導(dǎo)管相關(guān)血流感染PPT參考課件

1、導(dǎo)管相關(guān)性血行性感染(CRBSI)診斷、治療與預(yù)防,北京協(xié)和醫(yī)院MICU 江偉,CRBSI: 流行病學(xué),美國ICU每年發(fā)生16,000例CRBSI 病死率18% (0 35%) 每年死亡500 4,000例 每例CRBSI醫(yī)療費(fèi)用$28,690 - $56,000 每年醫(yī)療費(fèi)用$60,000,000 460,000,000,CDC. MMWR 2002; Heiselman JAMA 1994; Dimick Arch Surg 2001,2,9/3/2020,CRBSI: 中國 vs. 全球數(shù)據(jù),Tao L, Hu B, Rosenthal VD, et al. Device-associa

2、ted infection rates in 398 intensive care units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis 2011; 15: e774-e780,3,9/3/2020,中國CRBSI數(shù)據(jù): 致病菌(n = 845),Tao L, Hu B, Rosenthal VD, et al. Device-associated infection rates in 398 intensive car

3、e units in Shanghai, China: International Nosocomial Infection Control Consortium (INICC) findings. Int J Infect Dis 2011; 15: e774-e780,4,9/3/2020,CRBSI: Changing Epidemiology,Marcos M, Soriano A, Inurrieta A, et al. Changing epidemiology of central venous catheter-related bloodstream infections: i

4、ncreasing prevalence of Gram-negative pathogens. J Antimicrob Chemother 2011; 66: 2119-2125,5,9/3/2020,CRBSI: 發(fā)病機(jī)制,6,9/3/2020,CRBSI: 微生物學(xué)診斷方法,Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, and management. Lancet Infect Dis 2007; 7: 645-657,7,9/

5、3/2020,CRBSI: 腔外感染的臨床表現(xiàn),全身表現(xiàn) 發(fā)熱 白細(xì)胞增多 插管局部表現(xiàn) 炎癥表現(xiàn) 不敏感（多數(shù)導(dǎo)管感染并無插管局部炎癥表現(xiàn)） 不特異（出現(xiàn)相應(yīng)表現(xiàn)亦無需拔除導(dǎo)管） 提示導(dǎo)管感染的癥狀和體征 插管部位膿性分泌物 插管部位蜂窩織炎超過4 mm,8,9/3/2020,CRBSI: 腔外感染的實(shí)驗(yàn)室診斷,滾動(dòng)平板技術(shù)（Maki法）* 將導(dǎo)管尖端放置在含有5%羊血的Columbia瓊脂培養(yǎng)基的平皿上 將導(dǎo)管尖端在平皿表面前后滾動(dòng)至少3 4次 15 CFU/plate 外周血培養(yǎng)陽性且與導(dǎo)管尖端培養(yǎng)一致,Guembe M, Martin-Rabadan P, Echenagusia A,

6、 et al. How should long-term tunneled central venous catheters be managed in microbiology laboratories in order to provide an accurate diagnosis of colonization? J Clin Microbiol 2012; 50: 1003-1007,*even for long-term tunneled central venous catheters, with detection of 94.9% of catheter colonizati

7、on,9,9/3/2020,CRBSI: 插管部位消毒,Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorexidine for prevention of infection associated with central venous and arterial catheters. Lancet 1991; 338: 339-343,10,9/3/2020,CRBSI: 敷料選擇,Safdar N, OHoro JC, Ghufran A, e

8、t al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med 2014,含氯己啶敷料可能具有一定優(yōu)勢(shì),11,9/3/2020,CRBSI: 腔內(nèi)感染的臨床表現(xiàn),全身表現(xiàn) 發(fā)熱 白細(xì)胞增多 插管局部表現(xiàn) 無 其他表現(xiàn) 血培養(yǎng)革蘭陰性桿菌?,12,9/3/2020,CRBSI: 微生物學(xué)診斷方法,Raad I, Hanna H, Maki D. Intravascular catheter-relate

9、d infections: advances in diagnosis, prevention, and management. Lancet Infect Dis 2007; 7: 645-657,13,9/3/2020,CRBSI的DTP: 應(yīng)當(dāng)從幾個(gè)腔留取血標(biāo)本?,對(duì)于伴隨CRBSI的中心靜脈導(dǎo)管，約有40%僅有一個(gè)導(dǎo)管腔有細(xì)菌顯著定植 隨機(jī)選擇一個(gè)導(dǎo)管腔留取血標(biāo)本進(jìn)行培養(yǎng)，得到陰性結(jié)果的概率為66% 總體上看，隨機(jī)選擇從一個(gè)導(dǎo)管腔留取血標(biāo)本培養(yǎng) 60%的概率檢測(cè)到定植,Dobbins BM, Catton JA, Kite P, et al. Each lumen is a poten

10、tial source of central venous catheter-related bloodstream infection. Crit Care Med 2003; 31: 1688-1690,14,9/3/2020,CRBSI的DTP: 需要留取多少外周血標(biāo)本?,Guembe M, Rodriguez-Creixems M, Sanchez-Carrillo C, et al. Differential time to positivity (DTTP) for the diagnosis of catheter-related bloodstream infection: d

11、o we need to obtain one or more peripheral vein blood cultures? Eur J Clin Microbiol Infect Dis 2011 Oct 21 Epub ahead of print,當(dāng)根據(jù)DTP方法確診CLABSI時(shí)，僅留取一個(gè)（套）外周血培養(yǎng)并不會(huì)明顯遺漏CLABSI病例,15,9/3/2020,CRBSI的診斷,Raad I, Hanna H, Maki D. Intravascular catheter-related infections: advances in diagnosis, prevention, a

12、nd management. Lancet Infect Dis 2007; 7: 645-657,16,9/3/2020,CRBSI初始治療,OGrady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med 2011; 78: 10-17,臨床懷疑短期留置中心靜脈導(dǎo)管 相關(guān)性血行性感染,重癥患者,輕中癥患者 （無低血壓或器官功能衰竭）,拔除導(dǎo)管 至少留取2套血培養(yǎng)，其中至少1套來自外周靜脈 開始經(jīng)驗(yàn)性

13、 抗生素治療 請(qǐng)感染科醫(yī)生會(huì)診,有危險(xiǎn)因素*,無危險(xiǎn)因素,拔除導(dǎo)管 至少留取2套血培養(yǎng)，其中至少1套來自外周靜脈 開始經(jīng)驗(yàn)性 抗生素治療,如仍需要導(dǎo)管可保留 至少留取2套血培養(yǎng)，其中至少1套來自外周靜脈 開始經(jīng)驗(yàn)性 抗生素治療,*例如免疫功能抑制，血管內(nèi)異物，嚴(yán)重全身性感染表現(xiàn)，插管部位感染表現(xiàn)，確診菌血癥或真菌血癥,17,9/3/2020,CRBSI的治療: 拔除導(dǎo)管的實(shí)際感染率,Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in

14、critically ill patients: a randomized controlled trial. JAMA 2001; 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 2003; 31: 1318-1324. Ranucci M, Isgro G

15、, Giomarelli PP, et al. Impact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection. Crit Care Med 2003; 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

16、Care Med 2003; 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.,18,9/3/2020,CRBSI的治療: 拔管 vs. 不拔管,Rijnders BJ, Peetermans WE, Verwaest C, et al. Watchful waiting versus imm

17、ediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med 2004; 30: 1073-1080,懷疑CRBSI并計(jì)劃 更換中心靜脈導(dǎo)管,試驗(yàn)組,標(biāo)準(zhǔn)治療組,拔除導(dǎo)管,留取2套血培養(yǎng),保留導(dǎo)管繼續(xù)觀察5天,感染表現(xiàn)緩解,不拔除導(dǎo)管,感染表現(xiàn)持續(xù),拔除導(dǎo)管,血培養(yǎng)陽性，或 血流動(dòng)力學(xué)不穩(wěn)定,19,9/3/2020,CRBSI的治療: 拔管 vs. 不拔管,Rijnders BJ, Peetermans WE, V

18、erwaest C, et al. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med 2004; 30: 1073-1080,20,9/3/2020,CRBSI的治療: 拔管 vs. 不拔管,Deliberato RO, Marra AR, Correa TD, et al. Catheter Related Bloodstream Infectio

19、n (CR-BSI) in ICU Patients: Making the Decision to Remove or Not to Remove the Central Venous Catheter. PLoS ONE 2012; 7: e32687,21,9/3/2020,CRBSI的初始治療,OGrady NP, Chertow DS. Managing bloodstream infections in patients who have short-term central venous catheters. Cleve Clin J Med 2011; 78: 10-17,22,9/3/2020,CRBSI的預(yù)防,醫(yī)護(hù)協(xié)作 管理比技術(shù)更重要,23,9/3/2020,預(yù)防CRBSI的質(zhì)量改進(jìn)計(jì)劃,Blot K, Bergs J, Vogelaers D, et al. Prev