导管相关性血行性感染CRBSI诊断治疗与预防

1、导管相关性血行性感染(CRBSI)诊疗、治疗与预防北京协和医院MICU江伟第1页CRBSI: 流行病学美国ICU每年发生16,000例CRBSI病死率18% (0 35%)每年死亡500 4,000例每例CRBSI医疗费用$28,690 - $56,000每年医疗费用$60,000,000 460,000,000CDC. MMWR ; Heiselman JAMA 1994; Dimick Arch Surg 第2页CRBSI: 中国 vs. 全球数据INICC中国上海 -总体均值(95%CI)INICC -总体均值(95%CI)US NHSN -总体均值(95%CI)内科ICUCLABSI4

2、.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)儿科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, China: International Nosocomial Infection Contro

3、l Consortium (INICC) findings. Int J Infect Dis ; 15: e774-e780第3页中国CRBSI数据: 致病菌(n = 845)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 ; 15:

4、e774-e780第4页CRBSI: Changing EpidemiologyMarcos M, Soriano A, Inurrieta A, et al. Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens. J Antimicrob Chemother ; 66: 2119-2125第5页CRBSI: 发病机制第6页CRBSI: 微生物学诊疗方法诊疗标准敏感性特异性缺点无需拔除CV

5、C方法同时定量血培养经CVC留取血培养菌落计数相当于外周血培养菌落计数5倍或更多93%97-100%花费人力，价格昂贵血培养阳性时间差经CVC留取血培养报警时间较外周血培养报警时间提前 2小时89-90%72-87%若经CVC输注抗生素，结果难以解释经CVC留取定量血培养经CVC留取定量血培养 100 CFU/ml81-86%85-96%无法判别CRBSI和菌血症吖啶橙白细胞离心涂片发觉任何细菌87%94%未得到广泛应用腔内毛刷定量培养 100 CFU/ml95%84%可能造成菌血症，心律失常或栓塞需要拔除CVC方法CVC尖端半定量培养，滚动平板导管尖端 15 CFU/ml45-84%85%无

6、法培养腔内细菌CVC定量培养：离心，混旋，超声振荡导管尖端 103 CFU/ml82-83%89-97%临界值尚不明确CVC革兰染色和吖啶橙染色镜检直接看到微生物84-100%97-100%花费人力，缺乏实用性Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis ; 7: 645-657第7页CRBSI: 腔外感染临床表现全身表现发烧白细胞增多插管局部表现炎症表现不敏感（多数导

7、管感染并无插管局部炎症表现）不特异（出现对应表现亦无需拔除导管）提醒导管感染症状和体征插管部位脓性分泌物插管部位蜂窝织炎超出4 mm第8页CRBSI: 腔外感染试验室诊疗滚动平板技术（Maki法）*将导管尖端放置在含有5%羊血Columbia琼脂培养基平皿上将导管尖端在平皿表面前后滚动最少3 4次 15 CFU/plate外周血培养阳性且与导管尖端培养一致Guembe M, Martin-Rabadan P, Echenagusia A, et al. How should long-term tunneled central venous catheters be managed in mi

8、crobiology laboratories in order to provide an accurate diagnosis of colonization? J Clin Microbiol ; 50: 1003-1007*even for long-term tunneled central venous catheters, with detection of 94.9% of catheter colonization第9页CRBSI: 插管部位消毒10%碘仿(n = 227)70%乙醇(n = 227)2%氯己啶(n = 214)中心静脉插管(n = 77)(n = 32)(n

9、 = 67)局部感染(%)15 (19.5)5 (15.6)4 (5.9)菌血症(%)5 (6.5)2 (6.3)1 (1.5)动脉导管(n = 150)(n = 195)(n = 147)局部感染(%)6 (4.0)6 (3.1)1 (0.7)菌血症(%)1 (0.7)1 (0.5)0总计(n = 227)(n = 227)(n = 214)局部感染(%)21 (9.3)11 (7.4)5 (2.3)菌血症(%)6 (2.6)3 (2.3)1 (0.5)Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povido

10、ne-iodine, alcohol, and chlorexidine for prevention of infection associated with central venous and arterial catheters. Lancet 1991; 338: 339-343第10页CRBSI: 敷料选择Safdar N, OHoro JC, Ghufran A, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-an

11、alysis. Crit Care Med 含氯己啶敷料可能含有一定优势第11页CRBSI: 腔内感染临床表现全身表现发烧白细胞增多插管局部表现无其它表现血培养革兰阴性杆菌?第12页CRBSI: 微生物学诊疗方法诊疗标准敏感性特异性缺点无需拔除CVC方法同时定量血培养经CVC留取血培养菌落计数相当于外周血培养菌落计数5倍或更多93%97-100%花费人力，价格昂贵血培养阳性时间差经CVC留取血培养报警时间较外周血培养报警时间提前 2小时89-90%72-87%若经CVC输注抗生素，结果难以解释经CVC留取定量血培养经CVC留取定量血培养 100 CFU/ml81-86%85-96%无法判别CR

12、BSI和菌血症吖啶橙白细胞离心涂片发觉任何细菌87%94%未得到广泛应用腔内毛刷定量培养 100 CFU/ml95%84%可能造成菌血症，心律失常或栓塞需要拔除CVC方法CVC尖端半定量培养，滚动平板导管尖端 15 CFU/ml45-84%85%无法培养腔内细菌CVC定量培养：离心，混旋，超声振荡导管尖端 103 CFU/ml82-83%89-97%临界值尚不明确CVC革兰染色和吖啶橙染色镜检直接看到微生物84-100%97-100%花费人力，缺乏实用性Raad I, Hanna H, Maki D. Intravascular catheter-related infections: adv

13、ances in diagnosis, prevention, and management. Lancet Infect Dis ; 7: 645-657第13页CRBSIDTP: 应该从几个腔留取血标本?对于伴随CRBSI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%概率检测到定植Dobbins BM, Catton JA, Kite P, et al. Each lumen is a potential source of central venous catheter-

14、related bloodstream infection. Crit Care Med ; 31: 1688-1690第14页CRBSIDTP: 需要留取多少外周血标本?外周血培养数留取两个血培养CRBSI(n = 49)留取三个血培养CRBSI(n = 11)累计(n = 60)一个91.9%(83.7 98.0%)90.9%(72.7 100.0%)91.7%两个100%96.9%(81.8 100.0%)99.5%Guembe M, Rodriguez-Creixems M, Sanchez-Carrillo C, et al. Differential time to positiv

15、ity (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 Oct 21 Epub ahead of print当依据DTP方法确诊CLABSI时，仅留取一个（套）外周血培养并不会显著遗漏CLABSI病例第15页CRBSI诊疗Raad I, Hanna H, Maki D. Intravascular catheter-

16、related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis ; 7: 645-657第16页CRBSI初始治疗OGrady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med ; 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（无低血压或器官功效衰竭）拔

17、除导管最少留取2套血培养，其中最少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原因*无危险原因拔除导管最少留取2套血培养，其中最少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最少留取2套血培养，其中最少1套来自外周静脉开始经验性抗生素治疗*比如免疫功效抑制，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第17页CRBSI治疗: 拔除导管实际感染率Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterizatio

18、n in critically ill patients: a randomized controlled trial. JAMA ; 286: 700-707. Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study. Crit Care Med ; 31: 1318-1324. Ranucci M, Isgro G, G

19、iomarelli PP, et al. Impact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection. Crit Care Med ; 31: 52-59. Dobbins BM, Catton JA, Kite P, et al. Each lumen is a potential source of central venous catheter-related bloodstream infection. Crit Care Me

20、d ; 31: 1688-1690. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. Catheter Study Group. N Engl J Med 1999; 340: 1-8.第18页CRBSI治疗: 拔管 vs. 不拔管Rijnders BJ, Peetermans WE, Verwaest C, et al. Watchful waiting versus immediate catheter remova

21、l in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med ; 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连续拔除导管血培养阳性，或血流动力学不稳定第19页CRBSI治疗: 拔管 vs. 不拔管标准治疗亲密观察p更换中心静脉导管38/3816/42 0.2总住院日4234 0.2ICU病死率10/328/32 0.2Rijnders BJ, Peet

22、ermans 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 ; 30: 1073-1080第20页CRBSI治疗: 拔管 vs. 不拔管标准治疗(n = 37)保守治疗(n = 16)p年纪66.8 20.159.3 16.60.2男性17 (45%)11 (68%)0.127胃肠外营养13 (35%

23、)8 (50%)0.31菌血症时APACHE II15.4 4.615.4 4.40.99菌血症时SOFA7.0 4.47.1 3.40.94颈内静脉33 (89%)16 (100%)双腔导管29 (78%)9 (56%)导管留置天数17.09.214.86.80.35菌血症前住院日25 (3-245)24.5 (9-143)0.69最初二十四小时充分治疗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. Cathe

24、ter Related Bloodstream Infection (CR-BSI) in ICU Patients: Making the Decision to Remove or Not to Remove the Central Venous Catheter. PLoS ONE ; 7: e32687第21页CRBSI初始治疗OGrady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med ;

25、 78: 10-17第22页CRBSI预防医护协作管理比技术更主要第23页预防CRBSI质量改进计划质量改进干预方法定义与举例教育(n = 33)经过讲座传递相关CLABSI理论知识（针对CLABSI流行病学或预防方法进行每个月定时或单次讲座；带有课前与课后考试教学模块）培训(n = 4)与CVC护理及留置相关实际技能培训（经过模拟人进行无菌操作留置CVC个人培训）反馈(n = 20)向ICU医务人员汇报CLABSI发生率或感染预防方法依从性（每个月在员工会议上汇报感染率；改进预防方法依从性或CLABSI发生率招贴画）临床提醒(n = 15)相关适当临床操作提醒以改进预防方法知晓率或实施（相关手卫生或CLABSI发生率招贴画；每日提醒每位患者CVC是否能够停用；CVC上贴纸或佩戴徽章提醒正确操作主要性；信息一览表，流程图或每日目标清单）集束化方法(n = 11)包含最少2项IHI留置或保留CVC期间预防方法（包含2-5项IHI提议集束化方法；不包含意在提升依从性质量改进方法集束化方法）清单(n = 18)相关集束化预防方法清单以提升循证感染预防方法依从性（CVC置管过程中包含2-5项IHI提议清单以提升集束化方法依从性）授权终止操作(n = 10)发觉未能正确实施预防方法时，授权护士终止并重新开始CVC置管操作监测依从性