从ICU病房MRSA和CRAB的连续5年监测数据看不同多重耐药菌应有不同的防控策略

目的通过观察不同防控措施对不同多重耐药菌的防控效果,探讨和确定适合不同多重耐药菌的防控策略。方法采用每月新发的感染/定植菌检出密度的计算方法,对2008年1月至2012年12月ICU病房重要的耐甲氧西林金黄色葡萄球菌(MRSA)和耐碳青霉烯类抗生素的鲍曼不动杆菌(CRAB)两种多重耐药菌进行实时的动态追踪监测,对在监测过程中采用的手卫生、环境清洁消毒和严格接触隔离等防控措施进行了时间上的追踪比对。结果实施手卫生防控措施辅以环境清洁消毒后MRSA的感染/定植密度迅速减少并保持低水平检出密度;而在手卫生和环境清洁消毒措施基础上,增加了严格的接触隔离结合加强感染/定植上呼吸机患者气道管理后CRAB检出密度才逐步降低。结论针对不同的多重耐药菌应有不同的防控策略。手卫生对MRSA的防控效果好于对CRAB,防控CRAB需要多个措施综合防控。     

感控干预在控制多重耐药定植菌医院感染的临床研究

目的研究多重耐药定植菌与医院感染的关系以及去定植措施的效果。方法对入住ICU的患者进行多重耐药定植菌筛查,观察阳性患者和阴性患者医院感染发生率;将阳性患者随机分为对照组和试验组,对照组采用常规的预防控制措施,试验组加上安尔碘Ⅲ去鼻腔MRSA、口服金双歧去肠道产ESBLs肠杆菌措施,观察两组患者医院感染发生率以及定植菌与医院感染的关系,对比两组去定植效果。结果ICU多重耐药菌定植率为31. 16% ;多重耐药定植菌筛查阴性患者医院感染率为7. 56%,阳性患者医院感染率为15.47% （P 〈0.01）;对照组医院感染率为20.79%,试验组医院感染率为22. 22% （P 〉0. 05）;对照组定植菌医院感染率为4. 95% ,试验组定植菌医院感染为0（ P 〈0.01）;对照组产ESBLs大肠埃希菌定植自行清除率为26. 31% ,试验组产ESBLs大肠埃希菌去定植率为80. 95% （P 〈 0. 01）。结论ICU患者多重耐药菌定植率高,多重耐药菌定植患者医院感染率高,口服金双歧去肠道产ESBLs细菌干预措施有效,安尔碘Ⅲ去鼻腔MRSA效果需继续研究。     

ICU导管相关性感染目标性监测分析

目的 了解某院重症监护病房(ICU)医院感染发生情况,尤其是导管相关性感染基线数据,为干预措施的制定提供参考.方法 采用前瞻性调查方法对2010年6月-2011年12月人住ICU患者的医院感染发生情况进行目标性监测,并对侵入性操作使用率与相关医院感染发生率进行分析.结果 调查期间共监测2741例ICU患者,发生感染198例、307例次,感染率为7.22％、例次感染率为11.20％;同期ICU住院总日数9666 d,日感染率为20.48‰,例次日感染率为31.76‰;经ASIS调整后的日感染率为6.86‰,日感染例次率为10.64‰;导尿管、中心静脉插管及呼吸机的使用率分别为96.39％、58.66％和50.77％,使用导管所致相关泌尿道、血流感染和呼吸机相关性肺炎分别为3.11‰、5.47‰和20.58‰.结论 ICU医院感染发病率和导管相关性感染率较高,必须制定相应感染控制预防措施,使其相应的感染得到有效控制.     

医院内耐万古霉素肠球菌定植以及感染风险分析

目的:探究影响医院内耐万古霉素肠球菌(Vancomycin resistant Enterococcus,VRE)定植以及感染的影响因素,探讨合理的预防感染方式.方法:随机选取2006年7月-2011年7月在某院住院治疗的患者共1000例,对其直肠拭子标本进行生化鉴定,并对确定VRE定值、感染患者进行危险因素探究,并综合分析结果,提出预防VRE感染的方式.结果:1000例标本中,共有187例标本存在VRE,其中103例为定植,VRE定植率1.03％,74例出现感染症状,感染率0.74％,总VRE定植、感染率1.87％;除性别外,年龄、基础疾病、抗菌药物应用、医疗器械操作及万古霉素处方应用均为影响院内VRE定植及感染的独立危险因素.结论:年龄、基础疾病、抗菌药物应用、医疗器械操作及万古霉素处方应用均为影响院内VRE定植及感染的独立危险因素,只有做好院内感染的预防措施,才能遏制VRE的快速增长趋势,保证患者生命健康.     

ICU多重耐药菌的分布与耐药性分析

目的探讨ICU病区多重耐药菌(Multidrug resistant organism,MDRO)的分布和耐药性,为ICU患者抗感染治疗和医院感管工作提供科学依据。方法使用法国梅里埃ATB-Expression鉴定药敏分析仪完成微生物鉴定和药敏工作,回顾性分析ICU患者2011年1月至2013年12月的培养鉴定结果和药敏结果,利用WHONET 5.4软件对数据进行分析。结果共分离MDRO 432株,检出率居前三位的分别是:耐碳青霉烯类抗菌药物鲍曼不动杆菌(CR-AB,54.2%)、产超广谱β-内酰胺酶(ESBLs)细菌(23.8%)、多重耐药/泛耐药铜绿假单胞菌(MDR/PDR-PA,12.5%)。耐碳青霉烯类抗菌药物肠杆菌科细菌(CRE)的分离率逐年上升,未检出耐万古霉素肠球菌(VRE)。结论 MDRO是我院ICU病区医院感染的主要病原菌,临床应加强目标监测,控制和减少多重耐药菌在院内流行。     

急诊重症监护病房耐甲氧西林金黄色葡萄球菌定植与感染调查分析

目的 调查急诊重症监护病房( EICU)耐甲氧西林金黄色葡萄球菌(MRSA)定植与感染状况,为实时控制医院感染暴发流行提供参考依据.方法 对临床资料进行分析,环境卫生学监测采样方法参照卫生部《消毒技术规范》,制定干预措施.结果 6例MRSA定植和感染病例平均年龄62.5岁,原发性基础疾病重;41份环境标本和16份来自接触阳性患者的医务人员手部标本中均分离到病原菌,阳性率分别为24.39％和18.75％.结论MRSA定植是造成医院感染的源头,将仅出现定植的病例并入感染病例进行统计分析,可实时监控院内医院感染的暴发.     

军队干部病房与普通病房患者下呼吸道感染病原菌对比分析

目的调查干部病房与普通病房患者下呼吸道感染病原菌的分布状况,为临床经验用药治疗提供参考。方法采用回顾性方法对2009年5月至2010年2月解放军第44医院干部病房与普通病房下呼吸道感染住院患者送检痰培养结果进行统计分析。结果两个病区下呼吸道感染病原菌均以G-杆菌为主,干部病房G-杆菌所占比例低于普通病房,而真菌、耐甲氧西林金黄色葡萄球菌及产超广谱β-内酰胺酶细菌检出率高于普通病区。结论干部病房与普通病房患者下呼吸道感染病原菌存在差异,干部病房患者感染病原菌多以多重耐药菌株为主,临床应根据药敏结果使用抗菌药物。     

综合性医院重症监护病房病原菌分离情况分析

目的探讨重症监护病房（Icu）医院内感染的临床特点及病原菌种类、分布情况,为临床合理使用抗菌药物、预防和控制医院感染提供参考和依据。方法采用前瞻性监测与回顾性调查相结合的方法,对ICU患者的临床资料进行统计分析。结果ICU病人标本中分离出病原菌593株,得出菌种分布与感染情况。结论重症监护病房医院内感染发生率高,以呼吸道感染为主,主要病原菌以革兰阴性非发酵菌为主,加强ICU患者感染的控制,可减少ICU医院内感染的发生。     

老年住院患者口咽部念珠菌定植状况及菌种分布调查

目的调查老年住院患者口咽部念珠菌定植状况及菌种分布特点,为有效预防念珠菌感染提供参考。方法对解放军第44医院收治的894例住院患者口咽部念珠菌定植状态进行调查分析。结果894例住院患者口咽部标本共培养出念珠菌121株,念珠菌定植率为13．5％,老年患者的定植率高于非老年患者。念珠菌定植以白色念珠菌所占比例最大,占74．5％。年龄≥80岁、肺部基础疾病的存在及使用抗菌药物患者口咽部念珠菌定植率高于普通患者,两者比较差异有统计学意义（P〈0．05）。结论老年患者口咽部念珠菌定植率较高,菌种分布以白色念珠菌最为常见。念珠菌定植与患者年龄、肺部基础疾病的存在及抗菌药物使用情况密切相关。     

集束化干预控制MRSA感染与定植的效果观察

目的通过采取集束化干预措施,长期、持续地对急诊重症监护病房(EICU)耐甲氧西林金黄色葡萄球菌(MRSA)感染与定植患者进行干预,并通过日常监测MRSA感染与定植状况以验证干预效果。方法 2014年1月至12月采用前瞻性调查方法对浙江省台州医院EICU住院的MRSA感染与定植患者进行集束化干预措施;对2012年1月至2013年12月的EICU出院患者进行回顾性调查;分析EICU住院患者采取集束化干预措施产生的效果。结果通过采取集束化干预措施,EICU住院患者发生MRSA感染与定植率明显下降,从2.79%下降至1.01%(P0.01)。结论通过采取集束化干预措施可有效降低MRSA感染与定植率,从而阻断MRSA在医院内的传播。     

深部真菌感染调查及耐药性分析

目的了解住院患者真菌感染的临床特点及对药物的敏感情况。方法采用回顾性调查．对2002年8月至2005年8月住院病例中的真菌感染病例进行统计分析。结果3年间住院患者真菌感染536例,占检出病原菌的8．37％。引起深部感染的真菌以白色念珠菌为主,占39．37％;毛霉菌与曲霉菌的感染次之,分别达到16．79％和13．62％。呼吸内科、老年内科和ICU病房住院患者较易发生医院真菌感染。真菌感染的部位以呼吸道最高,其次为泌尿道。真菌对酮康唑、咪康唑和益康唑耐药率相对较高,对5一氟胞嘧啶、两性霉素B、制霉菌素相对敏感。结论医院深部真菌感染主要多发生于年老体弱、免疫功能低下、病情危重和长期使用抗生素的患者,已成为医院感染的主要因素之一。医院感染真菌的耐药性日趋严重,临床应用抗真菌药物尽量参考药敏试验结果。     

Prolonged outbreak of nosocomial urinary tract infection with a single strain of Pseudomonas aeruginosa.

Sixty-six hospitalized patients became infected with a single strain of multiply resistant Pseudomonas aeruginosa over a 22-month period. The catheterized urinary tract was the site of the infection in 59 patients (89%). The outbreak was confined to a urology ward until an infected patient from this ward spent 2 weeks in the surgical intensive care unit (SICU). Subsequently patients who acquired the infection in the SICU were discharged to surgical wards throughout the hospital. Urine measuring containers and urometers used in the SICU were the reservoir of the P. aeruginosa; daily sterilization of this equipment terminated the outbreak. Urometers appeared to be the reservoir of the epidemic strain in subsequent outbreaks. Five patients were still infected when they were readmitted 3 to 12 months after the first admission, and therefore represented an additional reservoir of infection.     

Sterile microenvironment in prevention of wound infection.

A prospective controlled trial was carried out to assess the effect of using a wound isolator on reducing postoperative infection. A total of 291 patients undergoing hip pinning for fractures of the neck of femur entered the trial and were allocated at random to have their wound contained in a wound isolator (study group) or dressed with a standard gamma-irradiated adhesive dressing (control group). The bacteriological flora of the patient was monitored before, during, and after operation and that of the ward before and after. No significant difference was found in the flora of the wards in which the patients were nursed. On several occasions the source of the infective organism was traced to the ward but never to the theatre. The isolator prevented direct contamination and airborne cross-infection of the wound and appreciably reduced the rate of infection.     

高海拔地区慢性阻塞性肺疾病患者 病原菌分布及相关因素分析

摘要：目的 探究高海拔地区慢性阻塞性肺疾病（COPD）患者病原菌分布及相关危险因素。方法 选取2016年1月至2019年1月青海省中医院收治的274例COPD患者为研究对象,对患者痰液进行病原菌培养,分析病原菌分布情况及感染多重耐药菌（MDRO）的相关危险因素。结果 274例患者痰液中共培养出致病菌165株,阳性率为60.2%;其中革兰阴性菌占71.5%（118/165）,革兰阳性菌占17.0%（28/165）,真菌占11.5%（19/165）。单因素分析显示,COPD患者发生MDRO感染与年龄、糖尿病病史、卧床时间、呼吸机污染、机械通气史和频繁更换抗菌药有一定相关性（χ2=8.326、4.868、21.298、5.534、19.686、11.549,均P<0.05）,Logistic分析显示,呼吸机污染、机械通气史、频繁更换抗菌药和卧床时间是COPD患者发生多重耐药菌感染的危险因素（OR=1.292、2.112、1.752、1.625,均P<0.05）。结论 高海拔地区COPD患者病原菌以革兰阴性菌为主,而呼吸机及管路污染、机械通气史、频繁更换抗菌药及卧床时间长是COPD患者发生多重耐药菌感染的危险因素。应加强对相关病原菌及危险因素的监测,降低患者感染风险。     

Ward meetings: a forum for patients' concerns.

A series of meetings between patients and staff were held on two general medical wards to discuss the concerns of patients. Issues ranged from the quality of hospital food, ward facilities, and visiting arrangements to the medical and nursing care provided and patients'' views on medical students. Most issues were raised by the patients themselves and the outcome was either acceptance or rejection of a suggestion, an explanation by the staff, or a general discussion if a specific decision was inappropriate. Most staff and patients considered the meetings to be valuable. Ward meetings thus seem to provide a way of making hospitals more responsive to patients'' concerns.     

Cluster randomised trial of a targeted multifactorial intervention to prevent falls among older people in hospital

Objective To determine the efficacy of a targeted multifactorial falls prevention programme in elderly care wards with relatively short lengths of stay.Design Cluster randomised trial.Setting 24 elderly care wards in 12 hospitals in Sydney, Australia.Participants 3999 patients, mean age 79 years, with a median hospital stay of seven days.Interventions A nurse and physiotherapist each worked for 25 hours a week for three months in all intervention wards. They provided a targeted multifactorial intervention that included a risk assessment of falls, staff and patient education, drug review, modification of bedside and ward environments, an exercise programme, and alarms for selected patients.Main outcome measure Falls during hospital stay.Results Intervention and control wards were similar at baseline for previous rates of falls and individual patient characteristics. Overall, 381 falls occurred during the study. No difference was found in fall rates during follow-up between intervention and control wards: respectively, 9.26 falls per 1000 bed days and 9.20 falls per 1000 bed days (P=0.96). The incidence rate ratio adjusted for individual lengths of stay and previous fall rates in the ward was 0.96 (95% confidence interval 0.72 to 1.28).Conclusion A targeted multifactorial falls prevention programme was not effective among older people in hospital wards with relatively short lengths of stay.Trial registration Australian New Zealand Clinical Trials Registry ACTRNO 12605000467639.     

福州地区庚型肝炎病毒重叠感染

为研究庚型肝炎病毒在福州地区的重叠感染,采用ＥＬＩＳＡ法检测本院住院的２８６例病毒性肝炎（ＨＶ）患者和５００名供血员的抗－ＨＧＶ。结果表明,甲、乙、丙、戊型肝炎患者和供血员的抗－ＨＧＶ检出率分别为２．０％、２．２％、４．０％、１０．０％和０．２％。急性肝炎、慢性肝炎、慢性重型肝炎、肝硬化、原发性肝癌和抗－ＨＣＶ阳性供血员的检出率分别为７．９％、４．３％、３３．３％、０％、７．１％和６．３％,慢性重型肝炎检出率较慢性肝炎显著升高（Ｐ＜０．０５）。各型肝炎患者和供血员均存在庚型肝炎病毒重叠感染,以慢性重型肝炎为著。     

原发性肾病综合征小儿发生院内感染的危险因素分析及护理研究

目的:探讨原发性肾病综合征患儿发生院内感染的危险因素及有效的护理对策。方法:回顾性分析在我院儿科住院的原发性肾病综合征患儿的临床资料,用单因素分析与多因素非条件Logistic回归分析原发性肾病综合征(PNS)患儿发生院内感染危险因素,探究合理的护理对策对患儿疾病恢复的影响。结果:PNS患儿院内感染发生率为32(36.4%),以呼吸道感染为最常见部位18(56.3%)。PNS患儿发生院内感染组的免疫球蛋白G(Ig G)、免疫球蛋白A(Ig A)、ALB水平低于非感染组(P0.05),住院天数、24 h尿蛋白定量非感染组(P0.05)。住院天数和血清白蛋白(ALB)是院内感染独立的危险因素,其OR值(95%CI)分别为3.461(1.33~9.01)和2.215(0.87~5.63)。早期、合理的护理措施使PNS患儿疾病恢复良好。结论:住院天数长和血清白蛋白降低是并发院内感染的独立危险因素,健全院内感染控制制度、加强病房管理、完善护理措施等,可降低院内感染发生率,改善患者预后。     

Varicella infection in a children's hospital: prevention by vaccine and an episode of airborne transmission

Varicella vaccine was used safely and effectively for preventing ward infection with varicella. Ward infection was experienced 34 times in 5 years between 1977 and 1982. During these ward infections, varicella developed in 4 of 142 patients who received vaccine, 21 of 47 patients who did not receive vaccine and 1 of 9 who received transfusion with vaccine-boostered blood. Of the 142 vaccinated patients, the four in whom varicella developed showed symptoms 3 to 10 days after vaccination, indicating that vaccination had been too late. Details of a ward infection with varicella by airborne transmission and its prevention by vaccination are presented.     

Improving Prediction of Surgical Site Infection Risk with Multilevel Modeling

Background

Surgical site infection (SSI) surveillance is a key factor in the elaboration of strategies to reduce SSI occurrence and in providing surgeons with appropriate data feedback (risk indicators, clinical prediction rule).

Aim

To improve the predictive performance of an individual-based SSI risk model by considering a multilevel hierarchical structure.

Patients and Methods

Data were collected anonymously by the French SSI active surveillance system in 2011. An SSI diagnosis was made by the surgical teams and infection control practitioners following standardized criteria. A random 20% sample comprising 151 hospitals, 502 wards and 62280 patients was used. Three-level (patient, ward, hospital) hierarchical logistic regression models were initially performed. Parameters were estimated using the simulation-based Markov Chain Monte Carlo procedure.

Results

A total of 623 SSI were diagnosed (1%). The hospital level was discarded from the analysis as it did not contribute to variability of SSI occurrence (p  = 0.32). Established individual risk factors (patient history, surgical procedure and hospitalization characteristics) were identified. A significant heterogeneity in SSI occurrence between wards was found (median odds ratio [MOR] 3.59, 95% credibility interval [CI] 3.03 to 4.33) after adjusting for patient-level variables. The effects of the follow-up duration varied between wards (p<10⁻⁹), with an increased heterogeneity when follow-up was <15 days (MOR 6.92, 95% CI 5.31 to 9.07]). The final two-level model significantly improved the discriminative accuracy compared to the single level reference model (p<10⁻⁹), with an area under the ROC curve of 0.84.

Conclusion

This study sheds new light on the respective contribution of patient-, ward- and hospital-levels to SSI occurrence and demonstrates the significant impact of the ward level over and above risk factors present at patient level (i.e., independently from patient case-mix).