2012 IDWeek 介绍宗志勇

四川大学华西医院医院感染管理科 感染性疾病中心

ID Week 4 个感染学会的联合年会• 美国感染病学会 IDSA• 美国医疗流行病学会 SHEA• 美国 HIV 医疗协会 HIVMA• 美国儿科感染病学会 PIDS

摘要和壁报下载https://idsa.confex.com/idsa/2012/webprogram/

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VAP 监测的改变• http://www.cdc.gov/nhsn/psc_da-vae.html

• 2013 年 1 月起 NHSN 改变监测 VAP 为 VAC（ VAE ） Ventilator-associated condition

Ventilator-associated complication 呼吸机相关并发症 Ventilator-associated event 呼吸机相关事件

VAC 监测适用人群：• ≥18 岁成人，接受机械通气≥ 3 天• 不包括：挽救性机械通气

（ HFV 、 ECMO 、俯卧位通气）

患者带机≥ 48h 且在氧疗恶化的前后 2 天内，如果同时具备以下两条： 1. T>38 或 <36 或者 WBC>12000 或 <4000 ；

2. 使用了一种新抗菌药物，并且连用至少 4 天 感染相关 VAC ， IVAC

患者氧疗恶化，较稳定期基线：1. 每日最低FiO2≥0.2超过2天；和/或2. PEEP≥3 cmH2O超过2天

VAC

患者≥2天通气情况（FiO2和PEEP）稳定或改善

开始监测

可能的 VAP ， possible VAP 以下两条中具备一条：• 脓性呼吸道分泌物：肺、气管、支气管分泌物在每低倍视

野中查见≥ 25 个白细胞和≤ 10 个鳞状上皮细胞；

• 痰、气管内抽吸物、支气管内灌洗液、肺组织或保护性毛刷培养阳性。

以下两条中具备至少一条：1. 脓性呼吸道分泌物：肺、气管、支气管分泌物在每低倍视野中

查见≥ 25 个白细胞和≤ 10 个鳞状上皮细胞，且具备以下一条：• 气管内抽吸物培养阳性， ≥ 105 CFU/ml• 支气管灌洗液培养阳性， ≥ 104 CFU/ml• 肺组织培养阳性，≥ 104 CFU/ml• 保护性毛刷培养阳性，≥ 103 CFU/ml

2. 以下任何一条（不需要脓性呼吸道分泌物）• 胸水培养阳性（留置引流管取标本培养阳性除外）• 肺组织病理阳性• 军团菌诊断试验阳性• 流感病毒、呼吸合胞病毒、腺病毒和副流感病毒诊断试验阳性

很可能的 VAP ， probable VAP

血透监测• 美国血透 CLABSI 37000 ， 6 例 100 病人月

A Four Year Experience with a Central Line Access-Related Bloodstream Infection (CL-ARB) Prevention Program in Six Outpatient Hemodialysis (HD) Centers

关于血透相关事件监测和防控资源CDC. CDC's Dialysis BSI Prevention Collaborative. 2012;http://www.cdc.gov/dialysis/provider/index.html.Recommendations for preventing transmission of infections among chronic

hemodialysis patients. MMWR Recomm Rep. 2001;50(RR-5):1-43.Patel PR, Kallen AJ, Arduino MJ. Epidemiology, surveillance, and prevention of

bloodstream infections in hemodialysis patients. American journal of kidney diseases 2010;56(3):566-577.

血透相关 BSI 的预防措施

Interventions included staff engagement and education to improve adherence to recommended practices, monthly feedback of CL-ARB rates, and participation in the CDC Dialysis BSI Prevention Collaborative. The Collaborative interventions included standard catheter care and vascular access practices including use of an observation audit tool to educate and assess compliance, participation in a catheter reduction initiative, use of an alcohol-based chlorhexidine solution for skin antisepsis, implementation of an enhanced catheter hub cleansing method, surveillance of hand hygiene and glove use, use of antimicrobial ointment at catheter exit sites, and patient education.

Surgical Site Infections after Craniotomy and Craniectomy: Risk Factors and Outcomes

1:3 配对研究 104 SSI 312 control

The Relationship of Operating Room Size, Length of Surgery and Surgical Site Infection Rates in Neurosurgical Procedures

• <64 平方米的手术室，感染风险增高

The Effect of Removal of Alcohol-Based Skin Prep on Operating Room Fires and Surgical Site Infection Rates

• After removal of alcohol prep, povidone-iodine and 4% chlohexadine gluconate were substituted as the standard skin prep agents.

SSI 监测多久合适？How Long is Long Enough? Determining the Optimal Surgical Site

Infection Surveillance Period

97% 的 SSI 发生在术后 6 个月内

Impact of Single Center Universal Screening followed by Universal Chlorhexidine (CHG) Bathing and Targeted Mupirocin Use in 3 ICUs on

Methicillin-Resistant Staphylococcus aureus (MRSA) and Vancomycin Resistant Enterococcus (VRE) Acquisition Rates

In 3 ICUs from a single center, a quality initiative of decolonization with universal CHG bathing and targeted mupirocin substantially reduced VRE acquisition, but did not prevent a VRE outbreak. Decolonization showed no effect on MRSA.

主动筛查 + 去定植对 MRSA 无效，但减少了 VRE 却未能阻止 VRE 暴发

Use of Fluorescent Marking Dye to Improve Compliance with Environmental Cleaning

• 美国约翰霍普金斯大学医院日常清洁中只有 43% 应该清洁的实际上清洁了，而出院后终末消毒有 60% 做好了清洁。通过教育、采取凝胶监测并反馈结果，日常清洁率提高到51% （ 8% 增长 , p = 0.03 ）、终末清洁率提高到了 70% （ 10% 增长 , p=0.06 ） .

Hospital Ward Design and Prevention of Nosocomial Infection and Colonization Events: A Prospective Clinical Trial

• 单间 vs 4 人间

全院改成 4 人间并未减少 HAIs

铜绿假单胞菌暴发An Outbreak of Pseudomonas aeruginosa Among

Cardiovascular Surgery Patients Related to Intrinsically-Contaminated Ultrasound Transmission Gel

• 经食道超声 凝胶污染• 16 例 PSA

戴手套前是否需要做手卫生？Utility of Hand Hygiene Before Donning Non-Sterile Gloves: A

Randomized Controlled Trial

• WHO Guidelines state that hand hygiene (HH) performed before donning non-sterile gloves is an unresolved issue.

• HH before donning non-sterile gloves does not decrease already low bacterial counts on gloves. The utility of HH before donning non-sterile gloves may be unnecessary; further study is needed to support current recommendations.

手卫生改善与多重耐药菌的降低Improved Hand Hygiene Compliance and Association with

Reduced Incidence of Multidrug-Resistant Organisms

• A sustained improvement in HH compliance was associated with an ongoing decrease in HO MDRO rates across a large healthcare system; a similar decrease in C. difficile was not observed.

Effectiveness of Ultraviolet (UV)-C light against C. difficile, Acinetobacter, and Vancomycin-Resistant Enterococci in the

Hospital Environment

隔帘的细菌污染情况Evaluation of Bacterial Contamination of Cubical Curtains in

Contact Precaution ICU and non-ICU Rooms

• Although no evidence of visible soiling, all curtains were positive for bacterial growth, as soon as 1 day after admission.

• The number of colonies isolated increased over time as the curtains remained in the patient rooms.

• Although most recovered bacteria were normal skin flora (i.e., Staph epidermidis and micrococcus), 2 curtains were contaminated with more ESO. A non-ICU curtain at day 1 contained 5 colonies/16 cm2 of methicillin sensitive Staph aureus, (MSSA) and an ICU curtain at 2 weeks contained 1 colony/16 cm2 of an extended spectrum beta lactamase (ESBL) producing Klebsiella pneumonia (KP).

• CC should only be used when privacy cannot be accomplished by other means.

• CC must be removed after a terminal clean in all contact isolation rooms. • CC in non-ICU rooms were just as likely to become contaminated as ICU

rooms.

中国的 HAI 现患率调查汇总Healthcare-associated Infection in Mainland China

A Systematic Review of Point Prevalence Survey Literature