【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）

放飞梦想

Coagulase-Negative Staphylococci
Colonization with CoNS occurs in all humans shortly afterbirth, and multiple strains inhabit human skin and mucousmembranes (140, 169). Thirty-two species of CoNS are recognized, with Staphylococcus epidermidis being the most common species isolated from humans. CoNS are readily able to form biofilms, and for this reason, they most commonly cause infections associated with indwelling foreign devices such as intravenous catheters, shunts, prosthetic joints, and pacemakers (62).
    凝固酶阴性葡萄球菌
    出生后不久，凝固酶阴性葡萄球菌（CoNS）即在人类体内定植。人类皮肤和黏膜上定居有多种CoNS菌株，共有32种CoNS，其中表皮葡萄球菌是从人类分离出的最常见的菌种。CoNS很容易形成生物膜，因此，它们最常引起与植入性外来物体如静脉导管、分流器、人工关节、起搏器等相关的感染。

CoNS were the most commonly isolated pathogens from HAIs reported to the NHSN in 2006 and 2007: 5,178 of 33,848 (15.3%) pathogens from 28,502 infections (136). CoNS are the most common cause of CLABSIs and the second most common cause of SSIs (18, 136). Less commonly, CoNS infection is the etiology of CA-UTIs and ventilator-associated pneumonias (VAPs) (136).
    2006-2007年报告给NHSN的医源性感染（HAIs）共28,502例、分离出病原菌33,848株，其中CoNS为5,178株，占15.3%，是分离出的最常见病原菌。CoNS是引起CLABSIs的首要原因、SSIs的第二大原因。CoNS还是引起CA-UTIs和呼吸机相关肺炎(VAPs)的原因。

The true impact of CoNS infections was unrecognized for years, until Martin et al. reported a CoNS BSI-attributable mortality rate of 14% (205). As it is now recognized as more than a contaminant, the incidence of CoNS infections has risen with the increasing use of intravascular catheters, prosthetic devices, and invasive procedures in combination with increasingly vulnerable hosts (145). Although CoNS infections may be due to endogenous strains from the patient’s native flora, there is emerging evidence that strains are often transmitted amonghospitalized patients. These nosocomial strains are increasingly antibiotic resistant, and strains with vancomycin resistance have been reported (145).
    多年来，在Martin等报导CoNS引起的血流感染死亡率为14%之前，人们没有意识到CoNS感染的真正影响。现在人们意识到，CoNS不仅仅是一个污染源，随着静脉插管、假体装置和侵入性操作的增多以及宿主的抵抗力降低，CoNS感染率也随之增高。尽管CoNS感染可能源于病人常居菌丛的内在菌株，新的证据表明住院病人之间可发生菌株的传播。这些医院内菌株的耐药性越来越强，有报告出现了耐万古霉素的CoNS菌株。

放飞梦想

一休哥说：休息休息！我也要休息了。大家一周辛苦了！

蓝鱼o_0

回复 39# jchsmg

整个翻译文稿的WORD文档，我会整理的。您认领的部分，放在一起就可以了。
好的，翻译纯粹是个人兴趣，不要耽误工作！

青城山

FUTURE CHALLENGES  
The need for hospital epidemiology and infection control programs has grown since its inception, and the need for hospital epidemiologists and IPs will continue to expand as out-of-hospital care increases, new invasive procedures and technologies are introduced, patients become more complex, and the scope of antimicrobial-resistant organisms broadens. As hospitals and health care institutions look to reduce costs and improve the quality of patient care, they will turn to hospital epidemiologists and infection control programs for strategies to conserve resources, prevent infections, and control outbreaks.
未来的挑战
从一开始，对医院流行病学和感染控制计划的需要就不断成长。随着院外医疗照护的增加，新的侵袭性操作和新技术引进，患者变得更加复杂，耐药菌范围扩张，对医院流行病学家和感染控制专家的需求将持续膨胀。医院和医疗保健机构需要降低医疗成本，同时又要提升患者医疗照护质量，将转而向医院流行病学家和感染控制计划寻求战略措施，以便节约资源、预防感染、控制暴发。

Moving forward, the challenges facing infection control programs will be many. These programs must take on new roles to curtail the expansion and spread of antimicrobial-resistant organisms within and between health care institutions. Recent literature has highlighted the role that long-term acute-care hospitals play in HAIs (222). Given that long-term care facilities have been implicated as the source of regional outbreaks of MDR organisms (187), it is now necessary for IPs to work closely with IPs at surrounding facilities in order to understand the spread of MDR organisms and define the local epidemiology of HAIs.
展望未来，感染控制计划面临的挑战将会很多。这些计划必须承担新的角色，减少耐药微生物在健康保健机构中和健康保健机构间的扩张和蔓延。新近的文献已经突显了长期急性照护医院在医疗保健相关感染中的角色。鉴于长期照护设备已经被公认为多重耐药微生物局部暴发的来源，为了了解多重耐药微生物的传播和确定当地医疗保健相关感染流行病学，感控专家与设备感染控制专家之间的密切合作是非常有必要的。

Infection prevention and control programs must work to expand HCW vaccination programs to reduce the risk of spread of pathogens such as influenza virus from HCWs to patients. Infection control programs will be handed the task of eliminating HAIs, which are seen as “never” events: those that should never occur and for which a health care institution will not be reimbursed.Infection control programs will grow beyond the walls of the hospital and work to understand the epidemiology and prevention of infections at all steps of the health care process, as patients move between the community and the hospital and between multiple health care institutions. Hospital epidemiologists and infection control practitioners will be charged with the task of investigating the next generation of technology and prevention strategies aimed at tackling HAIs. Finally, needs will broaden not only in the developed world but also in developing countries, where technology is growing and health care is modernizing, increasing the opportunities for HAIs.
为了减少病菌传播的风险，例如流感病毒从医务工作者传播到患者，感染预防与控制计划必须努力扩大到医务工作者（HCW）的计划免疫。感染控制计划今后将演变为消除HAIs，这被认为是不可能的事情。对于那些不应该发生的感染，医疗保健机构将自行承当费用。因为患者在社区和医院之间，以及多个卫生保健机构之间移动，感染控制计划将会超越医院，了解医疗照护过程中的所有步骤的流行病学和感染的预防。医院流行病学家和感染控制从业者的又一任务是针对解决医疗保健相关感染的新技术和预防策略展开调查。在科技进步和医疗保健现代化进程中的发展中国家，医院感染的机会正在增加。最终，无论是在发达国家，还是在发展中国家，对于感染控制的需要都将扩大。

Available data point to a lack of health care epidemiologists and other key members of the infection control team,such as data managers and statisticians (315).These roles are imperative to performing all the functions of an infection control program. Future directions must focus on expanding and increasing not only the numbers of members within the infection control team but also the expertise and experience of its leaders.

现有的数据表明，我们缺乏卫生保健流行病学家和感染控制小组其他主要成员，例如数据管理人员和统计人员。这些角色必须执行感染控制计划的全部功能。未来的发展方向，不但要着眼于增加感染控制小组成员的人数，而且还要提升其领导人的专业知识和经验。

CONCLUSION     
From Semmelweis to the SENIC study, evidence has evolved to support both the role of certain infection prevention and control practices and the role of trained professionals studying the transmission and prevention of infections in the health care setting (122, 232). While our knowledge of epidemiologically significant transmissible organisms and infections in the health  care setting has grown, these pathogens are an increasing threat to patient safety as health care extends from inpatient hospitals to community health care settings, antimicrobial-resistant organisms have flourished, and our patients and health care practices have become more complex.Now more than ever, well-structured infection control programs, with the expertise of a hospital epidemiologist and support of IPs, support of a microbiology laboratory, data managers, and statisticians,are imperative to the prevention of HAIs.
结论
从Semmelweis到医院感染控制效果研究，所有的证据都支持两种角色：一定的感染预防与控制措施，以及在医疗保健环境中研究感染传播与预防的专业人员。一方面，我们对于重大传染性微生物在医疗保健环境中的流行和感染的知识不断增长，同时这些病原体也日益严重威胁着患者安全。由于医疗保健从有住院患者的医院延伸到社区医疗保健机构，耐药微生物肆虐，我们的患者和医疗保健措施变得越来越复杂。现在比以往任何时候，迫切需要一个结构良好的感染控制计划预防HAIs。这个计划应该得到具有医院流行病学专长的流行病学家和感控专家的支持，微生物实验室，数据管理人员和统计学家的支持。

米奇朋克

有效的预防措施

随着HAI患者的增多和多重耐药菌数量的增加，许多其它的因素需要考虑进来，是否需要给医疗机构配备流行病学家就算其一。这其实也是一种干预，并且能提高有询证依据的感控措施的依从性。有研究表明，践行感染预防措施如手卫生能降低MRSA的传播，从而降低中心静脉导管相关血流感染的发生率，这是采用一揽子有询证依据的预防措施的结果。这些针对HAIs的有效地预防措施都强调需要精心地制定专门的感染预防和控制计划并且持续改进、完善干预及预防措施。

全国大流行防备计划

刚刚过去的2009年-2010年新型H1N1流感病毒大流行的经历同样强调了医疗机构流行病学家在预防传染性疾病在高危病人间传播所扮演的角色。流感病毒通常造成季节性流行，并且迅速传播，特别是在医疗机构。它们不但可以导致病人患病，甚至影响医院的运营。从最近的新型H1N1大流行期间的证据来看，医院流行病学家和感染控制专员成功追踪了流感疫情的变化趋势、对员工进行了培训、对最佳的切断疫情传播和执行感染预防措施的方案进行了风险评估。美国为流感大流行制定了一个多层次的国家策略，包括不同的政府健康部门、老百姓和医院。这个国家策略的三个主要目标均为限制流感疫情所带来的影响： 1）储备与沟通，包括疫苗和抗病毒药物的储备；2）监测和侦察；3）反应和控制。在医疗机构中，医院流行病学家和感控专员需要协调准备方案、指导监测、督查个案的发现及其治疗、妥善安排复杂的国家策略，例如隔离患者、配给抗病毒药物和疫苗。阐述国家防控流感大流行策略的这类文件不可能预料到医院和医疗机构流行病学家将要面临的挑战，它们包括对医疗机构所承担的任务的支持、管理高传播性疾病患者的流入以及照管需要关心的其他问题。

我们的医疗系统正变得越来越错综复杂，因为患者人群日趋复杂、耐药菌不断增加、侵入性诊疗操作越来越多、新型的致病菌不断出现。医院流行病学家和感控专员需要接受繁复的干预措施培训，目的就是要保护患者和医疗机构工作人员。通过制定精确的HAIs监测方案、研究和执行预防和治疗HAIs的最佳实践操作、教育医疗机构工作人员认识到他们在传播和预防医院感染上所扮演的角色，来降低HAI发生率、提高患者的愈后。表1，就重要的医院感染在危险因素、影响和预防策略三个方面进行了详细的描述。接下来的章节将讨论最常见的造成HAIs的病原微生物。

hxj123456

看到外文，我好羡慕懂英文的老师，我要学习，赶上你们。

红狐狸

太牛了，感觉自己被社会淘汰了，向你们致敬！

wney

(i) Infection prevention. After exposure to blood or potentially infectious body fluids, it must be determined whether the patient is HCV positive. If exposed to an HCV-infected patient, the HCW must be monitored serially to watch for HCV seroconversion. If seroconversion occurs, the HCW should be evaluated to determine the role of treatment for acute HCV with pegylated alpha interferon and ribavirin (195). Follow-up is critical in order to conduct counseling, allay fears, and assess for any symptoms of acute viral hepatitis.
感染预防  暴露于血液或潜在感染性体液后，首先必须确定源患者是否是HCV阳性。如暴露于HCV感染患者，则必须对暴露者进行序列监测。如暴露者发生血清转化，则必须对其进行评估，以确定是否需要用聚乙二醇化-干扰素和利巴韦林进行治疗。暴露后随访至关重要，通过随访可进行咨询、缓解恐惧、并评估是否出现急性病毒性肝炎症状。

蓝鱼o_0

回复 48# wney

能否将您的问题表达具体些？

您是翻译的还是转帖，还是纠正译者的错误呢？

小白兔

为什么最近下载的东东老是打不开呢？请指教！

蓝鱼o_0

回复 50# 小白兔

这个是PDF版本的，是不是你的ADOBE出了问题呢？
其他会员没有这类情况存在。

等翻译结束，会将英文WORD版本贴出来。您可以下载

放飞梦想

EPIDEMIOLOGICALLY SIGNIFICANT PATHOGENS

A total of 28,502 HAIs, including CLABSIs, CA-UTIs, and ventilator-associated pneumonias (VAPs), were reported to the NHSN between January 2006 and October 2007 from 621 U.S. hospitals (90) (Table 2). Of the 33,848 pathogens reported, 87% were bacteria and 13% were fungi. Over 15% of infections were polymicrobial. The most commonly isolated pathogens were coagulase-negative staphylococci (CoNS), S. aureus, Enterococcus species, Candida species, Escherichia coli, and Pseudomonas aeruginosa (136). With public reporting, increasing numbers of health care institutions participate in the NHSN, making comparisons of data more generalizable.
医院感染的流行病学主要致病菌
2006年1月至2007年10月，美国全国医院监测网络（NHSN）共接到来自621家美国医院的28,502例HAIs报告，包括中心导管相关血流感染（CLABSIs）、导尿管相关泌尿道感染（CA-UTIs）和呼吸机相关肺炎(VAPs)（表2）(90)。在分离的33,848个病原体中，87%为细菌、13%为真菌。15%以上的感染为多菌种感染。分离出的最常见病原菌为凝固酶阴性葡萄球菌(CoNS)、金黄色葡萄球菌、肠球菌属、念珠菌属、大肠杆菌和铜绿假单胞菌（136）。越来越多的医疗保健机构加入NHSN，得以更广泛地进行数据的比较。

The human and financial costs of antimicrobial-resistant organisms are enormous. A recent study from Chicago, IL, found 13.5% of inpatients to have infections due to antimicrobialresistant organisms (276). The cost attributed to these infections ranged from $18,588 to $29,069 per patient. The excess length of hospitalization ranged from 6.4 to 12.7 days. The excess societal cost ranged from $10 million to $15 million. In order to understand the scope of this problem, we must first briefly review the key pathogens.
抗生素耐药的微生物所造成的人力和经济花费巨大。伊利诺伊州芝加哥市最近的一项研究表明，13.5%的感染住院病人所患感染为耐药菌感染（276）。这些感染造成的费用为每位病人18,588 到29,069美元，增加住院时间6.4-12.7天，所造成的社会成本为1,000万至1,500万美元。为了更好地理解此问题的严重程度，我们首先需要简要地回顾一下主要的病原菌。

Staphylococcus aureus
S. aureus causes a variety of infections ranging from skin and soft tissue infections to BSIs, pneumonia, meningitis, endocarditis, and toxic shock syndrome (27, 28, 170, 192, 250, 251, 347, 365, 369). MRSA emerged as a significant problem in the 1980s. In the 10 years that followed, MRSA infection rates rose dramatically (228). In 2004, the NNIS reported that 59.4% of S. aureus infections in U.S. ICUs were methicillin resistant, a 29% increase over the preceding 5 years (227, 228). Interestingly, recent data have shown a decrease in the rates of invasive health care-associated MRSA infections between 2005 and 2008, possibly due to an expansion of MRSA prevention programs among U.S. hospitals (161). Several studies have demonstrated increased mortality from infections due to MRSA compared to that from infections due to methicillin-susceptible S. aureus (MSSA), which persists after controlling for the severity of underlying illnesses (77, 92, 299). MRSA also increases length of hospitalization and hospital costs compared with those associated with MSSA (76).
金黄色葡萄球菌
金葡菌可导致各种感染，如皮肤感染、软组织感染、血流感染、肺炎、脑膜炎、心内膜炎、中毒性休克综合征等(27, 28, 170, 192, 250, 251, 347, 365, 369)。20世纪80年代起，MRSA作为一个重要问题逐渐显现。在随之的10年中，MRSA感染显著上升（228）。据NNIS报告，2004年美国医院ICU的金葡菌感染中，59.4%为耐甲氧西林金葡菌（MRSA）感染，与之前的5年相比MRSA感染增加了29% (227, 228)。有意思的是，最近的数据表明与侵入性医疗操作相关的MRSA感染率在2005-2008年有所下降，这可能是由于在美国医院中广泛实行MRSA预防措施之故（161）。数项研究表明MRSA感染导致的死亡率比甲氧西林敏感的金葡菌（MSSA）导致的死亡率要高(77, 92, 299)。与MSSA相比，MRSA还致使住院时间延长、住院花费增加（76）。

MSSA and MRSA are normally found colonizing the nares and skin of healthy humans (250, 292). Approximately 20 to 30% of persons are colonized with S. aureus in the nares; the rate of MRSA colonization is lower, at around 1.5% (115).
However, higher rates of nasal MRSA colonization are seen among those with diabetes mellitus, intravenous drug users (IVDUs), patients undergoing hemodialysis, and those with AIDS (344). Carriage of S. aureus is an important risk factor for infection, especially among surgical patients and those in the ICU (214, 265, 334). In addition to colonization, risk factors for MRSA infection include recent hospitalization or surgery, dialysis, residence in a long-term care facility, and the presence of percutaneous devices and catheters (39, 189).
MSSA和MRSA一般定植于健康人的鼻腔和皮肤上(250, 292)，大约20-30%的人鼻腔定植有金葡菌，而MRSA的定植率为1.5%左右（115）。但是，糖尿病人、静脉吸毒者(IVDUs)、透析患者以及AIDS病人的MRSA鼻腔定植率增高(344)。金葡菌的携带是重要的感染危险因素，尤其是对于外科病人和ICU病人(214, 265, 334)。除定植外，MRSA感染的危险因素包括近期住院或手术经历、透析、长期居住在看护设施、以及有经皮装置或导管(39, 189)。

放飞梦想

Cases of MRSA infection in previously healthy individuals without established risk factors, namely, no contact with the health care system, have been increasingly reported over the last decade (55). These cases have been coined communityassociated MRSA (CA-MRSA). Cases of CA-MRSA are classically caused by microbiologically distinct strains of MRSA (most commonly pulsed-field gel electrophoresis type USA300) different from those strains associated with health care-associated MRSA (HA-MRSA) (303). Similarly, risk factors for CA-MRSA infection are distinct. Notable risk factors for CA-MRSA infection include close contact with someone colonized or infected with CA-MRSA strains, being an IVDU, incarceration, participation in contact sports, and being a man who has sex with men (30, 176). Recent data suggest the rectum and inguinal area, in addition to the nares, are important ecological niches for CAMRSA strains (359). In fact, one study found that patients with CA-MRSA strains were colonized at sites other than the nares 25% of the time, compared to only 6% among those with HA-MRSA (359).
上个世纪，有越来越多的以往健康且未无确定危险因素（即未与医疗保健体系接触）的人感染MRSA的病例报告（55），这些病例被称为社区相关MRSA (CA-MRSA)。导致CA-MRSA的MRSA菌株与医院感染相关的MRSA (HA-MRSA)菌株明显不同，最常见的为脉冲场凝胶电泳USA300型 (303)。CA-MRSA感染的危险因素也与HA-MRSA不同，其主要的危险因素为与有CA-MRSA菌株定植或感染的人员密切接触、静脉吸毒者、囚犯、参与有肢体接触的运动、以及男性同性之间性交者(30, 176)。近期有研究数据提示，除鼻腔外，直肠和腹股沟区也是CA-MRSA菌株的重要生态生境（359）。实际上，一项研究发现，25%的CA-MRSA病人在鼻腔外的其他部位发现有MRSA，而只有6%的HA-MRSA病人在鼻腔外的其他部位发现有MRSA（359）。

Recent studies demonstrated that CA-MRSA strains are increasingly responsible for HAIs (263). Popovich et al. found from 2000 to 2006 that the proportion of CA-MRSA strains causing hospital-onset MRSA BSIs increased from 24% to 49% (263). While CA-MRSA strains may represent an increasing proportion of HAIs due to MRSA, there is currently no evidence that HAIs due to CA-MRSA strains have different outcomes than those caused by HA-MRSA strains (263).
近期研究表明有越来越多的HAIs是由CA-MRSA引起的(263)。Popovich等发现，在2000-2006期间，由CA-MRSA菌株引起的医院MRSA血流感染（BSIs）从24%增加到了49% (263)。尽管CA-MRSA引起的MRSA医院感染有所增加，目前尚无证据表明CA-MRSA菌株与HA-MRSA菌株引起的HAIs的结局有任何不同(263)。

Infection prevention. Hospitalized patients colonized with MRSA are at an increased risk of developing MRSA infections (142). In response to increased risks associated with colonization, poor outcomes due to MRSA infection, and pressure from outside groups, many states and the Department of Veterans Affairs are now requiring routine MRSA surveillance cultures for high-risk patient populations. Active MRSA surveillance and the isolation of MRSA-colonized patients have been shown to control MRSA transmission and decrease MRSA infection rates when applied to high-risk patient populations or in outbreak settings (144, 191, 286, 350). Active surveillance is currently recommended for the prevention of MRSA transmission; however, surveillance frequency and target populations are debated (43). Patients found to be colonized with MRSA should be placed into contact isolation to decrease the risk of transmission to other patients. The routine use of clinical cultures alone does not identify the full reservoir of patients asymptomatically colonized with MRSA (143, 290).
预防控制    被MRSA定植的住院病人患MRSA感染的危险性增高(142)。鉴于与定植相关的危险性增加、MRSA感染的预后较差、以及来自于外部的压力，目前许多州和退伍军人事务部要求对于高危病人人群进行常规MRSA监测。结果表明，积极的MRSA监测和隔离MRSA定植病人控制了MRSA在高危病人群和爆发情况下的MRSA传播并降低了MRSA的感染率(144, 191, 286, 350)。对MRSA定植病人必须进行接触隔离以降低向其他病人传播的危险性。但仅常规临床培养一项并不能鉴别出所有MRSA定植但无症状的病人(143, 290)。

The evidence for universal MRSA surveillance is conflicting (127, 277), and at this time there is no recommendation for universal MRSA screening in the United States (43). Several uncontrolled trials have noted that patients placed in isolation are examined less frequently (167, 289) and exhibit higher rates of depression and anxiety (50). Another study reported an association between contact isolation for MRSA and the incidence of preventable adverse events such as falls and pressure ulcers (312). While these studies are not conclusive, they highlight the need for a thoughtful examination of the risks and benefits of MRSA screening. In order to decrease MRSA rates, active surveillance must be combined with HCW education, hand hygiene, environmental cleaning, contact precautions, and antimicrobial stewardship (43).
    对于是否普遍性进行MRSA监测，证据尚有争议(127, 277)，目前在美国并没有要求进行MRSA的普遍监测（43）。几项没有对照的临床试验发现，对于隔离的病人检查的频度要小(167, 289)，这些病人更易发生抑郁和焦虑(50)。另一项研究报到：MRSA接触隔离和跌伤以及压疮等可避免的不良事件的发生率之间具有相关性（312）。尽管这些研究没有得出定论，但它们强调应该对MRSA筛查的损益进行充分评价。积极的MRSA监测必须和医务人员培训、手卫生、环境清洁、接触预防和抗生素管理等措施相结合以降低MRSA感染率(43)。
   
There is recent increased interest in MRSA decolonization. An added benefit to decolonization may be to decrease MRSA transmission among patients. Various decolonization regimens have been tried in general medical patients, with mixed results (126, 278, 302). Although patients may be successfully decolonized in the short term, well-designed studies outside the perioperative setting have not demonstrated that decolonization of general medical patients prevents subsequent infections, and there is evidence to suggest that widespread decolonization may promote resistance to mupirocin (278). In contrast, preoperative decolonization of surgical patients colonized with S. aureus decreases rates of surgical-site infections (26, 249). Some institutions are now instituting this practice and recommending surveillance and decolonization prior to surgery.
近来对MRSA的去定植的兴趣也越来越浓。去定植的效益可能是能降低MRSA在病人间的传播。在内科病人中尝试了各种去定植的方法，其结果不一而足(126, 278, 302)。尽管在短期内可有效地去定植MRSA，但设计良好的研究发现，去定植并没有能够预防内科病人发生继发感染，而且有证据提示广泛去定植可增加对莫匹罗星的抗性(278)。但是，对外科金葡菌定植的病人在术前去定植可降低手术切口感染率(26, 249)。有些医院现在已采取此措施，要求在术前进行监测和去定植。

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EPIDEMIOLOGICALLY SIGNIFICANT PATHOGENS.doc (45 KB, 下载次数: 36)

2011-6-15 20:46 上传

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Vancomycin-Resistant Enterococcus
Enterococci, formerly classified as group D Streptococcus, have innate antibiotic resistance, with emerging antibiotic resistance related to antimicrobial pressure in and outside health care settings. Enterococcus faecalis and Enterococcus faecium are common enteric flora in humans and represent the two most clinically significant species. E. faecalis tends to be susceptible to ampicillin, with a low percentage of strains being resistant to vancomycin. E. faecium is more resistant to ampicillin and more commonly associated with vancomycin resistance (117, 353). Vancomycin resistance is most commonly mediated by the vanA gene, which produces altered amino acid residues at the normal site where vancomycin binds to inhibit cell wall synthesis (274). Vancomycin-resistant Enterococcus (VRE) infection was first reported in the 1980s but did not become a significant problem within the health care setting until the 1990s, as resistance and infection rates rose rapidly (275).
耐万古霉素肠球菌
    由于在医疗保健环境中和环境外的抗生素压力相关的抗生素抗性的出现，肠球菌（曾被归类为D组链球菌）对抗生素具有天然抗性。粪肠球菌和屎肠球菌是人类最常见的肠道菌丛成员，也是临床上最重要的菌种。粪肠球菌对氨苄西林易感，对万古霉素抗性的菌株较少。屎肠球菌对氨苄西林具有抗性，而且与万古霉素抗性相关性较高(117, 353)。万古霉素抗性主要被vanA基因介导，vanA基因可在万古霉素正常结合位点产生氨基酸残基的改变、从而抑制细胞壁合成(274)。抗万古霉素肠球菌(VRE)感染首次于1980s被报道，但直到1990s抗性显著增加、发病率显著增高之前在医疗机构并没有成为一个重要问题。
   
In the United States, hospitalizations attributable to VRE infections increased from 9,820 in 2000 to 21,352 in 2006 (271). Surveillance data from 1995 to 2002 revealed that 9% of CLABSIs were caused by Enterococcus species, of which 2% of E. faecalis isolates and 60% of E. faecium isolates were vancomycin resistant (353). In a prospective cohort of ICU patients, VRE was associated with increased ICU costs ($33,251), inhospital mortality (75% versus 24%), and length of stay (22 days) compared to uninfected patients (246). Similarly, a separate study assessing the effect of nosocomial VRE bacteremia on mortality, length of stay, and hospital costs compared to matched controls found an odds ratio (OR) of crude mortality of 2.52 when those with VRE bacteremia were compared to controls (309). Those authors also found a VRE-attributable excess length of stay of 17 days and excess charges of $81,208. Other studies have found similar results (48). While some studies have shown increased mortality due to infections caused by VRE compared to vancomycin-susceptible Enterococcus (VSE) (83), other studies have found conflicting results (106, 177, 190, 196, 246, 330), and this point remains debated. Risk factors for colonization and subsequent infection with VRE include having a hospital roommate colonized or infected with VRE, older age, duration of antibiotic use, specific types and numbers of antibiotics used, and the presence of a urinary catheter (320, 368). Molecular and epidemiological data suggest that VRE may be transmitted to patients directly from contact with infected or colonized patients, from the hands of HCWs, or from contact with contaminated equipment or environmental surfaces (320). Results for the effectiveness of antibiotic stewardship in curtailing VRE transmission, colonization, and infection among groups of patients are mixed (266, 304, 320).
    在美国，由于VRE感染而导致住院的病人从2000年地9,820上升到2006年地21,352（271）。1995-2002年的监测数据表明，9%的CLABSIs由肠球菌属引起，其中2%的粪肠球菌分离菌株和60%的屎肠球菌分离菌株为耐万古霉素菌株(353)。一项关于ICU病人的前瞻性队列研究中发现，与未感染病人相比，VRE与ICU费用增加（33,251美元）、院内死亡率上升（75%对24%）和住院时间（22天）相关(246)。同样，另一组研究人员利用配对对照评估了医院感染性VRE菌血症对死亡率、住院时间、住院费用的影响。与对照组相比， VRE菌血症死亡率的OR值为2.52 (309)。这些作者还发现，VRE导致住院时间增加17天、住院费用增加81,208美元。其他的一些研究也得出了相似的结果(48)。有些研究发现，与万古霉素敏感的肠球菌(VSE)相比，VRE感染所致死亡率增高(83)；而其他的一些研究得出了矛盾的结果(106, 177, 190, 196, 246, 330)，关于此仍有一定争论。VRE定植和感染的危险因素包括：同病室病人被VRE定植或感染、高龄、长时间使用抗生素、特定种类和数量抗生素的使用以及有导尿管插管(320, 368)。分子学和流行病学数据提示VRE可由于与定植和感染病人直接接触传播、有医务人员的手传播、或由于接触污染的仪器或环境表面传播(320)。抗生素管理对于减少VRE传播、定植和感染的效果的结果不一(266, 304, 320)。

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Infection prevention. Increased mortality, longer duration of hospitalization, and increased costs are the basis of recommendations for surveillance for VRE and contact precautions recommended by the Healthcare Infection Control Practices Advisory Committee (HICPAC) (368). Also influencing these recommendations are reports of two VRE outbreaks in the early 1990s that were aborted after contact precautions were instituted, including the mandatory use of gowns and gloves by anyone in contact with infected or colonized patients (32, 33, 275).
    感染预防  由于VRE导致的死亡率增高、住院时间延长、住院费用增加，因此医疗感染控制措施建议委员会(HICPAC)建议对VRE进行监测并实施接触隔离的基础(368)。此外，20世纪90年代发生的2例VRE暴发由于接触预防的实施（包括任何人接触VRE定植和感染病人时必须穿隔离衣、戴手套）而被遏制的例子(32, 33, 275)也对该建议的提出有一定影响。
   
Current guidelines for the prevention of nosocomial transmission of VRE recommend (i) active surveillance and contact precautions for colonized or infected individuals,      especially in populations with high prevalence or where transmission has been documented; (ii) appropriate hand hygiene by HCWs, with monitoring and feedback of hand hygiene compliance to HCWs; (iii) antimicrobial stewardship to avoid inappropriate or excessive antibiotic use; and (iv) aggressive cleaning and methods to verify the adequacy of environmental cleaning (224, 301). The use of active surveillance should target patients at a high risk of colonization, and the frequency of obtaining surveillance cultures is debated. When instituted, the use of surveillance cultures should be based on the institutional prevalence of VRE and patient risk factors for colonization. Antimicrobial stewardship programs should focus on restricting the use of implicated antibiotics, including those with anaerobic activity, broad-spectrum cephalosporins, and vancomycin, in an effort to decrease selective pressure for vancomycin resistance (224). Routinely used disinfectants such as quaternary ammonium, phenolic, and iodophor germicidals are active against VRE (224). However, several studies have shown improved rates of VRE surface eradication with enhanced disinfection involving a more thorough application of the disinfectant to the surface by drenching either the surface or the cleaning rag (42, 305).
    目前的关于预防VRE在医院内传播的指南中要求：(i) 积极监测并对定植和感染病人进行接触预防，尤其是对高发病率和有记录层发生过传播的部门；(ii) 医务人员采取适当手卫生措施，将对手卫生的监测和手卫生依从性的结果反馈给医务人员；(iii) 抗生素管理以避免抗生素的不当和过度使用；(iv)强有效的环境清洁，并有方法验证环境清洁的是否适当(224, 301)。积极监测必须针对定植高危病人，但关于监测培养的频度仍有争议。一机构是否进行监测培养应该基于该机构VRE的流行率以及病人VRE定植的危险性。抗生素管理应该集中于限制某些抗生素，包括的针对厌氧菌、广谱头孢菌素和万古霉素的使用，以降低对万古霉素抗性的选择性压力(224)。常规使用的消毒剂如季铵盐类、酚类和碘伏类杀菌剂对VRE非常有效(224)。也有研究表明，加强表面消毒如将物体表面或抹布浸透消毒剂可更好的去除物体表面的VRE(42, 305)。

Vancomycin.doc (37 KB, 下载次数: 13)

2011-6-15 20:52 上传

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蓝鱼版主，如尚无人认领，我可完成Antibiotic-Resistant Gram-Negative Organisms部分。

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非常感谢jchsmg的翻译，辛苦了！学习了。

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Thanks so much for your hard-working!Take care!

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感谢你们为大家做的工作！下载学习了。