【重奖翻译】急性病医疗机构流行病学和感染控制2011版（欢迎认领）

蓝鱼o_0

2011年CMR最新综述。急诊科医院流行病学和感染控制。由于页数很多，所以希望大家分批认领，翻译重奖！！

我已认领introduction。

题外话：CMR不用介绍了吧，影响因子大于15分。属于医院感染领域的顶级综述，笔者多为此领域的非常有影响力的专家。



——题目已经参照ICCHINA的建议修改


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【introduction】

Introduction

The Centers for Disease Control and Prevention (CDC) defines health care-associated infections (HAIs) as infections acquired while in the health care setting (e.g., inpatient hospital admission, hemodialysis unit, or same-day surgery), with a lack of evidence that the infection was present or incubating at the time of entry into the health care setting (139). These definitions need to respond to a changing medical environment. Modern medical care has become more invasive and therefore associated with a greater risk of infectious complications. An aging population, the AIDS epidemic, the growth of chemotherapeutic options for cancer treatment, and a growing transplant population have expanded the population at an increased risk for infection as a consequence of interactions with the health care system. Both surgical care and medical care that are increasingly complex and invasive are being provided in non-acute-care settings, making the definition of a health care setting more problematic. Finally, patients move freely within sometimes loosely defined elements of the health care system: between long-term care or rehabilitation facilities, to acute-care facilities, to free-standing surgical care providers.

美国疾病控制和预防中心（CDC）定义在医疗保健环境相关感染感染为医院感染，这些感染是在医疗卫生保健环境（如病患入院，血液透析装置，或同一天手术）里获得。但是表明感染已存在或一接触卫生保健环境后便开始发展的证据尚不足。这些定义需要应对不断变化的医疗环境。目前，侵入性现代医疗保健越来越多因此往往伴危险性更大的并发症。 人口老龄化，艾滋病的流行，癌症化疗的增长，和移植病人的增多等，这些都将增加医疗保健系统中交叉感染的风险。非急诊科外科护理和医疗护理日益复杂和侵入性操作逐渐增多，由此导致医疗保健环境问题重重。最后，病人便想当然的把医疗保健系统组成定义为：从长期护理和康复设施，急性保健设施，独立的外科护理者。

In 1980, the Study on the Efficacy of Nosocomial Infection Control (SENIC) demonstrated that surveillance for nosocomial infections and infection control practices that included trained professionals could prevent HAIs (122). As a result, an important role developed for hospital epidemiologists and infection control practitioners (298). As medical care has become more complex, antimicrobial resistance and HAIs have increased, as have their attributable morbidity and mortality (362). Additionally, HAIs increase hospital lengths of stay and health care expenditures (247). In response to patient risks and growing costs, in 2008 the Centers for Medicare and Medicaid Services (CMS) implemented a strategy of withholding reimbursement for certain HAIs such as catheter-associated urinary tract infections (CA-UTIs) and central line-associated bloodstream infections (CLABSIs) (336). Now more than ever, institution-specific surveillance driven by hospital epidemiologists and infection preventionists (IPs) is needed in order to enact early detection and prevention strategies to curtail HAIs.

1980年，医院感染控制疗效研究表明医院感染监测、感染控制（包括专业人员培训）监测能够预防HAIs。因此，医院流行病学家和感染执行者应运而生。随着于医疗保健日益复杂复杂的，抗生素耐药和医院感染发病率显著增加，并导致相应HAIS的发病率和死亡率增加。为降低病患风险和降低逐渐增长的医疗成本，2008年医疗保险和医疗中心服务（CMS）决定停用一些HAIS的支付，包括导管相关尿路感染（CA-UTI）和中央线相关血流感染（CLABSI）。现在比以往任何时候都要求医院流行病学家和感控专家推动机构相关的监测，早发现和早预防，以减少医院感染的发生。

This review is intended for general internists and infectious diseases physicians and provides a general overview of hospital epidemiology and infection control in acute-care settings. This review summarizes some of the challenges and opportunities faced by the health care epidemiology community. We discuss HAIs in the broadest sense to include all health care-associated infections, communicable diseases, and multidrug-resistant (MDR) and epidemiologically significant organisms.

本综述拟为内科医师和感染性疾病医生粗略介绍急诊科医院流行病学和感染控制的一般情况。概括医疗保健社区面临的机遇与挑战。我们广义的探讨HAIS，包括卫生保健相关感染，传染病，重大流行病学意义的多药耐药（MDR）微生物。

鬼才

HISTORY

Semmelweis

Ignaz Semmelweis is credited with first discovering that health care providers could transmit disease, as he described the mode of transmission of puerperal sepsis. Semmelweis was a Hungarian obstetrician at the Maternity Hospital in Vienna, Austria, who in 1847 noted higher rates of maternal mortality among patients cared for by obstetricians and medical students than among those cared for by midwives. At that time he also witnessed a pathologist die of sepsis after sustaining a scalpel wound while performing an autopsy on a patient with puerperal sepsis. He noted that the pathologist’s clinical illness mimicked that of women with puerperal sepsis and identified that not only a scalpel but also physicians’ hands contaminated after an autopsy could transmit contaminated material or organisms to mothers in labor. He introduced chlorinated lime hand washing into the clinic staffed by obstetricians and medical students, with drastic improvements in rates of maternal mortality (232). However, Semmelweis’ theories were dismissed by most of the medical establishment. When Koch’s postulates were published in 1890, the germ theory of disease and Semmelweis’ theory of transmission from patient to patient were considered plausible. In essence, Semmelweis gave us the first description of an HAI and an intervention to prevent its development through his demonstration of the benefits of hand hygiene.

历史

Semmelweis

Ignaz Semmelweis被认为是第一位发现医院可以传播疾病的人，他描述了产褥热的传染模式。Semmelweis是奥地利维也纳产科医院的匈牙利产科医生，1847年他注意到了由产科医生和实习医生接生的产妇死亡率比由助产士接生的要高。那时他也见证了一个病理学家死于因术后手术刀划伤引起的败血症，发现败血症是因在对一个产后败血症患者进行活检时引发的。他指出，病理学家的临床病症与妇女产后败血症类似，他认为不仅手术刀，而且医生的手进行尸体解剖后都被污染而传播病原体。他要求医院中的产科医生和实习医生用含氯的石灰水洗手，使产妇死亡率大幅度改善。然而Semmelweis的这一理论被大部分医疗机构拒绝了。当Koch的假设在1890年出版时，病原微生物在患者之间传播的Semmelweis的理论被认为振振有词。实质上，Semmelweis通过他的手卫生示范第一个描述了医院感染和干预预防措施。

Discovery of Penicillin

While studying color variants of Staphylococcus aureus onpetri plates, Alexander Fleming noted the growth of a contaminating mold with an associated zone of bacterial clearance (20). He demonstrated that the active substance causing bacterial lysis could be found in the filtrate of the contaminating mold culture, and the fungus was discovered to be a species of the genus Penicillium (81). Through the publication of his findings and Fleming’s persistence, in 1940 chemists were able to isolate, concentrate, and purify the substance that came to be known as penicillin (81). Penicillin G was first used in clinical practice in 1942. Penicillin’s lack of reliable activity against Gram-negative bacteria led to the search for other novel antibiotics, and cephalosporins were subsequently discovered in the 1950s.

青霉素的发现

在研究放在培养皿里的金黄色葡萄球菌颜色变化时，Alexander Fleming注意了一个被沾染的正在成长的细菌小团块被清除掉。他证实可引起细菌裂解的活性物质在污染霉菌培养滤液中被发现，并且发现了一种青霉菌类的真菌。通过找到记载他研究结果的出版物，1940年化学家分离出一种叫青霉素的物质。在1942年青霉素G首先用于临床实践。青霉素对革兰阴性菌缺乏有效性导致了寻找其他新颖的抗生素，头孢菌素在20世纪50年代后期被发现。

Staphylococcal resistance to penicillin increased during the 1950s, fueling the discovery of antistaphylococcal penicillins and aminopenicillins (e.g., ampicillin) (81). Since that time we have seen continually increasing rates of antimicrobial resistance among organisms infecting patients, with subsequently more-difficult-to-treat infections. Many of these resistant pathogens develop in health care settings and cause HAIs.

耐青霉素金黄色葡萄球菌在20世纪50年代开始增多，耐青霉素葡萄球菌的出现促进了氨苄西林的产生。自那时起感染病人体内耐药菌不断增多，使我们越来越难以对付感染。耐药性病原微生物的产生使医疗保健机构中出现了许多医院感染。

Growth of Infection Control Programs

Public health officials in the 1970s took notice of increasing numbers of HAIs, with their resultant increased morbidity, mortality, and hospital costs. Simultaneously, hospitals began implementing infection surveillance and control programs; however, their efficacy was unproven. In 1974, Haley and others at the CDC designed a nationwide study, the SENIC Project, to examine whether infection surveillance and control programs could lower the rates of HAIs (122). This study, performed over a 10-year period (1975 to 1985), examined HAI rates in a sampling of U.S. hospitals before and after the implementation of infection control programs (120, 122). The SENIC study demonstrated that four components were essential to an effective infection prevention and control program. These included (i) surveillance with feedback of infection control rates to hospital staff, (ii) enforcement of preventative practices, (iii) a supervising IP to collect and analyze surveillance data, and (iv) the involvement of a physician or microbiologist with specialized training in infection prevention and control (120). Programs with these elements reduced rates of the four most common HAIs by 32% (120, 146). This and subsequent studies have confirmed the effectiveness of infection surveillance and control programs and have stimulated an increase in numbers of infection control programs throughout hospitals in the United States.

感染控制程序的进程

20世纪70年代的公共卫生官员注意到了医院感染发生数量的增长，他们认为医院感染的发病率、死亡率和医院成本在增加。同时，医院开始实施感染监视和控制措施，然而，这些措施的效果没有得到证实。在1974年，Haley和其他CDC成员设计一项全国性研究，医院感染控制效率研究项目，去调查感染监视和控制能否降低医院感染的发生率。这项研究进行10年(1975年～1985年)的时间，审核了美国医院在这期间实施感染控制措施前后医院感染发生率的数据。医院感染控制效率研究显示以下四方面对预防和控制医院感染是必不可少的。他们包括：1、监测医院医务人员对控制感染评价的反馈信息；2、实施预防措施；3、一个收集和分析监测数据的管理网络；4、经过特别训练的从事感染控制的医生和微生物学家。这四个方面能减低医院感染发生率32%。这与随后的研究证实对感染的监测和控制是很有成效的，并促使美国各个医院增加了从事控制感染的人数。

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), now named the Joint Commission, was formed in 1976 in an effort to promote hospital reform based on patient-centered outcomes (159a). This private-sector nonprofit organization accredits health care institutions, which is necessary in order to meet requirements for Medicare reimbursement. Even before the results of the SENIC study were published, the Joint Commission began requiring certain components of infection prevention and control programs in the United States, including detailed surveillance systems.
    保健组织联合认证委员会，现在叫认证委员会，是1976年为偿试提升以病人为中心而改良医院的结果。是私营非赢利组织为保障老年医疗保险而委办的卫生保健社会公益机构。在医院感染控制效率研究结果报告出版之前,认证委员会规定在美国医院必须建立医院感染预防和控制措施，包括细节的监测体系。

After the results of the SENIC study were reported, infection surveillance and control programs expanded across the country. Using a standard surveillance methodology, infection surveillance and control programs reported infection rates through databases such as the National Nosocomial Infection Surveillance (NNIS) system. In 2005, the NNIS system was replaced by the National Health Safety Network (NHSN) based at the CDC and continues to be a voluntary reporting system that monitors components of HAIs, including those in acute-care settings. Elements of this novel system have been emulated worldwide. This reporting system requires the use of strict definitions, standard case-finding procedures, and risk stratification to generate data that are fed back to participating institutions and later used as benchmarks.

    在医院感染控制效率研究结果报告后，感染监测和控制扩展到整个国家。使用标准的监测方法，把感染监测和控制采取措施所获得的感染评价因素收集到诸如国家院内感染网(NNIS) 数据库系统。2005年，NNIS被疾病控制和预防中心(CDC)的国家保健安全网(NHSN)所取代，但仍然是对医院感染监控进行自愿报告的系统，且包括急性护理设施。这种新系统的组成部分被各国模仿。这一报告制度要求严格，在标准的情况下，调查程序和风险分层使用，以产生反馈参与机制，作为后来使用数据的基准。

In 1991, the Occupational Safety and Health Administration (OSHA), an agency of the U.S. Department of Labor, released the Bloodborne Pathogens Standard, aimed at minimizing occupational exposures to blood-borne pathogens. The Bloodborne Pathogens Standard implemented measures that employers must take in order to minimize the transmission of pathogens such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) to their employees. Such measures include providing education, HBV vaccination, use of personal protective equipment, and ensuring institutional medical surveillance. The Bloodborne Pathogens Standard both enforced the need for infection control programs and expanded their role within hospitals to include issues related to occupational health and health care worker (HCW) protection.

美国职业安全与卫生管理局(OSHA)，在1991年发布了血源性病原体标准，旨在减少职业暴露的血源性病原体。血源性病原体标准的实施措施，采取以尽量减少如人类免疫缺陷病毒（HIV），乙型肝炎病毒（HBV）和丙型肝炎病毒（HCV）等对职业人员的传播。这些措施包括提供教育，乙肝疫苗，个人防护设备的使用，并确保医疗机构监督。该标准既血源性病原体的感染控制实施方案的必要性在于扩大其对医院保护相关职业卫生和医疗保健工作者的作用。

In 2000, the Institute of Medicine published To Err Is Human: Building a Safer Health System and subsequently drew attention to preventable medical errors, including HAIs and patient safety. The Joint Commission issued the first-ever National Patient Safety Goals in 2003. Each accredited hospital was required to demonstrate programs that addressed the reduction of HAIs as a goal toward improving patient safety. Specifically, they recommended compliance with CDC or World Health Organization (WHO) hand hygiene guidelines and reporting death or major disability secondary to HAIs as sentinel events.

2000年，美国医学研究所发表的《犯错是人性：构建一个更安全的卫生系统》和随后提出的注意预防医疗差错，包括医院感染和病人安全的文件,认证委员会于2003年颁布了第一次全国患者安全目标。要求每个认证的医院需要提交对改善患者安全目标的医院感染减少的措施。具体来说，他们建议与CDC或世界卫生组织（WHO）手部卫生准则和报告死亡或重大伤残二级为定点医院感染事件的情况。

External Influences

In response to the passage of the Deficit Reduction Act of 2005, the CMS began requiring hospitals to submit data on 10 quality measures, including measures to prevent HAIs. Finally, in 2008 the CMS began withholding reimbursement for patients readmitted with certain HAIs, including CA-UTIs, CLABSIs, and surgical-site infections (SSIs). This change in reimbursement, coupled with public reporting, heightened public awareness, and the increasing accountability of health care systems has forced hospitals to expand infection prevention and control practices focusing on the prevention and monitoring of HAIs.

外部影响

在应对2005年赤字削减法案获得通过后，美国医保服务中心(CMS)开始要求医院提交10份质量测量数据，包括采取措施，防止医院感染。最后，在2008年CMS开始扣除因某些医院感染，包括导管相关尿路感染，导管相关性血流感染，与手术部位感染（SSIS）再次入院的病人相关的费用报销。对这些报销的变化，进行公开报道，提高公众意识和对卫生保健系统的问责制，迫使医院对感染预防和控制的措施在于加强对医院感染的预防和重点监控。

Today, there is a myriad of external influences impacting infection control programs. These external influences include legislative mandates, industry, accrediting agencies, payers, professional societies, and consumer advocacy groups. These groups are often at odds with each other and propose conflicting recommendations.

今天，对感染控制措施有一个强大的外部影响。这些外部影响包括立法授权，行业认证机构，纳税人，专业协会，以及消费者权益保护团体。这些团体往往因利益分歧而互相冲突，并提出建议。

Methicillin-resistant Staphylococcus aureus (MRSA) surveillance is one example of these competing interests. The CDC recommends MRSA surveillance strategies be decided locally and does not recommend routine MRSA surveillance cultures. The Society for Healthcare Epidemiology of America (SHEA) recommends obtaining MRSA surveillance cultures from high-risk patients upon admission and then periodically; however, these guidelines are controversial because the effectiveness of active MRSA surveillance is debated. Despite controversy over the effectiveness of MRSA surveillance, the Department of Veterans Affairs has mandated hospital-wide MRSA surveillance in its facilities; several states now mandate MRSA surveillance, and the CMS is considering withholding reimbursement for MRSA infections.

耐甲氧西林金黄色葡萄球菌（MRSA）的监测是其中一个相互竞争利益的例子。CDC建议MRSA监测策略决定在当地，不推荐常规MRSA监测制度。SHEA建议在入院时取得高风险患者MRSA的标本，然后定期监测。然而，这些准则是有争议的，时常对MRSA监督的进行有效性辩论。尽管对MRSA的监督的有效性有争论，退伍军人事务部已经要求在其全院设施MRSA的监测;现在几个州监督MRSA的任务是和CMS正在考虑扣除MRSA感染的费用报销。

The interest of the media in HAIs has had an immense effect on consumer advocacy groups, legislative bodies, and accrediting organizations. This effect has been seen in the form of increasing legislative mandates. Multiple states now mandate the public reporting of HAI rates
despite a lack of evidence supporting public reporting. Federal legislation which would require all hospitals to report HAIs has also been introduced. In addition to mandates for public reporting, interest has grown in withholding payment for HAIs. Like the CMS, commercial payers have initiated programs that would withhold reimbursement for some HAIs.

媒体对医院感染的兴趣，已在消费者权益保护团体，立法机构和评审机构中起了巨大影响。这种影响一直被视为授权立法的增加形式。尽管现在多个国家缺乏对医院获得性感染评价支持证据的公开报道。但联邦政府已立法，要求各医院报告医院感染的情况。除要求公开报道外，银行利息已成为代扣医院感染中的支出。像CMS，商业纳税人已开始计划，将截留部分医院感染费用的报销。

Growing mandates and restrictions on payments have the potential to lead to increased unnecessary antimicrobial use in an effort to prevent infections, lack of time and resources to address other potentially preventable infections, and instances of individuals gaming surveillance systems (i.e., falsifying data) in order to lower reported infection rates (89). Broad mandates also impose a one-size-fits-all strategy, when in reality local epidemiology varies, and infection control programs need flexibility to address local problems. We also need to beware of mandating and implementing practices that are not evidence based, and we should focus our energies on developing the best evidence-based practices.

增加要求和付款的限制有可能导致不必要抗生素的使用努力来防止感染，还缺乏时间和资源来解决其他潜在的可预防的传染病，以及个人监控系统实例（伪造数据），以降低感染率报道。更广的任务是加强策略，适合当地的流行病学变化和感染控制计划需要的灵活性，以解决当地的问题。我们还需要提防在没有证据的基础上执行强制措施，我们应该把我们的精力重点放在以最佳证据为基础上。

More resources and trained individuals are needed to enable infection control programs to respond to growing requirements. In this age of increasing external pressures, strong leadership is needed within infection prevention and control programs to develop research programs, promote evidence-based practices, educate the public, and set national priorities.

    需要更多的资源和受过培训的个人，落实感染控制方案，以应对不断增长的需求。在这个年代增加外部压力，需要强有力的领导制定感染的预防和控制方案，研究方案，促进以证据为基础的做法，教育公众，并设定国家优先事项。

随风飘尘

回复 2# 蓝鱼o_0

全英文的有点害怕看，那天跟你学英语翻译

米奇朋克

【DEFINING THE NEED FOR HOSPITAL EPIDEMIOLOGY AND INFECTION CONTROL】

医院流行病学和感染控制的需求

医疗机构获得性感染（英文简称HAIs）是住院病人最常见的并发症。HAIs会增加疾病的发病率、死亡率、医疗费用及住院时间，即使这些数据都经过调整（见表1）。传统的医院感染包含的范围较窄，它是指在急症照护机构所获得的感染，既不是指现在也不是指在入院时。有数据表明美国2003年入住急症照护医院的患者中有5％－10％发生HAIs，这个比例相当于每年有近200百万患者并且至少造成9万人死亡，这使得医院感染成为急症照护医院第五大死因。这些医院感染估计每年会额外增加患者照护费用45亿至57亿美元。粗略的的估计25％的医院感染发生在重症监护病房（ICU），它不但会延长住院时间4.3－15.6天，更占全部ICU总支出的20％还多。

    所有HAIs的危险因素都与宿主、治疗策略及医疗机构工作人员的行为有关联。大多数HAIs与医疗器械的使用有关，如导尿管、血管内插管及机械通气，这些医疗器械的使用扰乱了正常的宿主防御机制，如破坏了完整皮肤或黏膜。然而患者的免疫状态也同样会影响HAIs的危险因素。例如，以免疫受损患者为代表的患者人群HAIs发生的风险会增加，因为他们要不天生免疫系统被抑制，要不经常到医疗系统就诊，要不经常接受侵入性操作。除了以上危险因素，入住ICU、其它医疗器械的使用（如鼻胃管等）、抗生素暴露（包括剂型、使用时间、使用的数量）、超高龄及不治之症都会增加HAIs发生的风险。另外，特殊的感染或者致病菌也是独特的危险因素，以下段落会概述。有三类特殊的人群需要特别的关注，他们是：1）有HIV感染的人；2）因血液恶性肿瘤和或造血干细胞或固体器官移植而伴有明显的免疫抑制的患者；3）患有囊性纤维化疾病的人。

高危的患者人群

高效的抗逆转录病毒疗法（HAART）的扩大可及性提高了HIV阳性患者的存活率，但同时也增加了与HIV相关的慢性疾病的患病率，并且使得这种疗法要长期使用。这些疾病慢性的特点也增加了患者与医疗机构相互作用的机会。

三项前瞻性的研究已经预计有近8％的与HIV有关的入院因医院感染而变得复杂化。Stroud等发现HIV阳性患者医院感染的发生率为6.1/1000床位日，相比较全院的发生率只有3.5/1000床位日。在HIV阳性患者中，CD4+T淋巴细胞计数少于200cell/μl、慢性消耗性疾病及较差的体力状况都趋向于与较高的HAIs风险有关。

血流感染是HIV阳性患者最常见的HAI，其中血液中最常分离到的致病菌为金黄色葡萄球菌，而HIV阴性的患者血液标本中常见凝固酶阴性葡萄球菌。Petrosillo和他的同事们的研究显示HIV阳性并伴有血流感染的患者，其死亡率是没有血流感染的几乎4倍（24.6％VS7.4％）。

与HIV相似的情况，造血干细胞、固体器官及骨髓移植的患者代表了另一类独特的人群，他们因为中性粒细胞减少、黏膜破坏、免疫抑制剂暴露以及长时间暴露于医疗环境而发生HAI的风险增加。这些患者通常都会有耐药菌定植，当他们免疫受到抑制后这些耐药菌就会扮演致病菌的角色。

囊性纤维化疾病是一种复杂的遗传疾病，常引起反复的肺部感染，需要经常出入医疗机构。这些患者通常会发展成为细菌定植并感染耐药的革兰氏阴性菌。抗生素的暴露促生了耐药菌，然而，不断有证据表明在这个人群间有耐药菌人传人的现象。作为应对策略，囊性纤维化基金会已经制定了感染控制推荐措施，强调标准预防、手卫生、呼吸设备的管理以及携带多重耐药菌患者的隔离。

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【EPIDEMIOLOGICALLY SIGNIFICANT PATHOGENS】欢迎认领！
这个比较多，可以一小块一小块的认领！以细菌为单位（非页码），包括介绍和感控措施。

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Surveillance

Surveillance in hospital epidemiology and infection control is the process of identifying rates of HAIs, rates of infection or colonization with epidemiologically important organisms (e.g., MRSA, VRE, and Legionella), and rates of relevant processes of care such as compliance with hand hygiene (248). The SENIC investigators found that surveillance was the one essential component of an infection prevention and control program necessary to reduce rates of HAIs (122, 248). Surveillance data are used to identify problem areas where infection prevention and control measures should be instituted, with the goal of improving patient safety. Surveillance is truly the cornerstone of hospital epidemiology and infection control programs, as it highlights where these programs should focus their energies and allows programs to evaluate the effectiveness of their infection control efforts.

Given the growing pressure for transparency in the health care system, several countries and multiple states within the United States have passed legislation requiring that health care facilities report rates of HAIs, rates of infection and colonization with epidemiologically significant organisms, and rates of process-of-care measures to public health authorities or other agencies that can publicly display the data (248). The ultimate goal of reporting these rates is an increased public awareness and improvements in health care quality and patient safety. With increased interest in the public reporting of HAI rates and rates of epidemiologically significant organisms, proper surveillance techniques are imperative in order to make data from different health care facilities meaningful and comparable (210, 211).

医院流行病学和感染控制监测是确认HAI率（这个可能是构成比，而非incidence rate）、流行病学有重要意义的微生物的定植率和感染率（如MRSA VRE或者军团菌）的重要过程，并且通过监测还能了解一些护理过程的重要参数，比如手卫生依从性。SENIC调查者发现，监测是HAI感染预防和控制过程关键组成部分。监测数据可以被用确定感染预防和控制措施中的问题所在，达到改进患者安全的目的。监测可以说是医院流行病学和感控程序的基石，因为它不但能够突出需要集中努力的方向，并且可以评估感染控制措施的效果。鉴于医疗护理系统透明度增加，压力也随之增加，许多国家和很多州都已经通过法案要求医疗机构，如公共卫生授权机构护理措施和其他能够公布相关数据的机构报道HAI率（这个可能是构成比，而非incidence rate）、流行病学有重要意义的微生物的定植率和感染率。报道这些数据的最终目的增加公众意识，改进医疗保健质量和提高患者安全。公众对越来越多HAI率和流行病学有重要意义的微生物定植率公开报道的关注，适当的监测技术势在必行，以便来自不同的医疗设施和有意义的可比数据(210, 211)。

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    jchsmg认领Nosocomial Blood-Borne Pathogens。

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Nosocomial Blood-Borne Pathogens
In the health care setting, blood-borne pathogens pose a threat to patients and HCWs. HBV, HCV, and HIV represent the three most commonly transmitted blood-borne viruses in health care settings (19). Percutaneous injuries commonly occur via needle sticks or contact with sharp objects such as a scalpel. Surgeons are at the greatest risk of percutaneous injuries. During surgery, most (73%) injuries are related to suturing operations lasting longer than 1 h, and procedures with more than 250 ml of blood loss (244, 327). Blood-borne pathogens are generally transmitted from patient to provider, with fewer infections being transmitted from patient to patient and even fewer being transmitted from provider to patient. However, increased awareness and the implementation of preventative measures suggest that HCWs are less frequently exposed to blood-borne pathogens than they were 10 to 15 years ago (68). Still, a risk exists for blood-borne infection, and the likelihood of infection after exposure to a blood-borne pathogen is multifactorial and differs for each virus.

医院血源性病原体
在医疗保健环境中，血源性病原体不仅对病人也对医务工作者（health care workers，HCM）造成威胁。HBV，HCV和HIV是医疗保健环境中最常见的三种血源性传播病毒。经皮损伤往往由于针刺或与锐器如手术刀片接触而致。外科医生发生经皮损伤的危险性最大。手术中，大部分损伤（73%）与手术持续时间超过1小时、出血量大于250ml的缝合操作相关。血源性病原体通常由病人传播给HCW，病人之间的传播较前者少，而由HCW传播给病人就更为少见。由于对于血源性病原体的防护意识增强并采取了防护措施，目前HCW暴露于血源性病原体的机会较10-15年前有所减少。尽管如此，血源性感染的危险性仍然存在，暴露于血源性病原体后导致感染发生的因素多种多样，而且不同病毒各不相同。

放飞梦想

Patients are also at risk of acquisition of blood-borne pathogens once they come into contact with the health care system. This risk has fallen significantly in developed countries since 1985, when widespread HIV, HBV, and HCV testing became available; however, the nosocomial spread of blood-borne pathogens remains a problem in developing countries. In this setting, transmission to patients occurs following transfusion of infected blood or blood products, the use of infected transplanted organs, or invasive procedures performed without sterile needles or syringes and rarely occurs through transmission from an infected HCW (105).
病人一旦进入医疗保健体系，他们也有发生血源性病原体感染的危险。自1985年以来，由于HIV、HBV和HCV检测措施的普及，发生这些疾病的危险性在发达国家已显著下降。但在发展中国家，血源性病原体在医院内的传播仍然是一个问题。在发展中国家，血源性病原体主要通过输入感染的血液或血液制品、感染器官的移植、使用未灭菌的针头或注射器进行侵入性操作而传播，偶尔也有感染的HCW传播给病人的报导。

放飞梦想

It is estimated that approximately 5% of worldwide AIDS cases are acquired through the transfusion of contaminated blood products (105). The screening of blood donors for HIV has not been universally adopted around the world despite the demonstration that this practice reduces transfusion-related transmission. In fact, it is estimated that 40% of donated blood in Kenya is not screened for blood-borne pathogens, and in 2007, the transmission of HIV to 103 children through unscreened blood products was reported in Kazakhstan (1, 105).
据估计，全球约有5%的AIDS病例是由于输入污染的血液制品获得的。尽管研究表明对供血者进行HIV筛选可降低输血相关HIV传播，但在世界范围内还没有普遍采取筛选措施。据估计，肯亚有40%的供血未进行血源性病原体的筛选。2007年，卡萨克斯坦有103名儿童因输入未经过筛选的血液制品而感染HIV。

放飞梦想

The reuse of needles and syringes is a practice still reported in resource-limited settings, many of which have a high prevalence of HIV and hepatitis viruses. The transmission of HIV and HCV has been linked to the contamination and reuse of multidose medication vials (52, 166). The transmission of all three primary blood-borne pathogens to patients with chronic renal failure through the reuse of hemodialysis filters, reused needles, and a lack of infection control practices has been documented.
在资源有限地区，针头和注射器仍在重复使用，这些重复使用的针头或注射器上检出很高的HIV和乙肝病毒感染率。HIV和HCV的传播也与多（大）剂量药瓶的污染和重复使用相关。由于重复使用的血透过滤器、重复使用针头、缺乏感染控制措施而导致的这三种主要血源性病原体对慢性肾衰病人的传播的病例时有报道。

放飞梦想

Lastly, HCWs rarely transmit HIV or hepatitis viruses to patients (19, 46). Mathematical modeling suggests that 2 to 24 patients per million procedures will be infected if the procedure is performed by an HIV-positive surgeon (105). The most famous account of HIV transmission from an HCW to a patient occurred in 1995, when an HIV-positive dentist reportedly infected six patients (66). Several outbreaks of HCV and HBV have been associated with infected surgeons, although the precise mode of transmission is disputed (46, 93). In general, these transmissions involve health care providers performing invasive and “exposure-prone” procedures where blind suturing and other practices occur. Furthermore, these transmissions occurred prior to the widespread use of standard precautions and other barrier precautions such as single or double gloving.
HCW将HIV或肝炎病毒传播给病人的例子较为罕见。数学模型结果提示，如果一项操作由HIV阳性的外科医生进行的话，那么每百万操作将会有2-24病人被感染。最著名的HCW对病人的HIV传播的例子发生于1995年，据报道，一位HIV阳性的牙科医生引起了6名患者感染HIV。此外，还有数例HCV和HBV的感染暴发与感染的外科医生相关，尽管对于这些暴发的确切的传播途径仍有争议。总体来说，这些传播均与医务工作者进行侵入性及“暴露性”操作相关。此外，这些传播均发生于标准预防措施以及其它屏障性预防措施（如戴单层或双层手套）的广泛采用之前。

放飞梦想

Reducing nosocomial blood-borne pathogen transmission requires education, infrastructure, and resources. In 1991, the CDC published guidelines for the prevention of transmission of HIV and HBV to patients (51). Since that time, recommendations have expanded. In all settings, the public and HCWs need to be educated about the risk of transmission of HIV and hepatitis viruses from unsanitary and unsafe health care practices. This will encourage transparency in hospitals. Surveillance for blood-borne pathogen exposures among HCWs is not mandatory in many countries. All countries should screen blood and organ donors for blood-borne pathogens. Other necessary prevention strategies include (i) standard precautions, (ii) adequate and low-cost disinfectants, (iii) proper sterilization of equipment, and (iv) policies limiting the reuse of
certain supplies and equipment. Single-use safety injection devices have revolutionized modern medicine and should be made available at a low cost in resource-limited settings.
降低医源性血源性病原体的传播需要对人员进行培训、基础设施的完善和足够的资源。1991年，CDC发表了预防HIV和HBV向病人传播的指南。自此以来，又有各种建议出台。在任何情况下，均需教育公众和医务工作者，使他们明白不卫生和不安全的医疗保健行为有导致HIV和肝炎病毒传播的危险性。这也可以增强医院的透明度。在许多国家，没有强制性地在医务工作者中监测血源性病原体的暴露状况。所有国家均应该对供血者和器官捐献者进行血源性病原体的筛查。其它必须的预防性措施包括：(i)标准预防， (ii) 充足且价格低廉的消毒剂；(iii)对设备的适当灭菌； (iv)限制某些产品以及设备重复使用的政策。一次性安全注射装置使现代医学发生了革命性的改变因此应该使其能够低价提供给资源有限的国家或地区。

放飞梦想

HIV. Although it is the most commonly feared blood-borne virus, the nosocomial transmission of HIV is less commonly reported than HBV and HCV. This is likely due to the lower global burden of HIV than HBV or HCV and lower blood titers of HIV (105). Based on prospective studies of HCWs, the average risk of transmission of HIV after occupational percutaneous exposure is 0.3%, with the risk of transmission after mucosal exposure being much lower, at 0.09% (19). No transmission of HIV through the contact of blood with nonintact skin occurred in these studies. Therefore, the risk of HIV transmission appears to be low (113). Similarly, the risk of HIV transmission after exposure to other potentially infectious body fluids or tissues has not been well studied. In one study, 559 HCWs reported cutaneous exposure to different potentially infectious body fluids from patients presumed to have HIV, and no HCW became infected (95).
HIV 尽管HIV是人们最为恐惧的血源性传播病毒，但报导的HIV的医源性传播较HBV和HCV例子要少，这可能是由于HIV的全球的总体病例较HBV和HCV少、且HIV的血液滴定度要低。对医务工作者进行的回顾性研究结果表明，皮肤损伤职业暴露所致HIV感染的危险性平均为0.3%，黏膜暴露的危险性为0.09%。在这些研究中没有发现因非完整皮肤接触血液而导致HIV感染的病例。因此，HIV感染的危险性似乎并不高。同样，对于暴露于其他潜在感染性体液和组织后HIV感染的危险性也未做充分研究。有一项研究表明，559位医务工作者皮肤暴露于HIV感染的病人各种潜在感染体液，但无一例医务工作者感染HIV。

放飞梦想

Four factors increase the risk of HIV transmission after percutaneous exposure. These include (i) deep injury, (ii) visible blood from the source patient on the device that caused
the injury, (iii) injury from a large-gauge hollow-bore needle placed directly into a vein or artery of the source patient, and (iv) exposure to blood from a patient known to have a high plasma HIV viral load or symptomatic AIDS (19, 105). The risk is higher in an area with a high prevalence of HIV. Patients taking and responding to antiretroviral therapy with lower plasma viral loads are less likely to transmit HIV (19). In vitro models have demonstrated that wearing gloves directly reduces the amount of blood transferred from a device to the site of injury (19). As of 2001, 57 confirmed cases of occupationally acquired HIV infection and 138 possible occupational HIV infections had been reported to the U.S. National Surveillance for Occupationally Acquired HIV Infection (85). The reporting of possible occupational exposure to HIV is voluntary, and available data likely underrepresent the total number of cases.
皮肤暴露后4种因素增加HIV感染的危险，包括(i) 损伤较深，(ii) 导致损伤的器具上可见源患者的血液，(iii) 由直接刺入源患者静脉或动脉的大号空腔针头造成的损伤，(iv) 源患者的血浆中HIV病毒负载量高或已有AIDS症状。在HIV高感染率区域被HIV感染的危险性也增高。服用或进行抗逆转录病毒疗法、血浆中HIV病毒负载量较低的患者传播HIV的几率较低。体外研究表明戴手套可减少由器具带到损伤部位的血液量。截止2001年，向“美国职业性HIV感染国家监测机构”报告的确诊职业暴露感染HIV病例有57例、可能的职业暴露感染HIV病例有138例。