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1、经皮中心静脉置管感染预防指南,梁大伟 天坛医院神经内科,导管相关感染的诊断定义,局部感染定义： （ 1 ）局部自发或经触压后有脓性渗出，无需细菌学证据。 （ 2 ）穿刺部位的红肿、发热、硬结（三者中任两者），及血清样物质自发或触压后渗出，穿刺部位细菌培养阳性。,导管相关感染的诊断定义,菌血症感染的定义： （ 1 ）外周血培养结果阳性，且为一种微生物，导管片段（近端或远端）经定量或半定量方法分离出同一种微生物（种类及耐药谱），无其它感染源。 （ 2 ）导管内回抽血定量培养出 10 倍于同时外周血培养的菌株。 （ 3 ）导管穿刺部位渗出的脓液、血清、血浆样物质或导管皮下部分、皮下埋植部分培养与外周
2、血培养出同一种细菌（种类及耐药谱）。,导管相关感染的诊断定义,可能感染的定义包括： （ 1 ）两次或两次以上血培养（无论是外周血还是中心静脉回抽血）出同一种细菌（种类及耐药谱），且临床及实验室证实无其它感染源。 （ 2 ）一次阳性血培养结果为 或念球菌（无论是外周血还是中心静脉回抽血），且临床及实验室证实无其它感染源。 （ 3 ）免疫抑制或粒细胞减少（粒细胞 500ul ）的病人，血培养阳性（凝固酶阴性的葡萄球菌，杆菌属，棒状杆菌属，糠秕马拉色霉菌等），临床及实验室证实无其它细菌感染源，只有中心静脉留置导管，通常与导管相关性菌血症有关。,CVC引起相关感染的机制,1. infection of
3、 the exit site, followed by migration of the pathogen along the external catheter surface. 2. contamination of the catheter hub, leading to intraluminal catheter colonization. 3. hematogenous seeding of the catheter.,病原体,若不幸感染,常见的菌种包括: Coagulase-negative staphylococci (37%), Staphylococcus aureus (1
4、3%), Enterococcus (13%), Gram-negative rods (14%). 值得注意的是,抗药性强的菌种包括staph.以及Enterococcus都榜上有名所以如果不幸发生感染多半就非得要用上vancomycin可能不行还要用上linezolid相当的麻烦 另外一个值得注意的是fungifungi的感染扮演部分角色(在NNIS的数据中是8%)在Candidia的感染中,大约一半是non-albican species造成的.包括C. glabrata与C. krusei这些fungi对fluconazole容易产生抗药性.,Guidelines for preven
5、ting infections associated with the insertion and maintenance of central venous catheters 中心静脉置管相关性感染的预防指南,Journal of Hospital Infection (2001) 47(Supplement): S5S9,Intervention 1: Selection of catheter type 导管类型的选择 Intervention 2: Selection of catheter insertion site 置管点的选择 Intervention 3: Optimum
6、aseptic technique during catheter insertion 置管过程中无菌技术的最优化 Intervention 4: Cutaneous antisepsis 皮肤消毒 Intervention 5: Catheter and catheter site care 导管和置管点的护理 Intervention 6: Replacement strategies 更换方法 Intervention 7: Antibiotic prophylaxis 预防性使用抗生素,Selection of catheter type,1 Use a single-lumen ca
7、theter unless multiple ports are essential for the management of the patient. 尽量采用单腔管，除非患者需要多通道治疗， 2 If total parenteral nutrition is being administered, use one central venous catheter or lumen exclusively for that purpose. 如果需要TPN，专用一根中心静脉导管或专用一个管腔 3 Use a tunnelled catheter or an implantable vasc
8、ular access device for patients in whom long-term (30 days) vascular access is anticipated. 如果预计要长时间（30天）保留血管通路，采用管道式导管或植入式血管通路 4 Consider the use of an antimicrobial impregnated central venous catheter for adult patients who require short-term (10 days) central venous catheterisation and who are at
9、 high risk for CR-BSI. 需短期（10天）保留CVC者，并且是导管相关的血源性感染的高危患者， 使用外涂抗菌素的CVC,Selection of catheter insertion site,5 In selecting an appropriate insertion site, assess the risks for infection against the risks of mechanical complications. 选择置管位点时，要权衡感染风险和机械并发症的风险 6 Unless medically contraindicated, use the
10、subclavian site in preference to the jugular or femoral sites for nontunnelled catheter placement. 做非管道性置管，如无禁忌，采用锁骨下置管好于颈静脉或股静脉置管 7 Consider the use of peripherally inserted catheters as an alternative to subclavian or jugular vein catheterisation. 外周静脉置管可作为锁骨下置管或颈静脉置管的替代方法,Optimum aseptic techniqu
11、e during catheter insertion,8 Use optimum aseptic technique, including a sterile gown, gloves, and a large sterile drape, for the insertion of central venous catheters. 置管时采用最佳的无菌技术，穿无菌衣，戴无菌手套，盖无菌单,Cutaneous antisepsis,9 Clean the skin site with an alcoholic chlorhexidine gluconate solution prior to
12、 CVC insertion. Use an alcoholic povidone-iodine solution for patients with a history of chlorhexidine sensitivity. Allow the antiseptic to dry before inserting the catheter. 置管前用含酒精的葡萄糖酸洗必泰清洗穿刺点皮肤，如对碘剂过敏，使用含酒精的聚维酮碘消毒，待消毒剂干燥后置管 10 Do not apply organic solvents, e.g., acetone, ether, to the skin befo
13、re catheter insertion. 不要使用有机溶剂，如丙酮、乙醚等。 11 Do not routinely apply antimicrobial ointment to the catheter placement site prior to insertion. 置管前穿刺点不要使用抗生素软膏,Catheter and catheter site care,12 Before accessing the system, disinfect the external surfaces of the catheter hub and connection ports with a
14、n aqueous solution of chlorhexidine gluconate or povidone-iodine, unless contraindicated by the manufacturers recommendations. 接触前，要用葡萄糖酸洗必泰水溶液或聚维酮碘水溶液消毒导管活栓或接头的外表面，除非厂家禁止这样做 13 Use either a sterile gauze or transparent dressing to cover the catheter site. 用无菌纱布或透明贴膜覆盖置管点 14 If a gauze and tape cath
15、eter site dressing is used, it must be replaced when the dressing becomes damp, loosened, or soiled, or when inspection of the insertion site is necessary. 如果是使用纱布和胶布覆盖的，一旦浸湿、松脱或弄脏，或需要查看穿刺点时，要及时更换。 15 Do not apply antimicrobial ointment to CVC insertion sites as part of routine catheter site care. 不
16、要使用抗生素软膏处理穿刺点。 16 Routinely flush indwelling central venous catheters with an anticoagulant unless advised otherwise by the manufacturer. 常规使用抗凝剂冲洗置入的CVC，除非厂家有其它建议,Replacement strategies,17 Do not routinely replace non-tunnelled CVC as a method to prevent catheter-related infections. 不要把常规更换非管道性CVC作
17、为预防导管相关感染的方法 18 Use guide wire assisted catheter exchange to replace a malfunctioning catheter, or to exchange an existing catheter if there is no evidence of infection at the catheter site or proven CR-BSI. 借助导丝更换导管。 19 If CR-infection is suspected, but there is no evidence of infection at the cath
18、eter site, remove the existing catheter and insert a new catheter over a guide wire; if tests reveal CR-infection, the newly inserted catheter should be removed and, if still required, a new catheter inserted at a different site. 如果怀疑存在导管相关的感染，而置管点无明显的感染迹象，去掉原来的导管，在导丝引导下置入新管；如果检验显示存在导管相关的感染，去掉新置入的导管
19、，如仍然需要置管，另选穿刺点置入新管。,Replacement strategies,20 Do not use guide wire assisted catheter exchange for patients with CR-infection. If continued vascular access is required, remove the implicated catheter, and replace it with another catheter at a different insertion site. 患者有导管相关的感染时不采用借助导丝的导管更换。如果必须继续保
20、持血管通路，去掉受累导管，另取穿刺点置新管。 21 Replace all tubing when the vascular device is replaced. 更换血管装置的同时更换所有管路。 22 Replace intravenous tubing and stopcocks no more frequently than at 72-hour intervals, unless clinically indicated. 更换静脉内管道和活栓的间隔时间不能短于72小时，除非临床需要。 23 Replace intravenous tubing used to administer
21、blood, blood products, or lipid emulsions at the end of the infusion or within 24 hours of initiating the infusion. 若更换用于输血、血液制品、脂肪乳的静脉内管路，要在输注末或开始输注后24小时内更换。,Antibiotic prophylaxis,24 Do not administer systemic antimicrobials routinely before insertion or during use of a central venous catheter to
22、prevent catheter colonisation or bloodstream infection. 不要为了预防导管细菌生长或血行感染而常规给予全身应用抗菌素，不论是在插管前或在使用CVC中。,Preventing Complications of Central Venous Catheterization,N Engl J Med 2003;348:1123-33.,Interventions to Prevent infections,Use antimicrobial-impregnated catheters 使用外涂抗菌素的导管 Insert catheters at
23、the subclavian venous site 取锁骨下穿刺点置入导管 Use maximal sterile-barrier precautions during catheter insertion 在导管置入术中尽最大肯能采取无菌措施 Avoid the use of antibiotic ointments 避免使用抗生素软膏 Disinfect catheter hubs 消毒导管活栓 Do not schedule routine catheter changes 不要常规更换导管 Remove catheters when they are no longer needed
24、 如果不再需要，撤除导管,Use antimicrobial-impregnated catheters,The use of antimicrobial-impregnated catheters reduces the risk of catheter-related bloodstream infections and reduces costs when the rate of catheter-related bloodstream infection 2% 使用涂有抗菌素的导管减少导管相关的血流感染，当导管相关血流感染2%时减少花费。,Insert catheters at the
25、 subclavian venous site,The risk of catheter-related infection is lower with subclavian catheterization than with internal jugular or femoral catheterization 锁骨下静脉置管的导管相关感染风险小于颈内静脉或股静脉置管,Use maximal sterile-barrier precautions during catheter insertion,Use of a mask, cap, sterile gown, sterile glove
26、s, and large sterile drape reduces the rate of infections and reduces costs 戴口罩、帽子、无菌手套，穿无菌衣，覆盖无菌大单等能减少感染发生率，降低花费。,Avoid the use of antibiotic ointments,The application of antibiotic ointments increases the rate of colonization by fungi, promotes the development of antibiotic-resistant bacteria, and
27、 has not been shown to affect the risk of catheterrelated bloodstream infections 使用抗生素软膏增加真菌定殖率，增加耐药菌的产生，并不能降低导管相关血流感染的发生率,Disinfect catheter hubs,Catheter hubs are common sites of catheter contaminatio 导管活栓是导管污染的常见部位,Do not schedule routine catheter changes,Scheduled, routine replacement of central
28、 venous catheters at a new site does not reduce the risk of catheter-related bloodstream infection; scheduled, routine exchange of catheters over a guide wire is associated with a trend toward increased catheterrelated infections 有计划的、常规的CVC更换到新位置并不能降低导管相关血流感染的发生率；有计划的、常规的导丝引导下的导管更换有可能增加导管相关感染。,Remo
29、ve catheters when they are no longer needed,The probability of colonization and catheter-related bloodstream infection increases over time 随着时间推移，细菌定殖和导管相关血流感染的可能性增大。,Types of Catheter-Associated Infections,Catheter colonization导管细菌定殖 Growth of organisms from a catheter segment by either semiquantit
30、ative or quantitative culture 通过半定量或定量培养，使导管片段的微生物生长 Catheter-related bloodstream infection导管相关的血流感染 Isolation of the same organism from a blood culture and from a semiquantitative or quantitative culture of a catheter segment, accompanied by clinical symptoms of bloodstream infection without any ot
31、her apparent source of infection 血培养分理出的细菌与导管片段半定量或定量培养得到的细菌相同，并伴有血流感染的临床症状，而没有其它明显的感染源。 Exit-site infection出口感染 Erythema, tenderness, induration, or purulence within 2 cm of the exit site of the catheter 在导管出口2cm范围内出现红肿、触痛、硬结或化脓,Management of Suspected Catheter- Related Bloodstream Infection,Sepsis
32、 is defined as a systemic response to infection, manifested by two or more of the following conditions: temperature above 38.5C or below 36.0C; heart rate above 90 beats per minute; respiratory rate above 20 breaths per minute or partial pressure of arterial carbon dioxide below 32 mm Hg; and white-
33、cell count greater than 12,000 per cubic millimeter or less than 4000 per cubic millimeter or with 10 percent immature (band) forms. 脓毒症是指感染的全身反应，具有下列两条或两条以上的表现：体温高于38.5度或低于36度；心率高于90次/分；呼吸频率高于20次/分或动脉二氧化碳分压低于32mmHg；白细胞计数超过12000/mm3或低于4000/mm3或幼稚细胞达到10。,Management of Suspected Catheter- Related Bloo
34、dstream Infection,Septic shock is defined as sepsis-induced hypotension or a requirement for vasopressors or inotropic agents to maintain blood pressure despite adequate fluid resuscitation, along with the presence of perfusion abnormalities that may include (but are not limited to) lactic acidosis,
35、 oliguria, or acute alteration in mental status. 脓毒症性休克是指脓毒症诱发的低血压或在充分液体复苏下仍需要血管升压药或血管收缩药维持血压，伴有灌注异常，包括（但不限于）乳酸酸中毒、少尿、急性精神状态改变,Management of Suspected Catheter- Related Bloodstream Infection,When blood cultures are obtained, samples from peripheral sites are preferred. Cathetertip cultures should be
36、 performed by the semiquantitative or quantitative technique. 如果做血培养，最好是取周围位点的样本。导管尖培养应当采用定量或半定量方法。,Management of Suspected Catheter- Related Bloodstream Infection,Empirical antibiotic therapy for suspected catheter-related bloodstream infection should include vancomycin. Antibiotics that are effect
37、ive against gram-negative organisms should be added, especially if the patient is immunocompromised or has neutropenia, is infected with gram-negative organisms, or has other risk factors for infection with gram-negative organisms. In patients with a catheter-related bloodstream infection, treatment
38、 for more than 14 days is indicated in patients with endocarditis (duration of treatment, 4 to 6 weeks) or Staphylococcus aureus bacteremia (2 to 3 weeks). 怀疑导管相关血流感染时，进行经验性抗生素治疗要包括万古霉素。还要包括能有效对抗革兰氏阴性菌的抗生素，特别是当患者有免疫受损或中性粒细胞减少症时。有的患者至少治疗14天，有心内膜炎时治疗期为4-6周，金黄色葡萄球菌菌血症治疗2-3周。,临床路径,Guidelines for the Pre
39、vention of Intravascular Catheter Related Infections,Clinical Infectious Diseases 2002;35:1281-1307,MMWR 2002;51(No.RR-10):1-29,Eliminating catheter-related bloodstream infections in the intensive care unit.,Crit Care Med 2004; 32(10): 2014-2020,这是一篇由John Hopkins Hospital的ICU团队.利用一些实际的intervention将p
40、ractice guidelines转换为ICU里面的实际作为.包括每日执行checklist,评估病患需要CVC的indications,建立标准CVC catheterization的SOP, 对于相关人员的持续教育等等.对于整个ICU CRBSI感染率的影响.,The Effect of an Education Program on the Incidence of Central Venous Catheter-Associated Bloodstream Infection in a Medical ICU,Chest 2004; 126: 1612 - 1618.,也是类似的研究报告.可以提供对这个有兴趣的ICU成员们.想要setup相关program者的一个很好参考.,谢谢！,