Marschall Jonas
Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO 63110, USA.
Am J Infect Control. 2008 Dec;36(10):S172.e5-8. doi: 10.1016/j.ajic.2008.10.005.
Current recommendations for the prevention of central venous catheter-associated bloodstream infections (CA-BSIs) are mostly based on data from intensive care units (ICUs). The rates of CA-BSIs appear to be higher in non-ICU wards. Until this year, no published data were available on non-ICU CA-BSIs in the United States. This article is a summary of a talk given at an industry-sponsored conference on CA-BSIs. It summarizes an original article of ours previously published in a peer-reviewed journal.
The objective of this study was to determine the rate of CA-BSIs in non-ICU medical patients by developing a prospective surveillance program in a major tertiary care hospital. All positive blood cultures electronically detected from April 1, 2002, to April 30, 2003, were reviewed and clinical data collected by chart review.
Catheter utilization ratio = total number of days with a central venous catheter (CVC)/total number of patient-days; catheter-associated BSIs = defined by Centers for Disease Control and Prevention criteria, eg, a patient had to have a catheter at least 48 hours before detection of infection; CA-BSI rate = CA-BSIs/1000 catheter-days.
The 13-month study included 7337 catheter-days and 33,174 patient-days. The overall catheter-utilization ratio was 0.22 (range, 0.19-0.25). Of 42 cases of CA-BSIs, gram-positive organisms were recovered in 24 (57%); gram-negative bacteria in 7 (17%); and Candida spp in 6 (14%). The CA-BSI rate was 5.7 (95% confidence interval: 3.4-8.0) and varied from 4.3 to 8.0. There were no significant differences in CA-BSI rates among the wards (chi(2) for linear trend, 0.42; P = .52). The overall rate of CA-BSIs decreased steadily during the study period, from 7.8 during the first 6 months to 3.9 during the following 7 months, representing a rate ratio of 0.5 (95% confidence interval: 0.27-0.93).
Benchmark data for hospital infections in the non-ICU setting are starting to become available and efforts to improve care may have greater impact here than in the ICU. Upon patient transfer out of the ICU, it should be determined whether the catheter can be removed. Educational measures targeted at non-ICU wards are warranted. First results of computer-assisted methods to facilitate surveillance of larger number of patients are promising. The Healthcare Infection Control Practices Advisory Committee recommends that CA-BSIs be publicly reported. CA-BSIs in non-ICU patients could soon be part of a mandatory reporting.
目前预防中心静脉导管相关血流感染（CA-BSIs）的建议大多基于重症监护病房（ICU）的数据。非ICU病房的CA-BSIs发生率似乎更高。直到今年，美国尚无关于非ICU病房CA-BSIs的公开数据。本文是在一次由行业赞助的CA-BSIs会议上的演讲总结。它总结了我们之前发表在同行评审期刊上的一篇原创文章。
本研究的目的是通过在一家大型三级护理医院开展前瞻性监测项目，确定非ICU内科患者的CA-BSIs发生率。对2002年4月1日至2003年4月30日电子检测到的所有阳性血培养结果进行回顾，并通过病历审查收集临床数据。
导管使用率=中心静脉导管（CVC）使用总天数/患者总住院天数；导管相关血流感染=根据疾病控制与预防中心的标准定义，例如，患者在感染检测前必须至少留置导管48小时；CA-BSI发生率=CA-BSIs/1000导管日。
为期13个月的研究包括7337导管日和33174患者日。总体导管使用率为0.22（范围为0.19 - 0.25）。在42例CA-BSIs病例中，24例（57%）分离出革兰氏阳性菌；7例（17%）为革兰氏阴性菌；6例（14%）为念珠菌属。CA-BSI发生率为5.7（95%置信区间：3.4 - 8.0），范围为4.3至8.0。各病房之间的CA-BSI发生率无显著差异（线性趋势卡方检验，χ² = 0.42；P = 0.52）。在研究期间，CA-BSIs的总体发生率稳步下降，从前6个月的7.8降至随后7个月的3.9，发生率比为0.5（95%置信区间：0.27 - 0.93）。
非ICU环境中医院感染的基准数据开始可用，改善护理的努力在此处可能比在ICU产生更大影响。当患者转出ICU时，应确定是否可以拔除导管。针对非ICU病房的教育措施是必要的。计算机辅助方法用于促进对更多患者进行监测的初步结果很有前景。医疗保健感染控制实践咨询委员会建议公开报告CA-BSIs。非ICU患者的CA-BSIs可能很快成为强制报告的一部分。
