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  • 1. ... 5/12/2012

2. * * * * * (Hickman, Broviac, Groshong) * ( 15 CFU (Colony Forming Units) , BSI , , > 2 cm / . 8. CDC (pocket, ) : : 1 / , (, , ) 1 : (> 15 CFU/) (> 30 CFU/) / / 5:1 > 2 9. Commonly used definitions of intravascular catheterrelated infections. Infection Definition Catheter colonization Significant growth of a microorganism in a quantitative or semiquantitative culture of the catheter tip, subcutaneous catheter segment, or catheter hub (see the Diagnosis section) Phlebitis Induration or erythema, warmth, and pain or tenderness around catheter exit site Exit-site infection Microbiological Exudate at catheter exit site yields a microorganism with or without concomitant bloodstream infection Clinical Erythema, induration, and/or tenderness within 2 cm of the catheter exit site; may be associated with other signs and symptoms of infection, such as fever or pus emerging from the exit site, with or without concomitant bloodstream infectiona Tunnel infection Tenderness, erythema, and/or induration 12 cm from the catheter exit site, along the subcutaneous tract of a tunneled catheter (e.g., Hickman or Broviac catheter), with or without concomitant bloodstream infectiona Pocket infection Infected fluid in the subcutaneous pocket of a totally implanted intravascular device; often associated with tenderness, erythema, and/or induration over the pocket; spontaneous rupture and drainage, or necrosis of the overlying skin, with or without concomitant bloodstream infection, may also occura Bloodstream infection Infusate related Concordant growth of the same organism from infusate and cultures of percutaneously obtained blood samples with no other identifiable source of infection Catheter related Bacteremia or fungemia in a patient who has an intravascular device and 1 positive result of culture of blood samples obtained from the peripheral vein, clinical manifestations of infection (e.g.,fever, chills, and/or hypotension), and no apparent source for bloodstream infection (with the exception of the catheter). One of the following should be present: a positive result of semiquantitative (15 cfu per catheter segment) or quantitative (102 cfu per catheter segment) catheter culture, whereby the same organism (species and antibiogram) is isolated from a catheter segment and a peripheral blood sample; simultaneous quantitative cultures of blood samples with a ratio of 5:1 (CVC vs. peripheral); differential time to positivity (i.e., a positive result of culture from a CVC is obtained at least 2 h earlier than is a positive result of culture from peripheral blood) 10. 60% : . 20%: 11. () Catheter related blood stream infections (CR-BSIs): . . 12. & (hubs) ( , , ) [, Gram (-)] 13. : 14. 60 , 15. (1) 3-5 Polyvinyl chloride polyethylene Teflon 4-6 16. (2) ( eflon-- ) (>4-5 ) , 17. (3) () 70% povidone iodine (betadine) 2% chlorhexidine (hibitane) 18. > > / (1.2 vs. 4.5 /1000 - P=0.07) JAMA 2001;286:700-707 > > : Swan-Ganz & introducer 96-120 19. Bacteria living in biofilms are thought to be associated with 65% of all infections.80% 20% biofilms 18 8Ryder,MA. Catheter-Related Infections: It's All About Biofilm. Topics in Advanced Practice Nursing eJournal. 2005;5(3) 2005 Medscape Posted 08/18/2005 . ETHICON, INC., 2006 20. 3 way, stopcocks : PVC, Polyethylene ( ) vs. Teflon, silicon, polyurethane : (gram -) : S. aureus fibronectin , Candida spp 21. CR-BSI . (coagulase negative staphylococci, S. aureus, Pseudomonas aeruginosa and Candida species) (EPS). Staph. Aureus clumping factors (ClfA and ClfB). , , , ( ) Biofilm. Biofilm , , , . 22. Biofilm , biofilm . 23. Biofilm in-vivo biofilm. biofilm . , biofilm . 24. (2) ( ) , = GOLD STANDARD 25. ( ), (50%) ( , ) gram, acridine orange, / (roll plate): 15 cfu , < 1 : (flushing, vortex, sonication) 102 cfu , : roll plate: 60%, flushing: 40-50%, sonication: 80%: / 26. / 2 , 1 63-73% 99% / / / 5-10 100 cfu/ml 2 / / 27. /differential time to positivity ( 2 ) / / / hub CI D 2 001 , A rch I ntern M ed 2 002 , CI D 2 009 28. / , 29. Pathogen Coagulase-negative staphylococci S. Epidermitis Staphylococcus aureus Enterococcus Gram-negative rods Escherichia coli Enterobacter Pseudomonas aeruginosa Klebsiella pneumoniae Candida spp.19861989 (%) 2719921999 (%) 3716 8 19 6 5 4 4 813 13 14 2 5 4 3 8 30. SCOPE 49 USA 1995-2002:24.179 nosocomial BSIs 60 BSIs / 100.000 51% 75% 35% 15% 45% 27% 31. SCOPE Staphylococcus aureus 20 % Enterococci 9 % Candida species 9 % Escherichia coli 6 % Klebsiella species 5 % Pseudomonas species 4 % Enterobacter species 4 % Serratia species 2 % Acinetobacter baumannii 1 % Coagulase- negative staphylococci 31 % 32. EPIC II : 13,796 ICU 8 M 2007, (, , , )- 51% with infection, 71% on antibiotics - 70% in ICU > 7 days with infection, 32% on day 1 - 64% of infections were respiratory, 70% with infections had positive cultures - 62% gram-negative, 47% gram-positive, 19% fungal ICU mortality 25% vs. 11% if infected vs. not (p 4 10 , 41. / swan ganz, Acridine ornage leukocyte cytospin / 2 , 1 / 42. : MRSA 3 4 ( ) : , , 43. Coagulase-negative staphylococci (S. Epidermitis): 5 7 St. Aureus, Gram(-) Candida, , : 10 14 , (, , ): 4 6 : 6 8 44. antibiotic lock therapy CR-BSI , , , 7-14 / , 24 CR-BSI S. Aureus Candida spp , 1000xMIC 45. Risk Factors for BSI During the Process of CVC CareInsertionMaintenance Provider knowledge of risk factors Consider safest insertion site Patient positioned & sedated Trainee experience Pager(s) handed off Hand hygiene Skin antisepsis Maximal sterile barriers Number of needle sticks Hubs attached Line anchored Antibiotic-impregnated catheter Provider knowledge of risk factors Minimize CVC manipulation Consolidate blood draws Daily site inspection (visual & palpation) Dressing change protocol Hand hygiene prior to accessing hubs Hub antisepsis prior to accessing Tubing replaced after blood product infusions Hubs replaced after any opening Nurse-to-patient ratio Specialized line teams Protocol for CVC removal 46. Prevention of CVC-BSI InsertionMaintenanceRemoval 47. (AnnIntern Med. 2002;136:792-801) , (JAMA; 2001,286:700-7) , (N Engl J Med. 1992 Oct 8;327(15):1062-8) 2002;51:RR-10MMWR. 48. / ( ). (MMWR. 2002;51:RR-10) , (. , , ) (N Engl J Med. 2006 Dec 28;355(26):2725-32) 49. > > ( , ) 4.5 vs. 1.2 1000 - > ! ? ( 3.3 /1,000 >5 52. Chlorhexidine & silver sulfadiazine Arrowguard Blue, Arrow International1 & 2 Ag+ Gram (+) (-) 2 ~15 53. Minocycline-rifampicin Cook Spectrum Cook Critical CareA Gram (-) (+) >60 , 1 Chlorhexidine & silver sulfadiazine: 3/ 12/ 54. Ag+ Vantex Catheter with Oligon , Edwards life sciencesSilver with platinum and carbon Silver in a ceramic zeolite matrix Gram (-) (+) Ag+ Ag+ Ag+ DNA 55. Benzalkonium chloride Benzalkonium chloride Benzalkonium chloride heparin bonded . DNAA Gram (+) (-) & candida sp. 56. ? : , VRE/ ? povodine-iodine ( , ) Mupirocin (S. aureus , ) 10 IU/ml , , : 3 , 5 7 35%, 7 5-10% 10 IU/ml , 5000 U 6-12 , 2500 U 57. 58. 1. - Maximal Sterile Precautions 59. 2. Centers of Disease Control and Prevention, 2002 Journal of Hospital Infection, 2007 60. , , ( ) 61. ( 2 ) ( ) , ( 2%, 70%, ) 62. . (48h) (5-7 ) : , : , 63. IV , , & , 96 , / iv - , 24 24 12 6-12 . , (transducer, flush solutions) 96 64. ( 3 way)/ (>70%) 65. laminar flow hood , , , 66. ( ) 70% 67. , , 68. - : : CVC 69. (CLABSI) CLABSI 5 : . , , , , . , , , , . 0,5%, 10% ( >0,5%). 0,5% 30 sec, 10% 2 min. . . . . 70. - . , , , ,