- 學位論文
血液腫瘤住院病人血流感染危險因子之相關性探討
An exploration of bloodstream infection risk factors on hospitalized hematological malignancy patient
摘要
背景：中心靜脈導管是血液腫瘤科病人接受化學藥物給藥的一項重要途徑，但易因血流感染而影響預後。國外針對裝置中心靜脈導管血液腫瘤病人的血流感染之相關研究很多，但國內較少。故本研究預探討裝置中心靜脈導管血液腫瘤住院病人血流感染之危險因子。 目的：探討裝置中心靜脈導管血液腫瘤住院病人血流感染之危險因子。 設計：採回溯性研究設計。 方法：以南部某醫學中心的電子病歷為資料庫。研究工具為血液腫瘤科病人危險因子資料收集單，並經過專家效度審查，資料來源為醫療及護理病歷，自變項為病人屬性：年齡、性別、血液腫瘤疾病診斷分類、體能狀況、查爾森共病症指數、絕對嗜中性白血球（Absolute Neutrophil Count；以下簡稱ANC）低下持續天數、ANC低下的數值、主觀性整體營養狀況評量表分數（The Patient-Generated Subjective Global Assessment；以下簡稱PGSGA）、感染徵象、中心靜脈導管，干擾變項為危險因子，分二大部分：在醫療處置部分為有無接受抗微生物劑、有無接受類固醇、有無居住正壓保護隔離病房、有無接受白血球生長刺激因子、接受化學藥物的劑量、有無接受輸血、有無接受脊髓腔注射化學藥物、有無接受侵入性處置；在護理處置部分為內植式輸液塞（Subcutaneous Infusion Port；以下簡稱Port-A）彎針置留天數、一週內Port-A彎針穿刺次數、接觸性皮膚炎、使用輸液管路的數目、敷料更換的方式，依變項為中心靜脈導管血流感染狀況、菌種、住院天數、Port-A底座留置天數及週邊置入中心靜脈導管（Peripheral Inserted Central Catheter；以下簡稱PICC）留置天數，所得結果運用統計軟體分析，以描述性統計呈現個案基本屬性及危險因子，再以T-檢定、卡方檢定、變異數分析、邏輯式回歸分析確立血流感染之危險因子。 研究結果：本研究結果總共有405人，中心靜脈導管血流感染有122人（30.1%），血流感染密度2.5‰（465人次/186,897住院人日數*1000）。研究結果顯示住院平均天數、ANC低下數值、ANC持續低下天數、感染徵象（發燒、寒顫、低血壓）、敷料更換的方式、使用輸液管路的數目會影響有無中心靜脈導管血流感染。ANC低下小於等於500/mm3的血流感染率比ANC低下大於500/mm3的血流感染率高9.38倍、ANC持續低下1〜7天的血流感染率比ANC無低下的血流感染率高4.48倍、ANC持續低下8天以上的血流感染率比ANC無低下的血流感染率高14.33倍、非依常規換藥的血流感染率比依常規換藥的血流感染率高2.29倍。
並列摘要
Background：Central venous catheter is an important method for cancer patients in the Department of Hematology and Oncology to receive chemotherapy treatment. However, patients receiving this procedure are susceptible to bloodstream infections, therefore the prognoses of patients are adversely affected. Objective： The objective was to explore the bloodstream infection risk factors in hospitalized hematological malignancy patients with central venous catheter. Design：Retrospective studies were employed. Methods：Electronic medical records （EMR） from a medical center in southern Taiwan were used as the database. Self-prepared forms were used as research tools for risk factor data collection from patients in the Department of Hematology and Oncology. Medical and nursing records were used as the source of information. Independent variables were patient attributes （age, gender,central venous catheter, site of infection, diagnostic classification of hematological malignancies, physical status （Eastern Cooperative Oncology Group,ECOG）, Charlson comorbidity index （CCI）, number of days of low absolute neutrophil count（ANC）, low ANC value, the patient-generated subjective global assessment（PG-SGA）score,disturbance variables were risk factors Risk factors were categorized into two groups：（1）medical treatment-related factors — including whether the patients were admitted to the protective environment of positive pressure isolation rooms, the dose of chemical drugs, the use or not-use of antimicrobials, steroids, white blood cell growth stimulating factor, as well as whether received blood transfusions;（2）nursing care-related factors — including the number of infusion lines used simultaneously, whether the dressings were changed according to the care routines, days of Port-A curved needle placement, the number of Port-A curved needle placement in a week, and contact dermatitis）, and the dependent variables were the central venous catheter bloodstream infection status, days of hospitalization and bacterial species. The results obtained were analyzed using statistical software. The basic attributes and risk factors of individual cases were presented with descriptive statistics, and the bloodstream infection risk factors were then established using Student's t-test, analysis of variance（ANOVA）and logistic regression analysis. Results：According to the results of the study, there were total of 405 persons; among them, the central venous catheter-related bloodstream infection rate was 122 persons (30.1%).The bloodstream infection rate was 2.5 events/ days of stay *1000. This study showed that the average number of days in hospital, values of neutropenia, days of neutropenia, infection sign (fever, shivering, low blood pressure), and change of dressing would affect the central venous catheter-related bloodstream infection. The odds ratio of bloodstream infection rate of neutropenia not exceeding 500/mm3 was 9.38times higher than that of neutropenia exceeding 500/mm3.The odds ratio of bloodstream infection rate during the period between 1 and 7 days of the absolute neutrophil count (ANC) was 4.48times higher than that of non ANC, the bloodstream infection rate during the period more than 8 days of ANC was 14.33 times higher than that of non ANC, and the odds ratio of bloodstream infection rate of non-routine dressing is 2.29 times higher than that of routine dressing.