經皮中心靜脈置管感染預防指南,梁大偉 天壇醫院神經內科,導管相關感染的診斷定義,局部感染定義： （ 1 ）局部自發或經觸壓后有膿性滲出，無需細菌學證據。 （ 2 ）穿刺部位的紅腫、發熱、硬結（三者中任兩者），及血清樣物質自發或觸壓后滲出，穿刺部位細菌培養陽性。,導管相關感染的診斷定義,菌血癥感染的定義： （ 1 ）外周血培養結果陽性，且為一種微生物，導管片段（近端或遠端）經定量或半定量方法分離出同一種微生物（種類及耐藥譜），無其它感染源。 （ 2 ）導管內回抽血定量培養出 10 倍于同時外周血培養的菌株。 （ 3 ）導管穿刺部位滲出的膿液、血清、血漿樣物質或導管皮下部分、皮下埋植部分培養與外周血培養出同一種細菌（種類及耐藥譜）。,導管相關感染的診斷定義,可能感染的定義包括： （ 1 ）兩次或兩次以上血培養（無論是外周血還是中心靜脈回抽血）出同一種細菌（種類及耐藥譜），且臨床及實驗室證實無其它感染源。 （ 2 ）一次陽性血培養結果為 或念球菌（無論是外周血還是中心靜脈回抽血），且臨床及實驗室證實無其它感染源。 （ 3 ）免疫抑制或粒細胞減少（粒細胞 500ul ）的病人，血培養陽性（凝固酶陰性的葡萄球菌，桿菌屬，棒狀桿菌屬，糠秕馬拉色霉菌等），臨床及實驗室證實無其它細菌感染源，只有中心靜脈留置導管，通常與導管相關性菌血癥有關。,CVC引起相關感染的機制,1. infection of 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.,病原體,若不幸感染,常見的菌種包括: Coagulase-negative staphylococci (37%), Staphylococcus aureus (13%), Enterococcus (13%), Gram-negative rods (14%). 值得注意的是,抗藥性強的菌種包括staph.以及Enterococcus都榜上有名所以如果不幸發生感染多半就非得要用上vancomycin可能不行還要用上linezolid相當的麻煩 另外一個值得注意的是fungifungi的感染扮演部分角色(在NNIS的數據中是8%)在Candidia的感染中,大約一半是non-albican species造成的.包括C. glabrata與C. krusei這些fungi對fluconazole容易產生抗藥性.,Guidelines for preventing infections associated with the insertion and maintenance of central venous catheters 中心靜脈置管相關性感染的預防指南,Journal of Hospital Infection (2001) 47(Supplement): S5S9,Intervention 1: Selection of catheter type 導管類型的選擇 Intervention 2: Selection of catheter insertion site 置管點的選擇 Intervention 3: Optimum aseptic technique during catheter insertion 置管過程中無菌技術的最優化 Intervention 4: Cutaneous antisepsis 皮膚消毒 Intervention 5: Catheter and catheter site care 導管和置管點的護理 Intervention 6: Replacement strategies 更換方法 Intervention 7: Antibiotic prophylaxis 預防性使用抗生素,Selection of catheter type,1 Use a single-lumen catheter unless multiple ports are essential for the management of the patient. 盡量采用單腔管，除非患者需要多通道治療， 2 If total parenteral nutrition is being administered, use one central venous catheter or lumen exclusively for that purpose. 如果需要TPN，專用一根中心靜脈導管或專用一個管腔 3 Use a tunnelled catheter or an implantable vascular access device for patients in whom long-term (30 days) vascular access is anticipated. 如果預計要長時間（30天）保留血管通路，采用管道式導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 high risk for CR-BSI. 需短期（10天）保留CVC者，并且是導管相關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. 選擇置管位點時，要權衡感染風險和機械并發癥的風險 6 Unless medically contraindicated, use the subclavian site in preference to the jugular or femoral sites for nontunnelled catheter placement. 做非管道性置管，如無禁忌，采用鎖骨下置管好于頸靜脈或股靜脈置管 7 Consider the use of peripherally inserted catheters as an alternative to subclavian or jugular vein catheterisation. 外周靜脈置管可作為鎖骨下置管或頸靜脈置管的替代方法,Optimum aseptic technique 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. 置管時采用最佳的無菌技術，穿無菌衣，戴無菌手套，蓋無菌單,Cutaneous antisepsis,9 Clean the skin site with an alcoholic chlorhexidine gluconate solution prior to 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點皮膚，如對碘劑過敏，使用含酒精的聚維酮碘消毒，待消毒劑干燥后置管 10 Do not apply organic solvents, e.g., acetone, ether, to the skin before catheter insertion. 不要使用有機溶劑，如丙酮、乙醚等。 11 Do not routinely apply antimicrobial ointment to the catheter placement site prior to insertion. 置管前穿刺點不要使用抗生素軟膏,Catheter and catheter site care,12 Before accessing the system, disinfect the external surfaces of the catheter hub and connection ports with an aqueous solution of chlorhexidine gluconate or povidone-iodine, unless contraindicated by the manufacturers recommendations. 接觸前，要用葡萄糖酸洗必泰水溶液或聚維酮碘水溶液消毒導管活栓或接頭的外表面，除非廠家禁止這樣做 13 Use either a sterile gauze or transparent dressing to cover the catheter site. 用無菌紗布或透明貼膜覆蓋置管點 14 If a gauze and tape catheter 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. 如果是使用紗布和膠布覆蓋的，一旦浸濕、松脫或弄臟，或需要查看穿刺點時，要及時更換。 15 Do not apply antimicrobial ointment to CVC insertion sites as part of routine catheter site care. 不要使用抗生素軟膏處理穿刺點。 16 Routinely flush indwelling central venous catheters with an anticoagulant unless advised otherwise by the manufacturer. 常規使用抗凝劑沖洗置入的CVC，除非廠家有其它建議,Replacement strategies,17 Do not routinely replace non-tunnelled CVC as a method to prevent catheter-related infections. 不要把常規更換非管道性CVC作為預防導管相關感染的方法 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. 借助導絲更換導管。 19 If CR-infection is suspected, but there is no evidence of infection at the catheter 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. 如果懷疑存在導管相關的感染，而置管點無明顯的感染跡象，去掉原來的導管，在導絲引導下置入新管；如果檢驗顯示存在導管相關的感染，去掉新置入的導管，如仍然需要置管，另選穿刺點置入新管。,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. 患者有導管相關的感染時不采用借助導絲的導管更換。如果必須繼續保持血管通路，去掉受累導管，另取穿刺點置新管。 21 Replace all tubing when the vascular device is replaced. 更換血管裝置的同時更換所有管路。 22 Replace intravenous tubing and stopcocks no more frequently than at 72-hour intervals, unless clinically indicated. 更換靜脈內管道和活栓的間隔時間不能短于72小時，除非臨床需要。 23 Replace intravenous tubing used to administer blood, blood products, or lipid emulsions at the end of the infusion or within 24 hours of initiating the infusion. 若更換用于輸血、血液制品、脂肪乳的靜脈內管路，要在輸注末或開始輸注后24小時內更換。,Antibiotic prophylaxis,24 Do not administer systemic antimicrobials routinely before insertion or during use of a central venous catheter to prevent catheter colonisation or bloodstream infection. 不要為了預防導管細菌生長或血行感染而常規給予全身應用抗菌素，不論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 使用外涂抗菌素的導管 Insert catheters at the subclavian venous site 取鎖骨下穿刺點置入導管 Use maximal sterile-barrier precautions during catheter insertion 在導管置入術中盡最大肯能采取無菌措施 Avoid the use of antibiotic ointments 避免使用抗生素軟膏 Disinfect catheter hubs 消毒導管活栓 Do not schedule routine catheter changes 不要常規更換導管 Remove catheters when they are no longer needed 如果不再需要，撤除導管,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% 使用涂有抗菌素的導管減少導管相關的血流感染，當導管相關血流感染2%時減少花費。,Insert catheters at the subclavian venous site,The risk of catheter-related infection is lower with subclavian catheterization than with internal jugular or femoral catheterization 鎖骨下靜脈置管的導管相關感染風險小于頸內靜脈或股靜脈置管,Use maximal sterile-barrier precautions during catheter insertion,Use of a mask, cap, sterile gown, sterile gloves, and large sterile drape reduces the rate of infections and reduces costs 戴口罩、帽子、無菌手套，穿無菌衣，覆蓋無菌大單等能減少感染發生率，降低花費。,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 has not been shown to affect the risk of catheterrelated bloodstream infections 使用抗生素軟膏增加真菌定殖率，增加耐藥菌的產生，并不能降低導管相關血流感染的發生率,Disinfect catheter hubs,Catheter hubs are common sites of catheter contaminatio 導管活栓是導管污染的常見部位,Do not schedule routine catheter changes,Scheduled, routine replacement of central 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 有計劃的、常規的CVC更換到新位置并不能降低導管相關血流感染的發生率；有計劃的、常規的導絲引導下的導管更換有可能增加導管相關感染。,Remove catheters when they are no longer needed,The probability of colonization and catheter-related bloodstream infection increases over time 隨著時間推移，細菌定殖和導管相關血流感染的可能性增大。,Types of Catheter-Associated Infections,Catheter colonization導管細菌定殖 Growth of organisms from a catheter segment by either semiquantitative or quantitative culture 通過半定量或定量培養，使導管片段的微生物生長 Catheter-related bloodstream infection導管相關的血流感染 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 other apparent source of infection 血培養分理出的細菌與導管片段半定量或定量培養得到的細菌相同，并伴有血流感染的臨床癥狀，而沒有其它明顯的感染源。 Exit-site infection出口感染 Erythema, tenderness, induration, or purulence within 2 cm of the exit site of the catheter 在導管出口2cm范圍內出現紅腫、觸痛、硬結或化膿,Management of Suspected Catheter- Related Bloodstream Infection,Sepsis 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-cell count greater than 12,000 per cubic millimeter or less than 4000 per cubic millimeter or with 10 percent immature (band) forms. 膿毒癥是指感染的全身反應，具有下列兩條或兩條以上的表現：體溫高于38.5度或低于36度；心率高于90次/分；呼吸頻率高于20次/分或動脈二氧化碳分壓低于32mmHg；白細胞計數超過12000/mm3或低于4000/mm3或幼稚細胞達到10。,Management of Suspected Catheter- Related Bloodstream 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, oliguria, or acute alteration in mental status. 膿毒癥性休克是指膿毒癥誘發的低血壓或在充分液體復蘇下仍需要血管升壓藥或血管收縮藥維持血壓，伴有灌注異常，包括（但不限于）乳酸酸中毒、少尿、急性精神狀態改變,Management of Suspected Catheter- Related Bloodstream Infection,When blood cultures are obtained, samples from peripheral sites are preferred. Cathetertip cultures should be performed by the semiquantitative or quantitative technique. 如果做血培養，最好是取周圍位點的樣本。導管尖培養應當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 effective against gram-negative organisms should be