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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，如仍然需要置管，另选穿刺点置入新管。,
