPECTS OF TREATING PATIENTS WITH LONG-TERM CVCS OR IMPLANTED CATHETER-RELATED INFECTIONS THAT ARE NOT ASSOCIATED WITH HEMODIALYSIS CATHETERS?非透析导管的长期CVC或者植入物患者，怀疑导管感染如何处理,47. If an uncomplicated exit site infection fails to resolve with topical therapy or if it is accompanied by purulent drainage, then systemic antibiotics should be administered on the basis of the antimicrobial susceptibility of the causative pathogen; the catheter should be removed if treatment with systemic antibiotics fails (B-II).不复杂的出口处感染，局部治疗效果不佳，或是伴随脓性引流，需要使用系统抗生素，给予致病菌的微生物敏感性，系统治疗失败，则需要拔除导管48. If other vascular sites are unavailable and/or the patient is at increased risk for bleeding diathesis in the setting of CRBSI not complicated by an exit site or tunnel infection, then exchange the infected catheter over a guidewire (B-III). In such situations, an antimicrobial-impregnated catheter with an antiinfective intralumin.其他部位血管不可置管，和/或出血风险高，CRBSI未合并出口货隧道感染，可在导丝引导下更换抗生素浸润的导管，并导管腔内使用抗生素封管。,3.What are the unique aspects of treating pediatricpatients with catheter-related infections?儿科患者导管相关感染的处理,49. Indications for catheter removal for children are similar to those for adults (see recommendations 3032), unless there are unusual extenuating circumstances (e.g., no alternative catheter insertion site). However, the benefits of catheter removal must be weighed against the difficulty of obtaining alternate venous access for an individual patient A-II 8950. Children treated without catheter removal should be closely monitored with clinical evaluation and additional blood cultures; the device should be removed if there is clinical deterioration or persistent or recurrent CRBSI B-III 8951. In general, empirical antibacterial therapy for children with CRBSI should be similar to that for adults (see recommendations 2123)A-II 8952. Antibiotic lock therapy should be used for catheter salvageB-II however, if antibiotic lock therapy cannot be used in this situation, systemic antibiotics should be administered through the colonized catheter,3.儿科患者导管相关感染的处理,(49)小儿拔除导管的适应证和成人相似(见指南30-32)，除非有特殊情况(如没有可以替代的插管部位)。尽管如此，对患者而言，必须在拔除导管的收益和获得可替代静脉通路的困难性之间进行权衡 (A-)。(50)没有拔管的患儿应当通过临床评估和额外的血培养进行密切监护。如果临床症状持续或者反复发作的CRBSI，那么应该拔除导管(B-)。(51)通常小儿CRBSI的经验性抗生素治疗可以参照成人进行(见指南21-23)(A-)。(52)抗生素封管治疗应当用于导管感染补救 (B-)。然而，如果无法实行抗生素封管治疗，全身性抗生素治疗应当通过留置导管给药(C-)。,4.What are the unique aspects of managing patients receiving hemodialysis through catheters for whom catheter-related infection is suspected or proven?可疑或者被证实的导管相关性感染在以导管为血管通路的血透患者处理上有何特别的方面?,53. Peripheral blood samples should be obtained for culture from vessels that are not intended for future use in creating a dialysis fistula (e.g., hand veins) A-III 26554. When a peripheral blood sample cannot be obtained, blood samples may be drawn during hemodialysisfrom bloodlines connected to the CVC B-II 26555. In patients with suspected CRBSI for whom blood cultures have been obtained and for whom antibiotic therapy has been i