儿科中心静脉通路装置发生导管相关性血流感染危险因素的系统评价

Risk factors for central line-associated bloodstream infections caused by pediatric central venous access devices: A systematic review

目的系统评价儿科中心静脉通路装置(CVAD)发生中心静脉导管相关性血流感染(CLABSI)的危险因素。方法系统检索Ovid-Medline、Ovid-Embase、JSTOR、Cochrane Library、中国知网、中国生物医学文献数据库、万方数据库和维普数据库,纳入发表时间为2000年1月至2020年6月关于儿童CVAD发生CLABSI的病例对照研究和队列研究,并行PICU、NICU、血液肿瘤及儿科病房人群分层分析。结果纳入16篇文献,共计34478根CVAD和1585358个导管日。PICU、NICU、血液肿瘤及儿科病房人群发生CLABSI危险因素的合并OR(95%CI)分别为:①PICU:体重(<8 kg)2.72(1.89~3.92)、特指心脏疾病1.75(1.26~2.01)、输入血制品(RBC或PLT)4.95(3.65~6.72)、使用ECMO 5.83(3.50~9.70)、机械通气2.56(1.80~3.65)、血管活性药物2.89(2.05~4.08)、肠外营养10.60(6.44~17.47)、特指胃肠道疾病2.72(1.43~5.16)、胃造口术后管2.13(1.43~3.10)、股静脉置管2.32(1.84~2.94)、同时置管数>1根4.93(3.60~6.76)和长期管道2.15(1.68~2.75);②NICU:肠外营养2.60(1.25~5.41)、股静脉置管1.71(1.08~2.70)和置管时间>21 d 1.39(1.21~1.61);③血液肿瘤:肿瘤4.95(2.73~8.96)、处于密集进行化疗的阶段8.10(2.50~25.70)、1周前输入RBC 6.77(2.18~21.04)、1周前输入PLT 7.09(2.64~19.05)、多管腔数2.92(1.37~6.24)和隧道式导管3.36(1.41~7.97);④儿科人群:血流感染史2.22(1.58~3.10)、上肢静脉置管3.95(2.98~5.24)和下肢静脉置管2.03(1.94~3.04)。结论PICU、NICU、血液肿瘤和儿科人群CVAD发生CLABSI的危险因素具有其专科的独特性,治疗和置管因素对CVAD发生CLABSI的影响作用更大。

Objective:To systematically evaluate the risk factors of central line-associated bloodstream infections(CLABSI)caused by pediatric central venous access devices(CVAD).Methods:A systematic search of literature on CLABSI by pediatric CVADs was carried out in databases of Ovid-Medline,Ovid-Embase,JSTOR,Cochrane Library,CNKI,China Biomedical Medicine,Wanfang and VIP from January 2000 to June 2020.The stratified analysis was performed in terms of PICU,NICU,department of hematology and oncology,and pediatric populations.Results:A total of 16 case reports and cohort studies were included,with 34,478 CVADs and 1,585,358 catheter days.The combined OR(95%CI)of risk factors for CLABSI in PICU,NICU,department of hematology and oncology,and pediatric populations was:a.PICU:2.72(1.89 to 3.92)for body weight<8 kg,1.75(1.26 to 2.01)for heart disease(congenital heart diseases,chronic low cardiac output,heart failure,and cardiac arrest),4.95(3.65 to 6.72)for infusion of blood products(red blood cells or platelets)through central venous lines,5.83(3.50 to 9.70)for the use of ECMO,2.56(1.80 to 3.65)for mechanical ventilation,2.89(2.05 to 4.08)for vasoactive agent,10.60(6.44 to 17.47)for parenteral nutrition,2.72(1.43 to 5.16)for gastrointestinal diseases(gastrointestinal bleeding,acute and chronic liver failure,gastroesophageal reflux and esophageal diseases),2.13(1.43 to 3.10)for after gastrostomy,2.32(1.84 to 2.94)for catheters in femoral vein,4.93(3.60 to 6.76)for two or more catheters placed at the same time and 2.15(1.68 to 2.75)for long-term catheters;b.NICU:2.60(1.25 to 5.41)for parenteral nutrition,1.71(1.08 to 2.70)for catheters in femoral vein and 1.39(1.21 to 1.61)for over 21 days of catheter placement;c.department of hematology and oncology:4.95(2.73 to 8.96)for malignant tumors,8.1(2.5 to 25.7)for the stage of intensive chemotherapy,and 6.77(2.18 to 21.04)and 7.09(2.64 to 19.05)for infusion of red blood cells and platelets through central venous lines one week before respectively,2.92(1.37 to 6.24)for more than 1 lumen and 3.36(1.41 to 7.97)for tunneled catheter;d.pediatric populations:2.22(1.58 to 3.10)for bloodstream infection history,3.95(2.98 to 5.24)for catheters in upper limb vein and 2.03(1.94 to 3.04)for catheters in lower limb vein.Conclusion:The risk factors were unique for CLABSI caused by CVADs in PICU,NICU,department of hematology and oncology,and pediatric populations.Treatment and catheters had a greater impact on CLABSI caused by CVADs.