经皮中心静脉置管感染预防指南专家讲座

导管相关感染诊疗定义局部感染定义：（1）局部自发或经触压后有脓性渗出，无需细菌学证据。（2）穿刺部位红肿、发烧、硬结（三者中任二者），及血清样物质自发或触压后渗出，穿刺部位细菌培养阳性。经皮中心静脉置管感染预防指南专家讲座第1页导管相关感染诊疗定义菌血症感染定义：（1）外周血培养结果阳性，且为一个微生物，导管片段（近端或远端）经定量或半定量方法分离出同一个微生物（种类及耐药谱），无其它感染源。（2）导管内回抽血定量培养出10倍于同时外周血培养菌株。（3）导管穿刺部位渗出脓液、血清、血浆样物质或导管皮下部分、皮下埋植部分培养与外周血培养出同一个细菌（种类及耐药谱）。经皮中心静脉置管感染预防指南专家讲座第2页导管相关感染诊疗定义可能感染定义包含：（1）两次或两次以上血培养（不论是外周血还是中心静脉回抽血）出同一个细菌（种类及耐药谱），且临床及试验室证实无其它感染源。（2）一次阳性血培养结果为或念球菌（不论是外周血还是中心静脉回抽血），且临床及试验室证实无其它感染源。（3）免疫抑制或粒细胞降低（粒细胞<500ul）病人，血培养阳性（凝固酶阴性葡萄球菌，杆菌属，棒状杆菌属，糠秕马拉色霉菌等），临床及试验室证实无其它细菌感染源，只有中心静脉留置导管，通常与导管相关性菌血症相关。经皮中心静脉置管感染预防指南专家讲座第3页CVC引发相关感染机制1.infectionoftheexitsite,followedbymigrationofthepathogenalongtheexternalcathetersurface.2.contaminationofthecatheterhub,leadingtointraluminalcathetercolonization.3.hematogenousseedingofthecatheter.

经皮中心静脉置管感染预防指南专家讲座第4页病原体若不幸感染,常见菌种包含:

Coagulase-negativestaphylococci(37%),Staphylococcusaureus(13%),Enterococcus(13%),Gram-negativerods(14%).值得注意是,抗药性强菌种包含staph.以及Enterococcus都榜上有名..所以假如不幸发生感染..多半就非得要用上vancomycin..可能不行还要用上linezolid..相当麻烦..另外一个值得注意是..fungi..fungi感染饰演部分角色(在NNIS数据中是8%)..在Candidia感染中,大约二分之一是non-albicanspecies造成...包含C.glabrata与C.krusei..这些fungi对fluconazole轻易产生抗药性.经皮中心静脉置管感染预防指南专家讲座第5页Guidelinesforpreventinginfectionsassociatedwiththeinsertionandmaintenanceofcentralvenouscatheters

中心静脉置管相关性感染预防指南JournalofHospitalInfection()47(Supplement):S5–S9经皮中心静脉置管感染预防指南专家讲座第6页Intervention1:Selectionofcathetertype导管类型选择Intervention2:Selectionofcatheterinsertionsite置管点选择Intervention3:Optimumaseptictechniqueduringcatheterinsertion置管过程中无菌技术最优化Intervention4:Cutaneousantisepsis皮肤消毒Intervention5:Catheterandcathetersitecare导管和置管点护理Intervention6:Replacementstrategies更换方法Intervention7:Antibioticprophylaxis预防性使用抗生素经皮中心静脉置管感染预防指南专家讲座第7页Selectionofcathetertype1Useasingle-lumencatheterunlessmultipleportsareessentialforthemanagementofthepatient.尽可能采取单腔管，除非患者需要多通道治疗，2Iftotalparenteralnutritionisbeingadministered,useonecentralvenouscatheterorlumenexclusivelyforthatpurpose.假如需要TPN，专用一根中心静脉导管或专用一个管腔3Useatunnelledcatheteroranimplantablevascularaccessdeviceforpatientsinwhomlong-term(30days)vascularaccessisanticipated.假如预计要长时间（30天）保留血管通路，采取管道式导管或植入式血管通路4Considertheuseofanantimicrobialimpregnatedcentralvenouscatheterforadultpatientswhorequireshort-term(10days)centralvenouscatheterisationandwhoareathighriskforCR-BSI.需短期（10天）保留CVC者，而且是导管相关血源性感染高危患者，使用外涂抗菌素CVC经皮中心静脉置管感染预防指南专家讲座第8页Selectionofcatheterinsertionsite5Inselectinganappropriateinsertionsite,assesstherisksforinfectionagainsttherisksofmechanicalcomplications.选择置管位点时，要权衡感染风险和机械并发症风险6Unlessmedicallycontraindicated,usethesubclaviansiteinpreferencetothejugularorfemoralsitesfornontunnelledcatheterplacement.做非管道性置管，如无禁忌，采取锁骨下置管好于颈静脉或股静脉置管7Considertheuseofperipherallyinsertedcathetersasanalternativetosubclavianorjugularveincatheterisation.外周静脉置管可作为锁骨下置管或颈静脉置管替换方法经皮中心静脉置管感染预防指南专家讲座第9页Optimumaseptictechniqueduringcatheterinsertion8Useoptimumaseptictechnique,includingasterilegown,gloves,andalargesteriledrape,fortheinsertionofcentralvenouscatheters.置管时采取最正确无菌技术，穿无菌衣，戴无菌手套，盖无菌单经皮中心静脉置管感染预防指南专家讲座第10页Cutaneousantisepsis9CleantheskinsitewithanalcoholicchlorhexidinegluconatesolutionpriortoCVCinsertion.Useanalcoholicpovidone-iodinesolutionforpatientswithahistoryofchlorhexidinesensitivity.Allowtheantiseptictodrybeforeinsertingthecatheter.置管前用含酒精葡萄糖酸洗必泰清洗穿刺点皮肤，如对碘剂过敏，使用含酒精聚维酮碘消毒，待消毒剂干燥后置管10Donotapplyorganicsolvents,e.g.,acetone,ether,totheskinbeforecatheterinsertion.不要使用有机溶剂，如丙酮、乙醚等。11Donotroutinelyapplyantimicrobialointmenttothecatheterplacementsitepriortoinsertion.置管前穿刺点不要使用抗生素软膏经皮中心静脉置管感染预防指南专家讲座第11页Catheterandcathetersitecare12Beforeaccessingthesystem,disinfecttheexternalsurfacesofthecatheterhubandconnectionportswithanaqueoussolutionofchlorhexidinegluconateorpovidone-iodine,unlesscontraindicatedbythemanufacturer’srecommendations.接触前，要用葡萄糖酸洗必泰水溶液或聚维酮碘水溶液消毒导管活栓或接头外表面，除非厂家禁止这么做13Useeitherasterilegauzeortransparentdressingtocoverthecathetersite.用无菌纱布或透明贴膜覆盖置管点14Ifagauzeandtapecathetersitedressingisused,itmustbereplacedwhenthedressingbecomesdamp,loosened,orsoiled,orwheninspectionoftheinsertionsiteisnecessary.假如是使用纱布和胶布覆盖，一旦浸湿、松脱或弄脏，或需要查看穿刺点时，要及时更换。15DonotapplyantimicrobialointmenttoCVCinsertionsitesaspartofroutinecathetersitecare.不要使用抗生素软膏处理穿刺点。16Routinelyflushindwellingcentralvenouscatheterswithananticoagulantunlessadvisedotherwisebythemanufacturer.常规使用抗凝剂冲洗置入CVC，除非厂家有其它提议经皮中心静脉置管感染预防指南专家讲座第12页Replacementstrategies17Donotroutinelyreplacenon-tunnelledCVCasamethodtopreventcatheter-relatedinfections.不要把常规更换非管道性CVC作为预防导管相关感染方法18Useguidewireassistedcatheterexchangetoreplaceamalfunctioningcatheter,ortoexchangeanexistingcatheterifthereisnoevidenceofinfectionatthecathetersiteorprovenCR-BSI.借助导丝更换导管。19IfCR-infectionissuspected,butthereisnoevidenceofinfectionatthecathetersite,removetheexistingcatheterandinsertanewcatheteroveraguidewire;iftestsrevealCR-infection,thenewlyinsertedcathetershouldberemovedand,ifstillrequired,anewcatheterinsertedatadifferentsite.假如怀疑存在导管相关感染，而置管点无显著感染迹象，去掉原来导管，在导丝引导下置入新管；假如检验显示存在导管相关感染，去掉新置入导管，如依然需要置管，另选穿刺点置入新管。经皮中心静脉置管感染预防指南专家讲座第13页Replacementstrategies20DonotuseguidewireassistedcatheterexchangeforpatientswithCR-infection.Ifcontinuedvascularaccessisrequired,removetheimplicatedcatheter,andreplaceitwithanothercatheteratadifferentinsertionsite.患者有导管相关感染时不采取借助导丝导管更换。假如必须继续保持血管通路，去掉受累导管，另取穿刺点置新管。21Replacealltubingwhenthevasculardeviceisreplaced.更换血管装置同时更换全部管路。22Replaceintravenoustubingandstopcocksnomorefrequentlythanat72-hourintervals,unlessclinicallyindicated.更换静脉内管道和活栓间隔时间不能短于72小时，除非临床需要。23Replaceintravenoustubingusedtoadministerblood,bloodproducts,orlipidemulsionsattheendoftheinfusionorwithin24hoursofinitiatingtheinfusion.若更换用于输血、血液制品、脂肪乳静脉内管路，要在输注末或开始输注后24小时内更换。经皮中心静脉置管感染预防指南专家讲座第14页Antibioticprophylaxis24Donotadministersystemicantimicrobialsroutinelybeforeinsertionorduringuseofacentralvenouscathetertopreventcathetercolonisationorbloodstreaminfection.不要为了预防导管细菌生长或血行感染而常规给予全身应用抗菌素，不论是在插管前或在使用CVC中。经皮中心静脉置管感染预防指南专家讲座第15页PreventingComplicationsofCentralVenous

CatheterizationNEnglJMed;348:1123-33.经皮中心静脉置管感染预防指南专家讲座第16页InterventionstoPreventinfectionsUseantimicrobial-impregnatedcatheters使用外涂抗菌素导管Insertcathetersatthesubclavianvenoussite取锁骨下穿刺点置入导管Usemaximalsterile-barrierprecautionsduringcatheterinsertion在导管置入术中尽最大肯能采取无菌办法Avoidtheuseofantibioticointments防止使用抗生素软膏Disinfectcatheterhubs消毒导管活栓Donotscheduleroutinecatheterchanges不要常规更换导管Removecatheterswhentheyarenolongerneeded假如不再需要，撤除导管经皮中心静脉置管感染预防指南专家讲座第17页Useantimicrobial-impregnatedcathetersTheuseofantimicrobial-impregnatedcathetersreducestheriskofcatheter-relatedbloodstreaminfectionsandreducescostswhentherateofcatheter-relatedbloodstreaminfection>2%使用涂有抗菌素导管降低导管相关血流感染，当导管相关血流感染>2%时降低花费。经皮中心静脉置管感染预防指南专家讲座第18页InsertcathetersatthesubclavianvenoussiteTheriskofcatheter-relatedinfectionislowerwithsubclaviancatheterizationthanwithinternaljugularorfemoralcatheterization锁骨下静脉置管导管相关感染风险小于颈内静脉或股静脉置管经皮中心静脉置管感染预防指南专家讲座第19页Usemaximalsterile-barrierprecautionsduringcatheterinsertionUseofamask,cap,sterilegown,sterilegloves,andlargesteriledrapereducestherateofinfectionsandreducescosts戴口罩、帽子、无菌手套，穿无菌衣，覆盖无菌大单等能降低感染发生率，降低花费。经皮中心静脉置管感染预防指南专家讲座第20页AvoidtheuseofantibioticointmentsTheapplicationofantibioticointmentsincreasestherateofcolonizationbyfungi,promotesthedevelopmentofantibiotic-resistantbacteria,andhasnotbeenshowntoaffecttheriskofcatheterrelatedbloodstreaminfections使用抗生素软膏增加真菌定殖率，增加耐药菌产生，并不能降低导管相关血流感染发生率经皮中心静脉置管感染预防指南专家讲座第21页DisinfectcatheterhubsCatheterhubsarecommonsitesofcathetercontaminatio导管活栓是导管污染常见部位经皮中心静脉置管感染预防指南专家讲座第22页DonotscheduleroutinecatheterchangesScheduled,routinereplacementofcentralvenouscathetersatanewsitedoesnotreducetheriskofcatheter-relatedbloodstreaminfection;scheduled,routineexchangeofcathetersoveraguidewireisassociatedwithatrendtowardincreasedcatheterrelatedinfections有计划、常规CVC更换到新位置并不能降低导管相关血流感染发生率；有计划、常规导丝引导下导管更换有可能增加导管相关感染。经皮中心静脉置管感染预防指南专家讲座第23页RemovecatheterswhentheyarenolongerneededTheprobabilityofcolonizationandcatheter-relatedbloodstreaminfectionincreasesovertime伴随时间推移，细菌定殖和导管相关血流感染可能性增大。经皮中心静脉置管感染预防指南专家讲座第24页TypesofCatheter-AssociatedInfectionsCathetercolonization导管细菌定殖Growthoforganismsfromacathetersegmentbyeithersemiquantitativeorquantitativeculture经过半定量或定量培养，使导管片段微生物生长Catheter-relatedbloodstreaminfection导管相关血流感染Isolationofthesameorganismfromabloodcultureandfromasemiquantitativeorquantitativecultureofacathetersegment,accompaniedbyclinicalsymptomsofbloodstreaminfectionwithoutanyotherapparentsourceofinfection血培养分理出细菌与导管片段半定量或定量培养得到细菌相同，并伴有血流感染临床症状，而没有其它显著感染源。Exit-siteinfection出口感染Erythema,tenderness,induration,orpurulencewithin2cmoftheexitsiteofthecatheter在导管出口2cm范围内出现红肿、触痛、硬结或化脓经皮中心静脉置管感染预防指南专家讲座第25页ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepsisisdefinedasasystemicresponsetoinfection,manifestedbytwoormoreofthefollowingconditions:temperatureabove38.5°Corbelow36.0°C;heartrateabove90beatsperminute;respiratoryrateabove20breathsperminuteorpartialpressureofarterialcarbondioxidebelow32mmHg;andwhite-cellcountgreaterthan12,000percubicmillimeterorlessthan4000percubicmillimeterorwith10percentimmature(band)forms.脓毒症是指感染全身反应，含有以下两条或两条以上表现：体温高于38.5度或低于36度；心率高于90次/分；呼吸频率高于20次/分或动脉二氧化碳分压低于32mmHg；白细胞计数超出1/mm3或低于4000/mm3或幼稚细胞到达10％。经皮中心静脉置管感染预防指南专家讲座第26页ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionSepticshockisdefinedassepsis-inducedhypotensionorarequirementforvasopressorsorinotropicagentstomaintainbloodpressuredespiteadequatefluidresuscitation,alongwiththepresenceofperfusionabnormalitiesthatmayinclude(butarenotlimitedto)lacticacidosis,oliguria,oracutealterationinmentalstatus.脓毒症性休克是指脓毒症诱发低血压或在充分液体复苏下仍需要血管升压药或血管收缩药维持血压，伴有灌注异常，包含（但不限于）乳酸酸中毒、少尿、急性精神状态改变经皮中心静脉置管感染预防指南专家讲座第27页ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionWhenbloodculturesareobtained,samplesfromperipheralsitesarepreferred.Cathetertipculturesshouldbeperformedbythesemiquantitativeorquantitativetechnique.假如做血培养，最好是取周围位点样本。导管尖培养应该采取定量或半定量方法。经皮中心静脉置管感染预防指南专家讲座第28页ManagementofSuspectedCatheter-

RelatedBloodstreamInfectionEmpiricalantibiotictherapyforsuspectedcatheter-relatedbloodstreaminfectionshouldincludevancomycin.Antibioticsthatareeffectiveagainstgram-negativeorganismsshouldbeadded,especiallyifthepatientisimmunocompromisedorhasneutropenia,isinfectedwithgram-negativeorganisms,orhasotherriskfa