Transcript Preventing Central Line-Associated Bloodstream Infections (CLABSIs) 预防中心静脉导管相关的血流感染

Preventing Central
Line-Associated Bloodstream
Infections (CLABSIs)
预防中心静脉导管相关的血流感染
Steven M. Gordon, M.D.
Chairman, Infectious Diseases, Cleveland Clinic
Cleveland医院感染科主任
5/6/12
Objectives/目标
• Definitions and Epidemiology of
Catheter Associated Infections
导管相关感染的流行病学及定义
• Diagnosis 诊断
Examine strategies aimed at prevention
以预防为目的检查策略
• Review treatment and management of
intravascular catheter infections
回顾静疗管路感染的治疗及管理
Published Guidelines/发布的指南
• Strategies to Prevent Central Line-Associated
Bloodstream Infections in Acute Care Hospitals/
急症护理医院预防CLABSI 的策略指南
• Prevention of Intravascular Catheter Related
Infections /预防血管内导管的相关感染指南
 Mermel LA. Ann Intern Med 2000;132:391
 CDC MMWR Rep 51 (RR-10):1-26 (9 August 2000)
• Management of intravascular catheter-related
infections /血管内导管的相关感染的处理指南
 IDSA guidelines Clin Inf Dis 2001;32:1249
《美国传染病学会指南》
Resources 资源
SHEA vascular access guidelines /
《美国流行病学会—静脉管路指南》
http://www.shea-online.org/about/compendium.cfm
AHRQ Healthcare-Associated Infections /
《卫生保健研究和质量机构—医院感染》
http://www.ahrq.gov/qual/hais.htm
On the CUSP: Stop BSI /热门话题：遏制血流
感染
http://www.hret.org/quality/projects/stop-bsi.shtml
Health Research & Educational Trust (HRET): National Implementation of the
Comprehensive Unit-Based Safety Program (CUSP) to Reduce Central Line Associated
Blood Stream Infections (CLABSI) in the Intensive Care Unit
Vascular Access: Framing Opportunity and
Challenges /脉管通路：机遇与挑战并存
• Without venous access few current
treatment plans could be administered in
hospital /在医院，没有什么治疗能离得开静脉通路
• Venous access is most common invasive
experience for patients (with phlebotomy) /
对病人来说静脉用药或取血是最平常的手段
• Patient satisfaction tied to vascular access /
患者的满意度与静疗效果密切相关
• Implementation of vascular access clinical
pathway is right thing to do! /
因此，我们应该执行正确的静脉通路临床操作方法
出处: Moureau N et al A new evidence baed approach to vascular
access selection And management (submitted)
Classification of Intravascular
Catheters /血管内导管的分类
• By type of vessel occupied /按置入血管的类型分类
-
peripheral venous, arterial, central venous / 外周静脉，动脉，中心静脉
• Intended life-span /按留置时间分类
-
temporary, short-term Vs long-term /临时的，短期的 和长期的
• Pathway from skin to vessel/按穿刺点与皮肤血管关系分类
-
tunneled Vs non-tunneled /隧道式、非隧道式
• Physical length and number of lumens /按导管
和管腔数
- long Vs short 长导管、短导管
• Special attributes /按导管材质分类
-
antibiotic or antiseptic impregnated /抗菌导管、抗生素涂层导管
长度
Catheters Used for Venous and
Arterial Access /用于动/静脉的导管
• Peripheral venous and
arterial catheters /外周
动、静脉导管
• Midline catheters /中等
长度导管
• Peripherally inserted
central venous
catheters /PICC
• Umbilical catheters /
脐导管
 Non-tunneled central
venous catheters
(CVC)/非隧道中心静脉导管
•
•
•
Pulmonary artery
catheters /肺动脉导管
Tunneled central venous
catheters /隧道式中心静脉
导管
Totally implantable (port
accessed) /完全置入式（输
液港）
CDC Definition for Surveillance
Purposes /CDC监测定义
•
An intravascular catheter that terminates at or close to the heart
or in one of the great vessels which is used for infusion,
withdrawal of blood, or hemodynamic monitoring. /导管末端位置
靠近心脏或大血管，用于输液，抽血，或血流动力学监测。
• The following are considered great vessels for the
purpose of reporting central-line BSI and counting
central-line days in the NHSN system: /下列血管被认为是大血管，
需将其置管日上报NHSN(美国医疗安全网)用于统计并报告CVC感染率
-
Aorta, pulmonary artery, superior vena cava, inferior vena cava,
brachiocephalic veins, internal jugular veins, subclavian veins, external
iliac veins, common iliac veins, common femoral veins, and in neonates,
the umbilical artery/vein. / 主动脉,肺动脉,上腔大静脉,下腔大静脉,头臂静脉,颈
静脉,锁骨下静脉,髂外静脉,髂总静脉,股静脉和新生儿,脐静脉
Epidemiology of Central Venous
Catheters (CVC) / CVC的流行病学
• >1 billion intravascular devices used annually in US
/在美国，每年血管装置的使用量>10亿
 5 million CVCs inserted in patients in US annually
每年为患者置入500万条CVC
15 million CVC days 1500万的导管日
• > 15% complications />15%并发症
- mechanical 5-19% /机械性5-19%
- thrombotic 2-26% /血栓 2-26%
 infectious 5-26% /感染 5-26%
Peripherally Inserted Central
Catheter (PICC) venous thrombosis
/PICC静脉 血栓
•
•
•
•
Non-tunneled central venous
catheters /非隧道式中心静脉导管
Workhorse for outpatient IV
antibiotics at CCF /我院
(Cleveland医院)大量患者在门诊输
注抗菌素
Recent introduction of adapter
with saline flush (Vs heparin) /
先进的生理盐水（相对于肝素）冲
管器
Also, allows blood draws via
PICC /允许从PICC导管抽血
Types of Catheter-Associated
Infections 导管相关性感染的类型
• Catheter colonization /导管细菌定植
 growth of organisms from a catheter-segment by either
seimquantitative (roll plate) or quantitative (vortex) methods /
半定量或定量培养，导管尖端有微生物生长
• Catheter-related bloodstream infection /导管相关血
流感染
 isolation of the same organism from a blood culture and culture
of catheter segment accompanied by clinical signs of
bloodstream infection without any other apparent source of
infection /从血和导管培养中，找出相同的微生物, 结合血液感染的
临床表现，排除其他任何感源
• Exit-site infection /出口部感染
 Erythema, tenderness, induration or purulence within 2 cm of
the exit site of the catheter /发红，疼痛，发硬或化脓至少在穿刺口
周围2cm
Periperhal venous catheter (short)
infections /外周短导管感染
In adults, replace site no more frequently than 72-96
hours /成人，不要在72-96小时内更换穿刺部位
“Tunnel” Infection or Clinical
Exit Infection/隧道式感染或出口部感染
• Tenderness, erythema, or
site induration >2 cm from
the catheter site along the
subcutaneous tract of a
tunneled (e.g. Hickman)
catheter in absence of a
bloodstream infection /
隧道式导管(例如Hickman导管)引起
的敏感，红肿，或沿着导管穿刺部位
皮下有超过2cm的肿块，尚无血流感
染
CLABSI发病机理
Focus of
prevention
strategies
预防策略
Biofilm on Intravenous Catheter Connecter
24 hours after Insertion /置入静脉导管24小时
后，在连接处出现的生物膜
Scanning Electron Micrograph
CLABSI Pathogens /引起CRBSI的
病原体
Coagulase-negative
37%
staphylococci /凝固酶阴性金黄色葡萄球菌
S. aureus 金黄色葡萄球菌
13%
Enterococcus 肠球菌
13%
Gram-negative rods G14%
Candida spp. 念珠菌
8%
CDC National Nosocomial Infections Surveillance
Am J Infect Control 1999;27:520
Impact of CLABSI/ CLABSI的影响
• 250,000 cases of CVC-associated bloodstream
infections / 25万例CLABSI
• Increases hospital length of stay 11-23 days /增加住
院11-23天
• Increases costs /增加花费
– $7,288 - $29,156 per CLABSI episode /例CLABSI
– $670 million - $2.7 billion aggregate U.S. costs
annually (adjusted by 2007 CPI) / $ 6.7亿-27亿/年
Smith RL, et al. Chest 1991;100:164-167
Amow PM, et al. Clin Infect Dis 1993:16:778-784
Collignon Pl., Med J Aust 1994; 161:374-378
Complication of S. aureus catheter-related
bloodstream infection /金葡菌引起的导管相关性血流感染
并发症
Abscess on left
ventricular wall
左心室壁脓肿
Nosocomial/healthcare associated bloodstream
infection/；医源性血流感染
Must meet 1 of the following criteria:必须符合下列症状之一
• Recognized pathogen in > 1cultures with an organism not identified
/至少一套上血培养，确认出相同的病原菌
• Fever > 38oC, chills, hypotension and signs and symptoms and positive
laboratory findings not related to an infection at another site and common
skin contaminant is cultured from > 2 cultures on separate occasions /
发烧>38oC,寒颤,低血压症状和体征,不与其他部位感染相关,在2个以上不
同时段培养出皮肤常见微生物
• Pt < 1 year has fever > 38oC rectal, hypothermia < 37oC rectal, apnea, or
bradycardia AND signs and symptoms and positive laboratory results not
related to an infection at another site and common skin contaminant is
cultured from > 2 cultures on separate occasions /
患儿<1岁，肛温-->38oC, < 37oC ,无呼吸，心动过缓症状和体征,实验室结
果显示不与其他部位感染及皮肤常见污染物培养相关
Horan et al. AJIC 2008:36:309-32, (www.cdc.gov/ncidod/dhqp/nhsn.html
NHSN CLABSI Event June 2011
美国医疗安全网CLABSI事件 2011.6
• Treatment (pharmacology) no longer plays in to
Infection domain / 不再仅仅关注药物治疗
• No requirement for how long central venous catheter
in place to be considered hospital acquired
判断是否属于院内感染，不再依据CVC在体内留置时间
JAMA 2010;304:2035-41
检测机构公布的院内血流感染率的可信度调查
Infection Preventionist Rates Relative to Computer
Algorithm: Institutional Variability /感染预防专家对CRBSI的
估计值与实际统计值的差距：具有统计学差异
Mean: 3.3/1K
Mean 9/ 1K
• NHSN HAI definitions do not allow for BSI in patients with
mucositis, GVHD, or neutropenia to be classified as secondary – by
default counted as CLABSI if central line is present /美国医疗安全网
医院感染的定义不将患者有粘膜炎，移植物抗宿主病，白细胞减少症的继
发血流感染患者归类为医院感染，即使该患者带有导管，继发CLABSI，
也不计算在CLABSI里。
• These CLABSIs are “not preventable /这些CLABSI 是“不可预防的”
• Could harm morale of team and adverse effects in era of public
reporting /公布结果可能会打击团队的士气和起反作用
1Balzan et al. J Gastroenterology & Hepatology 2007;22:464-71
2Pehar et al. SHEA/Decennial 2010 Abstract #660
3DiGiorgio et al, SHEA 2011 Abstract #220
Modified CLABSI Definition – Eligible Patient
Populations /CLABSI定义修正—合理选定人群
Patient population/患者人群
BMT recipients with graft versus host disease (GVHD)
Patients with hematologic malignancy AND netropenia /骨髓移植
患者的排异反应，恶性血液病，白细胞减少症
•
Considerations/相关
-
Use of objective criteria to identify eligible patients /合理选定人群
•
-
Mucositis excluded – many grading scales, no consensus /排除粘膜炎—许多分级尺
度，没有达成共识
Inclusion of patients without hematologic malignancy /不包括恶性血液病患者
•
•
Solid organ transplant patients, just liver transplant patients, pediatric patients with
short gut syndrome /器官移植患者，肝移植，短肠综合症的小儿
Patients with neutropenia regardless of underlying illness /只要是白细胞减少症患者
而不论其原发疾病
The Impact of Central Line Insertion
Bundles /采用中心静脉导管置管集束的影响
• 103 ICUs in Michigan (Keystone Project) /密歇
根州的103个 ICU 试点项目
• Use of a checklist / 使用核查清单
• Emphasis on teamwork /强调团队合作
• Mean CLABSI rate decreased from 7.7/1000
CVC days to 1.4/1000 CVC days /CLABSI 率从
7.7降至1.4每千导管日
Pronvost PJ et al New Engl J Med 2006;35-2725+
The Good/可喜的是:
58% decrease in
CLABSIs in ICUs
/ICU CLABSI减少58%
The Challenge /挑战
37,000 CLABSIs in Dialysis Patients /有37000例导管
相关性血流感染发生于透析管着
Interventions To Prevent
Infectious Complications /
防止感染并发症的干预措施
Category IA: Supported by
evidence from one properly
randomized controlled trial and
good evidence to support a
recommendation for use
Before Insertion
穿刺前
• Engage hospital administration and staff about
the culture of safety, including risk of healthcareassociated infections and their prevention. /动员医
院管理者和所有员工一起投身于以安全为文化氛围，
认识到包括医护人员相关感染的风险及其预防。
• Educate healthcare personnel involved in central
line insertion, care, and maintenance about
CLABSI prevention. /培训负责CVC穿刺、维护的医
护人员的CLABSI预防知识
Education and Engagement
/教育和参与
• Education provided to HCWs on hire and
annually /不仅给予新员工入职培训，还要每
年给予培训
• Joint Commission also requires we
educate the patient/families about
CLABSI prevention before insertion
/JCI组织认为我们应该在穿刺前，教育患者家
属关于CLABSI的预防
• Simulation training /模拟训练
Category IA “DO NOT”
Recommendations /IA –不推荐
 Do Not Routinely culture catheter tips! /不推荐常
规培养导管尖端
 Do Not use topical antibiotic ointments or creams
on insertion sites/不推荐在穿刺部位使用抗菌素药膏
 Do Not use in-line filters routinely /不推荐常规使用
血管内过滤网装置
 Do Not routinely replace central venous or
arterial catheters solely for the purposes of
reducing infection /不推荐为预防感染常规更换CVC
或动脉导管
At Insertion/穿刺中
• Use an all-inclusive catheter cart or kit that contains
everything needed for safe, aseptic catheter
insertion / 将所有做无菌穿刺所需要用到的物品放在一
个穿刺车或包中
• Use a checklist that has all catheter infection
prevention bundle components listed and a
healthcare worker using the checklist who is
empowered to stop the procedure if a breach in
aseptic technique is observed. /使用核查清单将所有
导管穿刺套件按步骤列出以感染。负责核对的医护人员
若发现有违反无菌操作原则的操作时，可终止继续操作
Basic Steps:
The CLABSI Prevention Bundle /基本步骤：
CLABSI预防集束
1.
2.
3.
4.
5.
Hand hygiene /手卫生
Maximal barrier precautions /最大无菌屏障
Chlorhexidine skin antisepsis of catheter insertion
site except very LBW infants /用葡萄糖酸盐氯己定
(CHG)作穿刺部位皮肤消毒，及低体重儿除外
Non-femoral vein catheter insertion in adults /成人
避免股静脉穿刺
Daily review of line necessity; prompt removal of
unnecessary lines /每日检查导管保留的必要性，尽
早拔除不再需要的导管
Infection rates with improved hand hygiene
改进手卫生后的感染率
35
MRSA incidence
0.6
0.5
25
Nosocomial
Infections
0.4
30
20
0.3
15
0.2
10
16.9%  9.9% (p=0.04)
0.1
0
5
0
1993
1994
Pittet D, et al. Lancet 2000;356:1307-1312
1995
1996
1997
1998
Infections per 100 admissions
New MRSA per 100 admissions
0.7
Improving compliance with hand hygiene:
The role model /提高洗手的依从性：示范效应
• HCWs in a room with a senior medical staff
person or peer who did not wash their
hands were significantly less likely to wash
their own hands (OR = 0.2, p < .001) /如果
资深人员或组长若不带头严格手卫生，洗手
依从性将会大打折扣
Emerg Infect Dis 2003; 9:217-23
Prevention Strategy 2: Maximal Barrier
Precautions
预防策略2：最大无菌屏障
Maximal Barrier Precautions /最大
的无菌屏障
•
•
For the operator placing the central line and for those assisting
in the procedure: /为进行中心静脉导管穿刺操作者及其助手准备的流
程
-
Wear cap, mask, sterile gown, and gloves /戴帽子，口罩，无菌衣及手
套
-
Cap should cover all hair /帽子应覆盖所有头发
-
Mask should cover the nose and mouth/口罩应罩住口鼻
-
These precautions are the same as for any other surgical procedure
that carries a risk of infection /这些预防措施等同于外科手术准备程序以
预防感染风险
For the patient/患者:
-
Cover the patient with a large sterile drape, with a small opening for
the site of insertion /用无菌大单覆盖患者，在穿刺部位开一小孔
Do Maximal Barrier Precautions Prevent CA-BSI?
最大无菌屏障能预防CA-BSI吗?
Author &
Year
作者及时
间
Mermel
1991
Study Design
科研设计类型
Prospective
Cross-sectional
Type of
Line
导管类型
OR for infection
without MBP
SG
2.2 (p=0.03)
Central
3.3 (p=0.03)
无最大无菌屏障引
起的相对危险度
前瞻性对照研究
Raad
1994
Prospective
Randomized
随机性前瞻性研究
Am J Med 1991;91(3B):197S-205S; Infect
Control Hosp Epidemiol 1994;15:231-8
Efficacy of Barrier Precautions
During CVC Insertion /预防措施在
CVC穿刺时的有效性
Barrier precautions
屏障预防措施
Minimal/最小 Maximal/最大
Cath. Colonization/
7.2%
2.3%*
/导管定植
Cath Sepsis/脓毒血症
3.6%
0.6%*
*p≤0.05
Raad et al, ICHE 1994
Prevention Strategy 3: Choice of
skin prep
预防策略3：选择皮肤消毒剂
Antisepsis HICPAC 1999
消毒 –1999版美国医院感染控制实践顾问委员会
Prevention: CHG Skin Prep
预防策略：使用CHG 皮肤消毒剂
Pooled RR
for BSI
Ann Intern Med. 2002;136:792-801