NEJM：艰难梭菌感染现状和预防措施

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NEJM：艰难梭菌感染现状和预防措施


此文章来源于www.cmt.com.cn
　     根据疾病控制和预防中心（CDC）公布的最新数据显示，难辨梭状芽胞杆菌在2011年已感染近50万人，并造成29000人的相关死亡。近期，《新英格兰医学杂志》上一项研究对美国难辨梭状芽胞杆菌感染负担进行了描述，医脉通对相关内容整理编译，详情如下：
　　 “难辨梭状芽胞杆菌是一种可以引起严重腹泻并造成结肠损害的细菌，通常由于过度使用抗生素引起，难辨梭状芽胞杆菌在医疗机构和社区均较常见，并在过去几十年里越来越普遍。” Michael Bell教授（副主任医师，人畜共患疾病国家控制中心，美国疾病控制和预防中心）在一次CDC会议上讲到。
　　“过去，患者由于使用抗生素而导致难辨梭状芽胞杆菌感染型腹泻通常被认为仅是一个比较麻烦的疾病，而不是什么大问题。然而不幸的是，目前美国流行的难辨梭状芽胞杆菌所产生的毒素类型是如此强大，甚至会导致致命性腹泻。”Bell教授解释说。
　　“接受抗生素治疗的患者可能出现的潜在危险不仅仅是轻度的腹泻，甚至是更加严重的疾病，比如，结肠严重的损害甚至需要结肠部分切除，这就是通常说的中毒性巨结肠。”
　　Fernanda C.Lessa教授（人畜共患疾病国家控制中心，美国疾病控制和预防中心）和同事们2011年在美国10个不同地理区域进行了以人口和实验室为基础的监测，从而确定难辨梭状芽胞杆菌的感染情况。对于当地1岁以上的居民粪便标本中发现难辨梭状芽胞杆菌的毒素或分子等定义为标本阳性。他们将这些感染病例分类为社区相关性和医院相关性的。在病例的样本中，他们进行标本培养，并对其分子类型进行分离。
　　 利用回归分析模型，研究人员推测出全国整体发病率及总感染人数，第一次复发人数和及确诊30天内死亡人数。在10个不同的国家地理区域中，研究人员总共确诊了15461例难辨梭状芽胞杆菌感染病例，其中有65.8%为医院相关性感染，然而仅有24.2%为住院期间开始出现感染。
　　研究人员对于难辨梭状芽胞杆菌感染的发病率的预测进行了调整。对于社区相关性的调整包括：年龄、性别、种族及52%的核酸扩增试验；对于医院相关性的调整包括：年龄、住院天数及52%的核酸扩增试验。
　　通过调整之后，研究人员估计美国感染总人口数为453000（95%可信区间[CI]，397100～508500）。研究人员发现发病率较高的人群包括女性（比率比，1.26；95%CI，1.25～1.27），白种人（比率比，1.72；95%CI，1.56～2.0）以及年龄大于65岁的老年人（比率比，8.65；95%CI，8.16～9.31）。
　　根据研究人员估计，第一次复发的总人数为8300（95%CI，5700～108900）。死亡人数为29300（95%CI，16500～42100）。
　　医院相关性感染更严重
　　根据研究人员评估的第一次复发率，社区相关性感染方面为13.5%，医院相关性感染方面为20.9%。确诊30天内死亡率方面，社区相关性感染为1.3%，而医院相关性感染为9.3%。相对于社区性感染，NAP1型菌株在医院性感染中更为常见（30.7% vs 18.8%；P＜0.001）。

　　“由于缺少相关疫苗，未来难辨梭状芽胞杆菌的防治工作不单纯是医疗方面工作，需将更多精力放在抗生素的合理使用方面。这项措施在英格兰被证实可以降低难辨梭状芽胞杆菌的感染率。在英格兰包括合理使用抗生素在内的多项措施已经实施。”作者解释到。
　　“难辨梭状芽胞杆菌的防治工作成为美国的首要任务，并确认为美国2020的减排指标。自从2013年起，所有医院参与医疗保险和医疗补助服务中心组织的医院住院质量报告程序。这个程序可以将难辨梭状芽胞杆菌感染数据直接报告给国家医疗安全网。”他们如是总结。
　　医务人员为预防难辨梭状芽胞杆菌感染，可采取以下措施：
　　◆应谨慎开具和使用抗生素。
　　◆对于难辨梭状芽胞杆菌感染治疗期间，或者因生病需长达数月使用抗生素治疗的患者出现腹泻症状，均需接受难辨梭状芽胞杆菌感染的检测。
　　◆对于难辨梭状芽胞杆菌感染的患者需即刻隔离。
　　◆照顾难辨梭状芽胞杆菌感染患者需穿戴隔离衣及手套。洗手液不能杀死难辨梭状芽胞杆菌，因此洗手不足以成为一项安全措施。
　　◆难辨梭状芽胞杆菌感染患者治疗后的房间需要使用漂白剂清洗消毒表面，或者使用美国环境保护署批准的能够杀死芽孢的另外一种消毒剂消毒。
　　◆病人转诊时，需提前通知新机构转诊病人是否有难辨梭状芽胞杆菌感染。

　　编译自：C difficile Infected Almost Half a Million in Single Year，Medscape，February 25，2015

tzgengxiuxia

下载学习了，谢谢老师的分享！

良龙马

      学习了“艰难梭菌感染现状和预防措施“。是啊！未来难辨梭状芽胞杆菌的防治工作不单纯是医疗方面工作，需将更多精力放在抗生素的合理使用方面。

神仙鱼

路过学习了，谢谢老师的分享!

jcyyhlb

谢谢老师的资料，下载学习了。

功夫小懒猪

洗手液不能杀死难辨梭状芽胞杆菌，因此洗手不足以成为一项安全措施。而且65.8%为医院相关性感染还是有点恐怖。

玲珑心ss

请问是否有原始文献？NEJM啊，很想好好学学

蓝鱼o_0

http://www.nejm.org/doi/pdf/10.1056/NEJMoa1408913

Burden of Clostridium difficile Infection in the United States

[size=0.7em]Fernanda C. Lessa, M.D., M.P.H., Yi Mu, Ph.D., Wendy M. Bamberg, M.D., Zintars G. Beldavs, M.S., Ghinwa K. Dumyati, M.D., John R. Dunn, D.V.M., Ph.D., Monica M. Farley, M.D., Stacy M. Holzbauer, D.V.M., M.P.H., James I. Meek, M.P.H., Erin C. Phipps, D.V.M., M.P.H., Lucy E. Wilson, M.D., Lisa G. Winston, M.D., Jessica A. Cohen, M.P.H., Brandi M. Limbago, Ph.D., Scott K. Fridkin, M.D., Dale N. Gerding, M.D., and L. Clifford McDonald, M.D.

[size=0.7em]N Engl J Med 2015; 372:825-834February 26, 2015DOI: 10.1056/NEJMoa1408913

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BACKGROUND

[size=0.81em]The magnitude and scope of Clostridium difficile infection in the United States continue to evolve.

METHODS

[size=0.81em]In 2011, we performed active population- and laboratory-based surveillance across 10 geographic areas in the United States to identify cases of C. difficile infection (stool specimens positive for C. difficile on either toxin or molecular assay in residents ≥1 year of age). Cases were classified as community-associated or health care–associated. In a sample of cases of C. difficile infection, specimens were cultured and isolates underwent molecular typing. We used regression models to calculate estimates of national incidence and total number of infections, first recurrences, and deaths within 30 days after the diagnosis of C. difficile infection.

RESULTS

[size=0.81em]A total of 15,461 cases of C. difficile infection were identified in the 10 geographic areas; 65.8% were health care–associated, but only 24.2% had onset during hospitalization. After adjustment for predictors of disease incidence, the estimated number of incident C. difficile infections in the United States was 453,000 (95% confidence interval [CI], 397,100 to 508,500). The incidence was estimated to be higher among females (rate ratio, 1.26; 95% CI, 1.25 to 1.27), whites (rate ratio, 1.72; 95% CI, 1.56 to 2.0), and persons 65 years of age or older (rate ratio, 8.65; 95% CI, 8.16 to 9.31). The estimated number of first recurrences of C. difficile infection was 83,000 (95% CI, 57,000 to 108,900), and the estimated number of deaths was 29,300 (95% CI, 16,500 to 42,100). The North American pulsed-field gel electrophoresis type 1 (NAP1) strain was more prevalent among health care–associated infections than among community-associated infections (30.7% vs. 18.8%, P<0.001)

CONCLUSIONS

[size=0.81em]C. difficile was responsible for almost half a million infections and was associated with approximately 29,000 deaths in 2011. (Funded by the Centers for Disease Control and Prevention.)

The views expressed in this article are those of the authors and do not necessarily represent the official position of the CDC.

Supported by the Emerging Infections Program (EIP) Cooperative Agreement between the 10 EIP sites and the CDC.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

We thank Joelle Nadle, Erin Garcia, and Erin Parker of the California EIP; Helen Johnston of the Colorado EIP; Carol Lyons of the Connecticut EIP; Leigh Ann Clark, Andrew Revis, Olivia Almendares, Zirka Thompson, and Wendy Baughman of the Georgia EIP; Rebecca Perlmutter of the Maryland EIP; Ruth Lynfield of the Minnesota EIP; Nicole Kenslow of the New Mexico EIP; Rebecca Tsay and Deborah Nelson of the New York EIP; Valerie Ocampo of the Oregon EIP; Samir Hannah, L. Amanda Ingram, and Brenda Rue of the Tennessee EIP; Susan Sambol and Laurica Petrella of the Hines VA Hospital; and Ashely Paulick, Johannetsy Avillan, Kamile Rasheed, and Lydia Anderson of the CDC.

SOURCE INFORMATION

The authors' affiliations are listed in the Appendix.

Address reprint requests to Dr. Lessa at the Centers for Disease Control and Prevention, 1600 Clifton Rd., MS C-25, Atlanta, GA 30333, or atflessa@cdc.gov.

APPENDIX

The authors' affiliations are as follows: the Centers for Disease Control and Prevention (CDC), National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality Promotion (F.C.L., Y.M., J.A.C., B.M.L., S.K.F., L.C.M.), Emory University School of Medicine, Department of Medicine (M.M.F.), Atlanta Veterans Affairs Medical Center (M.M.F.), the CDC Office of Public Health Preparedness and Response, Division of State and Local Readiness (S.M.H.), and the Atlanta Research and Education Foundation (J.A.C.) — all in Atlanta; the Colorado Department of Public Health and Environment, Denver (W.M.B.); Oregon Health Authority, Public Health Division, Portland (Z.G.B.); University of Rochester Medical Center, Rochester, NY (G.K.D.); Tennessee Department of Health, Nashville (J.R.D.); Minnesota Department of Health, St. Paul (S.M.H.); Yale School of Public Health, Connecticut Emerging Infections Program, New Haven (J.I.M.); University of New Mexico, New Mexico Emerging Infections Program, Albuquerque (E.C.P.); Maryland Department of Health and Mental Hygiene, Baltimore (L.E.W.); Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (L.G.W.); and Department of Medicine, Loyola University Chicago Stritch School of Medicine, Maywood (D.N.G.), and Edward Hines, Jr., Veterans Affairs Hospital, Hines (D.N.G.) — both in Illinois.

青柠檬

艰难梭菌的防控在日后的工作中越来越重要，从现在起认真学习。

因与果

现在洗手液的有效成分有很多，是所有成分的洗手液都不能杀死它吗？