【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）

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Antibiotic-Resistant Gram-Negative Organisms
Many Gram-negative bacteria are implicated in the most common HAIs, including CLABSIs, CA-UTIs, VAPs, and SSI (136). In 2006 to 2007, NHSN data demonstrated that E. coli and P. aeruginosa were the Gram-negative organisms most frequently isolated from HAIs, with other frequently isolated organisms including Klebsiella pneumoniae, Enterobacter species, Acinetobacter baumannii, and Klebsiella oxytoca (136). These data and others suggest that the proportion of HAIs due to Gram-negative bacteria has increased (179). In fact, the authors of a recent publication from a major university medical center described an increase in primary health care-associated BSIs caused by Gram-negative bacteria from 15.9% in 1999 to 24.1% in 2003 (3).
抗生素耐药的革兰氏阴性菌
许多革兰氏阴性菌与最常见的医院感染（HAIs）如中心导管相关血流感染（CLABSIs）、导尿管相关泌尿道感染（CA-UTIs）、 呼吸机相关肺炎（VAPs）和手术切口感染（ SSI）相关 (136)。2006-2007年，NHSN的数据表明，大肠杆菌和铜绿假单胞菌是最常见的医院感染分离病菌，其他的常见病菌包括肺炎克雷伯菌、肠杆菌属、鲍曼不动杆菌和奥克西托克雷伯菌(136)。NHSN的数据和其他的一些数据提示，由于革兰氏阴性菌所引起的医院感染比率有所增加(179)。实际上，一所大学医学中心最近发表的文章表明，由于革兰氏阴性菌所致的医院血流感染已由1999年的15.9%上升到2003年的24.1% (3)。

The proportion of Gram-negative bacteria resistant to available antibiotics is increasing (245). National data demonstrate a significant increase in multidrug resistance (defined as resistance to three or more antibiotic agents from three different
antibiotic classes) among several species, including Klebsiella, Acinetobacter, and Pseudomonas spp. (227). In a recent analysis of isolates of Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter baumannii reported to the NHSN from January 2006 through December 2008, up to 60% of isolates were found to be MDR (160). In one hospital, susceptibility to ciprofloxacin, an agent with broad Gram-negative coverage, fell from 86% to 76% over 5 years (230). Antibiotic resistance due to extended-spectrum beta-lactamase (ESBL)-producing organisms and carbapenemase-producing Enterobacteriaceae has now been reported globally (132).
    革兰氏阴性菌对现有抗生素耐药的比率也在增加(245)。全国数据表明，克雷伯菌、不动杆菌和假单胞菌中多重耐药菌（MDR，多重耐药菌指对三种或三种以上不同类型的抗生素耐药）显著增加(227)。经对2006年1月至2008年12月报告给NHSN的数据进行分析，发现多达60%的肺炎克雷伯菌、铜绿假单胞菌和鲍曼不动杆菌分离株为多重耐药菌（MDR）(160)。在一家医院，对环丙沙星（一种革兰氏阴性菌的广谱抗生素）的敏感性在5年之内由86%下降到了76% (230)。现在世界各地均有产延伸光谱β-内酰胺酶(ESBL)菌和产碳青霉烯类肠杆菌抗生素耐药的报告(132)。

The most significant risk factors for colonization or infection with MDR Gram-negative bacteria among children and adults are residence in a long-term care or rehabilitation facility, antibiotic treatment in the last 3 months, and hospitalization within the last 3 months (233). Additional risk factors for colonization or infection with MDR Gram-negative bacteria include immunosuppression, hospitalization for 5 days or longer, participation in chronic dialysis, and home infusion therapy or wound care in the last 30 days (7). In the modern health care structure, patients often transition between multiple facilities, and long-term acute-care hospitals have been implicated as the source of regional outbreaks of MDR Gramnegative infections (222).
多重耐药革兰氏阴性菌在儿童和成人定植和感染的最危险因素为在长期看护或康复设施居住、过去的3个月中接受过抗生素治疗以及在过去的3个月中曾经住院(233)，其他的危险因素包括免疫抑制、住院时间≧5天、长期透析、家庭灌注疗法、或过去的30天中有过伤口照护经历(7)。在现代医疗保健体系中，病人往往在不同的医疗设施之间移动，MDR革兰氏阴性菌感染区域性暴发与长期急救医院之间具有相关性(222)。

Infections due to antibiotic-resistant bacteria lead to increased morbidity, mortality, and hospital costs (75, 137). A cohort study of surgical patients compared patients with resistant Gram-negative infections to those with susceptible Gram negative infections and found that resistant Gram-negative infections were associated with higher median costs ($80,500 versus $29,604) and longer lengths of stay (29 versus 13 days) (94). Another study estimated mortality attributed to infection with Gram-negative organisms to be 6.5% overall (137). It is worth discussing a few salient examples that are increasingly encountered and are notable for significantly impacting morbidity, mortality, and health care costs.
    耐药菌感染使患病率增加、死亡率增高、住院花费增加(75, 137)。一项关于外科病人的队列研究对耐药革兰氏阴性菌感染和敏感革兰氏阴性菌病人进行了对比，发现耐药菌感染所致住院费用更高(80,500美元对29,604美元)、住院时间更长（29天对13天）(94)，另一项研究估计由于革兰氏阴性菌感染所致死亡率占全部死亡率的6.5% (137)。因此有必要对不断涌现的、而且明显影响发病率、死亡率和医疗费用的突出例子进行讨论。

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3. Vancomycin-Resistant Enterococcus.doc (42.5 KB, 下载次数: 16)

2011-6-16 12:32 上传

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昨日的耐万古霉素肠球菌有打字错误之处，请参考今日校对后内容。

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4. Antibiotic-Resistant Gram-Negative Organisms.doc (37.5 KB, 下载次数: 27)

2011-6-16 12:36 上传

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抗生素耐药的革兰氏阴性菌word版本

icchina

回复 1# 蓝鱼o_0

这个活动非常好！原作者是Trish M. Perl，曾经是SHEA的主席，集中了当前感染控制领域的精华。
希望能早日看到中文版的全文。
非常感谢积极参与文件翻译的朋友！

icchina

回复 1# 蓝鱼o_0

Acute-Care Settings
不是指急诊科。可以翻译为急性病医疗机构，相对于老年护理院、精神病院等来说的，我国绝大多数的医院，都是属于Acute-Care Settings。

米奇朋克

回复 64# icchina
谢谢胡主席的鼓励！我会继续努力的。

蓝鱼o_0

回复 64# icchina

谢谢胡老师的鼓励，您的鼓励是我们的动力！会尽快组织将中文稿件上传

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Pseudomonas aeruginosa. P. aeruginosa is ubiquitous in health care settings and is an important pathogen in the immunocompromised and among the critically ill. P. aeruginosa becomes resistant to antimicrobials through a variety of mechanisms that lead to MDR Pseudomonas, defined as resistance to three or more classes of antipseudomonal antibiotics (112). The increasing use of fluoroquinolones has led to increasing resistance, with 97.1% of MDR Pseudomonas strains being resistant to fluoroquinolones (231). One-quarter of 52,637 P. aeruginosa isolates reported from 1999 to 2002 were MDR (100). P. aeruginosa is a significant nosocomial pathogen. In a cohort of 489 patients, one-third of P. aeruginosa infections were nosocomial (49). Sites of infection included wound (41%), urine (22%), respiratory tract (21%), effusion (5%), blood (4%), and tissue (4%). This study revealed a relationship between increasing P. aeruginosa resistance and increasing mortality and length of stay.
铜绿假单胞菌  铜绿假单胞菌在医疗保健机构无处不在，是免疫缺陷和重症病人的重要致病菌。铜绿假单胞菌可通过各种机制产生抗生素耐药导致多重耐药铜绿假单胞菌(112)。氟喹诺酮类药物使用的增加导致了对氟喹诺酮类耐药的增加，97.1%的多重耐药铜绿假单胞菌菌株对氟喹诺酮类耐药(231)。1999-2002年报告的52,637株铜绿假单胞菌分离菌株中，1/4为多重耐药菌(100)。铜绿假单胞菌为重要的医院感染病原菌。一项涉及489个病人的队列研究发现，1/3的铜绿假单胞菌感染为医院感染(49)，感染部位包括伤口(41%)、尿道(22%)、呼吸道(21%)、渗出物(5%)、血液(4%)和组织(4%)。这项研究发现铜绿假单胞菌的耐药性增强与死亡率增加和住院时间延长相关。

Water is one of the main environmental reservoirs of P. aeruginosa. Outbreaks of P. aeruginosa in ICUs have been associated with water faucets colonized with P. aeruginosa and tap water used to clean bronchoscopes (24, 273). This organism is a concern due to its associated morbidity, mortality, impact on health care costs, and increasing prevalence; the lack of currently effective antimicrobials for MDR strains; and the absence of new antimicrobials in development for MDR Gram-negative infections.
水源是铜绿假单胞菌的主要环境储存场所。ICU中铜绿假单胞菌感染暴发与水龙头铜绿假单胞菌定植、以及用于清洁气管镜的自来水污染相关(24, 273)。由于铜绿假单胞菌与发病率、死亡率、住院费用和流行的增高相关，目前尚无有效的抗该菌多重耐药菌株的药物以及对多重耐药革兰氏阴性感染缺乏新的抗生素，因此铜绿假单胞菌令人担忧。

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铜绿假单胞菌部分的word文档 6. Pseudomonas aeruginosa.doc (27.5 KB, 下载次数: 17)

2011-6-16 20:43 上传

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Acinetobacter species. Acinetobacter species have become a growing cause of HAIs with increasing antibiotic resistance (110, 179). Acinetobacter species are not only ubiquitous in the environment, they can also live for long periods on equipment and surfaces and are frequent patient colonizers. Due to these characteristics, A. baumannii frequently causes outbreaks in hospital settings. Traditionally, these outbreaks are associated with ICUs, respiratory equipment, or water sources and have been difficult to contain because of the associated environmental contamination (101, 199, 331). Surveillance methods used to identify carriers of Acinetobacter are insensitive, further hindering infection control and prevention efforts. Resistance profiles of isolates collected during outbreaks show high rates of antibiotic resistance, and in 2003, nearly 70% of isolates were resistant to amikacin (179). Growing numbers of A. baumannii strains are MDR, thereby limiting therapeutic options.
    不动杆菌属   不动杆菌属引起的HAI越来越多、其耐药性也逐渐增强(110, 179)。不动杆菌不但在环境中广泛存在，而且可在仪器和环境表面存活很长时间、是病人身上常见的定植菌。由于这些特点，鲍曼不动杆菌经常引起医院内感染的暴发。传统上，这些暴发与ICU、呼吸机或水源相关，而且由于暴发与环境污染有关，因此难以控制(101, 199, 331)。用于鉴定不动杆菌携带者的监测方法往往不敏感，更进一步地影响了感染的预防和控制的效应。对暴发中分离菌株的耐药性分析表明不动杆菌有较高的抗生素耐药率。2003年，约70%的分离株对卡那霉素耐药(179)。越来越多的鲍曼不动杆菌为多重耐药菌，因此限制了治疗的选择范围。

Infection prevention. Standard infection control practices should be used for MDR Gram-negative infections. Hand hygiene is imperative when one comes into contact with patients, their secretions, and the environment. Patients should be isolated, and the use of gowns and gloves (contact precautions) is recommended. In some cases, the cohorting of patients with similar organisms is used to prevent transmission (56). The role of active surveillance is less clear for MDR Gram-negative organisms; however, active surveillance has been effective in controlling outbreaks of carbapenemase-producing Enterobacteriaceae (223).
感染预防  必须采取标准感染控制措施控制多重耐药革兰氏阴性菌感染。当与病人、其分泌物以及其周围环境接触时，必须实施手卫生。病人必须被隔离，要求穿隔离衣、戴手套（接触隔离）。为预防传播，可将同类感染病人安置在同一病房(56)。主动监测对于多重耐药革兰氏阴性菌的作用不明，但是，主动监测对于控制产碳青霉烯类肠杆菌的暴发是有效的(223)。

Few studies aimed at estimating the proportion of resistant Gram-negative organisms due to antibiotic use compared to the proportion due to patient-to-patient transmission have been conducted in nonoutbreak settings, with a significant variability in reported estimates (22, 107, 130, 131, 156, 219, 238, 241). Harris and colleagues have provided evidence that some strains of Klebsiella are transmitted in ICU patients (129). Of the 27 patients who acquired Klebsiella pneumoniae infection, 52% were transmitted from patient to patient. These data suggest that in the setting of outbreaks and in certain high-risk groups, there may be a role for case finding and active surveillance.
评价在非暴发情境下由于抗生素使用引起的革兰氏阴性耐药菌的比例和由于病人-病人间传播引起的革兰氏阴性耐药菌的比例的比较研究数量很少，而且这些研究得到的结果差异很大(22, 107, 130, 131, 156, 219, 238, 241)。Harris及其同事发现某些克雷伯菌株可在ICU病人中传播(129)。在被肺炎克雷伯菌感染的27个病人中，52%是病人-病人间传播的。这些数据提示在感染暴发情景及特定高危人群中，尽早发现病例以及主动监测可能会起一定作用。

Due to the growing challenge of carbapenem-resistant and carbapenemase-producing Enterobacteriaceae, the CDC and HICPAC recently provided updated infection prevention and control guidelines for these organisms in acute-care facilities (56). The guidelines recommend the strict use of hand hygiene when one comes into contact with patients and/or the environment and recommend that all acute-care facilities implement contact precautions for all patients colonized or infected with carbapenem-resistant and carbapenemase-producing Enterobacteriaceae. Clinical microbiology laboratories should establish a protocol, consistent with Clinical and Laboratory Standards Institute (CLSI) guidelines (69), for the detection of carbapenem-resistant and carbapenemase-producing Enterobacteriaceae.
    由于抗碳青霉烯类和产碳青霉烯类肠杆菌的日益增多，CDC和HICPAC最近发布了关于在急症医疗机构预防和控制这些病原菌感染的指南(56)。指南要求当与病人和/或其环境接触时应严格执行手卫生，并要求所有急症医疗机构对所有抗碳青霉烯类和产碳青霉烯类肠杆菌定植或感染的病人实施接触隔离。临床微生物学实验室必须依据临床和实验室标准协会(CLSI)指南(69)制定出检测抗碳青霉烯类和产碳青霉烯类肠杆菌的操作规程。

In areas where these organisms are endemic, facilities should monitor clinical cases due to carbapenem-resistant and carbapenemase-producing Enterobacteriaceae and consider intensifying infection control strategies if rates are not decreasing. The guidelines also recommend facilities where carbapenem-resistant and carbapenemase-producing Enterobacteriaceae are not endemic review microbiology records at least semiannually. If previously unrecognized cases are found, a single round of active surveillance should be conducted to identify unrecognized sources of colonization where infection control strategies may be targeted. Of note, other experts advocate for a hierarchical and aggressive approach to isolating patients, identifying cases, cohorting, and cleaning the environment (47, 56, 171). An outbreak with a carbapenemase-producing organism requires more aggressive surveillance and case-finding activities.
在有抗碳青霉烯类和产碳青霉烯类肠杆菌流行的区域，医疗机构必须监测抗碳青霉烯类和产碳青霉烯类肠杆菌感染的临床病例，如果感染率不降低的话，应考虑采取强化感染控制策略。指南中也对没有抗碳青霉烯类和产碳青霉烯类肠杆菌流行的机构提出要求，要求这些机构至少每半年对微生物学记录进行复习和评估。如果发现了以前未曾识别的病例，必须进行一轮主动监测，鉴定出未识别的定植源并据此进行感染控制措施。其他一些专家倡导序贯和更为积极的方式隔离病人、识别病例、分类隔离、环境清洁(47, 56, 171)。对于产碳青霉烯类肠杆菌的感染暴发，需要更为积极主动的监测和病例的鉴定检出。

Not only are antimicrobial-resistant Gram-negative organisms responsible for a significant proportion of HAIs, they are also a group of bacterial organisms becoming more resistant to available antimicrobials, with no new antimicrobials in sight. The recognition of risk factors for infection with these organisms can guide institutional practices to ensure the prevention of colonization and infection.  
    抗生素耐药的革兰氏阴性菌不仅仅是导致部分HAI的重要致病菌，它们也是对现有抗生素越来越具有抗性的一组细菌。而目前我们还没有发现新的抗生素。对于这些病原菌感染危险因素的识别可指导机构性措施以保证对于定植和感染的预防。

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7. Acinetobacter species.doc (37.5 KB, 下载次数: 20)

2011-6-16 21:06 上传

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不动杆菌属部分的word文档

青城山

回复 64# icchina

第一次参加翻译活动，就有幸得到胡老师鼓励，非常高兴！
以后一定会积极参与！

青城山

回复 67# 蓝鱼o_0

感谢蓝鱼o_0老师，
一双慧眼发现好文章，提供机会让我们锻炼！

蓝鱼o_0

回复 72# huiqing.li

感谢你的付出，翻译的不错！
翻译也是个学习的机会，可以强化理解。
而且还能纠正错误，比如ACS的概念，胡教授就指出来了。好的资料也许您能看的懂，但是就不一定能表达出来，就是这个意思。

蓝鱼o_0

【ROLE OF HOSPITAL EPIDEMIOLOGY AND INFECTION CONTROL】

In 1958, nationwide epidemics of nosocomial Staphylococcus aureus infection in newborn nurseries were recognized. TheAmerican Hospital Association’s Advisory Committee on Infectionswithin Hospitals subsequently recommended routine surveillancefor nosocomial infections (294). In the 50 years sincethen, the role of infection control and hospital epidemiology hasexpanded, and its contribution to the quality of health care ishighlighted.

In 1976, the Joint Commission included requirementsfor infection control and prevention in its requirements forhospital accreditation (294). Finally, in 1985, the SENIC Projectprovided scientific evidence that infection control programs withqualified IPs and hospital epidemiologists could prevent 32% of nosocomial infections. This and other studies have found thatinfection control programs prevent infections and lead to decreasedmorbidity, improved survival, and shorter hospital stays,and they are cost-effective (121, 345).Since their inception in the 1960s and 1970s, the role andresponsibilities of infection control programs have grown substantially.This growth has been fueled by more complicated cases andan intricate health care system but also due to an increased awarenessof patient safety and medical accountability and the need formass infectious disease casualty planning and delivery of high qualityclinical care. Given this trend, the SHEA created a consensuspanel to help define the infrastructure and activities ofhospital epidemiology and infection control programs (294).Foremost, the SHEA laid out the goals for infection controlprograms as (i) to protect the patient, (ii) to protect HCWs and all others in the health care environment, and (iii) to accomplishthe first two goals in a cost-effective manner (294). Infectioncontrol and hospital epidemiology programs obtain their goalsthrough many activities. We will discuss the main roles and activitiesof an infection prevention and control program.

1958年，在全国新生儿室发生了金黄色葡萄球菌院内感染疫情。美国医院协会医院感染咨询委员会建议（294）院内感染进行常规监测。在此后的50年里，感染控制和医院流行病学的作用不断扩大，其在医疗质量中的贡献日益突出。

1976年，联合委员会包括感染预防和控制，及其医院评审（294）的要求。最后，在1985年，SENIC的项目提供了科学证据，研究表明，合格的IP和医院感染流行病学家可以防止32％的院内感染。他与其他的研究证实，感染控制程序可以有效预防感染，并导致降低发病率，提高生存率，缩短病患住院时间，而且符合成本效益（121，345）。自从这些机构在60年代和70年代成立以来，感染控制规划的责任和作用急剧增加。随着越来越多复杂的医院感染事件和错中复杂的医疗保健系统发展趋于白热化。病人安全意识的提高，医疗问责制，大规模传染病伤亡规划的需要和高质量的医疗保健服务需求进一步促进了增长。鉴于这一趋势，SHEA创造了一个共识面板，以辅助确定基础设施和医院流行病学的活动和感染控制规划（294）。最重要的，SHEA奠定了感染控制程序的目标：（i）保护病患，（ii）为保护医护人员和医疗环境中其他人（iii）完成实现前两个目标的成本效益方式（294）。医院感染控制及流行病学方案获得通过许多活动实现了预期目标。我们将讨论感染预防和控制方案的主要角色和活动。

-to be continue

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Extended-spectrum beta-lactamase- and carbapenemase producing Enterobacteriaceae.  ESBLs are enzymes produced by Gram-negative organisms, commonly of the family Enterobacteriaceae, that hydrolyze the beta-lactam ring of beta-lactam antibiotics, yielding them inactive. ESBLs have become a worldwide problem, and studies have shown that these organisms are associated with increased mortality rates and lengths of hospital stays (112). ESBLs, first described in 1983, are commonly found in E. coli and Klebsiella species. ESBLs inactivate broad-spectrum cephalosporins and beta-lactamases, and they are associated with beta-lactam resistance and frequent resistance to fluoroquinolones, aminoglycosides, and trimethoprim-sulfamethoxazole (112, 231). Based on a well-designed case-control study, common sites of infection include the urinary tract (51.5%), wounds (51.5%), catheters (12%), blood (9%), respiratory tract (9%), and intraabdominal sources (3%) (178). Total antibiotic exposure was the only independent predictor for ESBL production in E. coli or K. pneumoniae. This study also demonstrated that infections with an ESBL-producing organism increased mortality 1.9-fold, ICU length of stay 1.2-fold, and mean hospital charges 1.7-fold.
超广谱-内酰胺酶（ESBLs）和产碳青霉烯酶肠杆菌  超广谱-内酰胺酶（ESBLs）是由革兰氏阴性菌（常常是肠杆菌属）产生的可水解β-内酰胺类抗生素上β-内酰胺环的酶，最终导致β-内酰胺类抗生素失活。ESBLs已成为一个世界性问题，研究表明该类细菌与死亡率增高和住院时间延长相关（112）。ESBLs最早于1983年被描述，常见于大肠埃希菌和克雷伯菌属。ESBLs可失活广谱头孢菌素类和-内酰胺酶，与β-内酰胺类抗生素、氟喹诺酮类、氨基糖甙类和甲氧苄氨嘧啶-磺胺甲基异噁唑耐药相关(112, 231)。根据一项设计良好的病例对照研究结果，常见感染部位包括泌尿道(51.5%)、伤口(51.5%)、导管(12%)、血流(9%)、呼吸道(9%)和腹腔内感染(3%) (178)。完全性抗生素暴露是大肠埃希菌和肺炎克雷伯菌产生ESBL的唯一的独立预示因子。该研究还表明产ESBL细菌感染可使死亡率增加1.9倍、ICU住院时间增加1.2倍，平均住院费用增加1.7倍。

Another emerging and concerning resistant class of organisms are those that produce carbapenemases, which are carbapenem-hydrolyzing beta-lactamases. Carbapenemases are classified based on amino acid homology. Class A and D betalactamases are referred to as serine beta-lactamases, and this group contains enzymes that function as carbapenemases.
    另一类新出现而且令人担忧的耐药菌为产碳青霉烯酶细菌，碳青霉烯酶是水解碳青霉烯的β-内酰胺酶。根据氨基酸序列的同源性而将碳青霉烯酶分类。A类和D类β-内酰胺酶为丝氨酸β-内酰胺酶，该类酶含有可行使碳青霉烯酶功能的酶。


Klebsiella pneumoniae was the first clinically significant organism identified that produced a carbapenemase. These organisms were originally named Klebsiella pneumoniae carbapenemase (KPC)-producing organisms. KPC-type carbapenemases are class A serine beta-lactamases. These enzymes reside on transmissible plasmids, and carbapenemases have now been identified in several species of the family Enterobacteriaceae. These organisms are now referred to as carbapenemase-producing Enterobacteriaceae. The first carbapenemase-producing Klebsiella species were reported in the late 1990s (360); however, these organisms did not gain notoriety until outbreaks of KPC-producing Klebsiella species were reported around the world (34, 36, 180, 306, 332). Carbapenemases have also been identified in non-Enterobacteriaceae species such as Pseudomonas aeruginosa (367).
肺炎克雷伯菌    肺炎克雷伯菌是第一个在临床上被鉴定出来的产碳青霉烯酶的重要细菌。肺炎克雷伯菌起初被命名为肺炎克雷伯产碳青霉烯酶（KPC-）菌，KPC-型碳青霉烯酶为A类丝氨酸β-内酰胺酶，这些酶位于传递质粒上，在数种肠杆菌中发现了碳青霉烯酶，这些细菌现在被称为产碳青霉烯酶肠杆菌。二十世纪九十年代末报告了第一个产碳青霉烯酶克雷伯菌(360)，但在发生产KPC的克雷伯菌感染暴发以前一直没有引起人们的广泛关注(34, 36, 180, 306, 332)。在非肠杆菌属如铜绿假单胞菌中也发现了碳青霉烯酶(367)。

The most recently emerged carbapenemase is the New Delhi metallo-beta-lactamase (NDM-1). This carbapenemase is a member of class B, the metallo-beta-lactamases. NDM-1 was first reported in 2009 in a patient who traveled to New Delhi, India, and acquired a urinary tract infection due to a carbapenem-resistant K. pneumoniae strain (364). The strain was found to be resistant to all antibiotics except colistin. The NDM-1 gene is located on a plasmid and is easily transferrable to other organisms. These plasmids also often harbor genes conferring resistance to other classes of antibiotics. NDM-1 has already been reported in other Enterobacteriaceae and non-Enterobacteriaceae Gram-negative organisms from around the world (53, 165, 175, 220). NDM-1 has now been reported from nearly every continent, with the majority of patients having traveled to India or Pakistan, reflecting worldwide dissemination from a local source (279). The emergence of the NDM-1 strain is alarming given its rapid worldwide spread and the association with other genes conferring antimicrobial resistance, rendering strains carrying the NDM-1 gene resistant to almost all currently available antibiotics.
   
最新的碳青霉烯酶为新德里-β-内酰胺酶(NDM-1)。NDM-1是B类金属-β-内酰胺酶，于2009年首次报导。一位去印度新德里旅行的病人患碳青霉烯耐药的肺炎克雷伯菌菌株所致尿路感染(364)，除多粘菌素外，该菌株对所有抗生素耐药。NDM-1基因位于质粒上，易于传递到其他微生物上。这些质粒通常也携带有对其他种类抗生素耐药的基因。 在世界各地也发现了其他肠杆菌和非肠杆菌革兰氏阴性菌上有NDM-1的报导(53, 165, 175, 220)，现在几乎各个大洲都有NDM-1报导，患者的大多数有印度和巴基斯坦旅行史，表明感染由局在地向世界各国扩散(279)。由于NDM-1扩散迅速、而且与其他具有抗生素耐药的基因相关，使得携带NDM-1基因的细菌对现有几乎所有抗生素耐药，因此NDM-1菌株的出现非常令人恐慌。

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【Surveillance】Part II

In addition to meeting regulations and guidelines, surveillance serves multiple other roles important for an infection prevention and control program. Surveillance can be used to establish baseline infection rates, detect outbreaks, convince clinicians and administrators of potential problems, affect hospital policy, assess the impact of interventions, guide antimicrobial stewardship practices, conduct research, reduce HAI rates, and make comparisons of rates and practices within and between hospitals (248). Another important application of surveillance is the monitoring of process measures. Process measures are evidence-based interventions or procedures known to decrease HAIs. Examples of surveillance based on process measures include vaccination rates among HCWs, rates of compliance with recommended hand hygiene, and rates of compliance with surgical antibiotic prophylaxis. Process measure surveillance provides information on what infection control measures should be the focus of prevention efforts (328).
除了满足法规和指南，监测还可以在感染预防和控制方案的发挥多种多样的作用。比如建立基线感染率，发现疫情，发现医生和管理人员的潜在问题，影响医院的政策，评估干预措施，指导抗菌管理，进行研究，降低HAI率，比较医院内部和医院间的率比和执行情况（248）。监测的另一个重要应用可以用来监控过程措施。这些操作时以证据为基础的干预措施，被用于降低医院感染的发生。基于对过程的监控措施的例子包括医护人员接种率，手卫生依从性、术前抗生素预防的依从性。过程措施监测提供感染控制措施的重要信息，可成为预防工作的（328）焦点。
There are several necessities for a productive surveillance program. A surveillance program must first set clear goals and objectives. Undoubtedly, resources will be scarce and should be focused where they can have the most effect. An infection prevention and control program should focus surveillance efforts on specific pathogens, infections, and patient populations. Surveillance programs should be tailored to infections or pathogens that frequently occur in the facility, cause morbidity and mortality, and can be prevented (248). Second, surveillance programs must apply standardized case definitions. The CDC HAI definitions are widely used and accepted (109). These definitions have been used for years and are well understood in the health care epidemiology community. Third, rates must be calculated using appropriate numerator and denominator data that have been validated. Correct numerator and denominator data are imperative in the setting of public reporting and comparison of rates between health care facilities. Surveillance programs must also have easy access to computer and medical records, and data should be collected with a standardized method. There must be a mechanism in place to report surveillance results. This includes not only required reporting to public health officials and other agencies but also a productive forum in which to report results to clinicians and administrators. Finally, a surveillance program must have strong leadership and human and financial resources. A leader needs the ability to set goals and objectives for the program as well as a vision for the future and the changing needs of a surveillance program.
对一个富有成效的监测而言，有几个必要条件。一个监控程序首先要明确目标和目的。毫无疑问，资源匮乏，所以必须集中于最有效果的地方。感染预防和控制方案应侧重于具体的病原体，感染和患者人群监测工作。监测计划应针对病原体感染或经常发生的设施，造成发病率和死亡率，是可以预防的（248）。二，监测程序必须运用标准病例定义。CDC对于HAI定义被广泛使用和接受（109）。这些定义已使用多年，并被保健流行病学协会广泛理解。三，率必须采用已验证的数据作为分子分母进行计算。正确的分子和分母的数据在公共报告和卫生保健机构之间的比较势在必行。监测程序还必须要易于计算机操作和医疗记录读取，数据应以标准化的方法收集。必须形成一个机制来监测结果报告。这不仅要求公共卫生官员和其他机构的报告，而且在这个产业链中的任何个体临床医生和管理人员都应该如此。最后，监测程序必须有强有力的领导、人力和财政资源。监测程序的领导者需要具有确定程序目标和任务的能力，对未来的前景有个蓝图以及达到计划不断变化的需求。

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【surveillance】Part III

Several surveillance methods exist, and infection prevention and control programs must decide which method is best suited to their facility. The most common surveillance methods include hospital-wide surveillance, prevalence surveys, targeted surveillance, and periodic surveillance (248). Hospital-wide surveillance is the most comprehensive and includes the prospective continuous survey of all areas to identify HAIs or epidemiologically significant organisms (248, 346). Hospitalwide surveillance is costly and may identify infections that cannot be prevented. This method is not commonly recommended. A prevalence survey determines the number of active cases (new and existing) of a particular infection or organism in a given area during a specified time period (259). Prevalence surveys can be applied to individual wards or an entire health care facility. Prevalence surveys can be used to determine the burden of a particular HAI or epidemiologically significant organism as well as assess risk factors for a particular infection within a given population. Targeted surveillance is focused on selected areas of the hospital, selected patient populations, or selected organisms (e.g., VRE, MRSA, or C. difficile). Examples of targeted surveillance include MRSA surveillance for ICU patients only or surveillance of infections associated with specific devices, such as VAP.

By performing targeted surveillance, infection prevention and control programs can focus on patients at increased risk and areas with high infection rates where interventions are proven to be beneficial. Periodic surveillance is used when surveillance methods are done only during specified time intervals. Examples would be hospitalwide surveillance 1 month every quarter or targeted surveillance rotating among different units. Periodic surveillance is less time-intensive and less expensive (248).

几种监测方法存在，感染预防和控制方案必须决定哪种方法最适合本机构。常用的监测方法包括综合性监测，患病率调查，目标性监测，定期监测（或者周期性监测）（248）。综合性监测是容易理解的，最全面的持续性、前瞻性调查，覆盖全院，以确定HAI和流行病学上有重要意义的微生物（248，346）。然而其很昂贵，确认的感染难以预防。通常这种方法不予以推荐。患病率调查决定在特定地区，特定时间内（259）存活病例数量（新发或者现患的，特定的感染或者特殊病原体引起的感染）。患病率调查可以应用到个人或整个病房的医疗设施。患病率调查可以被用来确定某一特定HAI的负担，或者重大流行病学意义微生物危险因素评估以及对目标人群的特殊感染的危险度评估。目标性监测在于集中于所选医院，患者人群或选定的微生物（如VRE，MRSA或艰难梭菌）。目标性监测的实例包括ICU患者MRSA监测或特殊设备感染监测，如VAP。通过进行目标性监测，感染预防和控制方案可以集中于危险增加的患者或者高感染风险区域，并进行行之有效的干预处理。定期监测（或者周期性监测）的监测方法通常用于特定时间段。比如在每个季度在不同的科室轮转，开展为期一个月的全院监测或者目标性监测。定期监测耗时较少且成本更低（248）。

New surveillance technologies are emerging. Computer software that integrates microbiological, clinical, radiographic, and pharmacy data has been developed. This new technology allows automated surveillance for HAIs and has been shown to be more efficient at identifying outbreaks than routine surveillance (357). Automated surveillance systems should free up time for IPs to focus on rounding on units, infection prevention, policy implementation, and educational activities. The future for infection prevention and control programs will require automated surveillance systems as information technology is expanding. In addition, IPs will need to communicate with those in the outpatient setting and IPs at outside institutions as the health care system grows more complex and patients need to be tracked within this complex system. With increasing emphasis on public reporting, the importance of standardized definitions and standard approaches for identifying infections cannot be overemphasized. Surveillance is the cornerstone of infection control and prevention programs; however, to be most effective, surveillance must be individualized to the needs of the facility and performed in a methodical and efficient manner.

新的监控技术不断涌现。计算机软件，集成了微生物学，临床，影像学和药学数据已经研制成功。这种新技术可以自动监测HAI的发生且已被证明在确定爆发时比常规监测更有效率（357）。自动监控系统可以随时辅助感控专家关注各个高危科室，感染预防，政策实施和教育活动。随着信息化加剧，感染预防和控制规划的未来需要自动监控系统。此外，感控专家需要与门诊进行进行沟通，并且外界机构的从事医疗保健系统的感控专家变得越来越复杂，病人需要这个复杂的系统进行跟踪。随着公开报道要求的强化，标准化的定义和确定感染的标准方法的重要性再怎么强调也不过分。监测是控制感染和预防方案的基石，但是，是最有效，监测根据设施的需求必须因材施教，并有条不紊，高效地进行。

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【OUTBREAK SURVEILLANCE】爆发调查

Outbreak Investigations

An outbreak is defined as an increase in the incidence of a particular disease over the baseline expected incidence (311). Five percent of HAIs occur as epidemics or outbreaks (348). During outbreaks of HAIs, the infection either is usually spread from a common source or from person to person or is associated with specific procedures. Outbreak investigations often provide critical information about the epidemiology of important pathogens (153, 207). They have led to the identification of new routes of infection transmission in health care settings and enhanced measures to improve patient safety (54, 150). Electronic data and surveillance systems and expanded molecular typing methods that determine organism relatedness have improved our ability to recognize outbreaks of HAIs. The first step when an outbreak is suspected is to review all available information and confirm the presence of an outbreak. This requires comparing current rates with previous rates and determining if there is clustering in time or space. If an outbreak is confirmed, the next step is to create a case definition, verify the diagnosis, and then determine the nature, location, and extent of the problem. All cases need to be identified and aggregated into a line list, which is a summary of all affected patients and important case data such as location, demographic data, signs and symptoms, underlying diseases, and procedures which the patient has undergone. This information will ultimately help with one’s investigation and will be used to identify case risk factors and define outbreak epidemiology. As in other settings, the organism identified can commonly provide clues as to additional steps to be taken to identify the source (Table 3.) An epidemic curve should also be graphed, with time along the “x” axis and the number of cases along the “y” axis. The shape of the epidemic curve may suggest the source and mode of transmission. Infection control personnel should request that the microbiology laboratory save and store all isolates from case patients for possible molecular typing. Finally and concomitantly, emergency control measures need to be instituted (311). After the initial investigation is under way, the next steps involve generating hypotheses about disease transmission and risk factors. These hypotheses should then be tested with comparative studies and supported by using microbiological studies. The final step in an outbreak investigation is communicating the results of the outbreak investigation to involved departments and implementing definitive control measures (311). Outbreaks are almost always politically charged. Key in health care settings is keeping all parties informed, including the administration, the unit involved, and any personnel involved. Risk management and the microbiology laboratory should also be involved. Most states or provinces require notification of the public health authority. Outbreaks of HAIs increase morbidity, mortality, hospital costs, and liability (348). The recognition and investigation of outbreaks of HAIs are two of the most important activities of a hospital epidemiology and infection prevention and control program. Such investigations can lead directly to improved patient care and patient safety by assessing practices and policies while simultaneously expanding medical and epidemiological knowledge.

爆发调查

爆发被定义为在某一特殊疾病的发病率显著增加，高于基线的发病率。5％的医院感染疾病可发生流行或爆发（348）。医院感染暴发或者感染通常由一个共同的来源或从人到人或基于特定程序关联进行传播。爆发调查往往提供有关的重要病原体流行病学关键信息（153，207）。他们能够确定卫生保健机构感染传播的传播土建和加强改善患者安全的措施（54，150）。电子数据和监测系统，确定微生物溯源关联的分子生物学技术改善了我们认识到医院感染暴发的能力。当疑似感染爆发时，第一步，回溯所有可用的信息，确认爆发的存在。这就要求与以前的数据进行比较，以确定是否有时间或空间聚集。如果爆发确定，下一步是创建一个病例定义，核实诊断，然后确定该爆发性质，位置和问题的严重程度。

所有病例需要确定名单，列出所有受影响病患相关信息的清单，比如位置，人口统计数据，症状和体征，基础疾病，感染病患的发病过程，将这些重要情况汇总。这些信息最终将辅助个案调查，并将被用于识别危险因素和定义流行病学爆发。至于其他部门，通常可以提供生物识别，以确定应采取的额外步骤线索来源（表3）。也可以绘制流行病曲线，以时间“X”轴，以发病数目为“Y”轴。流行病曲线的形状可能提示传染的来源和传播模式。感染控制人员应应尽可能将各种分子分型的病患分离物保存和存储。最后，随之而来，制定紧急控制措施（311）。通过实施初步调查，接下来的步骤涉及到对疾病传播和危险因素产生的假说。这些假设可以通过比较研究和微生物研究的支持得到检验。爆发调查的最后一步，是与涉及的部门及时沟通爆发调查的结果，实施明确的控制措施（311）。爆发的控制需要政策推动。在卫生保健机构，关键保持各方情况通报，包括管理层，各个科室和参与人员。风险管理和微生物学实验室也应参与其中。大多数国家或省规定公众健康权威的通知。医院感染爆发增加病患发病率，死亡率，住院费用和债务（348）。确认和医院感染暴发调查是医院感染流行病学预防和控制方案最重要的两项活动。当在扩展医疗和流行病学知识的同时，通过评估操作和政策，爆发调查能够直接提高病患护理水平，促进患者安全。