临床医学血管导管和气管导管感染的相关问题课件

ICU常用导管1血管导管气管导管导尿管鼻胃管、鼻肠管引流管其他ICU的主要医院感染是什么？VAPCR-BSICR-UTI耐药菌感染其他2国际医院感染控制协会（INICC）公布的2002-2007院内感染的发生率3欧美已经将ICU感染列为重点4血管导管感染5CRBSI导管类型与感染发生率6外周静脉导管外周动脉导管中心静脉导管CVC中心动脉导管即肺动脉插管经外周静脉插至中心静脉的导管PICCs有隧道的中心静脉导管全植入式血管内装置TIDsINICC公布的2002-2007CRBSI总的发生率7相关性血源感染的严重程度8整体死亡率相关死亡率医院住院天数延长相关费用3189例次深静脉导管标本取得的514株病原菌分类中华急救医学2006年10月第26卷第10期病原菌G＋菌％病原菌G－菌％表皮葡萄球菌15.56铜绿假单胞菌13.23金黄色葡萄球菌13.8肺炎克雷伯菌7.59溶血葡萄球菌3.69鲍曼不动杆菌6.23屎肠球菌2.72阴沟肠杆菌2.53其他葡萄球菌2.53嗜麦芽窄食假单胞菌2.14粪肠球菌真菌1.56大肠埃希菌1.95未分类11.09白色念珠菌3.11热带念珠菌1.959CRBSI形成的机制10细菌移行内皮细胞机械损伤生物膜形成CRBSI感染途径11①

皮肤感染②

接头污染③

血源性感染④

输液感染①②③④CRBSI诊断－临床表现12IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45临床表现：发热、寒颤或置管部位红肿、硬结、或有脓液渗出。推荐意见：CRBSI的临床表现不典型，诊断需重视临床表现并结合实验室检查。CRBSI诊断－导管培养13IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45当怀疑CRBSI而拔除导管时，导管培养是诊断CRBSI

的金标准。定量培养和半定量培养技术是目前最可靠的诊断方法。

当怀疑CRBSI而拔除导管时，应同时对导管尖端进行培养。当怀疑CRBSI而拔除导管时应进行导管培养，不应常

规进行导管培养

。不推荐进行导管尖端的定性肉汤培养。对于CVC，应当进行导管尖端培养，而不是导管皮下段培养。CRBSI诊断－血培养14IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45导管尖端以及至少一次经皮穿刺留取的血培养分离到相同致病菌，即可确诊CRBSI。血培养诊断：只有15％－25％被证实存在感染。经皮穿刺留取血培养时，应仔细进行皮肤消毒，使用

酒精或碘酊或洗必太(＞0.5%)，不应使用碘伏；消毒

时应充分接触皮肤，然后等待足够长的时间待其干燥，以减少血培养污染的机会。经导管留取血培养时，应使用酒精或碘酊或洗必太(＞

0.5%)进行导管接头的消毒，而不应使用碘伏。CRBSI确诊标准至少包括以下各项中的1项：有1次半定量(每导管节段≥15

CFU)或定量(每导管节段≥1000CFU)导管培养阳性，从导管节段和外周血中分离出

相同的微生物(种属和抗生素敏感性)；从导管和外周静脉同时抽血做定量血培养，两者血培养菌

落计数（导管血：外周血）≥5：1；中心静脉导管和外周静脉同时抽血做定性血培养，中心静脉导管血培养阳性出现时间比外周血培养阳性至少

2h;外周血和导管出口部位脓液培养均阳性，为同一株微生物。15血管内导管相关感染的预防与治疗指南Basic

and

Special

Aproaches

for

theprevention

of

CRBSI16Marschall,J,et

al.ICHE,2009;29:S22-30Basic

PracticesCatheter

Checklist（导管置管流程表）Hand

Hygiene（洗手）Site

choice（置管位置选择）Catheter

Cart

or

Kit（置管包）Maximal

sterile

barriers（最大无菌化）Chlorhexidine

skin

antisepsis（洗必泰皮肤消毒）Special

PracticesChlorhexidine

Bathe（洗必泰冲洗）Coated

catheters（涂层导管）Antimicrobial

lock（抗生素封管）Maximal

sterile

barriers帽子口罩无菌手套无菌衣大范围的无菌辅巾1718Time

to

CRBSIbetween

baseline

period

and

intervention(hand

hygiene

and

cathetercare)

period

(p<0.02).

CVC,

central

venous

catheterHand

HygieneCrit

Care

Med

2009

Vol.

37,

No.

719Does

coated-catheter

reducethe

incidence

ofCRBSI?Study:

109

patients

were

enrolled

in

a

prospectiverandomised

study

comparing

the

colonisation

rates

ofchlorhexidine/silversulfadiazine-impregnatedCVCs(group

1)

against

standard

CVCs(group

2).

In

order

toassess

catheter

colonisation

rates,

a

4cm

segmentfromthe

tips

of

aseptically

removed

catheters

was

cultured

bythe

roll-plate

method.Result：The

colonisation

rates

were

29.4%

for

group

1and

34.5%forgroup2(P=0.50).Conclusion：Double-lumen

CVCs

impregnated

withchlorhexidine

and

silver

sulfadiazine

were

not

effectivein

reducing

the

incidence

of

catheter

colonisation

in

ICUpatients.20Camargo

LF,et

al.J

Hosp

Infect

2009;72:227-233Antimicrobial

lock部分文献显示有效，尤其对于免疫力低下的患者不能忽略抗生素治疗可能产生耐药21Use

of

Vancomycin-ContainingLock

or

Flush

can

reduceCRBSI?Conclusions.

Use

of

a

vancomycin

locksolutioninhigh-risk

patient

populations

being

treated

withlong-term

central

IVDs

reduces

the

risk

ofBSI.The

use

of

an

anti-infective

lock

solution

warrantsconsideration

for

patients

who

require

centralaccess

but

who

are

at

high

risk

of

BSI,

such

aspatients

with

malignancy

or

low-birthweightneonates.22Safdar

N,et

al.CID

2006;43:474-484CRBSI预防中的问题Not

Routinely

use

antimicrobial

prophylaxisNot

Routinely

replece

CVCs

or

arterial

cathetersNurse-to-patient

ratioand

use

offloat

nursesIntravenous

therapy

teams

of

reduce

CRBSIratesSurveillance

of

other

types

ofcatheters23CRBSI治疗策略24IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45MRSA发生率较高的医院推荐使用万古霉素进行经验性治疗；在多数MRSA分离株

的万古霉素MIC>2ug/mL的医院，则应使用其他药物，如达托霉素。CRBSI治疗策略25IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45应当根据当地抗生素敏感性资料以及疾病的严重程度决定经验性治疗是否需要覆盖革兰阴性杆菌（如四代头孢菌素，碳青霉

烯，β-内酰胺/β-内酰胺酶复合制剂，加或不加氨基糖甙类抗生素）。CRBSI治疗策略26IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45留置股静脉导管的危重病患者怀疑存在CRBSI时，经验性抗生素治疗除覆盖革兰阳性菌外，还应该覆盖革兰阴性杆菌及念珠菌属。CRBSI治疗策略27IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45对于具有下列危险因素的感染患者，应经验

性治疗可疑的导管相关性念珠菌血症：完全

胃肠外营养，长期使用广谱抗生素，血液系

统恶性肿瘤，骨髓或或实质脏器移植受体，

股静脉留置导管，全身多部位念珠菌属定植。CRBSI治疗策略28IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45对于可疑导管相关性念珠菌血症进行经验性治疗时，应使用棘白菌素类药物，拔除导管

后(>72

h)若真菌血症或菌血症仍持续存在，或者存在感染性心内膜炎或化脓性血栓性静脉炎，以及合并骨髓炎的患儿，抗生素疗程应为4-6周。CRBSI治疗策略29IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45金黄色葡萄球菌、铜绿假单胞菌、真菌或分

枝杆菌引起的CRBSI，应拔除导管。对于CRBSI患者，若想保留导管，应再次留取血培养

。CRBSI治疗策略30IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45发生导管隧道感染或输液港脓肿时应当拔除导管，必要时切开引流。如没有合并菌血症

或真菌血症，抗生素疗程为7-10天。怀疑导管出口部位感染的患者，应留取导管出口部位渗出液培养及血培养。CRBSI治疗策略31IDSA

Guidelines

for

Intravascular

Catheter-Related

Infection.CID

2009;49:1-45对于非复杂性CRBSI，如果拔除导管，抗生

素疗程为5-7天，若保留导管且联合应用抗生素封管治疗，抗生素疗程为10-14天。金黄色葡萄球菌CRBSI患者应拔除感染导管，并接受4-6周的抗生素治疗。气管导管相关感染32呼吸机相关性肺炎启动MV≥24h后发生的感染性肺炎，包括撤停呼吸机和拔除人工气道导管后

48h内发生的肺炎。MV最初4天内发生的肺炎为

发性VAP，≥5天者为晚发性VAP。33气管导管内壁定植菌气管导管内壁细菌的定植可发生于插管后

的12小时内，而以48小时达到高峰。在肺内所发现的细菌最早是和口咽部分泌物一致，其后和气管导管内壁上的定植菌一致，最后才和下呼吸道内细菌一致。European

Respiratory

Journal

1999;

13:546–551Journal

of

Clinical

Microbiology

2007;

45:1588–159334VAP致病因素和感染途径致病因素细菌在呼吸道和消化道的定植细菌侵入下呼吸道

感染途径吸入上呼吸道的菌丛来自不恰当的呼吸治疗细菌的血行播散35气管导管相关性肺炎（ETAP）36Endotracheal

Tube-associated

Pneumonia（ETAP）37ETAP发病机制38抑制咳嗽反射抑制纤毛清除功能损伤气管上皮细胞为细菌从进入下呼吸道提供直捷通路导管表面生物膜形成VAPorETAP39?气管导管40气管插管经鼻气管插管经口气管插管气管套管经鼻气管插管优点：插管操作方便，舒适，保留时间长。缺点：管径小，不易

引流，鼻窦炎。41经口气管插管优点：管腔大，易于吸痰。缺点：不宜长期使用，不便于口腔护

理，易误吸。42气管套管43保留时间长。纵隔完整性破坏。ARDS－纵隔气肿、皮下气肿。有创－无创序贯。死腔与生物膜44病原学

发性VAP(机械通气≤4天)：多为敏感菌，

如肺炎链球菌、流感嗜血杆菌、MSSA和敏感的肠道革兰阴性杆菌(如大肠杆菌、肺炎克雷伯杆菌、变形杆菌和粘质沙雷杆菌)。晚发性VAP(机械通气≥5天)：很可能是MDR细菌所致，包括铜绿假单胞菌、产ESBL的肺炎克雷伯杆菌和鲍曼不动杆菌、耐药肠道细

菌属、嗜麦芽窄食单胞菌，以及MRSA、MRSE等。45Am

J

Respir

Crit

Care

Med,

2005；171:388–416ICU呼吸机相关性肺炎的病原菌46江苏医药2007年11月33卷11期VAP预防措施Continuous

aspiration

of

subglottic

secretinsSilver-coated

ETTOral

hygienePeepProne

positionClosed

tracheal

suntion

systemsSelective

oropharyngeal

decontamination

andselective

digestive

tract

decontamination47Continuous

aspiration

of

subglotticsecretins（CASS）In

the

largest

trial

to

date

,

CASS

was

able

to

reduce

theincidence

density

of

VAP,

median

length

of

ICU

stay,and

antibiotic

use,

and

led

to

overall

cost

savings

in

thepostoperative

course

of

patients

undergoing

majorsurgery.The

recent

Canadian

Critical

Care

Trials

groupguideline

update

on

VAP

prevention

recommendssubglottic

secretion

drainage

in

patients

predicted

torequire

more

than

72

h

of

mechanical

ventilation.Muscedere

J,et

al.J

Crit

Care

2008;23:126–13748Bouza

E,et

al.Chest

2008;

134:938–946Silver-coated

ETTPatients

receiving

asilver-coated

endotracheal

tube

had

astatisticallysignificant

reduction

in

the

incidence

of

VAP

and

delayed

time

to

VAPoccurrence

compared

with

those

receiving

a

similar,

uncoated

tube.49Marin

H,et

al.Jama

2009;300(7):805-813Oral

hygieneSumma

Health

System

VAP

Rates

2003–200850Lorraine

B,et

al.

Journal

of

Neuroscience

Nursing

2008;40:291-298Peep51Manzano

F,et

al.CCM

2008;36:2225-2231Closed

tracheal

suctionz

systemsno

beneficial

effects

onVAP

incidence,mortality,

or

ICU

stay.higher

colonization

ofthe

respiratory

tract.52Siempos

II,

et

al.Br

J

Anaesth

2008;100:299–306Prone

position?Two

recent

meta-analyses

suggest

that

theprone

position

during

mechanical

ventilationdoes

not

reduce

mortality

or

duration

ofventilation

and

should

not

be

used

routinelyfor

acute

hypoxemic

respiratory

failure.

Thetwo

reports

are,

nevertheless,

contradictory

intheir

appreciation

of

the

VAP

incidencereduction.Sud

S,et

al.CMAJ2008;178:1153–1161Tiruvoipati

R,

et

al.J

Crit

Care

2008;23:101–11053selective

digestive

tract

decontamination

(SDD)selective

oropharyngeal

decontamination

(SOD)Design：Prospective

observational

study

of

determination

the

incidencerates

of

hospital

acquired

infections

(HAI)

during

the

first

14

days

afterICU

discharge

after

treatment

duringICU-stay

with

SDD,SOD

orStandard

Care

(SC).Results

：

Post-ICU

incidences

of

HAI

per 1,000days

at

risk

were11.2(SDD),

12.9(SOD)

and

8.3(SC)

in

ICU,

yielding

relative

risks,

ascompared

to

SC,

of

1.49

(0.9–2.47)

for

SOD

and

1.44

(0.87–2.39)

forSDD.

Incidences

of

surgical

site

infections

(per

100

surgical

procedures)were

4(SC)

and

11.8(SOD)

and

8(SOD).

Among

patients

thatsuccumbed

in

the

hospital

after

ICU-stay (

n

=

58) eight

(14%)

haddeveloped

HAI

after

ICU

discharge;

3

of

21

after

SDD,

3

of

15

afterSOD

and

2

of

22

after

SC.Conclusions：Incidences

of

HAI

in

general

wards

tended

to

be

higher

inpatients

that

had

received

either

SDD

or

SOD

during

ICU-stay,

but

itseems

unlikely

that

these

infections

have

an

effect

on

hospital

mortalityrates.54Anne

Marie

G,et

al.

Intensive

Care

Med

2009;35:1609–1613Does

the

orientation

of

the

tracheaeffect

bacterial

colonization

？Result：Pneumonia

was

found

in

6/8of

trachea-up

sheepand

the

samemicroorganisms

were

isolated

fromthe

lungs

and

the

proximaltrachea.No

pneumonia

was

found

in

trachea-down

sheep

(p＝0.007).Conclusions:

The

trachea

is

orientedabove

horizontal,

a

flow

of

mucusfrom

the

proximal

trachea

toward

thelungs

is

highly

associated

withbacterial

colonization

of

the

airwaysandpneumonia.Bassi

GL,et

al.Crit

Care

Med

2007;36:518–52555Novel

System

for

Complete

RemovalofSecre