Soman Rajeev, Gupta Neha, Suthar Mitesh, Kothari Jatin, Almeida Alan, Shetty Anjali, Rodrigues Camilla
Consultant Internal Medicine and Infectious Diseases.
Consultant Infectious Disease, Division of Internal Medicine, Medanta - The Medicity, Gurgaon.
J Assoc Physicians India. 2016 Feb;64(2):32-37.
Central-line-associated blood-stream infection (CLABSI) is a highly consequential nosocomial infection. The most effective management includes the removal of the infected catheter. Retention of the catheter and antibiotic lock therapy (ALT) along with systemic antibiotics may be attempted only if there are unusual extenuating circumstances. CLABSIs due to Gram-negative bacteria (GNB) is more common in our setting and the organisms are often highly resistant. Hence, there is a need to explore the use of novel antimicrobials for catheter lock solutions along with antibiofilm agents.
We report the use of antibiotic lock therapy in the first 29 patients who had 37 episodes of bacteremia (CLABSI/symptomatic colonization) due to long-term catheters in our unit from February 2008 to September 2014. Patients received ALT if they had CLABSI or were symptomatic with a colonized catheter. Patients who needed removal of the catheter were ineligible for ALT. Patients received systemic antibiotic therapy and lock solutions were kept in the catheter for dwell times of 24 hours, and therapy was continued for 14 days. Successful treatment was defined as any of the following: 1) Clinical cure with disappearance of signs of sepsis 2) Microbiological cure with resolution of bacteremia (confirmed by a negative blood culture which was obtained through the catheter 2-5 days after stopping therapy.
Among the 37 episodes treated with ALT, 30 episodes were caused by GNB and four episodes were caused by Gram-positive cocci (GPC); Enterococcus, methicillin-sensitive S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), and methicillin-sensitive coagulase-negative staphylococcus (CoNS). There were three episodes of CRBSI due to Candida and one episode each due to L. monocytogens and Bacillus spp. Of the other 30 episodes due to GNB, Acinetobacter baumannii were isolated in eight episodes, Stenotrophomonas (n=6), E. coli (n=5), Flavobacterium (n=2), and P. aeruginosa (n=4), and B. cepacia in three episodes. The other organisms isolated were K. pneumoniae, and non-typhoidal Salmonella (1 episode each). Successful treatment with ALT was observed in 30 (81.08%) of the 37 episodes.
In patients with CLABSI due to Gram-negative pathogens, the use of ALT along with systemic antibiotics has an excellent catheter salvage rate. Newer antibiotics (tigecycline and colistin) may be useful options as antibiotic lock solutions along with antibiofilm agents especially in the setting of resistant Gram-negative bacilli producing CLABSI.
中心静脉导管相关血流感染（CLABSI）是一种后果严重的医院感染。最有效的处理措施包括拔除感染的导管。仅在存在特殊的情有可原的情况下，才可以尝试保留导管并联合全身使用抗生素进行抗生素封管治疗（ALT）。在我们的医疗环境中，革兰氏阴性菌（GNB）引起的CLABSI更为常见，且这些微生物往往具有高度耐药性。因此，有必要探索将新型抗菌药物与抗生物膜药物用于导管封管溶液。
我们报告了2008年2月至2014年9月在我们科室因长期导管导致37例菌血症（CLABSI/有症状的定植）的前29例患者中抗生素封管治疗的应用情况。患有CLABSI或导管定植有症状的患者接受ALT治疗。需要拔除导管的患者不符合ALT治疗条件。患者接受全身抗生素治疗，封管溶液保留在导管内24小时，治疗持续14天。成功治疗定义为以下任何一种情况：1）临床治愈且败血症体征消失；2）微生物学治愈且菌血症消退（通过在停止治疗后2 - 5天经导管采集的血培养阴性证实）。
在接受ALT治疗的37例中，30例由GNB引起，4例由革兰氏阳性球菌（GPC）引起；肠球菌、甲氧西林敏感金黄色葡萄球菌（MSSA）、甲氧西林耐药金黄色葡萄球菌（MRSA）和甲氧西林敏感凝固酶阴性葡萄球菌（CoNS）。有3例念珠菌引起的CRBSI，1例单核细胞增生李斯特菌和1例芽孢杆菌属引起的感染。在由GNB引起的其他30例中，8例分离出鲍曼不动杆菌，6例嗜麦芽窄食单胞菌，5例大肠埃希菌，2例黄杆菌，4例铜绿假单胞菌，3例洋葱伯克霍尔德菌。分离出的其他微生物为肺炎克雷伯菌和非伤寒沙门氏菌（各1例）。37例中有30例（81.08%）通过ALT治疗成功。
对于革兰氏阴性病原体引起的CLABSI患者，ALT联合全身抗生素使用具有出色的导管挽救率。新型抗生素（替加环素和多粘菌素）作为抗生素封管溶液联合抗生物膜药物可能是有用的选择，特别是在产生CLABSI的耐药革兰氏阴性杆菌的情况下。
