住院病人留置中央靜脈導管相關血流感染之危險因素

Risk Factors of Retained Central Venous Catheter Associated Bloodstream Infections in Hospitalized Patients

10.6224/JN.201810_65(5).09

孫淑美(Shu-Mei SUN)；陳瑛瑛(Yin-Yin CHEN)

不合理留置 ； 中央靜脈導管 ； 導管相關血流感染 ； retained inappropriate ； central venous catheter ； catheter associated bloodstream infection (CABSI)

護理雜誌

65卷5期（2018 / 10 / 01）

68 - 79

繁體中文

背景：國內近年推動預防導管相關血流感染組合式照護，雖見感染率下降，但相較美國零感染的顯著成效及國內醫學中心每年仍有約1,700餘例的導管相關血流感染通報個案，我們應持續探究感染之危險因素，以利於推動有效改善策略。目的：探討住院病人中央靜脈導管相關血流感染之潛在危險因素，以及分析中央靜脈導管留置合理性和其對血流感染之影響。方法：本研究經倫理委員會審核通過；採回溯性個案對照研究法，以2014年3月1日至10月31日期間，年齡≥20歲及首次置放中央靜脈導管發生相關血流感染之病人為感染組，採1:2隨機抽樣同期間相同條件但無感染者當對照組。收集病人屬性與導管置放資訊，並依定義判讀感染或移除前48小時內是否合理留置導管。結果：住院病人首次置放之中央靜脈導管相關血流感染65人，抽樣非感染組130人。研究發現感染之顯著危險因素（p ＜ .05）包括住加護病房、APACHE II（acute physiology and chronic health evaluation II）分數增加以及病人有糖尿病病史等因素；而中央靜脈導管不合理留置對感染之影響雖無統計顯著差異（勝算比2.41；95%信賴區間[0.65, 8.91]），但不合理留置仍達10.8%。結論：建議護理人員照護高風險病人，務必提醒醫師審慎評估使用中央靜脈導管與正確執行各項無菌措施；評估無使用需求時提醒醫師即時移除。

Background: Despite recent efforts in Taiwan to reduce the risk and incidence of central venous catheter associated bloodstream infections (CABSI), the results as reported by the Taiwan Centers for Disease Control, when compared with the results achieved in the USA, indicate that Taiwan must promote the central venous catheter bundle approach more effectively. Furthermore, the risk factors for CABSI should be explored further in order to facilitate the development and implementation of effective related improvement strategies. Purpose: To explore the risk factors for CABSI after adjusting for confounding factors and to analyze the appropriate protocol for applying retained central venous catheters in hospitalized patients and the impact of CABSI. Methods: The ethics committee approved this retrospective case-control study. Hospitalized patients who were older than 20 years of age and were currently experiencing their first instance of CABSI were recruited between March 1, 2014 to October 31, 2014 as the case group. In addition, a control group was recruited in a 1:2 ratio from a random sample of patients listed in the medical order system who had received a central venous catheter but did not experience CABSI. Anyone who did not meet the above criteria was excluded. Data collected included basic demographic characteristics, basic catheter information, and the main reason for the catheter being in situ during the 48 hours prior to contracting CABSI or catheter removal. Results: A total of 65 patients with CABSI comprised the case group and 130 patients without CABSI comprised the control group. After controlling for potentially confounding factors using logistic regression analysis, the independent risk factors of CABSI (p ＜ .05) were identified as: staying in the intensive care unit, having a high APACHE II (acute physiology and chronic health evaluation II) score, and having diabetes mellitus. Moreover, while having inappropriate central venous catheter in situ was found to not significantly influence CABSI (OR, 2.41; 95% CI [0.65-8.91]), we identified that about 10.8% of retained central venous catheter applications were unnecessary due to the lack of sufficient indications for use. Conclusion: We recommend that nursing staffs should remind physicians to evaluate carefully the need to use central venous catheters and should fully implement sterile protocols to protect the health of high-risk patients. In addition, nursing staffs should assess the central venous catheter daily and should remind physicians to remove the catheter as soon as possible in the absence of indications for use.

1. 簡麗蓉、張淑玲、曾淑慧(2016)。應用組合式照護預防中心導管相關血流感染。榮總護理，33(3)，222-228。
   連結：
2. Burdeu, G.,Currey, J.,Pilcher, D.(2014).Idle central venous catheter-days pose infection risk for patients after discharge from intensive care.American Journal of Infection Control,42(4),453-455.
3. Ceballos, K.,Waterman, K.,Hulett, T.,Makic, M. B. F.(2013).Nurse-driven quality improvement interventions to reduce hospital-acquired infection in the NICU.Advances in Neonatal Care,13(3),154-163.
4. Chen, Y. Y.,Chen, L. Y.,Lin, S. Y.,Chou, P.,Liao, S. Y.,Wang, F. D.(2012).Surveillance on secular trends of incidence and mortality for device-associated infection in the intensive care unit setting at a tertiary medical center in Taiwan, 2000-2008: A retrospective observational study.BMC Infectious Diseases,12,209.
5. Chen, Y. Y.,Chi, M. M.,Chen, Y. C.,Chan, Y. J.,Chou, S. S.,Wang, F. D.(2013).Using a criteria-based reminder to reduce use of indwelling urinary catheters and decrease urinary tract infections.American Journal of Critical Care,22(2),105-114.
6. Chen, Y. Y.,Yen, D. H. T.,Yang, Y. G.,Liu, C. Y.,Wang, F. D.,Chou, P.(2003).Comparison between replacement at 4 days and 7 days of the infection rate for pulmonary artery catheters in an intensive care unit.Critical Care Medicine,31(5),1353-1358.
7. Chopra, V.,Govindan, S.,Kuhn, L.,Ratz, D.,Sweis, R. F.,Melin, N.,Saint, S.(2014).Do clinicians know which of their patients have central venous catheters? A multicenter observational study.Annals of Internal Medicine,161(8),562-567.
8. Davis, J.(2011).Central-line-associated bloodstream infection: Comprehensive, data-driven prevention.Pennsylvania Patient Safety Authority,8(3),100-104.
9. Furuichi, M.,Miyairi, I.(2016).Risk factors for persistent bacteremia in infants with catheter-Related bloodstream infection due to coagulase-negative Staphylococcus in the neonatal intensive care unit.Journal of Infection and Chemotherapy,22(12),785-789.
10. Ippolito, P.,Larson, E. L.,Furuya, E. Y.,Liu, J.,Seres, D. S.(2015).Utility of electronic medical records to assess the relationship between parenteral nutrition and central line-Associated bloodstream infections in adult hospitalized patients.JPEN: Journal of Parenteral and Enteral Nutrition,39(8),929-934.
11. Kuehn, B. M.(2012).Hospitals slash central line infections with program that empowers nurses.JAMA: The Journal of the American Medical Association,308(16),1617-1618.
12. Lai, N. M.,Lai, N. A.,O'Riordan, E.,Chaiyakunapruk, N.,Taylor, J. E.,Tan, K.(2016).Skin antisepsis for reducing central venous catheter-related infections.Cochrane Database of Systematic Reviews,7,Art. No.: CD010140.
13. Lissauer, M. E.,Leekha, S.,Preas, M. A.,Thom, K. A.,Johnson, S. B.(2012).Risk factors for central line-Associated bloodstream infections in the era of best practice.The Journal of Trauma and Acute Care Surgery,72(5),1174-1180.
14. Maki, D. G.,Kluger, D. M.,Crnich, C. J.(2006).The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies.Mayo Clinic Proceedings,81(9),1159-1171.
15. Mermel, L. A.(2011).What is the predominant source of intravascular catheter infections?.Clinical Infectious Diseases,52(2),211-212.
16. O'grady, N. P.,Alexander, M.,Burns, L. A.,Dellinger, E. P.,Garland, J.,Heard, S. O.,Saint, S.(2011).Guidelines for the prevention of intravascular catheter-related infections.Clinical Infectious Diseases,52(9),e162-e193.
17. Pronovost, P. J.,Goeschel, C. A.,Colantuoni, E.,Watson, S.,Lubomski, L. H.,Berenholtz, S. M.,Needham, D.(2010).Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: Observational study.BMJ,340,c309.
18. Pronovost, P. J.,Nolan, T.,Zeger, S.,Miller, M.,Rubin, H.(2004).How can clinicians measure safety and quality in acute care?.The Lancet,363(9414),1061-1067.
19. Rosenthal, V. D.,Maki, D. G.,Rodrigues, C.,Álvarez-Moreno, C.,Leblebicioglu, H.,Sobreyra-Oropeza, M.,Fernández-Hidalgo, R.(2010).Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries.Infection Control and Hospital Epidemiology,31(12),1264-1272.
20. Rotz, S.,Sopirala, M. M.(2012).Assessment beyond central line bundle: Audits for line necessity in infected central lines in a surgical intensive care unit.American Journal of Infection Control,40(1),88-89.
21. Safdar, N.,Kluger, D. M.,Maki, D. G.(2002).A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: Implications for preventive strategies.Medicine,81(6),466-479.
22. Safdar, N.,Maki, D. G.(2004).The pathogenesis of catheter-related bloodstream infection with noncuffed short-term central venous catheters.Intensive Care Medicine,30(1),62-67.
23. Smith, J. W.,Egger, M.,Franklin, G.,Harbrecht, B.,Richardson, J. D.(2011).Central line-associated blood stream infection in the critically ill trauma patient.The American Surgeon,77(8),1038-1042.
24. Tarpatzi, A.,Avlamis, A.,Papaparaskevas, J.,Daikos, G. L.,Stefanou, I.,Katsandri, A.,Petrikkos, G. L.(2012).Incidence and risk factors for central vascular catheter-related bloodstream infections in a tertiary care hospital.The New Microbiologica,35(4),429-437.
25. Tejedor, S. C.,Tong, D.,Stein, J.,Payne, C.,Dressler, D.,Xue, W.,Steinberg, J. P.(2012).Temporary central venous catheter utilization patterns in a large tertiary care center: Tracking the "idle central venous catheter".Infection Control and Hospital Epidemiology,33(1),50-57.
26. Tiwari, M. M.,Hermsen, E. D.,Charlton, M. E.,Anderson, J. R.,Rupp, M. E.(2011).Inappropriate intravascular device use: A prospective study.The Journal of Hospital Infection,78(2),128-132.
27. Wacholder, S.(1995).Design issues in case-control studies.Statistical Methods in Medical Research,4(4),293-309.
28. Zingg, W.,Sandoz, L.,Inan, C.,Cartier, V.,Clergue, F.,Pittet, D.,Walder, B.(2011).Hospital-wide survey of the use of central venous catheters.The Journal of Hospital Infection,77(4),304-308.
29. 疾病管制署（2016，9月30日）．TNIS_97-104年加護病房HAI個案侵入性導管相關比率資料．取自https://www.syndriver.com/portal/#/sharing/09b30c65ae0d4f5b8fbb9ce39b5bba5a [Centers for Disease Control, Taiwan, ROC. (2016, September 30). The rate of healthcare invasive catheter associated infection in the TNIS intensive care unit between 2008 and 2015. Retrieved from https://www.syndriver.com/portal/#/sharing/09b30c65ae0d4f5b8fbb9ce39b5bba5a]
30. 黃萬翠、王復德、陳瑛瑛、孫淑美(2014)。應用電腦提醒拔除導尿管機制對導尿管使用及尿路感染之影響。護理暨健康照護研究，10(1)，70-77。