crbsi導(dǎo)管感染概述詳解

1、Device 設(shè)備(catheter導(dǎo)管 ) Related Infection 相關(guān)感染,Agenda議程,What are the Devices.裝置Epidemiology.流行病學(xué)Pathogenesis.發(fā)病機(jī)理Diagnosis.診斷Treatment.處置Prevention.預(yù)防,,Downloaded from: Infectious Diseases (on 16 November 2007 12:04

2、 PM),© 2007 Elsevier,艾斯維爾--傳染病,,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,,Dow

3、nloaded from: Infectious Diseases (on 16 November 2007 12:04 PM),© 2007 Elsevier,Device (catheter ) Related Infection裝置(導(dǎo)管)相關(guān)感染,,,,美國醫(yī)院內(nèi)部相關(guān)設(shè)施感染數(shù)據(jù)(每1000套-天),導(dǎo)尿管引發(fā)感染,呼吸器引發(fā)肺炎,中心管引發(fā)血液感染,感染形式,ICU類型,PICU兒科,MICU內(nèi)科,SICU外科重

4、癥監(jiān)護(hù),,發(fā)病率和死亡率周報,重癥室類型,中心靜脈管相關(guān)的血液感染,冠動脈,心臟檢查,內(nèi)/外科主要技術(shù),神經(jīng)外科,高風(fēng)險嬰幼兒,小兒科,外科,創(chuàng)傷科,燒傷科,呼吸科,Nonvalvular Cardiovascular Device–Related Infections,Circulation. 2003;108:2015-2031.,AHA Scientific Statement:,非瓣膜心血管裝置相關(guān)感染,美國心臟協(xié)會,,Down

5、loaded from: Infectious Diseases (on 16 November 2007 12:04 PM),© 2007 Elsevier,Device( catheter related )infections,導(dǎo)管引發(fā)感染,IF YOU REMEMBER ONE THING是否記得一件事,PLEASE WASH YOUR HANDS請洗手!,Alcohol Based Hand Sanitizers

6、醇基手消毒,Recommended by CDC based on strong experimental,clinical, epidemiologic and microbiologic data 美國疾控中心強(qiáng)力以實(shí)驗(yàn)、臨床、流行病學(xué)和微生物數(shù)據(jù)為基礎(chǔ)推薦Antimicrobial superiority抗菌劑優(yōu)勢Greater microbicidal effect 強(qiáng)力滅菌Prolonged residual eff

7、ect 效力持久Ease of use and application使用簡單,Agenda議程,What are the Devices.Epidemiology.流行病學(xué)Pathogenesis.Diagnosis.Treatment.Prevention.,Epidemiology流行病學(xué),In the United States, the use of central venous catheters is asso

8、ciated 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. 在美國,中心靜脈管

9、的使用導(dǎo)致大約80,000CRBI(導(dǎo)管相關(guān)血流感染)(或者250,000菌血癥和真菌血癥),這個結(jié)果導(dǎo)致在ICU患者中28000人死亡.這導(dǎo)致護(hù)理中心每年的費(fèi)用超過20億美元.,Types of catheter導(dǎo)管類型,Peripheral IV靜脈輔助設(shè)備Multiple Lumen central lines多腔主線PICC穿刺中心靜脈導(dǎo)管(外周導(dǎo)管)Chemotherapy port化療端口Quinton cathe

10、ter昆頓透析導(dǎo)管Swan Ganze catheter斯旺甘茲式導(dǎo)管Others其他,Agenda,What are the Devices.Epidemiology.Pathogenesis.發(fā)病機(jī)理Diagnosis.Treatment.Prevention.,皮膚微生物感染,The major cause of infection during the first weeks of indwelling time

11、is from skin microorganisms.主要原因是皮膚留置微生物導(dǎo)致的最初幾周的感染Rannem, et. al., 1990Maki, et. al., 1991Maki (review), 1994 Widmer (review), 1997,MECHANISM Of INFECTION感染機(jī)理,Operator操作員Skin flora 皮膚菌叢Contamination of catheter h

12、ub and Lumen.導(dǎo)管接口和內(nèi)腔污染Contamination of Infusate.輸液污染,醫(yī)院感染的內(nèi)源和外源,菌叢,環(huán)境,靜脈輸液裝置導(dǎo)致污染,病人飛沫,地板或水污染,交叉感染,間接接觸,其他病人,直接接觸,工作人員,Risk factors風(fēng)險因子,Loss of skin integrity. 皮膚完整性缺失Severity of underlying illness. 潛在疾病嚴(yán)重性Thrombogenic

13、ity. 凝血活性Number of catheter lumens.導(dǎo)管腔數(shù)量Availability of IV team Arch Intern Med. 1998;158:473. 靜脈注射團(tuán)隊(duì)的可能性 Location of catheter 導(dǎo)管定位Complications of femoral and subclavian venous catheterization in critically i

14、ll patients: A randomized controlled trial. JAMA. 2001;286:700 Duration of placement (more or less than 72 hrs)(大于或低于72小時)處置時間Emergent placement > elective緊急處置>選擇Nursing staffing variables (nurse-to-patient rat

15、io)護(hù)理人員變動(護(hù)士-患者比例),Infusate related Infections輸液相關(guān)感染,Primary (i.e. no source site identified) nosocomial bacteremia caused by psychrophilic (cold-growing) organisms, such as non-aeruginosa pseudomonads, Achromobacter, Fl

16、avobacterium, Enterobacter, Serratia, Salmonella or Yersinia spp., 最重要的是(也就是無法確認(rèn)來源)由嗜冷菌(溫度降低)導(dǎo)致的菌血癥.比如假單胞菌,無色桿菌,黃桿菌,腸桿菌,沙雷氏菌,沙門氏菌或耶爾森菌等.,Agenda,What are the Devices.Epidemiology.Pathogenesis.Diagnosis.診斷Treatment.P

17、revention.,When to suspect可疑情況,Local cellulites.局部發(fā)炎Bactremia without source.無源菌血癥Clinically septic without source.臨床無源敗血Non functioning catheter.無效導(dǎo)管Positive tip culture.細(xì)菌培養(yǎng)陽性反應(yīng)Pus at insertion site. 插入點(diǎn)有膿Shiver

18、ing during the use of catheter (Quinton昆頓).使用導(dǎo)管期間顫抖,Definitions定義,Catheter Colonization導(dǎo)管細(xì)菌定植: Considered significant growth if > 15 cfu of organism is isolated from catheter segment , or more > 1000 cfu/ml is iso

19、lated from the lumen or hub, in the absence of clinical infection. 如果被分離導(dǎo)管段微生物生長> 15 cfu ,或者來自導(dǎo)管段內(nèi)腔或端部的微生物生長1000 cfu/ml ,而無臨床癥狀,具有重要意義.Catheter Related Blood Stream Infection CR-BSI.導(dǎo)管相關(guān)的血流感染Phlebitis靜脈炎: indurati

20、on or erythema, warmth, and pain or tenderness around catheter exit site.硬塊或紅斑,發(fā)熱和疼痛或?qū)Ч苤車鷫和?Definitions定義,Tunnel infection隧道感染: tenderness, erythema, and/or induration >2 cm from the catheter exit site, along the su

21、bcutaneous tract of a tunneled catheter (e.g., Hickman or Broviac catheter). 沿著導(dǎo)管通道有壓痛,紅斑和導(dǎo)管出口段大于2CM硬塊,2. Exit-site infection出口感染 : erythema, induration, and/or tenderness within 2 cm of the catheter exit sit

22、e; 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 紅斑,硬塊,或?qū)Ч艹隹?CM內(nèi)壓疼,或者有其它感染癥狀關(guān)聯(lián),比如出口處發(fā)燒,膿,是否

23、伴隨血流感染?,,,靜脈輸液港相關(guān)感染,纖維碎片,隔膜,Groeger, J. S. et. al. Ann Intern Med 1993;119:1168-1174,Microbiologic Isolates: First Device-related Bacteremia or Fungemia,分離微生物:初次使用設(shè)備相關(guān)的菌血癥和真菌血癥,微生物,How To Diagnose?如何診斷?,A positive result

24、 of semiquantitative Culture 半定量培養(yǎng)陽性結(jié)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 cathet

25、er segment and a peripheral blood sampleSimultaneous quantitative cultures of blood samples with a ratio of 5 : 1 (CVC vs. peripheral)同步血液定量培養(yǎng),5:1(導(dǎo)管血和外周血菌落比) Differential time to positivity 陽性時間差:positive

26、result of culture from a CVC is obtained at least 2 hr earlier than is a positive result of culture from peripheral blood) 導(dǎo)管血比外周血陽性出現(xiàn)時間至少早2H,Remember………….記得,If You put a central line in a patient with documented Ba

27、cteremia, 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

28、is the source.如果置入導(dǎo)管的病人有菌血癥記錄,那么第二天某人就要做中心管和外周管的血液培養(yǎng),雙方的血液培養(yǎng)為陽性,也不意味導(dǎo)管時細(xì)菌源.,Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Issam Raad, Dennis Maki血管內(nèi)導(dǎo)管相關(guān)感染在診斷\預(yù)防\管理的進(jìn)展,,,穿刺

29、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留置導(dǎo)管的導(dǎo)管血流感染診斷研究,半定量表面培養(yǎng),差量血液培養(yǎng),陽性差時,措施,敏感性,特性,精確,A

30、 Randomized and Prospective Study of 3 Procedures for the Diagnosis of Catheter-Related Bloodstream Infection without Catheter Withdrawal CID march 2007,Conclusions結(jié)論.     CR-BSI can be assessed

31、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 w

32、ide 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

33、 technique. CR-BSI可能被確定,在病人沒有撤出導(dǎo)管的情況下,并且他沒有嗜中性白血球減少和血液疾病,他在醫(yī)院監(jiān)護(hù)室短時間插入導(dǎo)管.由于性能好,成本低,可用性強(qiáng),我們推薦使用結(jié)合半定量技術(shù)表面培養(yǎng)和外周靜脈血管排查,然后采用差別定量血培養(yǎng)作為驗(yàn)證技術(shù).確定CR-BSI,Agenda,What are the Devices.Epidemiology.Pathogenesis.Diagnosis.Treatment

34、.處置Prevention.,Treating the garbage!!!!!!!!!廢物處理,A central line is removed and it is growing less than 15 CFU.中心管被移除,且微生物成長少于15CFUPatient is not septic and blood Culture is negative.病人無敗血癥且血液培養(yǎng)為陰性>>> No in

35、dication to treat the infected or colonized central line, which is in the garbage.無跡象表明要對垃圾桶里的中心管或細(xì)菌處理,Coagulase Negative Staphylococci凝固酶陰性葡萄球菌,CVC can be retained, if necessary, in patients with uncomplicated, cathe

36、ter-related, bloodstream infection.如有必要,中心靜脈管能夠保留,且病人無并發(fā)癥和關(guān)聯(lián)導(dǎo)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,病人應(yīng)該采用7天全身抗生素處置Treatment failure is a clear i

37、ndication for removal of the catheter .處置失敗的清晰跡象是移除導(dǎo)管,Staphylococcus Aureus 葡萄球菌,REMOVE the central line . 移除中心線Systemic antibiotics for minimal 14 days. 最少14天的全身抗生素治療Failure to clear bactremia within 72 hours

38、 Or patient with high risk for endovascualr infection or having prosthesis may be indicative for longer 3-6 weeks of treatment. 72小時內(nèi)清理大腸桿菌失敗,或者高風(fēng)險病人血管內(nèi)感染或者假體處置超過3—6周TTE or TEE are strongly advised.大力推薦胸超聲心動圖或食管超聲心動圖

39、Blood Culture should be repeated during therapy and1-2 weeks after completion of therapy, looking for relapses.治療期間重復(fù)做血液培養(yǎng),并且在治療結(jié)束后的1—2周也要進(jìn)行,索取報告單.,Staphylococcus Aureus Relapse葡萄球菌復(fù)發(fā),WARNING警告,Gram Negative Organisms

40、革蘭氏陰性菌,IF gram negative organism were the cause of CR-BSI, then central line should be removed, unless other sources can be found.如果革蘭氏陰性菌是CR-BSI的原因,那么中心管應(yīng)該被移除,除非找到其他感染源.Antimicrobial should be given for 7-10 days. 抗生

41、素治療7—10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.移除中心線,持續(xù)14天抗菌治療,最后一天做陰性培養(yǎng)It is advisable to repeat the culture at the end of therapy,

42、to document clearance of the Fungemia. 在治療后期重復(fù)進(jìn)行培養(yǎng)是必要的,排除真菌血癥Some authorities advise funduscopical examination. 一些權(quán)威人士建議眼底鏡檢查,Septic Thrombosis敗血血栓,Remove the Central line移除中心線Systemic antibiotics for 4-6 weeks or m

43、ore4—6周或更多時間的全身抗生素治療Remove the infected vein if patient clinically not improving如果病人臨床癥狀沒有改變,移除被感染血管Systemic anticoagulation is also highly recommended.強(qiáng)力推薦全身抗凝血治療,,Downloaded from: Infectious Diseases (on 16 Novemb

44、er 2007 12:26 PM),© 2007 Elsevier,,Downloaded from: Infectious Diseases (on 16 November 2007 12:26 PM),© 2007 Elsevier,Treatment Of local Infections局部感染處理,Antibiotics for 7 days or less + Removal of central li

45、ne, as far as patient does NOT have bactremia .移除中心管至少7天抗生素治療,直至病人沒有菌血癥Do NOT change over Guide wire if patient has local infection.如果病人局部感染,不要改變線規(guī)Antimicrobial Therapy WITHOUT catheter removal is also an option , pr

46、ovided the patient does not have systemic signs and symptoms of infection. it is IMPERATIVE that patient should be closely monitored.在病人沒有全身感染的癥狀和體征的情況下,導(dǎo)管移除后也要進(jìn)行抗菌治療.重要的是病人要被全程監(jiān)控.Tunnel or Pocket infection >>>

47、; catheter MUST be removed. 通道或者囊狀感染>>導(dǎo)管必須被移除,,Do NOT think of treating local infection with local antibiotics ointment不要采用局部抗生素藥膏來處理局部感染,CVC中心靜脈管或ID直入裝置相關(guān)的菌血癥,復(fù)雜,不復(fù)雜,Agenda,What are the Devices.Epidemiology.Pa

48、thogenesis.Diagnosis.Treatment.Prevention.預(yù)防,If you remember one thing : WASH YOUR HANDS是否記得洗手?,,Alcohol based hand hygiene solutions乙醇基手部衛(wèi)生溶液,Quick: 5- 15 seconds,Easy to use,Very effective antisepsis due to bacteri

49、cidal properties of alcohol,高效,快速,簡便,Hand washing : 洗手Historical Perspectives回顧歷史,1846,IgnazSemmelweis postulated that the puerperal fever was caused by "cadaverous particles" transmitted from the autopsy suit

50、e to the obstetrics 1846年,賽麥爾維斯提出孕婦產(chǎn)后發(fā)燒是醫(yī)生們離開解剖室進(jìn)入產(chǎn)科病房把“尸體顆粒(cadaverous particles)”帶給了產(chǎn)婦導(dǎo)致的.1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient examination in

51、 the clinic. 1847年他要求學(xué)生和醫(yī)生在診所里對每個病人檢查時用含氯消毒劑清潔手部,Center For Disease control (CDC) guidelines\CDC疾病控制中心規(guī)范,,預(yù)防導(dǎo)管相關(guān)感染規(guī)范,CDC RECCOMENDATIONCDC推薦,,預(yù)防血管內(nèi)裝置相關(guān)血流感染推薦規(guī)程,一般方法,體外診斷試劑,監(jiān)控,英國BSI的ivdr體外診斷試劑法規(guī)的ICU,CVC相關(guān)標(biāo)準(zhǔn),CDC RECCOMEN

52、DATIONCDC推薦,,無菌技術(shù),插入,IVD插入和維護(hù)前手部衛(wèi)生,非中心IVD插入和維護(hù)期間衣物清潔和手套消毒,CVC期間使用最大面積遮蔽預(yù)防措施,皮膚殺菌,無菌紗布或聚氨酯半透膜包裹導(dǎo)管插入端,在插入或移植前不使用抗生素殺菌,Cutaneous Antisepsis and Topical Anti-Infectives 皮膚消毒和抵御局部感染,Maki and Band prospectively studied three

53、regimens of catheter care:導(dǎo)管事故處理方式 (1) application of polymyxin-neomycin-bacitracin ointment at insertion and every 48 hours,每48小時用新霉素軟膏襯墊 (2) application of iodophor ointment at insertion and every 48 hours, or每48小

54、時用含碘消毒劑襯墊 (3) no ointment.無軟膏 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% pe

55、rcent, 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 sign

56、ificantly reduces the incidence of bacteremia in patients with central venous catheters compared to povidone-iodine for insertion-site skin disinfection.一元分析確定洗必泰相對于碘液襯墊皮膚消毒顯著降低了中心靜脈管病人的菌血癥Chaiyakunapruk et al. Chlorhe

57、xidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med. 2002;136:792.,Chlorhexidine Skin Antisepsis洗必泰皮膚消毒,Prepare skin with antiseptic/detergent chlorhexidine

58、 2% in 70% isopropyl alcohol. 70%異丙醇里加2%洗必泰用于皮膚抗菌Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad.捏住安瓶的兩翼 握住填充器,直到溶液浸透爪墊Press sponge against skin,

59、apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. 逆向擠壓海綿,使用洗必泰溶液由后向前摩擦,至少30秒,不要抹去液體.Allow antiseptic solution time to dry completely before puncturing the

60、 site (~ 2 minutes).確認(rèn)穿刺位置前抗菌溶液完全干燥時間(約2分鐘),The inanimate environment is a reservoir of pathogens無生命環(huán)境是致病菌儲藏庫,~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination afte

61、r Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.,X represents a positive Enterococcus culture,The pathogens are ubiquitous,X代表陽性球菌培養(yǎng),病原體無處不在,污染表面增加了交叉感染,Compliance with hand washing手部清洗

62、對比,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乙醇手部衛(wèi)生溶液,Quick: 5- 15 seconds,Easy to use,Ver

63、y effective antisepsis due to bactericidal properties of alcohol,An intervention to decrease catheter-related bloodstream infections in the ICU.ICU中降低導(dǎo)管相關(guān)性血流感染的措施 N Engl J Med Pronovost P, et al: 355(26):2725-2732, 200

64、6,(1) hand washing, 洗手(2) use of full-barrier precautions during placement of catheters, 布置導(dǎo)管時完全屏蔽預(yù)防(3) cleansing of the skin with chlorhexidine, 皮膚用氯己定清洗 (4) use of sites other than the femoral vein when possible, 盡

65、可能不使用大腿靜脈 (5) removal of catheters that were no longer needed. The analysis included almost 2000 ICU-months and >375,750 catheter-days of data. 不需要的時候移除導(dǎo)管,An intervention to decrease catheter-related bloodstream inf

66、ections in the ICU. N Engl J Med Pronovost P, et al: 355(26):2725-2732, 2006,Catheter infection rate reduced from 7.7 to 1.4 over 16 months( p< 0.002)大于16個月的時間(P<0.002)導(dǎo)管感染率從7.7降低到1.4,375757 catheter days included

67、.導(dǎo)管時間包括,CDC RECCOMENDATION推薦,,CDC RECCOMENDATIONCDC推薦,The Central Line Bundle*中心線束,…is a group of interventions related to patients with intravascular central catheters that, when implemented together, result in better

68、 outcomes than when implemented individually. 與病人內(nèi)腔中心管相關(guān)的一組干預(yù)方法,同時實(shí)施的時候,比單獨(dú)實(shí)施時候有更好的效果. *Bundle束: Grouping of best practices一組最好的方法,Central Line Bundle Elements中央線束要素,Hand hygiene手衛(wèi)生Maximal barrier precautions最大

69、的屏障預(yù)防Chlorhex idine skin antisepsis碘酒皮膚消毒Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters in adults合適的導(dǎo)管位置選擇,成人導(dǎo)液推薦鎖骨下靜脈Daily review of line necessity with prompt