烧伤患者中心静脉导管相关性感染发生情况及其危险因素分析

Analysis on the prevalence of central venous catheter-related infection in burn patients and its risk factors

目的探讨烧伤患者中心静脉导管相关性感染（CRI）的发生情况及其危险因素，以指导临床实践。方法回顾性分析2011年6月-2014年12月笔者单位收治的符合人选标准的烧伤患者临床资料，共228例患者中心静脉置管480例次总计5026d。（1）统计各例次置管后患者CRI、导管相关性血流感染（CRBSI）发生情况（计算千日感染率）及其所致病死率、细菌检出情况。（2）根据性别、年龄、烧伤总面积、Ⅲ度面积、致伤原因、吸入性损伤程度、置管部位、是否经创面置管、置管持续时间进行分类，统计各例次置管后患者CRI发生情况，对数据行X2检验；选取差异有统计学意义的指标，行多因素logistic逐步回归分析，筛选患者发生CRI的独立危险因素。（3）分别针对所有置管例次、经创面置管例次，按不同置管持续时间分段，统计各时间段内各例次置管后患者CRI发生情况，对数据行x。检验、Fisher确切概率法检验，并进行Bonferroni校正。结果（1）CRI千日感染率为50．14％e（252／5026），所致病死率为3．51％（8／228）；CRBSI千日感染率为18．70％e（94／5026），所致病死率为2．19％（5／228）。CRI、CRBSI中分别检出病原菌319、105株，其中检出率居前4位的细菌均为鲍氏不动杆菌、铜绿假单胞菌、金黄色葡萄球菌、肺炎克雷伯菌，主要真菌均为近平滑念珠菌。（2）不同性别、年龄、致伤原因、吸入性损伤程度、置管部位患者各例次置管后CRI发生情况比较，差异均无统计学意义（z。值为0．427～6．991，P值均大于0．05）。不同烧伤总面积、Ⅲ度面积、置管持续时间及是否经创面置管患者各例次置管后CRI发生情况比较，差异均有统计学意义（X2值为7．202～14．246，P〈0．05或P〈0．01）。（3）烧伤总面积、是否经创面置管、置管持续时间为患者发生CRI的独立危险因素（比值比分别为1．495、1．670、1．924，95％置信区间分别为1．096～2．040、1．077～2．590、1．303～2．841，P〈0．05或P〈0．01）。（4）在所有置管例次中，置管持续时间小于或等于3d、大于3d且小于或等于5d各例次置管后患者CRI发生比例相近（x2〈0．001，P〉0．05），置管持续时间大于5d且小于或等于7d、大于7d且小于或等于14d、大于14d各例次置管后患者CRI发生比例均显著高于前2个时间段（X2值为3．625—13．495，P值均小于0．05）；在经创面置管例次中，置管持续时间小于5d、大于或等于5d且小于7d各例次置管后患者CRI发生比例相近（P〉0．05），置管持续时间大于或等于7d且小于14d、大于或等于14d各例次置管后患者CRI发生比例均显著高于大于或等于5d且小于7d（x2值分别为6．828、4．940，P值均小于0．05）。结论烧伤患者CRI千日感染率相对较低，CRBSI千日感染率相对较高，二者所致病死率均相对较低，鲍氏不动杆菌为主要病原菌；烧伤总面积、是否经创面置管、置管持续时间为可预测烧伤患者并发CRI的独立危险因素。建议临床上中心静脉置管5d内拔除并尽量避免经创面置管，当不能避免经创面置管时，建议7d内拔除导管。

Objective To investigate the prevalence of central venous catheter-related infection （CRI） in burn patients and its risk factors, so as to guide the clinical practice. Methods Clinical data of 5 026 days of 480 cases of central venous catheterization altogether in 228 burn patients admitted to our ward from June 2011 to December 2014, conforming to the study criteria, were retrospectively analyzed. （1） The incidence of CRI and that of catheter-related bloodstream infection （CRBSI） in patients （the infection rates per thousand days were calculated） and mortality due to them, and detection of concerning bacteria were recorded after each case of catheterization. （2） The incidence of CRI after each case of catheterization in patients was recorded according to the classification of their gender, age, total burn area, full-thickness burn area, cause of injury, severity of inhalation injury, location of catheterization, whether catheterization through wound or not, duration of catheterization, and the data were processed with ehi-square test. Indexes with statistically significant differences were selected, and they were processed with multivariate logistic stepwise regression analysis to screen the independent risk factors of CRI. （3） To all cases of catheterization and cases with catheterization through wound, incidence of CRI after each case of catheterization in patients at each time period was recorded according to the sorting of duration of catheterization. Data were processed with chi-square test and Fisher＇s exact test, and the values of P were adjusted by Bonferroni. Results （1） Infection rate of CRI per thousand days was 50. 14‰ （252/5 026）, resulting in the mortality rate of 3.51% （8/228）. Infection rate of CRBSI per thousand days was 18.70‰（94/5 026）, resulting in the mortality rate of 2.19% （5/228）. Respectively 319 and 105 strains of pathogens were detected in CRI and CRBSI, in which the top four bacteria detected were Acinetobacter baumannii, Pseudomonas aeruginosa, Staphylococcus aureus , and Klebsiella pneumoniae , and the most common fungus found was smooth Candida . （2） There were no statistically significant differences in the incidence of CRI after each case of catheterization among patients with different gender, age, cause of injury, severity of inhalation injury, and location of catheterization （ with x2 values from 0. 427 to 6. 991, P values above 0.05 ）. There were statistically significant differences in the incidence of CRI after each case of catheterization among patients with different total burn area, full-thickness burn area, whether catheterization through wound or not, duration of catheterization （ withX 2 values from 7. 202 to 14. 246, P 〈 0.05 or P 〈 0.01 ）. （3） Total burn area, whether catheterization through wound or not, and duration of catheterization were the independent risk factors of CRI （with odd ratios respectively 1. 495, 1. 670, 1. 924, 95% confidence intervals respectively 1. 096 - 2. 040, 1. 077 - 2. 590, 1. 303 - 2. 841, P 〈 0.05 or P 〈 0.01 ）. （4） In all eases enduring catheterization, the incidenee of CRI in patients after each episode of catheterization was close between eases enduring catheterization shorter than or equal to 3 days and those longer than 3 days and shorter than or equal to 5 days （ X2 〈 0. 001 , P 〉 0.05 ） ; the incidence of CRI in patients after each episode of catheterization was signifi- cantly higher in eases enduring catheterization longer than 5 days and shorter than or equal to 7 days, longer than 7 days and shorter than or equal to 14 days, and longer than 14 days than the former two periods （ with X 2 values from 3. 625 to 13. 495, P values below 0.05 ）. In the eases with catheterization through wound, the incidence of CRI of patients after each episode of catheterization was close between eases enduring catheterization shorter than 5 days and those longer than or equal to 5 days and shorter than 7 days （ P 〉 0.05） ; the incidence of CRI of patients after each episode of catheterization was significantly higher in eases enduring catheterization longer than or equal to 7 days and shorter than 14 days and longer than or equal to 14 days than those with longer than or equal to 5 days and shorter than 7 days （ withX 2 values respectively 6. 828 and 4. 940, P values below 0.05）. Conclusions The infection rate of CRI per thousand days in burn patients is relatively low, while that of CRBSI is relatively high, both resulting in relatively low mortality, and Acinetobacter baumannii is the main pathogen. Total burn area, whether catheterization through wound or not, and duration of catheterization are independent risk factors of CRI in burn patients, and with which its occurrence could be predicted. It is suggested that central venous catheterization should be removed within 5 days, and catheterization through wounds should be avoided as much as possible. If catheterization through wound is unavoidable, removal of the catheter within 7 days is recommended.