T. C. Sağlik bakanliği okmeydani e
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ÖZET
Bu çalışma 1 Şubat 2007 - 1 Ağustos 2007 tarihleri arasındaki 6 aylık dönemde Sağlık Bakanlığı Okmeydanı Eğitim ve Araştırma Hastanesi Reanimasyon, Genel Cerrahi Yoğun Bakım (GCYB), Beyin Cerrahi Yoğun Bakım (BCYB), Dahiliye, Genel Cerrahi ünitelerinde yatan hastalarda katetere bağlı infeksiyon (KB ) ve kateter kolonizasyon sıklığını, risk faktörlerini, etken mikroorganizmaları ve periferik ven ile santral venöz kateterden (SVK) alınan kan kültürlerinin üreme zaman farkının tanıdaki yerini belirlemek amacıyla yapıldı. Çalışmamıza dahil edilen 100 vakada 37 (%37) kateter steril, 9 (%9) kateter kontamine iken 39 (%39) kateter kolonizasyonu, 10 (%10) katetere bağlı kan akımı infeksiyonu (KBKA ) ve 5 (%5) lokal kateter infeksiyonu (LK ) saptandı. Yaş, cinsiyet ve hastaların altta yatan hastalıkları ile KB ve kateter kolonizasyonu arasında istatistiksel olarak anlamlı bir ilişki saptanmadı (p>0.05). Subklavian vene takılan 32 (%45.7), Juguler vene takılan 19 (%76) ve femoral vene takılan 3 (%60) kateterde üreme saptandı. Juguler vene takılan kateterlerde saptanan üreme sıklığının subklavian vene takılan kateterlere göre yüksek olması istatistiksel açıdan anlamlı saptandı (p=0.03). Total parenteral nütrisyon (TPN) kullanan vakalarda KB ve kateter kolonizasyon oranı TPN kullanmayan hastalara göre daha sıktı (p=0.003). Kateter ucundan maya üreyen 5 vakanın 3 (%60)’ünde TPN kullanımı vardı. Kan ürünü kullanan hastalarda KB oranı kullanmayan hastalara oranla daha sıktı (p=0.025). Opere edilmiş olan vakalarda cerrahi yara tipleri ile KB ve kolonizasyon arasında ilişki saptanmadı (p>0.05). Kateterlerin takıldığı ünite ve kateterlerin elektif/acil olarak takılma durumuyla KB arasında ilişki saptanmadı (p>0.05). Kateteri 10 günden daha kısa süre takılı bulunan hastaların 2 (%5.7)’sinde KB saptanırken kateteri 10 gün ve daha uzun süre takılı kalan vakalarda 13 (%20) KB saptandı (p=0.004). Kateterin takılı kaldığı süre uzadıkça KB riskinde artış olduğu gözlendi. 67
Çalışmamızda 54 (%54) kateterden 54 etken üredi. Bunlardan 32 (%59.2) kateterde Gram-pozitif kok, 17 (%31.5) kateterde Gram-negatif çomak, 5 (%9.3) kateterde maya üredi. En sık üreyen etkenler sırası ile metisiline dirençli S. aureus (MRSA), metisiline dirençli koagülaz negatif stafiolokok (MRKNS), Pseudomonas spp., K.pneumoniae spp., Candida spp. olarak belirlendi. KB ’ye neden olan etkenler arasında 6 (%40) Gram-pozitif kok, 6 (%40) Gram-negatif çomak, 3 (%20) maya saptandı. KB 'ye en sık neden olan etkenler sırası ile MRSA, Candida spp., K.pneumoniae spp., Pseudomonas spp., MRKNS olarak belirlendi. Exitus olan vakalar değerlendirildiğinde KB ile KB olmayan vakalar arasında anlamlı fark saptanmadı (p>0.05). APACHE (Acute Physiology and Chronic Health Evaluation) II skoru (p=0.019) ve prediktif mortalite oranlarının (p=0.023) KB olan vakalarda daha yüksek saptanması istatistiksel açıdan anlamlı bulundu. SVK ve perifer venden alınan eş zamanlı kan kültürlerinin üreme zamanlarının karşılaştırılmasına dayanan pozitif zaman farkı KBKA tanısı için %93 özgüllük, %90 duyarlılık ile saptandı. Hastaneler arası karşılaştırma yapabilmek için, kateter kullanım gününe göre belirlenmiş kateter ilişkili hızların kullanılması benimsendi. Hastanemizin ünitelere göre SVK infeksiyon hızları 1000 kateter günü başına yoğun bakım ünitelerinde 8.4 ve yoğun bakım dışı ünitelerde 4.1 olarak saptandı. Tüm ünitelerde 6.9 olarak belirlendi. Üniteler bazında BCYB’de 8.8, GCYB’de 5.5, Reanimasyon’da 9.1, Dahiliye’de 2.6, Genel Cerrahi’de 9.3 olarak belirlendi. Çalışmamızda sonuç olarak APACHE II skoru ve prediktif mortalite oranı, kateterin 10 günden uzun süre takılı kalması, TPN ve kan ürünü kullanımı, kateterin takılı olduğu ven risk faktörleri olarak belirlendi. nfeksiyon kontrol politikaları ile geliştirilen kontrol önlemleri sayesinde risk faktörlerinin önemli ölçüde önlenebilir olması katetere bağlı infeksiyon hızlarında önemli bir oranda azalma sağlayabilecektir.
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SUMMARY
The present study has been carried out during the 6-month period between February 1st, 2007 and August 1st 2007 on patients hospitalized in Neurosurgery Intensive Care Unit (NICU), General Surgery ICU; General Surgery, Internal Medicine, and Reanimation Departments of Okmeydani Teaching and Research Hospital of Health Ministry in order to determine roles of catheter-related infection (CRI) and catheter colonization, risk factors, causative microorganisms, and differences in growth rate exhibited by blood drawn from periperal vein and central venous catheter (CVC). Among 100 cases included in the present study, while 37 (37%) catheters were sterile, 9 (9%) were contaminated, 39 (39%) had catheter colonization, 10 (10%) had catheter-related bloodstream infection (CRBSI), and 5 had local catheter-related infection (LCRI). No statistically significant difference was determined between age, gender, underlying diseases, catheter-related infection (CRI) and catheter colonization (p>0.05). Growth was determined in 32 (45.7%) catheters placed in subclavian vein, 19 (76%) catheters placed in jugular vein, and 3 (60%) catheters placed in femoral vein. The higher incidence of growth in catheters placed in jugular vein, was found to be statistically significant, compared to those of subclavian vein (p=0.03). CRI and catheter colonization rates of cases receiving total parenteral nutrition (TPN), were more higher than non-TPN patients (p=0.003). TPN usage was found to be present in 3 (60%) of 5 cases exhibiting yeast growth on catheter tip. CRI rate of patients using blood products was higher than patients who do not use (p=0.025). No association was found between operated cases in terms of surgical lesion types and CRI - colonization (p>0.05). No relation was determined between catheter receiving unit, elective/urgent placement of catheters and CRI (p>0.05). While 2 (5.7%) of the patients who had a placed catheter stayed for more than 10 days, revealed CRI; 13 (20%) CRI cases were determined in patients who had a placed catheter stayed ≥ 10 days (p=0.004). As the duration of catheter stay increased, CRI risk was observed to be elevated. In the present study, 54 microorganism growth were observed in 54 (54%) catheters. Among those, while 32 (59.2%) catheters exhibited Gram-positive cocci, 17 (31.5%) catheters revealed Gram-negative bacilli, and 5 (9.3%) catheters manifested yeast growth. Most common agents showing growth were methicillin-resistant S. Aureus (MRSA), methicillin-resistant coagulase negative staphylococcus (MRCNS), Pseudomonas spp., K pneumoniae spp., and 69
candida spp., respectively. CRI causing microorganisms were observed to be 6 (40%) Gram- positive cocci, 3 (20%) Gram-negative bacilli, and 3 (20%) yeast. The most common causes leading to CRI were MRSA, Candida spp., K. Pneumoniae spp., Pseudomonas spp., and MRCNS, respectively. The evaluation of exitus cases revealed no significant difference between CRI and non-CRI cases (p>0.05). The assessment of APACHE (Acute Physiology and Chronic Health Evaluation) II score (p=0.019) and predictive mortality rates (p=0.023) were revealed statistically significant to be high in CRI. CRBSI diagnosis based on differential time to positivity including comparison of the growth rates of blood cultures sampled simultaneously from peripheral vein and CVC, revealed a specificity of 93% and a sensitivity of 90%. In order to make a comparison between hospitals, catheter-related rates determined according to catheter usage day, were decided to be used. In our hospital, while CVC infection rate in ICUs was 8.4/1000 catheter day, it was 4.1/1000 catheter day for the remaining units. Overall rate was 6.9. Distribution over units was as follows: NICU = 8.8, General Surgery ICU = 5.5, Reanimation = 9.1, Internal Medicine = 2.6, and General Surgery = 9.3.
In the present study, APACHE II score, predictive mortality rate, catheter stays longer than 10 days, usage of TPN and blood product, and the vein catheter placed in, were found to be the risk factors. Preventable nature of risk factors due to the help of precautions developed by infection control policies, might cause a considerable decrease in CRI rates.
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KAYNAKLAR
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