JAMA：使用抗菌药物导管敷料可以降低与导管使用相关的感染

David

据3月25日刊JAMA上的一则研究披露，对那些在深切治疗部进行治疗的严重病患来说，应用一种含有洗必泰（chlorhexidine gluconate）的抗菌药物作为导管的敷料的一部份可以减轻严重的与导管有关的治疗风险。研究人员同时发现，将更换未弄脏的敷料的频率从每3天一次减少到每7天一次看来是安全。
进入深切治疗部（ICU）治疗的病患通常需要被插入中央静脉导管（CVCs）。在美国，每年在ICU的患者中估计有大约8万例会发生与CVC有关的血液感染。与CVC有关的血液感染的死亡范围在0-11.5%。而因为这些感染而造成的在ICU中逗留额外的时间估计为9-12天。文章的作者写道：“因此有必要采取措施来减少这些感染的发生率。”
对那些短期插入CVC的患者来说，大多数的造成与CVC有关的血液感染的细菌来自于导管插入的部位。使用含有洗必泰的海绵（CHGIS）作为静脉内导管插入部位处皮肤的敷料可能会减少与导管插入有关的感染（CRIs）。根据文章的背景资料，人们尚不清楚的是，每三天更换一次导管敷料是否比必要的更换次数要更为频繁。
University Joseph Fourier, Albert Bonniot Institute, Grenoble, France的Jean-Fran?ois Timsit, M.D., Ph.D.及其同僚对应用CHGIS敷料的效果以及增加ICU成年病患的敷料更换之间的时间长度进行了评估。这项随机对照的试验中包括来自法国三所大学和2家总医院的7个ICU中的1636位病患。这些患者都需要插入一根动脉导管、一根中央静脉导管，或两者兼具。其导管插入的时间为48小时或更长。这些患者的导管中位（即中点）插入时间为6天。这些病患或者使用含有洗必泰的海绵敷料，或使用标准性的敷料（作为对照组）。按计划，对未弄脏的敷料的更换时间被定在每3天或每7天一次，但如果发生敷料弄脏或有渗漏的情况的话，敷料将被立刻更换。
使用CHGIS敷料降低了重大的CRI发生率（即与导管有关的临床败血症，但没有发生血液感染或与导管有关的血液感染），其降幅为61%（10/1953 [0.5%] vs. 19/1825 [1.1%]）。使用CHGIS敷料据估计可以在平均10天的时间中，在每117根留置在病人体内的导管中防止发生一次严重的CRI。
在3天更换一次敷料的小组中，导管形成菌落（即在移除导管时导管上存在的细菌）的发生率为7.8%，而在每7天更换一次敷料的小组中，该发生率为8.6%。绝对的平均差为0.8%。
文章的作者写道：“…更换敷料的时间间距可以安全地延长到3 天以上，但不要超过7天。前提条件是对敷料进行严密的监视，并在发现敷料脱离或弄脏时即刻对其进行更换。”（生物谷Bioon.com）
生物谷推荐原始出处：
JAMA. 2009;301(12):1231-1241.

Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults

A Randomized Controlled Trial

Jean-Fran?ois Timsit, MD, PhD; Carole Schwebel, MD, PhD; Lila Bouadma, MD; Arnaud Geffroy, MD; Ma?té Garrouste-Orgeas, MD; Sebastian Pease, MD; Marie-Christine Herault, MD; Hakim Haouache, MD; Silvia Calvino-Gunther, RN; Brieuc Gestin, PhD; Laurence Armand-Lefevre, PharmD; Véronique Leflon, PharmD; Chantal Chaplain, PharmD; Adel Benali, MD; Adrien Francais, MSc; Christophe Adrie, MD, PhD; Jean-Ralph Zahar, MD; Marie Thuong, MD; Xavier Arrault, PharmD; Jacques Croize, PharmD; Jean-Christophe Lucet, MD, PhD; for the Dressing Study Group

Context  Use of a chlorhexidine gluconate–impregnated sponge (CHGIS) in intravascular catheter dressings may reduce catheter-related infections (CRIs). Changing catheter dressings every 3 days may be more frequent than necessary.
Objective  To assess superiority of CHGIS dressings regarding the rate of major CRIs (clinical sepsis with or without bloodstream infection) and noninferiority (less than 3% colonization-rate increase) of 7-day vs 3-day dressing changes.
Design, Setting, and Patients  Assessor-blind, 2 x 2 factorial, randomized controlled trial conducted from December 2006 through June 2008 and recruiting patients from 7 intensive care units in 3 university and 2 general hospitals in France. Patients were adults (>18 years) expected to require an arterial catheter, central-vein catheter, or both inserted for 48 hours or longer.
Interventions  Use of CHGIS vs standard dressings (controls). Scheduled change of unsoiled adherent dressings every 3 vs every 7 days, with immediate change of any soiled or leaking dressings.
Main Outcome Measures  Major CRIs for comparison of CHGIS vs control dressings; colonization rate for comparison of 3- vs 7-day dressing changes.

Results  Of 2095 eligible patients, 1636 (3778 catheters, 28 931 catheter-days) could be evaluated. The median duration of catheter insertion was 6 (interquartile range [IQR], 4-10) days. There was no interaction between the interventions. Use of CHGIS dressings decreased the rates of major CRIs (10/1953 [0.5%], 0.6 per 1000 catheter-days vs 19/1825 [1.1%], 1.4 per 1000 catheter-days; hazard ratio [HR], 0.39 [95% confidence interval {CI}, 0.17-0.93]; P = .03) and catheter-related bloodstream infections (6/1953 catheters, 0.40 per 1000 catheter-days vs 17/1825 catheters, 1.3 per 1000 catheter-days; HR, 0.24 [95% CI, 0.09-0.65]). Use of CHGIS dressings was not associated with greater resistance of bacteria in skin samples at catheter removal. Severe CHGIS-associated contact dermatitis occurred in 8 patients (5.3 per 1000 catheters). Use of CHGIS dressings prevented 1 major CRI per 117 catheters. Catheter colonization rates were 142 of 1657 catheters (7.8%) in the 3-day group (10.4 per 1000 catheter-days) and 168 of 1828 catheters (8.6%) in the 7-day group (11.0 per 1000 catheter-days), a mean absolute difference of 0.8% (95% CI, –1.78% to 2.15%) (HR, 0.99; 95% CI, 0.77-1.28), indicating noninferiority of 7-day changes. The median number of dressing changes per catheter was 4 (IQR, 3-6) in the 3-day group and 3 (IQR, 2-5) in the 7-day group (P < .001).

Conclusions  Use of CHGIS dressings with intravascular catheters in the intensive care unit reduced risk of infection even when background infection rates were low. Reducing the frequency of changing unsoiled adherent dressings from every 3 days to every 7 days modestly reduces the total number of dressing changes and appears safe.

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