【强烈推荐】WHO报道全球医院感染负担

蓝鱼o_0

强烈推荐这篇文献给大家阅读。
内容丰富，基本上概述了全球范围内HAIS的情况，想要做REVIEW或者PPT的朋友一定要看！

1. Health care-associated infections in different settings and related risk factors. . . . . . . . . . . . . . . . . . . . . . . . . 6不同部门HAIS情况和相关危险因素
2. Methods and challenges of health care-associated infection surveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . 8HAIS监测的方法和挑战
3. The burden of endemic health care-associated infection in high-income countries. . . . . . . . . . . . . . . . . . . . . 12高收入国家HAIS的负担
4. The burden of endemic health care-associated infection in low- and middle-income countries . . . . . . . . . . . . . 16低收入和中等收入国家HAIS负担
5. The impact of health care-associated infection worldwide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20全球范围内HAIS的影响
6. Lessons learned and the way forward. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22经验教训及未来

感兴趣的朋友也可以来翻译，本斑将给予重奖！

chenhui

遗憾，他认识我，可我不认识他。

梅飞色舞

希望翻译大师快快出现，把您的辛勤成果分享给我们吧

天天，天蓝

英文基础差，需要大师翻译过来再看了！

鬼才

summary
小结

Health care-associated infection (HCAI) is acquired by patients while receiving care and represents the most frequent adverse event. However, the global burden remains unknown because of the difficulty to gather reliable data.In many settings, from hospitals to ambulatory and long-term care, HCAI appears to be a hidden, cross-cutting problem that no institution or country can claim to have solved yet.HCAI surveillance is complex and requires the use of standardized criteria, availability of diagnostic facilities and expertise to conduct it and interpret the results. Surveillance
systems for HCAI exist in several high-income countries but are virtually nonexistent in most low- and middle-income countries.

医院感染是患者在医院治疗过程中，所获得的一种伤害事件。然而由于缺乏可靠性数据，医院感染所造成的全球负担还不知道。在医院的日常护理和长期护理许多环境中，医院感染似乎是一个隐藏的，交叉的问题，没有任何机构或国家声称已经解决。对医院感染的监控是复杂的，需要使用规范的标准，及诊断设备和专业知识进行，才能解释其获得的结果。只是一些高收入国家有医院感染监控系统，大多数低收入和中等收入国家几乎不存在。

Data included in this report are the results of systematic reviews of the literature on endemic HCAI from 1995 to 2010 in high- and low / middle-income countries. According to published national or multicentre studies, pooled HCAI prevalence in mixed patient populations was 7.6% in high-income countries. The European Centre for Disease Prevention and Control (ECDC) estimated that 4 131 000 patients are affected by approximately 4 544 100 episodes of HCAI every year in Europe. The estimated HCAI incidence rate in the USA was 4.5% in 2002, corresponding to 9.3
infections per 1000 patient-days and 1.7 million affected patients.

在本报告中所列数据包括高收入国家，低/中等收入国家从1995年至2010年对医院感染地方流行性系统评价的结果。据所公布的国家和多中心的研究，医院感染在患者人群中的发生率在高收入国家平均为7.6％。欧洲疾病预防和控制中心估计，在欧洲每年的4 544 100余名患者中约有4 131 000余名患者遭到医院感染的影响。估计2002年在美国医院感染的发生率是4.5％，相应每1000住院病人日中有9.3个病人遭到感染，受影响的病人达170万。

The systematic review of the literature revealed clearly an extremely fragmented picture of the endemic burden of HCAI in the developing world. Only very scanty information was available from some regions and no data at all for several countries (66%). Many studies conducted in health-care settings with limited resources reported HCAI rates higher than in developed countries. Hospital-wide prevalence of HCAI varied from 5.7% to 19.1% with a pooled prevalence of 10.1%. Of note, the pooled HCAI prevalence was significantly higher in high- than in low-quality studies (15.5% vs 8.5%, respectively). Surgical site infection (SSI) is the most surveyed and most frequent type of infection in low and middle income countries with incidence rates ranging from 1.2 to 23.6 per 100 surgical procedures and a pooled incidence of 11.8%. By contrast, SSI rates vary between 1.2% and 5.2% in developed countries.

本系统评价只是从一些地区得到了很少一部分可靠性资料，而许多国家(66%)没有资料，显示在全球发展中对医院感染的负担极不平衡。许多调查研究指出在资源有限的卫生保健机构，医院感染的发生率比发达国家要高。汇集各医院的医院感染发生率在5.7％～19.1％之间，平均为10.1％。值得注意的是，对医院感染的研究中，高质量的研究比低质量的研究中医院感染的发生率明显要高（分别为15.5％和8.5％）。外科手术部位感染（SSI）是调查最为频繁的感染类型，在低收入和中等收入国家中感染率在1.2%～23.6%之间，平均为11.8％。相比之下，在发达国家中的外科手术部位感染率在1.2％～5.2％之间。

The risk of acquiring HCAI is significantly higher in intensive care units (ICUs), with approximately 30% of patients affected by at least one episode of HCAI with substantial associated morbidity and mortality. Pooled cumulative incidence density was 17.0 episodes per 1000 patient-days in adult high-risk patients in industrialized countries. By contrast, the incidence of ICU-acquired infection among adult patients in low- and middle-income countries ranged from 4.4% up to 88.9% and pooled cumulative incidence density was 42.7 episodes per 1000 patient-days.

医院感染的风险主要在重症监护病房，其发病率和死亡率与医院感染都有较大的关系。在工业化国家****高危患者中约30％的患者至少遭受过一次医院感染，平均感染发病率为17‰。与此相反，在低收入和中等收入国家的成年患者中的重症监护病房获得性感染的发病率在4.4％～88.9％间不等，平均感染率为42.7‰。

High frequency of infection is associated with the use of invasive devices, in particular central lines, urinary catheters, and ventilators. Among adult ICU patients in high-income countries, pooled cumulative incidence densities of catheter-related BSI (CR-BSI),urinary catheter-related UTI (CR-UTI), and ventilator-associated pneumonia (VAP) were 3.5 per 1000 CL-days, 4.1 per 1000 urinary catheter-days, and 7.9 per 1000 ventilator-days, respectively. In low and middle-income countries, pooled cumulative incidence densities of CR-BSI, CR-UTI, and VAP were 12.2 per 1000 CL-days, 8.8 per 1000 urinary catheter-days, and 23.9 per 1000 ventilator-days, respectively. Newborns are also a high-risk population in developing countries and neonatal infection rates are three to 20 times higher than in industrialized countries.

感染的高频率与侵入设备的使用，特别是中央线，导尿管和通风设备密切相关。在高收入国家****ICU患者中统计导管相关血流感染（CR - BSI），导管相关尿路感染（CR - UTI）以及呼吸机相关肺炎（VAP）的发病率为3.5‰、4.1‰、7.9‰。在低、中等收入国家，导管相关血流感染（CR - BSI），导管相关尿路感染（CR - UTI）以及呼吸机相关肺炎（VAP）的发病率为12.2‰、8.8‰，23.9‰。新生儿在发展中国家是高危感染人群，其感染率比工业化国家高出3至20倍。

The impact of HCAI implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, a massive additional financial burden for health systems, high costs for patients and their families, and excess deaths. In Europe, HCAIs cause 16 million extra-days of hospital stay, 37 000 attributable deaths, and contribute to an additional 110 000 every year. Annual financial losses are estimated at approximately 7 billion, including direct costs only. In the USA, approximately 99 000 deaths were attributed to HCAI in 2002 and the annual economic impact was estimated at approximately US$ 6.5 billion in 2004. Information is again very scanty from low- and middle-income countries and no data are available at national or regional levels. According to a report on device-associated infections in 173 ICUs from 25 countries in Latin America, Asia, Africa, and Europe, crude excess mortality in adult patients was 18.5%, 23.6%, and 29.3% for CRUTI, CR-BSI, and VAP, respectively. A review of several studies showed that increased length of stay associated with HCAI varied between 5 and 29.5 days.  Although HCAI global estimat

医院感染的影响意味着住院时间延长，终身残废，耐药菌增多，给患者及其家庭带来巨额的经济负担，甚至死亡。在欧洲，因医院感染造成1600000人在医院治疗，37000人死亡，每年的额外花费超过110000元。年财政预算估计损失约70亿元，仅包括直接的花费。

AlthoughHCAI global estimates are not yet available, by integrating data from publishedstudies, there is clear evidence that hundreds of millions of patients areaffected every year worldwide, with the burden of disease much higher in low-and middle-income countries. There is an urgent need to establish reliablesystems for HCAI surveillance and to gather data on the actual burden on aregular basis. Evaluation of the key determinants of HCAI is an essential stepto identify strategies and measures for improvement. Robust evidence existsthat HCAI can be prevented and the burden reduced by as much as 50% or more.Solid recommendations have been issued by national and internationalorganizations, but their application needs to be strengthened and accompaniedby performance monitoring both in high-income and low- and middleincome countries.HCAI must be treated as a priority patient safety issue within comprehensiveapproaches to be tackled effectively. The WHO Patient Safety programmeintegrates efforts with other WHO programmes to reduce HCAI by assisting withthe assessment, planning, and implementation of infection prevention andcontrol policies, including timely actions at national and institutional levels.

米奇朋克

1．不同医疗机构医疗照护相关感染和危险因素

医疗照护相关感染（英文：Health care-associated infection，缩写HCAI）被定义为：“在一所医院或其它医疗照护机构照护过程中发生在病人身上的感染，并不是指在入院时已存在或处于潜伏期的感染，但是包括在医院内获得出院后发生的感染及机构内工作人员职业性感染。” 运用这个定义（在未分析流行病学数据前）可以全面地审查HCAI事件、鉴别它们是如何与不同类型的医疗照护机构产生联系的以及确定导致医疗照护相关致病菌传播和感染发病风险不断增加的原因。

大多数研究报告描述过当地HCAI的负担，然而，它们都是在急症处理机构和高收入国家进行的。越来越多的证据表明，非急症处理机构和中低收入国家的HCAI负担与前者存在着流行病学上的差异性。感染与预防控制领域中循证的方法已清晰地告诉我们世界上没有任何一个国家的任何一种类型的医疗照护机构能声称自己没有HCAI的风险。

“医疗照护相关感染”已取代先前使用过的与感染相关的名词，诸如“医院内”或“医院”感染，因为有证据显示HCAI事件可以影响任何一所医疗照护机构的病人。为何除医院之外的医疗照护机构关于HCAI负担的数据较少？原因是：感染预防和控制文化及HCAI事件监测系统在这些机构根本不存在或者发展相当迟缓。例如，许多因其它疾患去医疗机构就诊的病人在门诊等候的时候可能获得了呼吸道感染，特别在发展中国家拥挤的医疗机构内或是在疾病流行期间。像这些门诊病人看完病就回到各自的社区去，所以几乎不可能去鉴别它们初次进入医疗机构感染的发生。虽然没有初次或二次门诊就医发生HCAI的系统的流行病学资料，但是在这些医疗机构需采取目标性的方法来控制感染已被强调，有的国家如英格兰已经发布了专门的推荐指南。

居家式照护已相当的普及。1996年美国有800万患者接受过居家照护，其中774113人至少有一种医疗装置留置，大多数是在血管内。HCAI的发生已不再局限于医院，这就要求其它医疗照护机构也必须执行专门的感染控制措施。

    因预期寿命的延长和社会交往的频繁，在高收入国家进入专为老年人提供居家式医疗照护机构的人数不断增加，但是这些机构HCAI的负担我们却知之甚少。在欧洲，过去的五年中，已启动了许多项目对提供长期医疗照护的机构的感染控制进行了研究。不断有研究成果表明，在这种提供居家式照护的机构内，居住者平均每年发生1－3种感染，以泌尿道感染和肺炎最为常见。甚至有证据可以说明这些感染是居住者被送往医院和死亡最常见原因，主要归因于肺炎。

因医疗照护机构的类型和接诊区域的不同发生HCAI的危险因素亦有不同，这方面发展中国家与发达国家有所区别。在高收入国家医院里开展的研究显示，最常见与HCAI有关的独立危险因素有：年龄＞65岁；急诊入院或进入ICU；住院超过7天；中心静脉导管留置、导尿管留置或气管插管；手术；创伤后免疫抑制；中性粒细胞减少症；一项迅速的、严重的致死性疾病（根据McCabe-Jackson分类）以及功能受损和昏迷状态。同样的危险因素也可以在中低收入国家急症处理医疗机构被找到，但是还有一些其它的决定因素，它们都广泛地与贫困有关，如缺少基本的卫生设施和有限的资源。这些决定因素还包括：营养不良、年龄＜1、低出生体重，肠外营养或有2种以上基础疾病。在中低收入国家想践行最佳的感染控制措施有一些普遍存在的难处，如缺少资金支持、训练有素的感染控制专职人员数量不足以及不充足的医疗设备和其它物资供应，虽然这些在研究中并没有被描述为独立的危险因素。

蓝鱼o_0

回复 6# mickeypank

非常好，我有时间也会加入您们的队伍。

青城山

2 Methodsand challenges of health care-associated infection surveillance

健康相关感染监测的方法与挑战（一）

Most HCAIs become evident 48 hours or more following admission (typical incubation period) 5 Infection may present also after patient discharge. In these cases, the patient has become colonized or infected while in hospital, but the pathogen incubation period exceeds the patient’s hospital stay.For instance, several studies report that over 50% of surgical site infections (SSI) manifest post-discharge 29-38。

绝大部分的HCAIs在入院后48小时或更长一点的时间内变得明显（典型的潜伏期）。患者也可能在出院后才呈现感染。在这样的病例中，患者在住院期间已被病原体寄居或被感染，但是病原体的潜伏期超过了患者的住院天数。例如，数个研究报告指出50%以上的外科部位感染（SSI）是发生在患者出院后。

HCAI may be caused by infectious agents from endogenous or exogenous sources.Endogenous sources are body sites, such as the skin, nose, mouth, gastrointestinal tract, or vagina, that are normally colonized by local microbial flora.These microorganisms can become invasive under certain .favourable conditions and/or cause infection when they contaminate sterile sites.Transmission to these sites occurs most frequently via health-care workers’ hands39 Exogenous sources are those external to the patient, such as health-care workers, visitors, patient care equipment, medical devices, or the health-care environment HCAIs are not restricted only to patients; health-care workers, ancillary staff, and visitors can also be affected .    

内源性的内源性或外源性的病原体都可导致HCAIs.内源性的病原体来源于身体某些部位，例如皮肤、鼻部、口腔、消化道、或阴道，这些部位通常有局部的菌落寄居。在一定的有利条件下这些病原体就会入侵人体或者当病原体污染无菌部位时就引发感染。经由健康照护工作者的手，病原体被频繁传播到这些部位。外源性病原体是那些来源于病患以外的病原体，例如健康照护工作者、访客、护理病患使用的设备、医疗设备、或保健环境。HCAIs不仅仅局限于患者，健康照护工作者、辅助员工、和访客也会被影响。

HCAIs occur both as part of an endemic (ongoing) trend within a health-care facility or as epidemic situations, i e when new cases in a given population and during a given period substantially exceed what is expected, based on local endemic data.The endemic situation and occurrence of outbreaks in a health-care setting are important indicators of the quality and safety of patient care.For this reason, surveillance is at the heart of infection prevention and control.Surveillance is defined as “the ongoing, systematic collection, analysis, and interpretation of health data essential to the planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know” 40 Surveillance activities are an essential tool to reduce HCAI as they are the important first step in identifying problems and priorities。Furthermore, it has been show that conducting prospective surveillance activities, especially if prolonged, help to raise awareness of the problem and, finally, to decrease infection rates 41-43

HCAIs的发生，即是区域保健机构（正在进行）趋势的一部分，也是流行情况的一部分。例如在特定的人群中、特定期间内，超过基于当地区域数据预期的新病例大量出现。在医疗保健机构中，地方流行情况和爆发的发生是重要的质量和患者照护安全指标。由于这个原因，监测就成为感染预防与控制的核心工作。监测被定义为“持续地、系统的收集、分析卫生数据，并从本质上解释计划、实施和评价公共健康实践，紧密地整合数据、及时地将这些数据传播给那些需要知道的人”。监测是减少HCAIs不可或缺的工具，在确立问题和优先次序时，监测是重要的第一步。除此之外，进行前瞻性的监测活动，尤其是持续长时间的监测有助于提高对问题的认识而最终降低感染发生率。（Continued）

蓝鱼o_0

回复 8# huiqing.li

Your participation is my great pleasure!
Look forward to your achievement！

青城山

回复 9# 蓝鱼o_0
Thanks for your encouragement!
I will  try  my  best!

青城山

2Methods and challenges of health care-associated infection surveillance

健康相关感染监测的方法与挑战（二）

The use of standardized definitions is crucial to the reliability of HCAI surveillance  These allow to establish that the infection was acquired during hospital stay, to ascertain that the condition is a true infection and not a colonization (i e  the presence of microorganisms on skin or mucous membranes, in open wounds,in excretions/secretions, but without any overt adverse clinical sign  or symptoms) or contamination (ie  the exceptional and accidenta presence of microorganisms in normally sterile body sites or fluids that does not reflect actual infection status), and to define the type of infection according to the body site。  The most reliable definitions are those issued by the USA National Nosocomial Infections Surveillance (NNIS) system and recently revised by the National Healthcare Safety Network (NHSN) 5 . The application of standardized definitions is one of the minimum requirements for data comparisons at local, national, and international levels, although other variables need to be taken into account to allow appropriate benchmarking。
标准定义的使用决定了HCAI 监测的可靠性。这些定义让我们可以证实感染是在住院期间获得的，查明是真正的感染而不是定植（例如：存在于皮肤、粘膜、开放伤口、排泄物/分泌物中的微生物，但是没有任何明显的有害的临床症状和体征）或污染（例如：微生物罕见地、偶然地存在于身体通常无菌的部位或体液中，这不能代表确实的感染情况），并根据身体部位定义感染的分类。最可靠的定义是由美国国家院内感染监测（NNIS）系统出版的和由国家医疗保健安全网络（NHSN）最新修订过的。标准定义的运用是数据可以在当地、国家和世界水平内进行比较的最低要求之一，虽然其他变量也需要被考虑允许适当地确定基准点。

The use of these definitions requires the evaluation of clinical evidence collected from a review of the patient chart or other clinical records and/or the performance of microbiologic tests and/or direct observation of the infection site, e g  surgical wound, catheter insertion site, etc 5 Further evaluation of diagnostic investigations or clinical information by a physician or a surgeon may be necessary (e g  direct observation during a surgical operation, endoscopic examination) for the application of some criteria defining HCAI. These requirements lead to an accurate diagnosis in most cases, but make surveillance a resource-demanding activity  In settings where electronic patient records and automated systems exist, combining this information with the use of specific software or databases greatly simplifies HCAI surveillance  In settings with limited resources, these systems are usually lacking, medical and nurse records are often not well organized and detailed, and access to laboratory and radiological facilities is very limited and frequently of low quality  In addition, in low- and middle-income countries, a lack of expertise in the field of infection prevention and control, understaffing, overcrowding, and limited financial resources constitute real constraints to HCAI surveillance performance。
运用这些定义需要对从临床收集到的证据进行评价。我们从患者病历回顾、或是其他临床记录和/或微生物报告和/或感染部位的直接观察，例如外科伤口、导管插入点等收集证据。对于运用规范去定义HCAI时，进一步的评价、诊断调查、或由内科或外科医师提供临床信息是必要的（例如：在外科手术、内镜检查时直接观察）。这些需求使得在大多数情况下，感染诊断准确，但是同时也使得监测成为一项耗费资源的活动。在有电子病例记录和自动系统存在的机构中，运用特别的软件或数据库整合这些信息大大地简化了监测。但是，在资源有限的机构，这些系统缺乏，医疗和护理记录没有被很好的详细的组织，使用试验室检查和放射检查设备非常有限，且质量不高。此外，在低收入和中等收入国家，在感染预防与控制领域缺乏专业技能，人员不足、过度拥挤，和有限财政资源构成了HCAI监测工作的真正参数。（Continued）

青城山

2Methods and challenges of health care-associated infection surveillance

   健康相关感染监测的方法与挑战（三）

HCAI surveillance is a challenging task also because it requires a particular expertise after obtaining epidemiological data to assess the quality of the information produced, and to interpret its meaning and root cause in order to tailor intervention and prevention measures.The establishment and maintenance of surveillance encompasses various steps including specific components (Table 2 1)  
HCAI 监测是一项具有挑战性的工作，因为这需要特殊的专业技能。为了制定完全适合的干预措施和预防方法，在获得流行病学数据之后，需要评价所获得资料的质量，解释数据的意义和数据产生根本原因。监测的建立和维持包括了不同的步骤和特定的组成（表2-1）。

Table 2.1
Main steps and components of a HCAI surveillance system

Surveillance steps	Components
1. Planning	•Assessment of available expertise, facilities and resources •Identification of specific objectives, cope, and methods, according to the local reality •Selection of standardized definitions and preparation of surveillance protocols
2. Implementation	•Clinical data collection and other investigations conducted •Completion and finalization of data collection forms •Ongoing laboratory surveillance of sentinel microorganisms
3. Analysis and feedback	•Data analysis and interpretation •Local feedback adapted to the most appropriate means
4. Interventions driven by surveillance	•Identification of appropriate and feasible interventions and priority areas according to specific results of surveillance •Repetition of surveillance activities to assess the impact of interventions and their adjustment according to results

表2.1

HCAI监测系统的主要步骤和组成

监测步骤	组成
1.计划	•评估可获得的专业技能、设备和资源 •按照当时实际确定特定目标，范围方法， •选择标准定义和准备监测计划
2. 实施	•临床资料的收集和其他调查的进行 •资料收集格式的完成 •实时的确定微生物的实验室监测
3.分析和反馈	•资料的分析和解释 •运用最适合的方法向当地反馈
4. 基于监测的干预	•根据监测的具体结果，确认适当的和可行的干预措施以及优先区域 •重复监测活动，评价干预措施的影响，并根据结果进行调整

（Continued）

青城山

2Methods and challenges of health care-associated infection surveillance

   健康相关感染监测的方法与挑战（四）

Surveillance can be passive or active, prospective or retrospective.Passive surveillance is the most common form of surveillance and relies on data routinely generated from automated patient records, e glaboratory-based surveillance and data extraction from patient records after discharge.It has typically a low sensitivity and may lead to misclassification and underreporting because the criteria for diagnosis may be not easily available.However, passive surveillance is less demanding and may be the only feasible method in settings lacking expertise and resources for active urveillance.Conversely, active surveillance should be conducted by trained personnel, usually infection control professionals, who look for evidence to meet standardized diagnostic criteria of HCAI by using a variety of data sources.Active surveillance has higher specificity and sensitivity than passive surveillance and should be preferred if resources permit .

   
监测可以是被动的或主动的，前瞻性的或回顾性的。被动监测是最普通的监测形式，依赖于从自动患者记录中常规产生的资料。例如，基于实验室的监测和从出院后患者病历记录中提取的数据。被动监测典型地低敏感，因为诊断的规范不容易获得，导致分类错误和漏报。然而，被动监测不耗费资源，在缺乏专业技能和资源的机构，被动监测可能是唯一可行的方法。相反地，主动监测由受过训练的专业人员进行，通常是感染控制专家，通过多种数据源，寻找满足HCAI的标准诊断规范的证据。主动监测比被动监测具有较高的特异性和敏感性，如果资源允许，应当首选主动监测。

Prospective surveillance monitors pre-selected indicators in hospitalized patients, according to a specific protocol.In some cases, it may be extended to the post-discharge period; this is particularly important for SSI 29-38,44,45. Retrospective surveillance relies on previously-recorded routine data after patient discharge and, thus, relevant information may be lacking and some diagnostic criteria not fulfilled.Prospective surveillance is considered the gold standard for the collection of reliable and timely information, particularly in areas housing high-risk patients, and its inherent active nature strengthens the link to related interventions.However, it is more resource-expensive and time-consuming than retrospective surveillance

前瞻性监测是按照特别的计划在住院患者中的预先指示器。在某些情况下，它扩展到出院后的期间，这对外科部位感染是特别重要的。回顾性监测是在患者出院后，依赖于以前记录的常规数据进行监测，由于可能缺乏相关信息，一些感染诊断不能得到确认。前瞻性监测被认为是可靠、适时信息收集的金标准，特别是在那些居家高风险患者的区域，与干预措施相关联具有内在的有效的加强。然而,与回顾性监测相比，前瞻性监测是一种更加昂贵和耗时的方法。（Continued）

蓝鱼o_0

回复 13# huiqing.li

翻译是个重要的学习过程，不但可以帮助您自己深化理解，也可以进一步强化认识。
感谢您的付出，对其他会员来说，帮助很大。

青城山

2Methods and challenges of health care-associated infection surveillance

   健康相关感染监测的方法与挑战(五)

The clinical history and diagnosis of a HCAI case is given below to illustrate its complexity, the diagnostic implications, and the consequences of this complication at all levels in a patient seeking care for different underlying diseases (A HCAI case: diagnosis and clinical situation)

下面给出了临床病史和HCAI 病例诊断。从患者为不同的隐晦疾病寻求治疗的各个层面，举例说明了感染诊断的复杂性，诊断的内涵，合并症的后果（一例 HCAI：诊断和临床情况）

A HCAI case: diagnosis and clinical situation

In July 2009, a 46-year-old woman was admitted to a university hospital for further investigation of chronic eczema that had not responded to several treatment regimens with oral corticoster-oids and topical medication.On admission, the patient was found to be colonized with methi-cillin-resistant Staphylococcus aureus (MRSA) and received de-colonization treatment with chlorhexidine and nasal mupirocin.A chest X-ray, performed because of persistent cough, revealed lung cancer
She was transferred to the oncology unit and surgi-cal removal of the lesion was planned after three cycles of neo-adjuvant chemotherapy.The first cycle was administered without any major complication.A port-a-catheter (PAC) was inserted via the jugular vein under antibiotic prophylaxis (cefuroxime).Swab cultures of the nose performed after de-colonization treatment remained positive for MRSA.The patient was discharged in good condition under treatment with oral dexamethasone and topical medication for her dermatitis, and with the PAC in place while waiting for her second chemotherapy cycle.

A HCAI 病例：诊断和临床情况

2009年7月，一名46岁的女性，在慢性湿疹，对口服皮质激素和局部用药几种治疗都没有效果后，被送到一所大学医院进一步观察。入院时，发现患者有MRSA定植，患者接受了洗必泰和莫匹罗星鼻部涂抹的去定植治疗。因为持续咳嗽进行的胸部X-光检查显示胸部肿瘤。于是她被转到肿瘤病房，计划在三个新的辅助化疗疗程后外科切除病灶。第一个疗程后没有任何重要的并发症，在预防性使用抗生素的情况下（头孢呋辛），经颈静脉植入输液港。去定植治疗后鼻部拭子培养仍然MRSA阳性；患者情况好转时出院。出院后继续口服地塞米松，皮炎给与局部用药，并为第二次化疗保留了PAC。

Ten days later, the patient was admitted to the emergency unit of a peripheral hospital for fever, severe hypotension, and leuco-cytosis。Pus secretions were observed on the PAC insertion site wound.Staphylococci were detected in secretions by microscopy and 24 hours later the blood cultures performed at admission grew MRSA.Intravenous antibiotic treatment with vancomycin was started and the patient was transferred to the university hospital where the catheter was removed and a drain was put in place.Cul-ture of the catheter tip was performed and yielded MRSA 。

十天以后，患者因为发烧，严重的低血压，白细胞增多，送到附近医院的急诊室，  在PCA 插入点的伤口发现有脓性分泌物。分泌物显微镜检查法检测到葡萄球菌。24小时后，入院时做的血培养有MRSA生长。开始使用万古霉素静脉治疗，患者被转至大学医院，在那里拔除导管，并置入引流。导管尖端培养出MRSA。

A few days later, the patient developed neck oedema and sep-tic thrombosis of the left internal jugular, subclavian, and axillary veins was diagnosed.Intravenous rifampin was added to the pre-vious antibiotic therapy and a trans-oesophageal echocardiog-raphy was performed to exclude endocarditis.The examination proved negative.After three weeks of antibiotic therapy, the pa-tient developed vaginal candidiasis that was treated with topical antifungal drugs。
几天以后，患者颈部水肿，左侧颈内静脉、锁骨下静脉、腋静脉诊断血栓形成。先前的抗生素治疗中加入静脉使用的利福平。为排除心内膜炎，进行了经食管超声心动图检查，检查结果阴性。3个星期的抗生素治疗之后，患者发生阴道念珠菌感染，使用局部抗真菌药物进行治疗。

The patient’s condition slowly improved after an overall four-week intravenous antibiotic treatment course.Once recovered from the infection, the patient underwent her second chemotherapy cycle and was subsequently treated with radiotherapy and surgery 。

全面的4周的静脉抗生素治疗过程后，患者的情况渐渐改善。一旦从感染中恢复，患者就开始第二次化疗，紧接着使用放射治疗和外科治疗。

Source: University of Geneva Hospitals, Geneva, Switzerland

来源：瑞士，日内瓦，日内瓦大学医院   (Continued )

青城山

2Methods and challenges of health care-associated infection surveillance

健康相关感染监测的方法与挑战(六)

  Why is this a case of HCAI?The patient was at risk because she probably developed immunosuppression due to long-term corticosteroid treatment.She was found to be colonized by MRSA and underwent standard topical eradication treatment, but she remained positive at first follow-up.She subsequently developed signs of infection following insertion of PAC: fever >38°C; inflammatory syndrome; and signs of a localized infection (purulent discharge of the catheter insertion site)
为什么这个病例是HCAI？由于长期的皮质类固醇治疗，患者可能发生免疫抑制，所以患者有感染的风险。患者MRSA定植，使用了标准的局部根除治疗。但是在第一次追踪时，结果保持阳性。患者接下来发生PAC穿刺点感染，发热，体温大于38℃，炎性症候群；有局限的感染症状（导管穿刺点排脓）。 The following criteria indicated that the patient developed a deep surgical site infection associated with catheter-related bacteraemia:•
an infection occurring 30 days following a surgical procedure;•
purulent discharge at the PAC insertion site;•
deliberate opening of the PAC insertion site and PAC removal by the surgeon;•
positivity of the purulent secretions, blood cultures and catheter tip for the same microorganism (MRSA) 以下标准表明患者发生了与导管相关菌血症有关的深部外科部位感染：
1、外科操作30天后发生感染
2、PCA 穿刺点排脓
3、外科医师谨慎拔除PCA,开放穿刺点
4、脓性分泌物培养、血培养，导管尖端培养出相同的微生物（MRSA）

As a consequence of this complication:•
extensive vascular complications occurred (septic thrombosis of jugular, subclavian, and axillary veins); •
an invasive diagnostic procedure was performed to exclude endocarditis (trans-oesophageal echocardiography);•
an additional surgical intervention was required to remove the PAC;•
there was a need for long-term antibiotic treatment;•
multiple peripheral venous lines and one central venous line were inserted for supportive and antibiotic therapy; •
vaginal mycosis occurred due to prolonged antibiotic therapy;•
there was a delay in the treatment of the pulmonary cancer; •
the patient (mother of three children) was hospitalized and away from home for 35 days
这个合并症的后果
1、广泛的血管合并症发生（颈内静脉、锁骨下静脉、腋静脉脓毒血栓）
2、为除外心内膜炎，执行侵入性的诊断操作（经食管的超声心动图）
3、额外的外科手术，拔除PAC
4、需要长期的抗生素治疗
5、由于长期抗生素治疗，发生阴道念珠菌感染。
6、延迟了肺癌的治疗7、患者（母亲和三个女儿）住院，离家35天。（END）

小潭

谢谢老师为我们提供学习的方便，我深深地感到我们院感事业后继有人，兴旺发达！老师真是人才啊

蓝鱼o_0

回复 6# mickeypank


欢迎再次认领。两个最关键的部分.
发达国家的HAI，发展中国家的HAI现状！

米奇朋克

回复 19# 蓝鱼o_0

3.高收入国家所特有的医疗照护相关感染负担

国家层面的HCAI监测系统在许多高收入国家都已建立，相关的数据通常可以在全国性报告和（或）全国范围的或多中心的研究报告中获取，它们都发表在相关的科学文献上（见表3.1）。根据我们的回顾性调查，1995年至2010年间23个高收入国家实施了131项全国范围的或多中心的研究。欧洲疾病预防控制中心（以下简称ECDC）2008年报告28个欧洲高收入国家中已有13国建立起国家监测系统，占46.4%。这些系统用来监测ICU获得性感染、外科手术部位感染（以下简称SSI）或两者都监测，相关数据常通过监测网报告给欧洲感染控制网成员医院。在美国，有超过3000家医疗照护机构常规地向国家健康监测网络（以下简称NHSN）报告ICU获得性感染，这个网络由美国国家疾病预防控制中心建立。其他高收入国家如澳大利亚、法国、德国和日本，也有同类型的国家级或州级监测系统。我们这篇关于高收入国家HCAI负担的回顾性文献所确认的55项全国范围的研究项目，大多数在已建立起全国监测系统的国家展开。

全国范围的和多中心的研究显示，住院患者中发生至少一种HCAI的患病率从3.5%~12%不等（见表3.2）。混合患者人群研究的荟萃分析中HCAI总的例次感染率为7.6%（95%可信区间6.9-8.5）；感染率为7.1%（95%可信区间6.5-7.8）。高收入国家最新的研究数据中HCAI患病率见表3.3。

ECDC报告每年欧洲有413.10万人、453.41万人次发生HCAI，平均患病率为7.1%。2002年美国预计的HCAI发病率为4.5%，这相当于1000住院病人日有9.3个病人发生感染或者等于170万人感染。在美国和欧洲，泌尿道感染（以下简称UTI）是最常见的HCAI感染类型（分别占36%和27%）。美国排在第二至四位的感染类型分别是手术部位感染（以下简称SSI）（占20%）、血流感染（以下简称BSI）和肺炎（均占11%）。欧洲排名第二位的感染类型是下呼吸道感染（占24%），第三位是SSI（占17%），第四位是BSI（占10.5%）。诸多的研究结果显示，在高收入国家SSI的发生率从1.2%~5.2%不等。

HCAI给高危人群中带来的负担更为巨大，如入住ICU的患者、烧伤和器官移植患者及新生儿。根据最新的欧洲多中心研究成果显示，ICU患者的感染率高达51%，其中大多数为HCAI。在高收入国家ICU患者中有近30%至少发生一种HCAI，这与ICU感染发病率和死亡率持续相关。在我们的回顾性调查中，美国和欧洲的大规模研究显示在工业化国家的成人高危患者人群中HCAI的发病强度从13.0个/1000住院病人日到20.3个/1000住院病人日不等（见表3.4），总的发病率为17.0个/1000住院病人日。HCAI的发生率如此之高，与侵入性装置的使用有关，特别是中心静脉导管、导尿管和呼吸机。美国NNIS监测系统有一份报告说83%的医院获得性肺炎与器械通气有关；97%的UTI发生在泌尿道插管患者身上；87%的早期BSI患者都有中心静脉置管。在高收入国家的成人ICU患者中，导管相关血流感染（以下简称CR-BSI）、导尿管相关泌尿道感染（以下简称CR-UTI）和呼吸机相关性肺炎（以下简称VAP）总的发生强度分别为3.5个/1000静脉置管日（95%的可信区间2.8-4.1）、4.1个/1000泌尿道插管日（95%的可信区间3.7-4.6）和7.9个/1000呼吸机使用日（95%的可信区间5.7-10.1）。这三项数据与英国的NHSN及德国的KISS监测数据相比较，后者的稍许高一些，其VAP是ICU最常见的感染类型（占32%），第二、三位分别是CR-UTI和CR-BSI（均占20%）

需要重症监护的出生极低体重儿（＜1500g）是HCAI高危人群。在加拿大和德国开展的多中心研究最新数据显示，两国新生儿HCAI的发生率分别为23.5%和12.3%。儿科ICU中HCAI的发生率相对较低，如美国这类患者人群HCAI的发生率只有5.7%；器械相关性感染的发生强度分别为：VAP——1.8个/1000呼吸机使用日、CR-BSI——3.0个/1000静脉置管日、CR-UTI——4.2个/1000泌尿道插管日。

法国、德国和意大利开展的大规模研究报告，13954株ICU获得性感染分离株中最常见的致病菌有：金黄色葡萄球菌（占21.8%）、肠杆菌（占20.2%）、假单胞菌属（占17.2%）、肠球菌（占10.0%）、大肠埃希菌（占9.1%）、念珠菌属（占8.8%）、凝固酶阴性葡萄球菌（占7.0%）及不动杆菌属（占5.1%）。这些分离到的微生物类型与1995年欧洲ICU患病率研究项目（EPIC）所报告的相近，除了凝固酶阴性葡萄球菌，其他都是常见菌。在这篇回顾性调查里还另外的研究报告，在42247株HCAI分离株中大肠埃希菌（占20.1%）和金黄色葡萄球菌（占17.8%）是混合患者人群最常见致病菌，这也揭示UTI和SSI是最普遍的感染类型。其他的重要致病菌还有假单胞菌属（占11.5%）、肠杆菌（占10.6%）、念珠菌属（占6.7%）、肠球菌（占6.5%）、不不动杆菌属（占5.8%）、凝固酶阴性葡萄球菌（占5.3%）。

【4.The burden of endemic HCAI in Low-and middle income countries】的翻译在34楼！

yhuister

很好的文献，我已经下载了要好好学习一下，谢谢热心人的翻译，看起来快一些，希望继续翻译下去－前人栽树，我们后人乘凉啦，非常感染！