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艰难梭菌无需接触隔离即可传播:一项针对 451 名患者的前瞻性观察研究结果。

Transmissibility of Clostridium difficile Without Contact Isolation: Results From a Prospective Observational Study With 451 Patients.

机构信息

Divisions of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, University Basel, Basel, Switzerland.

Divisions of Clinical Microbiology, University Hospital Basel, University of Basel, Switzerland.

出版信息

Clin Infect Dis. 2017 Feb 15;64(4):393-400. doi: 10.1093/cid/ciw758.

Abstract

BACKGROUND

Contact precautions are recommended by health authorities in Europe and the United States for patients with Clostridium difficile infection (CDI). Recently, the significance of nosocomial transmission has been challenged by screening on admission studies and whole-genome sequencing, providing evidence for an endogenous source of C. difficile. We discontinued contact precautions for patients with CDI, except for patients infected with hypervirulent ribotypes or with stool incontinence, to determine the rate of transmission.

METHODS

From January 2004 to December 2013, contacts of each index case with CDI were screened for toxigenic C. difficile by culturing rectal swabs. Transmission was defined as possible if toxigenic C. difficile was detected in contacts, as probable if the identical polymerase chain reaction ribotype was identified in index–contact pairs, and as confirmed if next-generation sequencing (NGS) revealed clonality of strains.

RESULTS

Four hundred fifty-one contacts were exposed to 279 index patients nursed in 2-to 4-bed rooms. Toxigenic C. difficile was detected in 6.0% (27/451) after a median contact time of 5 days. Identical ribotypes were identified in 6 index–contact pairs, accounting for probable transmission in 1.3% (6/451). NGS was performed for 4 of 6 pairs with identical strains, and confirmed transmission in 2 contact patients.

CONCLUSIONS

The rate of transmission of toxigenic, predominantly nonhypervirulent C. difficile, was low and no outbreaks were recorded over a 10-year period after discontinuing contact precautions for patients with CDI who were not severely incontinent and who used dedicated toilets. As contact precautions may lead to lower levels of care, their implementation needs to be balanced against the risk of nosocomial transmission.

摘要

背景

欧洲和美国的卫生当局建议对艰难梭菌感染(CDI)患者采取接触预防措施。最近,入院筛查和全基因组测序对医院内传播的重要性提出了挑战,为艰难梭菌的内源性来源提供了证据。我们停止了对 CDI 患者的接触预防措施,除了感染高毒力核糖型或粪便失禁的患者,以确定传播率。

方法

从 2004 年 1 月至 2013 年 12 月,对每个 CDI 索引病例的接触者进行了直肠拭子培养,以筛选产毒艰难梭菌。如果在接触者中检测到产毒艰难梭菌,则将传播定义为可能;如果在索引-接触者对中鉴定出相同的聚合酶链反应核糖型,则将传播定义为可能;如果下一代测序(NGS)显示菌株的克隆性,则将传播定义为确认。

结果

451 名接触者暴露于 279 名在 2-4 床病房接受护理的索引患者。在中位接触时间为 5 天后,检测到 6.0%(27/451)的接触者产毒艰难梭菌。在 6 对索引-接触者对中鉴定出相同的核糖型,占可能传播的 1.3%(6/451)。对 6 对具有相同菌株的对中的 4 对进行了 NGS,并在 2 名接触者中确认了传播。

结论

在停止对非严重失禁且使用专用厕所的 CDI 患者采取接触预防措施 10 年后,产毒、主要是非高毒力艰难梭菌的传播率较低,且未记录到暴发。由于接触预防措施可能会导致护理水平降低,因此需要在医院内传播风险与接触预防措施的实施之间取得平衡。

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