重症监护病房多重耐药菌交叉感染降阶梯防控策略的临床应用研究  

Utility of de-escalation bundle intervention strategy in prevention and control of cross infection of multidrug-resistant bacteria in intensive care unit

作　　者：李梅玲[1] 黄洁[1] 赵昱瑾[1] 顾秋莹[1] 王晓丽[1] 谭若铭[1] 李磊[1] 武均[1] 闵东[1] 瞿洪平[1] 

机构地区：[1]上海交通大学医学院附属瑞金医院重症医学科,上海200025

出　　处：《中国感染与化疗杂志》2015年第6期552-556,共5页Chinese Journal of Infection and Chemotherapy

基　　金：上海市科学技术委员会科学引导项目(124119a6100)

摘　　要：目的高耐药菌群在重症监护病房(ICU)患者中不易清除,易导致交叉传播,为防控耐药菌的交叉感染实施降阶梯防控策略,以期减少耐药菌定植与感染,改善患者预后。方法前后对比、干预对照研究上海瑞金医院外科ICU(SICU)从2013年8月—2014年7月的危重患者,进行主动性、多部位筛查耐药菌,后半年干预组实施组合式降阶梯集束化防控措施。结果 SICU共184例患者,干预组和对照组各92例。对照组检出耐药菌69株,干预组为41株。其耐药菌株检出率分别为75.0%和44.6%,P<0.001。去除带入细菌,ICU内获得性耐药菌株分别为55株和26株,耐药菌株检出率为59.8%和28.3%,P<0.001。无菌病例数分别为49例和59例,所占比例为53.3%和64.1%,P=0.13。经过分级防控的综合策略,对照组和干预组的ICU获得性耐药菌感染千日率分别为14.12‰和7.64‰,P=0.16。ICU获得性耐药菌血流感染千日率分别为3.14‰和0.69‰,P=0.45。ICU获得性耐药菌肺炎千日率分别为6.28‰和1.39‰,P=0.16。ICU获得性耐药菌腹腔感染千日率分别为4.18‰和2.78‰,P=0.88。从预后角度来看,干预组平均住院天数、住院期间病死率、28 d病死率及90 d病死率均有下降,其中以感染归因病死率有明显下降趋势(13.04‰和5.43‰,P=0.07)。结论经降阶梯防控措施能有效减少患者ICU获得性耐药菌定植与感染,缩短ICU患者住院时间,降低ICU患者因感染引起的病死率。Objective High incidence and morbidity of multidrug-resistant bacteria make it necessary to examine the utility of de-escalation bundle intervention strategy for prevention and control of cross-infection of such bacteria in intensive care unit（ICU）.Methods An intervention study was conducted in surgical ICU patients in a university hospital from August 2013 to July 2014.All patients treated in the SICU were under active surveillance of bacterial infection.The de-escalation bundle intervention strategy was administered in the second half of the year.Results Overall 184 patients were included in the analysis.The prevalence of pandrug-resistant bacteria was 75.0%in control group and 44.6%in intervention group（P〈0.001）.The incidence of acquired pandrug-resistant bacteria was 59.8%in control group and 28.3%in intervention group（P〈0.001）in ICU patients.Bacteria were not isolated in 49（53.3%）of the patients in control group and 59（64.1%）of the patients in intervention group（P=0.13）.At end of de-escalation bundle intervention strategy,the incidence of acquired pandrug-resistant bacteria was 14.12 in control group and 7.64 in the intervention group per 1000 patient days（P = 0.16）.Moreover,the incidence of acquired drug-resistant infections per 1000 patient days was also lowered in ICU,including bloodstream infection（3.14 vs 0.69,P=0.45）,pneumonia（6.28 vs 1.39,P =0.16）and intra-abdominal infection（4.18 vs 2.78,P=0.88）.Compared to the patients in control group,the average days of hospital stay,in-hospital mortality,28-day mortality and90-day mortality were also lower in intervention group,especially sepsis-related mortality（13.04 vs 5.43,P=0.07）.Conclusions The de-escalation bundle intervention strategy is useful for curbing the spread and control the infection of pandrug-resistant bacteria in SICU.Such an intervention is associated with shorter ICU stay and lower mortality.

关 键 词：多重耐药 交叉感染 感染防控 降阶梯 

分 类 号：R446.5[医药卫生—诊断学]