Central venous catheter-related bloodstream infections: an analysis of incidence and risk factors in a cohort of 400 patients

Objective: To determine the incidence of central catheter-related bloodstream infection (CR-BSI) and to compare patient and catheter characteristics of those with and without CR-BSI from a clinically suspected subgroup. Secondly, to assess the efficacy of the acridine orange leucocyte cytospin test (AOLC) as a rapid in situ method of detecting central venous catheter (CVC) infection. Design: One-year prospective audit. Setting: Intensive care unit/high dependency unit (ICU/HDU) and general wards of a tertiary referral hospital. Patients and participants: 400 patients with non-tunnelled CVCs. Interventions: Daily surveillance, blood culture from peripheral venepuncture, blood sample from the CVC for assessment of the AOLC test and removal of suspected CVCs were carried out on patients clinically suspected of having CR-BSI. Measurements and results: CR-BSI was diagnosed using well defined criteria. Infection rate was calculated by dividing the number of definitive catheter associated infections by the total number of appropriate catheter in situ days. The AOLC test was performed on all those with suspected CR-BSI. A total of 499 CVCs in 400 patients were assessed, representing 3014 catheter in situ days. Over 80 % of patients were from our ICU/HDU, representing 404 CVCs and 1901 catheter in situ days. A total of 49/499 (9.8 %) CVCs in the same number of patients were suspected of being infected subsequently 12/499 (2.4 %) CVCs [95 % confidence interval (CI) 1.25 to 4.16] in 12 separate patients were demonstrated to be the direct cause of the patient's BSI. Rates of CR-BSI per 1000 catheter days were 3.98 (95 % CI 2.06 to 6.96) for the whole cohort and 4.20 (95 % CI 1.81 to 8.29) for the ICU/HDU subgroup. In the group suspected of having CR-BSI, CVCs were removed unnecessarily in 55 %, and no patient or catheter variables measured were predictive of the development of CR-BSI. The AOLC test was negative in all 12 catheters subsequently shown to be the definitive cause of BSI. Conclusions: We have defined the incidence of CR-BSI in a cohort of patients from a tertiary referral hospital, the rates comparing favourably with those reported for similar populations. We were unable to demonstrate significant differences in any patient or catheter variables between those with and without CR-BSI. The AOLC test used alone was unhelpful as a method to diagnose in situ CVC infection in this patient population. Received: 26 February 1998 Accepted: 30 June 1998     

中心静脉导管相关性感染

目的：探讨导管相关性感染(CRI)的病原学及临床特点。方法：回顾分析2001年1月-2003年6月期间我院1327例次中心静脉置管病例中确诊的24例CRI病例，分析其病原体分布，感染与静脉导管留置类型、时间的关系。结果：CRI病例中，留置单腔导管者9例，留置双腔导管者15例。共分离菌株25株，其中革兰阳性菌12株．革兰阴性菌7株．真菌6株。金黄色葡萄球菌最多见(7株)，其次是真菌(6株)。CRI以置管后第8～14天发生率最高(56％)。结论：预防的重点在于避免导管腔内及腔外的污染。重视穿刺点皮肤的消毒，选用单腔导管，减少不必要的间置装置，操作者水平的提高以及抗生素的合理应用均能有效减少CRI的发生。对怀疑CRI者不应立即拔管，可先试行抗生素锁治疗，在24～48h后无效者应立即拔除导管。对于免疫功能低下、感染不易控制、病情严重以及金黄色葡萄球菌或真菌感染的病例。应及时拔除导管。     

The wandering central venous catheter

A subclavian central venous catheter wandered spontaneously between the superior caval and the internal jugular veins. The case supports the routine of regular X-ray checks for catheter position.     

A survey of central venous catheter practices in Australian and New Zealand tertiary neonatal units

BackgroundInfection is the most common problem with central venous catheters (CVCs) in neonates. There are two published guidelines, including the Centers for Disease Control and Prevention (CDC), for the prevention of intravascular catheter-related infection that describes evidence-based practice to reduce nosocomial infection.ObjectiveOur aims were to survey current medical and nursing management of central venous catheters in tertiary neonatal intensive care units in Australia and New Zealand and to compare with the CDC evidence-based practice guideline.MethodsA cross sectional survey was performed across 27 Australian and New Zealand neonatal units in September 2012. Two web-based questionnaires were distributed, one to medical directors related to the insertion of CVCs while CVC “maintenance” surveys were sent to nurse unit managers.ResultsSeventy percent (19/27) medical management and 59% (16/27) on nursing management surveys were completed. In all neonatal intensive care units (NICUs) there were guidelines for CVC maintenance and for 18 out of 19 there were guidelines for insertion. In the seven units using femoral lines, three had a guideline on insertion and four for maintenance. CVC insertion was restricted to credentialed staff in 57.9% of neonatal units. Only 26.5% used full maximal sterile barriers for insertion. Skin disinfection practices widely varied. Dressing use and dressing change regimens were standardised; all using a semi-permeable dressing. Duration of cleaning time of the access point varied significantly; however, the majority used a chlorhexidine with alcohol solution (68.8%). Line and fluid changes varied from daily to 96 h. The majority used sterile gloves and a sterile dressing pack to access the CVC (68.8%). In the majority of NICUs stopcocks were used (62.5%) with a needle-less access point attached (87.5%). In less than 50% of NICUs education was provided on insertion and maintenance.ConclusionThere is diversity of current practices and some aspects vary from the CDC guideline. There is a need to review NICU current practices to align with evidence based guidelines. The introduction of a common guideline may reduce variations in practice.     

血液透析患者临时中心静脉导管相关感染的回顾性研究

目的 通过对临床病例资料的回顾性研究,探讨使用临时中心静脉导管的血液透析患者发生中心静脉导管相关感染（Central venous catheters related infections,CVC-RI）的情况及危险因素.方法 以同济大学附属东方医院肾内科2010年1月至2013年6月临时中心静脉插管的132例血液透析患者为研究对象,收集资料,分析CVC-RI的发生情况及危险因素.结果 ①132例患者中,共行中心静脉置管术149例次,符合中心静脉导管相关感染诊断标准的病人31例,CVC-RI发病率为23.5％.②置管后发生感染的时间最短9d,最长41d,不同置管时间的感染率有统计学差异（P＜0.05）.③颈内静脉和股静脉置管的感染分别为13例（41.9％）和18例（58.1％）.二者比较无统计学意义（P＞0.05）.④CVC-RI患者相关培养中革兰阳性菌17例（54.8％）和革兰阴性菌14例（45.2％）,二者比较无统计学差异（P＞0.05）.⑤年龄、留置时间、穿刺过程是否顺利、有无他处感染、糖尿病、是否使用免疫抑制剂均是导致CVC-RI的危险因素（P＜0.05）.结论 ①年龄、留置时间、穿刺过程是否顺利、有无他处感染、糖尿病、是否使用免疫抑制剂是导致CVC-RI的危险因素.②静脉置管时间大于2周的患者CVC-RI发生率明显增高.③颈内静脉和股静脉置管患者CVC-RI的发生无明显差异.④CVC-RI患者中革兰阳性菌和阴性菌发生感染的比例无明显差异.     

心胸外科中心静脉导管感染患者的相关因素分析及预防对策

目的探讨并分析心胸外科中心静脉导管感染的相关因素及预防对策。方法2002年1月-2005年12月，随机抽取行中心静脉穿刺患者560例。治疗结束后，取导管尖端进行细菌培养，并对结果进行分析。结果引起心胸外科深静脉置管相关感染的病原菌中，葡萄球菌占50％，真菌占16．7％；深静脉置管3，4，5周的感染率分别为24．5％、35．6％和65．2％；普胸手术及开放性胸外伤患者导管感染发生率分别为14．8％、18．0％，高于心脏手术及化疗患者；锁骨下静脉穿刺及贵要静脉置管感染发生率（9．6％、9．4％）低于颈内静脉（18．7％）。结论引起心胸外科深静脉置管相关感染的病原菌以葡萄球菌为首位病原菌；深静脉留置时间愈长，则导管感染率越高；普胸手术及开放性胸外伤患者导管感染发生率显著高于心脏手术及化疗患者；锁骨下静脉穿刺及贵要静脉置管感染发生率低于颈内静脉。严格深静脉置管护理和缩短留置时间对防止相关性感染具有重要临床意义。     

Prevention of central venous line associated bloodstream infections in adult intensive care units: A systematic review

BackgroundIn adult Intensive Care Units, the complexity of patient treatment requirements make the use of central venous lines essential. Despite the potential benefits central venous lines can have for patients, there is a high risk of bloodstream infection associated with these catheters.AimIdentify and critique the best available evidence regarding interventions to prevent central venous line associated bloodstream infections in adult intensive care unit patients other than anti-microbial catheters.MethodsA systematic review of studies published from January 2007 to February 2016 was undertaken. A systematic search of seven databases was carried out: MEDLINE; CINAHL Plus; EMBASE; PubMed; Cochrane Library; Scopus and Google Scholar. Studies were critically appraised by three independent reviewers prior to inclusion.ResultsNineteen studies were included. A range of interventions were found to be used for the prevention or reduction of central venous line associated bloodstream infections. These interventions included dressings, closed infusion systems, aseptic skin preparation, central venous line bundles, quality improvement initiatives, education, an extra staff in the Intensive Care Unit and the participation in the ‘On the CUSP: Stop Blood Stream Infections' national programme.ConclusionsCentral venous line associated bloodstream infections can be reduced by a range of interventions including closed infusion systems, aseptic technique during insertion and management of the central venous line, early removal of central venous lines and appropriate site selection.     

中心静脉导管细菌定植和相关菌血症

目的：研究中心静脉导管(CVC)细菌定植和相关菌血症的发生情况和细菌谱及其临床危险因素。方法：对96例CVC留置病人的临床资料、血培养和导管培养的细菌学结果、导管细菌定植和相关菌血症的危险因素进行统计学分析。结果：发生CVC细菌定植57例(59．4％)，其中金黄色葡萄球菌5例；表皮葡萄球菌8例；溶血葡萄球菌10例；肠球菌2例；念珠菌9例；铜绿假单胞菌5例；大肠埃希菌、肺炎克雷伯菌各3例；多种细菌混合感染7例；其他细菌5例。革兰阳性球菌中甲氧西林耐药葡萄球菌(MRS)21例(21／25，84％)，革兰阴性杆菌中产超广谱β内酰胺酶(ESBLs)10例(10／16，63．6％)，念珠菌中耐氟康唑6例。CVC相关菌血症23例(23．9％)。经非条件Logistic回归分析发现CVC停留时间(OR=3．92)、置管位置(OR=1．24)和经CVC肠道外营养(OR=3．62)、病人年龄(OR=1.02)等因素的OR值大于1。结论：CVC细菌定植和相关菌血症发生率甚高．细菌为常见定植菌，耐药现象严重。CVC导管滞留时间、插管部位、经CVC肠道外营养、病人年龄是CVC细菌定植和相关菌血症的临床危险因素。     

Transient vocal cord paralysis following central venous hemodialysis catheter insertion

In this article, we present a case of recurrent laryngeal nerve palsy not caused by nerve injury but due to local anesthetic infiltration that was applied prior to central venous catheterization. A 47-year-old female patient was admitted to emergency room with fatigue and nausea and was diagnosed with acute renal failure. Right jugular venous catheterization was performed for emergency hemodialysis with Seldinger technique using middle approach. Within minutes and immediately after the procedure the patient complained of hoarseness and shortness of breath, and she had stridor in her physical exam. Awake flexible fibreoptic laryngoscopy revealed unilateral right-sided vocal cord paralysis with no edema. The patient was asked to remain nil per os and observed in ER with nasal oxygen. At the 3rd hour of follow-up without any other intervention, her symptoms resolved. Due to its proximity to the internal jugular vein injury to the recurrent laryngeal nerve while attempting to insert a central venous line can occur, particularly with difficult and repeated attempts. Local anesthesia led temporary ipsilateral vocal cord paralysis in patients undergoing carotid endarterectomy is described in literature. We think temporary vocal cord palsy in our case was due to local anesthetic infiltration rather than nerve injury, since it resolved spontaneously within only hours. Expectant treatment is a good choice ensuring the patient's airway is safe. Emergency physicians should be aware of this rare complication and its right management.     

中心静脉导管代替胸腔穿刺引流治疗胸腔积液的临床观察

目的 简述中心静脉导管代替胸腔穿刺引流治疗胸腔积液的临床观察与疗效分析.方法 将我院100例胸腔积液住院患者随机分为两组:治疗组50例,给于中心静脉导管引流治疗胸腔积液;对照组50例,给于常规胸腔穿刺引流治疗胸腔积液.对其两组患者进行治疗方法及临床疗效观察分析总结.结果 治疗组(50例)完全吸收27例占54%、部分吸收11例占22%、不变化6例占12%、进展6例占12%.对照组(50例)完全吸收16例占32%、部分吸收13例占26%、不变化10例占20%、进展11例占22%.结论 中心静脉导管代替胸腔穿刺引流治疗胸腔积液其患者耐受好,操作简单,适合胸腔积液患者的治疗,适用于临床推广应用.     

血液透析患者中心静脉留置导管失功原因与处理

目的提高对中心静脉留置导管失功的认识和诊治水平,改善血液透析患者预后。方法分析156例中心静脉置管的维持性血液透析患者。采用Seldinger技术置管,其中36例为长期双腔导管,120例为临时双腔导管。结果导管失功有两大类：①导管通路功能障碍22例,原因以导管血栓形成为主（占59％）,导管纤维外鞘形成是长期双腔导管功能障碍的另一个重要因素,在导管使用过程发生;于置管后即刻发生者多由导管打折、贴壁等技术因素引起;②导管相关性感染27例：糖尿病肾病（DN）患者感染发生率显著高于非DN患者;股静脉置管的感染发生率显著高于颈内静脉置管;临时导管感染发生率显著高于长期导管,且留置越久,临时导管感染发生率越高。结论导管内血栓形成是两类导管通路障碍的主要原因,长期双腔导管发生障碍的重要原因还有纤维外鞘;临时导管留置时间延长及会增加感染的机会,影响感染的因素还有糖尿病和置管部位;需长期留置导管时,应用带涤纶套的导管可明显减少感染。     

中心静脉导管相关性感染的分析及预防

目的:探讨引起中心静脉导管相关性感染的因素、菌群分布及预防对策。方法:对本院2003年1月~2005年10月620例住院患者的中心静脉留置导管进行菌种分离鉴定及统计分析。结果:本组总体相关性感染率约25%,留置导管2周以上的感染率明显升高,常见病原体为葡萄球菌、鲍曼不动杆菌、洋葱伯克霍尔德菌及念珠菌等。结论:中心静脉导管相关感染的病原体主要为源于体表的正常菌群,严格的无菌操作、缩短置管时间及合理使用抗生素对防止导管相关性感染具有重要意义。     

品管圈活动在降低ICU中心静脉置管患者非计划性拔管中的应用

目的:探讨品管圈活动在降低ICU中心静脉置管患者非计划性拔管中的应用效果。方法:选择2011年4～12月ICU中心静脉置管患者133例作为对照组,实行常规护理;选择2012年1～9月ICU中心静脉置管患者133例作为观察组,成立品管圈,运用品管圈PDCA循环管理方法,确立"降低ICU中心静脉置管患者非计划性拔管率"为活动主题,设定目标,分析原因及制定对策。比较两组患者非计划性拔管率。结果:通过圈员参与该项活动,实施品管圈活动后观察组患者非计划性拔管率低于对照组(P<0.05)。结论:品管圈活动对降低ICU中心静脉置管患者非计划性拔管率效果显著,运用品管圈管理方法管理ICU中心静脉置管患者,确保了患者安全,提高了护理质量。     

集束化护理对ICU留置中心静脉导管患者护理质量及感染预防的影响

目的 探讨集束化护理对ICU留置中心静脉导管患者护理质量及感染预防的影响.方法 选取2013年1月至2015年12月我院ICU留置中心静脉导管患者180例为研究对象,随机分为观察组和对照组各90例.观察组实施集束化护理,对照组实施常规护理.比较两组患者的护理质量及感染预防效果.结果 观察组患者穿刺点感染、导管相关性血流感染率均低于对照组,差异有统计学意义(P<0.05);观察组患者导管脱出、堵管、血栓及非计划性拔管发生率均低于对照组,差异有统计学意义(P<0.05);观察组患者导管留置天数和住院天数均均短于对照组,差异有统计学意义(P<0.05);观察组患者护理满意度明显高于对照组,差异有统计学意义(P<0.05);观察组患者经护理后的各项生活质量评分均明显高于对照组,差异有统计学意义(P<0.05).结论集束化护理能够降低和预防ICU留置中心静脉导管患者的感染率及其他并发症发生率,减少非计划性拔管发生率,缩短置管时间和住院时间,提高患者护理满意度和生活质量,建议在临床上推广应用.     

Central venous catheter dressings: a systematic review

BACKGROUND: Gauze and tape or transparent polyurethane film dressings such as Tegaderm, Opsite or Opsite IV3000 are the most common types of dressing used to secure central venous catheters (CVCs). Currently, there are no clear guidelines as to which type of dressing is the most appropriate. AIMS: To identify whether there are any differences between gauze and tape and/or transparent polyurethane film dressings in the incidence of CVC-related infection, catheter-related sepsis, catheter security, tolerance to dressing material, dressing condition and ease of application in hospitalized patients. METHODS: The Cochrane Controlled Trials Register and Medline, Embase and CancerLit databases were searched to identify any controlled trials comparing the effects of gauze and tape and/or transparent polyurethane dressings on CVCs. Additional references were sought from published and non-published literature. Twenty-three studies were reviewed. Data were extracted independently from each paper by two members of the review team and results compared. Differences were resolved either by consensus or referral to a third person. Authors were contacted for missing information. RESULTS: Of the 23 studies reviewed, 15 were excluded. Of the remaining eight, data were available for meta-analysis from six studies. Of the six included studies, two compared gauze and tape with Opsite IV3000, two compared Opsite with Opsite IV3000, one compared Tegaderm with Opsite IV3000, and one compared Tegaderm with Opsite. CONCLUSIONS: There was no evidence of any difference in the incidence of infectious complications between any of the dressing types compared in this review. Each of these comparisons was based on no more than two studies and all of these studies reported data from a small patient sample. Therefore it is unlikely that any of these comparisons would have had sufficient power to detect any differences between groups.     

心脏外科术后中心静脉导管相关感染致病菌及危险因素分析

目的 研究心脏外科术后中心静脉导管相关感染(CRI)、导管相关性菌血症(CRB)的发生率和菌群分布状况,以及CRI的危险因素,为临床科学管理中心静脉导管,降低CRI、CRB的发病率提供有益的参考.方法 自2005年1月至2005年12月共随机选取在心脏外科手术治疗的300例患者留置的中心静脉导管进行尖端细菌培养,同时进行血培养.结果 300例中35例(11.7%)发生CBI,CBB 5例(1.7%).病原菌菌群分布:革兰阳性球菌占54.3%,革兰阴性杆菌占34.3%.真菌占11.4%.前5位致病菌分别为:表皮葡萄球茵、金黄色葡萄球菌、肺炎克雷白杆菌、铜绿假单胞杆茵、白色念珠菌.CRl、CRB的危险因素包括:原发疾病种类、穿刺置管部位、中心静脉导管留置时间等.中心静脉导管留置时间>6d,感染率明显增加.结论 CBI、CBB是留置中心静脉导管最严重的并发症,旱期诊断、及时合理应用抗生素对降低病死率具有重要的意义.     

Impact of MaxZero™ needle-free connector on the incidence of central venous catheter-related infections in surgical intensive care unit

Background

Central venous catheter-related infections (CRIs) are a complication of central venous catheters in intensive care unit (ICU). Some needle-free connectors have been designed to decrease CRI, but there is a lack of data concerning their impact on infection.

经外周导入中心静脉置管的相关问题及应用

对近年来国内外外周导入中心静脉置管(PICC)置管前置管中、置管后的相关问题及临床应用等方面进行了综述.其目的 是对PICC相关的知识予以总结,给广大护理人员以借鉴.     

中心静脉导管留置感染的相关因素分析及预防对策

目的:探讨中心静脉导管留置感染的相关因素及预防对策。方法:根据中心静脉导管留置时间分为Ⅰ组、Ⅱ组、Ⅲ组,按穿刺部位分为颈内静脉置管组(A组)和股静脉置管组(B组)。比较其局部感染和导管堵塞发生率。结果:导管留置时间大于15d组(Ⅲ组)局部感染和导管堵塞发生率最高;股静脉置管组局部感染和导管堵塞发生率高于颈内静脉置管组。结论:局部感染和导管堵塞的发生与中心静脉留置时间有关,颈内静脉置管组优于股静脉置管组。