使用2%Chlorhexidine沐浴於預防血液腫瘤科病人醫療照護相關血流感染之成效

The Efficacy of Daily Bathing with 2%Chlorhexidine for Reducing Healthcare-Associated Bloodstream Infections in Hematology Patients

田貴蓮(Kuei-Lian Tien)

指導教授 ： 方啟泰 ； 盛望徽 ； 王振泰

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2017年)

https://doi.org/10.6342/NTU201700298

摘要

血液腫瘤病人由於接受細胞毒性化學治療誘發中性粒細胞減少，造成免疫力低下，增加醫療照護相關血流感染的風險。侵入性醫療裝置如中心靜脈導管，是血液腫瘤科病人不可避免的醫療處置，但卻也是血流感染(BSI)重要危險因子。導管置入點為細菌進入人體的途徑，造成病人局部和全身性感染，而皮膚菌叢常移生於置入之導管進而發生血流感染，因此置入導管前皮膚清潔消毒是預防感染之重要措施。回顧國外多篇研究，每日使用含2% Chlorhexidine (CHG) 浸漬紙巾擦拭浴，可以有效降低醫療照護相關血流感染，且為國外之醫療常規。但在國內則尚未有相關研究。
目的：為釐清每日以較高濃度2% CHG抗菌劑沐浴相較於每日使用一般常規抗菌潔膚露(劑)沐浴是否可減少皮膚菌叢引起血流感染(SKIN_BSI)、中心靜脈導管相關血流感染(CLABSI_CVC)，進而降低醫療照護相關血流感染(HABSI)之發生率，以提升病人之存活率。
方法：本研究為前瞻性介入性研究，研究期間為2015年12月~2016年6月。研究對象為二個血液腫瘤單位住院病人，符合受納者條件者，經同意並簽屬受試者同意書，於住院期間每日使用含2%CHG抗菌劑沖洗浴或含2%CHG浸漬紙巾擦拭浴為實驗組；每日使用一般常規抗菌潔膚露(劑)沐浴之血液腫瘤科住院病人，將回溯性利用電子病歷紀錄收集其相關人口學資料、臨床資料及實驗室檢查資料等為對照組。比較二組first SKIN_BSI、first CLABSI_CVC及first HABSI之發生率。
結果：總計485人為實驗組，408人為對照組，利用Chi_score檢定，實驗組first SKIN_BSI發生率相較對照組減少65.5% (1.0 vs 2.9每1000住院人日, P=0.012)，有顯著差異；實驗組first CLABSI_CVC發生率相較對照組減少61% (6.6 vs 16.9每1000住院人日, P=0.005)，有顯著差異；實驗組first HABSI 發生率相較對照組減少35% (7.8 vs 12.0 每1000住院人日, P=0.035) ，有顯著差異。以邏輯斯迴歸分析，經調整干擾變項後，結果顯示實驗組病人可因介入措施使得發生first SKIN_BSI之風險，顯著下降70% (OR=0.3, P=0.02)；first CLABSI_CVC之比例，顯著下降68% (HR=0.32, P=0.009)；first HABSI之風險，顯著下降59% (OR=0.41, P=0.002)，但對腸道來源之大腸桿菌(Escherichia coli)及克雷伯氏肺炎菌(Klebsiella pneumoniae) 菌血症（作為對照指標）則無預防效果 (OR=0.993, P=0.99)。
結論：每日使用含2% CHG抗菌劑進行沖洗浴，主要加強病人皮膚清潔外，並能對皮膚菌叢有殺菌及抑菌之作用，而結果顯示研究期間病人SKIN_BSI、CLABSI_CVC之發生率明顯下降，進而降低整體HABSI。使用2% CHG沐浴，提供一種相對簡單、省成本又安全的策略，建議此措施可推行於血液腫瘤科病人，以預防血流感染。

關鍵字

2% Chlorhexidine 沐浴 ； 皮膚菌叢引起血流感染 ； 中心靜脈導管相關血流感染 ； 醫療照護相關血流感染 ； 血流感染

並列摘要

Background
Hematology patients undergoing immunocompromising cytotoxic chemotherapy are at risk for healthcare-associated infections. It remains unclear whether daily bathing with 2% chlorhexidine can reduce the risk. The aim of this study is to compare the incidence of healthcare-associated bloodstream infection (HABSI) between patients using of 2% CHG daily bath and those using general antibacterial cleansers daily bath.
Methods
This was a single-arm prospective interventional study. Patients admitted to two hematological units during the period from December 2015 to June 2016 were the study population. We recruited patients to receive 2% CHG daily bath (intervention group). Those who refused to participate were provided with general antibacterial cleansers daily bath (control group). The incidence rate of skin flora-related bloodstream infection (SKIN_BSI), central venous catheter (CVC)-associated bloodstream infection (CLABSI_CVC), and HABSI of the intervention group were compared with that of the control group.
Results
In total, 485 patients were enrolled as the intervention group, and the other 408 patients served as control group. Compared with the control group, the incidence rate of first SKIN_BSI was reduced by 65.5% (1.0 vs 2.9 per 1,000 patient-day, p=0.012), the incidence rate of first CLABSI_CVC was reduced by 61% (6.6 vs 16.9 per 1,000 patient-day, P = 0.005) and the incidence rate of first HABSI was reduced by 35% (7.8 vs 12.0 per 1,000 patient-day, P=0.035) in the intervention group. After adjusting for effects of confounding variables by logistic regression, the 2% CHG daily bath reduces the risk of first SKIN_BSI by 70% (adjusted OR=0.3, P=0.02), the risk of first CLABSI_CVC by 68% (adjusted OR=0.32, P=0.01), and the risk of first HABSI by 59% (adjusted OR=0.41, P=0.002). In contrast, the risk of gut-origin bacteremia, such as Escherichia coli and Klebsiella pneumoniae-related bloodstream infection, did not change (adjusted OR=0.99, P=0.99).
Conclusion
Daily bathing with 2% CHG is effective in reducing skin flora-related bloodstream infection and cathether-related bacteremia. We recommend routine adoption of this simple and low-cost intervention to reduce BSI among patients with hematological malignancy.

並列關鍵字

2% Chlorhexidine bath ； skin flora-related bloodstream infection ； central line-associated bloodstream infection ； healthcare-associated bloodstream infection ； bloodstream infection

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