抗生素管路溶液預防透析管路相關感染:系統性回顧與統合分析

Antibiotic Lock Solution for Central Line Associated Blood Stream Infection Prevention in Hemodialysis Catheter: a Systematic Review and Meta-analysis

劉佳美(Jia-Mei Liou)

指導教授 ： 杜裕康

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/NTU201702601

摘要

研究目的
透析管路相關血流感染是院內感染花費金額最高的感染，對於透析病人和醫療系統有顯著的影響，本研究目的是探討使用抗生素管路容易是否可以預防透析管路相關血流感染。
方法
本研究為一系統性回顧與統合分析，搜尋Pubmed、Cochrane Central Register of Controlled Trials及Scopus，收納研究類型為隨機分派研究，由兩位作者分別以Cochrane risk of bias tool評估研究品質。研究終點為管路相關血流感染(Catheter related blood stream infection, CLABSI)、管路失效(catheter failure)、導管相關菌血症(catheter related bacteremia, CRB)、導管出口感染(exit site infection, ESI)。
分析使用隨機效應(random-effects)統合分析，異質性以Cochran Q test 及 I-2 statistics 評估，發表性誤差以漏斗圖、Egger’s test及trim and fill test評估。以隨機效應統合性迴歸分析（meta-regression）分析導管留置時間與管路相關血流感染的關聯，次群組分析以抗生素導管溶液內的抗凝血劑分為肝素組與非肝素組，敏感性分析探討符合National Kidney Foundation’s Kidney Disease Outcomes and Quality Initiative (NKF-K/DOQI)預防管路感染措施是否影響抗生素管路預防管路相關血流感染。
結果
本研究共收納15篇符合收納條件的隨機分派研究。在管路相關血流感染方面，抗生素導管顯著降低發生風險(rate ratio [RR], 0.36 [95% CI 0.27-0.48])，抗生素管路組的管路失敗風險較低但未達顯著標準(RR, 0.89 [95% CI 0.62-1.29])。在統合性迴歸分析中，導管留置時間與管路相關血流感染有顯著關聯(P=0.04)，導管留置時間增加，發生管路相關血流感染的風險增加。次群組分析中非肝素組有較低的管路相關血流感染風險，且兩組異質性檢定達顯著標準(P=0.033)。敏感性分析中在符合NKF-K/DOQI預防管路感染措施的研究中，抗生素管路仍顯著降低管路相關血流感染的發生率(RR, 0.22 [95% CI 0.12-0.43])。漏斗圖及Egger’s test顯示有發表性誤差(Egger’s test, P=0.05)，但trim and fill test並未改變分析結果。
結論
抗生素導管溶液可顯著降低透析導管發生管路相關血流感染風險，統合回歸中導管留置時間與管路相關血流感染有顯著關聯，導管留置時間愈短，抗生素導管溶液預防血流感染的成效愈高，因此抗生素管路溶液可考慮使用在暫時性留置的透析導管。

關鍵字

抗生素 ； 血液透析 ； 血流感染 ； 導管留置時間

並列摘要

Background
Central line-associated blood stream infection (CLABSI) is a severe complication in hemodialysis patients. Although the application of an antibiotic lock solution can reduce CLABSI risk, the practice guidelines limit its use if CLABIS recurs despite application of standard preventive measures in long-term catheter users. Therefore, we evaluated whether catheter duration and guideline-recommended preventive measure affect the efficacy of an antibiotic lock solution for CLABSI prevention.
Methods
We searched PubMed, the Cochrane Central Register of Controlled Trials, and Scopus from their inception to July 2016 and included randomized controlled trials; we evaluated their methodological quality levels using the Cochrane Risk of Bias Tool. Study outcomes were incidence rate ratio of CLABSI, exit-site infection, catheter-related bacteremia (CRB), and catheter failure. Random effect models were used for all meta-analyses. Publication bias was evaluated using funnel plots, the Egger test, and the trim and fill method. We used random-effects meta-regression to investigate the effect of catheter duration on the efficacy of antibiotic lock for CLABSI prevention. Subgroup analysis was stratified by antithrombotic agents.
Results
In total, 993 citations were evaluated, and 15 studies were included in the meta-analysis. Our meta-analysis showed that antibiotic lock solution application reduced CLABSI risk by 63% (rate ratio [RR], 0.37 [95% CI 0.28–0.48]). Exit-site infection, catheter failure, and CRB also demonstrated risk reduction. In meta-regression, we found correlation between catheter efficacy for CLABSI prevention and catheter duration (P=0.04).
Conclusion
Antibiotic lock solutions can significantly reduce risk of CLABSI; in addition, the correlation between catheter duration and efficacy of antibiotic lock solution is significant. Efficacy of antibiotic lock of CLABSI prevention decreases as catheter duration is longer; therefore, antibiotic lock solution should be considered in temporary catheter users.

並列關鍵字

Antibiotic lock ； hemodialysis ； blood stream infection ； catheter duration

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