本文選題：重癥監(jiān)護(hù)病房 + PICC��； 參考：《河北醫(yī)科大學(xué)》2015年碩士論文

【摘要】：目的:掌握我院重癥監(jiān)護(hù)病房2011年1月-2014年12月經(jīng)外周靜脈置入中心靜脈導(dǎo)管(PICC)的相關(guān)血流感染病原菌的分布特點(diǎn)及耐藥情況,幫助臨床醫(yī)師確診導(dǎo)管相關(guān)血流感染,為臨床預(yù)防、診斷和治療提供科學(xué)依據(jù)。同時,也為控制院內(nèi)感染提供參考依據(jù),從而使PICC護(hù)理程序進(jìn)一步規(guī)范化、程序化。方法:1研究對象研究2011年1月-2014年12月我院重癥監(jiān)護(hù)病房ICU患者,出現(xiàn)發(fā)熱、寒戰(zhàn)和/或低血壓,而無其他明顯的感染來源,或穿刺點(diǎn)局部出現(xiàn)炎性表現(xiàn)甚至化膿等癥狀。疑似經(jīng)外周靜脈置入中心靜脈導(dǎo)管感染病例423例,進(jìn)行血培養(yǎng)和導(dǎo)管尖端培養(yǎng)。2導(dǎo)管管尖培養(yǎng)接種方法(半定量培養(yǎng)):取導(dǎo)管尖端5cm,接種在哥倫比亞血平板、麥康凱平板及營養(yǎng)肉湯內(nèi)(增菌)。在平板表面,導(dǎo)管尖端來回滾動1次,經(jīng)培養(yǎng)24小時后,培養(yǎng)出細(xì)菌的菌落數(shù)≥15CFU/平板,即為陽性。隨后進(jìn)行分純、鑒定及藥敏。3血培養(yǎng)分別從中心靜脈導(dǎo)管、外周靜脈同時抽血送血培養(yǎng),血培養(yǎng)瓶置于梅里埃全自動血培養(yǎng)儀Bac T/ALERT 3D中進(jìn)行培養(yǎng)。血培養(yǎng)結(jié)果一致(菌種和藥敏結(jié)果);二者細(xì)菌濃度比例超過5:1;血培養(yǎng)報陽的時間中心靜脈導(dǎo)管所取血樣比外周靜脈血提前2個小時以上。一旦血培養(yǎng)儀報告陽性,轉(zhuǎn)種哥倫比亞血平板,麥康凱平板,培養(yǎng)24小時后,進(jìn)行鑒定及藥敏。4菌株鑒定及藥敏測定按照美國臨床實驗室標(biāo)準(zhǔn)化協(xié)會標(biāo)準(zhǔn),使用采用VITEK2 compact和ATB Expression細(xì)菌鑒定藥敏分析儀對細(xì)菌進(jìn)行鑒定及藥敏分析。菌懸液的配置:使用新鮮的純培養(yǎng)物進(jìn)行檢測(菌齡:18-24小時),懸浮液:0.85%Na CL或去離子水調(diào)制相應(yīng)的鑒定菌懸液濃度,并使用DENSITMAT比濁儀校正濃度,使其菌懸液的濃度在0.5-0.63麥?zhǔn)媳葷�。再上機(jī)進(jìn)行鑒定和藥敏。結(jié)果:1病原菌種類及構(gòu)成疑似PICC感染患者423例中,確診導(dǎo)管相關(guān)性血流感染34例,陽性率為8.04%,共分離出38株病原菌。其中革蘭陽性菌23株,占60.52%,分別為金黃色葡萄球菌9株、溶血葡萄球菌6株、糞腸球菌4株、表皮葡萄球菌2株、屎腸球菌1株、人葡萄球菌1株。其中4株金黃色葡萄球菌為耐甲氧西林金黃色葡萄球菌(MRSA),4株溶血葡萄球菌為耐甲氧西林凝固酶陰性葡萄球菌(MRSCON)。革蘭陰性菌11株,占28.95%,分別是肺炎克雷伯菌3株、大腸埃希菌3株、粘質(zhì)沙雷菌3株、瓊氏不動桿菌1株、銅綠假單胞菌1株。其中1株大腸埃希菌是產(chǎn)超廣譜β-內(nèi)酰胺酶(ESBL)的菌株,2株肺炎克雷伯菌是產(chǎn)超廣譜β-內(nèi)酰胺酶(ESBL)的菌株。真菌4株,占10.53%,分別是光滑假絲酵母菌2株、近平滑假絲酵母菌1株、白假絲酵母菌1株。2分離菌株時間分布2011年至2014年培養(yǎng)分離到導(dǎo)管相關(guān)血流感染病原菌38株,分別為2011年19株分離率為13.1%、2012年3株分離率為4.0%、2013年8株分離率為8.3%和2014年8株分離率為8.3%。其分離率成逐年遞減的趨勢。3菌株藥敏試驗結(jié)果23株革蘭陽性菌對萬古霉素、替考拉寧、呋喃妥因、喹奴普汀/達(dá)福普汀敏感率較高,對青霉素,紅霉素、克林霉素,復(fù)方新諾明、苯唑西林、諾氟沙星耐藥性較高。11株革蘭陰性菌,對哌拉西林/他唑巴坦、氨芐西林/舒巴坦、阿米卡星、碳青霉烯類敏感率較高,對阿莫西林、哌拉西林、氨芐西林、頭孢噻吩、頭孢西丁耐藥性較高。所分離出的假絲酵母菌中,白假絲酵母菌對氟康唑、兩性霉素B、5-氟胞嘧啶、伊曲康唑、伏立康唑均較敏感,光滑假絲酵母菌對氟康唑和伊曲康唑敏感性低。結(jié)論:1疑似PICC導(dǎo)管感染患者423例中,確診導(dǎo)管相關(guān)性血流感染34例,陽性率為8.04%。在醫(yī)院開始應(yīng)用PICC階段感染率較高,達(dá)13.10%。2 PICC導(dǎo)管相關(guān)性血流感染病原菌以革蘭陽性菌為主,占60.52%;其次為革蘭陰性菌,占28.95%,真菌,占10.53%。3葡萄球菌和腸桿菌科細(xì)菌是經(jīng)外周靜脈置入中心靜脈導(dǎo)管相關(guān)血流感染的主要病原菌,病原菌耐藥現(xiàn)象較為普遍。4 PICC需要醫(yī)院具備規(guī)范化操作培訓(xùn)模式和完善的管理機(jī)制。
[Abstract]:Objective: to understand the distribution characteristics and drug resistance of the pathogenic bacteria in the central venous catheter (PICC) of the peripherally inserted central venous catheter (PICC) in the intensive care unit of our hospital in January 2011 -2014 years -2014 years, to help clinicians to confirm the catheter related blood flow infection, and to provide a scientific basis for clinical prevention, diagnosis and treatment. To provide a reference basis to further standardize and program the PICC nursing procedure. 1 research subjects studied ICU patients in ICU of our hospital in December January 2011, with fever, chills and / or hypotension, without any other obvious source of infection, or local inflammation or even suppurative symptoms in the punctures. 423 cases of peripherally inserted central venous catheter infection were inoculated in blood culture and ductal tip culture of.2 catheter tip culture (semi quantitative culture): Taking the catheter tip 5cm, inoculated in Columbia blood plate, Mai Kang Kai plate and nourishment broth (increasing bacteria). On the flat surface, the catheter tip rolled back and forth 1 times and cultured for 24 hours after culture. The number of bacterial colonies was more than 15CFU/, which was positive. Then, the bacteria were purified, identified and sensitized.3 blood culture from the central venous catheter, peripheral vein blood and blood culture, and the blood culture bottle was cultured in the Bac T/ALERT 3D of the full-automatic blood culture instrument of the maseret. The results of blood culture were consistent (bacteria and drug sensitivity results); the two bacteria were bacteria. The concentration ratio was more than 5:1; the blood samples taken from the central venous catheter in the time central venous catheter for blood culture were more than 2 hours ahead of the peripheral venous blood. Once the blood culture instrument was reported positive, the Columbia blood plate was transferred to the wheat Kang Kai plate, and after 24 hours culture, the identification and identification of the drug sensitive.4 strain and the determination of drug sensitivity were in accordance with the American clinical laboratory standardization association. Standard, using VITEK2 compact and ATB Expression identification drug sensitivity analyzer for identification and drug sensitivity analysis. Configuration of bacterial suspension: use fresh pure culture to test (age: 18-24 hours), suspension: 0.85%Na CL or deionized water modulation phase identification of bacterial suspension concentration, and use DENSITMAT turbidimeter calibration In positive concentration, the concentration of the bacterial suspension was cloudy at 0.5-0.63 Mastle. Then the identification and drug sensitivity were carried out on the machine. Results: among the 1 pathogenic bacteria and 423 cases of suspected PICC infection, 34 cases of catheter related blood flow infection were confirmed, the positive rate was 8.04%, and 38 strains were isolated. Among them, 23 strains of Gram-positive bacteria, accounting for 60.52%, were golden yellow grapes. 9 strains of Staphylococcus, 6 strains of hemolytic Staphylococcus, 4 strains of Enterococcus faecalis, 2 strains of Staphylococcus epidermidis, 1 strains of Enterococcus faecium, 1 strains of Staphylococcus aureus, 4 of Staphylococcus aureus were methicillin resistant Staphylococcus aureus (MRSA), 4 strains of hemolytic Staphylococcus were methicillin resistant coagulase negative staphylococcus (MRSCON). 11 strains of Gram-negative bacteria, accounting for 28.95%, 28.95%. 3 strains of Klebsiella pneumoniae, 3 strains of Escherichia coli, 3 strains of salebella mucilinae, 1 strains of Acinetobacter jonmannii, 1 strains of Pseudomonas aeruginosa, 1 strains of Escherichia coli were strains producing broad-spectrum beta lactamase (ESBL) and 2 strains of Klebsiella pneumoniae were strains of broad-spectrum beta lactamase (ESBL). Fungi 4, respectively, were smooth Pseudomonas. 2 strains of mother bacteria, 1 strains of Candida albicans, and 1 strains of Candida albicans isolated from.2 from 2011 to 2014, 38 isolates were isolated from 19 strains in 2011, 13.1% in 2011, 4% in 2012, 8.3% in 2013 and 8.3%. in 2014 for 8.3% and 8.3%. in 2014. Drug sensitivity test of strain.3, 23 strains of Gram-positive bacteria were sensitive to vancomycin, teicoplanin, furanotin, quetiapine / Dafoe prtin, and penicillin, erythromycin, clindamycin, compound penicillin, oxacillin, norfloxacin,.11 resistant gram-negative bacteria, and piperacillin / tazobactam and ampicin Xilin / sulbactam, Amikacin, carbapenems were sensitive to amoxicillin, piperacillin, ampicillin, cefotathiophene, and cefoxitin. Candida albicans isolated from Candida albicans were sensitive to fluconazole, amphotericin B, 5- fluorosinidine, itraconazole, and voriconazole. Conclusion: 1 of 423 patients with suspected PICC catheter infection, 34 cases of catheter related blood flow infection were diagnosed. The positive rate of the positive rate was that the infection rate of 8.04%. in the PICC stage was higher in the hospital, and the pathogenic bacteria of the 13.10%.2 PICC catheter related bloodstream infection were mainly Gram-positive bacteria, accounting for 60.52%, and the second was gram negative. Bacteria, accounting for 28.95%, fungi, 10.53%.3 Staphylococcus and Enterobacteriaceae are the main pathogens of central venous catheter related blood flow infection through peripherally inserted vein. The drug resistance of pathogenic bacteria is more common.4 PICC needs standardized operation training mode and perfect management mechanism in hospital.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2015
【分類號】：R446.5

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