医院环境清洁集束措施与医院相关感染(REACH): 一项多中心随机试验

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[Lancet Infect Dis发表论文]: 医院环境清洁集束措施与医院相关感染(REACH): 一项多中心随机试验
2019年04月21日 ⁄ 时讯速递, 进展交流 ⁄ 暂无评论
An environmental cleaning bundle and health-care-associated infections in hospitals (REACH): a multicentre, randomised trial
Brett G Mitchell, Lisa Hall, Nicole White,  et al
Lancet Infect Dis 2019; 19: 410-418
Background 背景
The hospital environment is a reservoir for the transmission of microorganisms. The effect of improved cleaning on patient-centred outcomes remains unclear. We aimed to evaluate the effectiveness of an environmental cleaning bundle to reduce health care-associated infections in hospitals.

医院环境是微生物传播的源地。改进清洁措施对患者为中心的预后指标的影响尚不清楚。我们旨在评价环境清洁集束措施对降低医院相关感染的效果。

Methods 方法
The REACH study was a pragmatic, multicentre, randomised trial done in 11 acute care hospitals in Australia. Eligible hospitals had an intensive care unit, were classified by the National Health Performance Authority as a major hospital (public hospitals) or having more than 200 inpatient beds (private hospitals), and had a health-care-associated infection surveillance programme. The stepped-wedge design meant intervention periods varied from 20 weeks to 50 weeks. We introduced the REACH cleaning bundle, a multimodal intervention, focusing on optimising product use, technique, staff training, auditing with feedback, and communication, for routine cleaning. The primary outcomes were incidences of health-care-associated Staphylococcus aureusbacteraemia, Clostridium difficile infection, and vancomycin-resistant enterococci infection. The secondary outcome was the thoroughness of cleaning of frequent touch points, assessed by a fluorescent marking gel. This study is registered with the Australian and New Zealand Clinical Trial Registry, number ACTRN12615000325505.

REACH研究是一项实效性、多中心、随机试验，在澳大利亚的11个急性病医院进行。入选医院须设置ICU，且被划定为大医院（公立医院）或超过200张住院床位（私立医院），并有医院感染监测项目。研究采用阶梯设计，干预阶段为20至50周不等。我们采用REACH清洁集束措施，这是一种多模态干预措施，强调针对常规清洁措施的优化产品使用，技术与员工培训，监测结果反馈及交流。主要预后指标为医院获得性金黄色葡萄球菌菌血症，难辨梭状芽孢杆菌感染及万古霉素耐药肠球菌感染。次要预后指标包括经常触摸部位清洁是否彻底（通过荧光标记凝胶评估）。研究在澳大利亚和新西兰临床试验注册网注册，注册号ACTRN12615000325505。

Findings 结果
Between May 9, 2016, and July 30, 2017, we implemented the cleaning bundle in 11 hospitals. In the pre-intervention phase, there were 230 cases of vancomycin-resistant enterococci infection, 362 of S aureus bacteraemia, and 968 C difficile infections, for 3&#8200;534&#8200;439 occupied bed-days. During intervention, there were 50 cases of vancomycin-resistant enterococci infection, 109 of S aureusbacteraemia, and 278 C difficile infections, for 1&#8200;267&#8200;134 occupied bed-days. After the intervention, vancomycin-resistant enterococci infections reduced from 0·35 to 0·22 per 10&#8200;000 occupied bed-days (relative risk 0·63, 95% CI 0·41–0·97, p=0·0340). The incidences of S aureus bacteraemia (0·97 to 0·80 per 10&#8200;000 occupied bed-days; 0·82, 0·60–1·12, p=0·2180) and C difficile infections (2·34 to 2·52 per 10&#8200;000 occupied bed-days; 1·07, 0·88–1·30, p=0·4655) did not change significantly. The intervention increased the percentage of frequent touch points cleaned in bathrooms from 55% to 76% (odds ratio 2·07, 1·83–2·34, p<0·0001) and bedrooms from 64% to 86% (1·87, 1·68–2·09, p<0·0001).

2016年5月9日至2017年7月30日间，我们对11所医院实施了清洁集束措施。在干预前阶段（共计3534439个住院日），共有230例万古霉素耐药肠球菌感染，362例金黄色葡萄球菌菌血症及968例难辨梭状芽孢杆菌感染。在干预后，万古霉素耐药肠球菌感染发生率从每10000个住院日0.35例降低到0.22例（相对危险度 0·63, 95% CI 0·41–0·97, p=0·0340）。金黄色葡萄球菌菌血症（从每10000个住院日0·97例到0·80例；0·82, 0·60–1·12, p=0·2180）和难辨梭状芽孢杆菌感染（从每10000个住院日2·34例到2·52例；1·07, 0·88–1·30, p=0·4655）发生率无明显变化。干预措施使得浴室中经常触摸部位清洁比例从55%增加到76% (OR 2·07, 1·83–2·34, p<0·0001)，卧室内经常触摸部位清洁比例从64%提高到86% (1·87, 1·68–2·09, p<0·0001)。





Interpretation 结论
The REACH cleaning bundle was successful at improving cleaning thoroughness and showed great promise in reducing vancomycin-resistant enterococci infections. Our work will inform hospital cleaning policy and practice, highlighting the value of investment in both routine and discharge cleaning practice.

REACH清洁集束措施能够成功改进清洁彻底性，显著减少万古霉素耐药肠球菌感染。我们的研究为医院清洁政策与行为提供信息，强调了常规清洁及出院清洁的重要性。

Funding
National Health and Medical Research Council (Australia).

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