某醫院血液透析相關感染的十一年變遷

Eleven-Year Experience of Infection in Hemodialysis Patients

台灣民眾擁有全世界最高的慢性腎臟病發生率及盛行率。透析相關的感染是常見的併發症，因此，醫療人員有必要對於此醫療照護相關感染深入了解。本研究收集本院透析病人自 2006 至 2016 年的資料作為分析。根據台灣疾病管制署醫療照護相關感染定義，將血流感染及動脈或靜脈感染予以收案。研究期間血液透析共 466,861 人次，共 276 人發生 345 次透析相關感染，感染個案平均年齡 69 歲，平均感染密度為每千人次 0.74。血流感染密度為 0.56‰；動靜脈感染密度為 0.17‰。住院病人血液透析感染之相對危險值是門診血液透析病人的 12.46 倍 （95% 信賴區間 [CI]，10.08~15.41） （p < 0.001）。抗 methicillin 金黃色葡萄球菌 （MRSA） 占所有病原菌的 23.1%。2011 年 （含） 以前 MRSA 的占率平均 31.6%，2012 年以後 MRSA 占率平均 13.5%，勝算比為 2.95 （95% CI，1.73~5.03） （p < 0.001）。各種透析血管通路的感染密度，動靜脈瘻管 0.11‰、動靜脈人工血管 0.81‰、長期中心靜脈導管 4.26‰、暫時性雙腔中心靜脈導管 5.57‰。動靜脈人工血管的感染風險是動靜脈瘻管的 7.4 倍 （95% CI，4.13~13.25）、長期中心靜脈導管是 39.1 倍 （95% CI，23.18~65.86）、暫時性雙腔中心靜脈導管是51.1 倍 （95% CI，29.57~88.49） （p < 0.001）。本研究建議末期腎臟病病人應及早建立動靜脈瘻管，透析單位可推廣氯胍消毒注射部位以降低 MRSA 感染；以及病人因急性病症住院時要格外留意血液透析相關感染的發生。

Taiwan was reported to have the highest incidence Taiwan was reported to have the highest incidence and prevalence of end-stagerenal disease (ESRD). Thus, healthcare workers need to have in-depth knowledgeon dialysis-related complications, such as healthcare-associated infections. A retrospective study was conducted between 2006 and 2016, and we evaluatedvarious healthcare-associated infections including bloodstream and vascular accessrelatedinfections according to the definition of the Centers for Disease Control, Taiwan. Totally, there were 466, 861 person-times of hemodialysis during theseyears. Hemodialysis-related infections occurred 345 times in 276 subjects, and the incidence density was 0.74 per 1000 patient-times, including 0.56 of blood stream infection cases and 0.17‰ of vascular access-related infection cases. The riskratio (RR) of inpatients was 12.46 (95% confidence interval [CI] 10.08~15.41)compared with that of outpatients (p < 0.001). Approximately 23.1% of the identified pathogens were methicillin-resistant Staphylococcus aureus (MRSA),which was prevalent before 2012 and became less predominant afterward (31.6%vs. 13.5%; odds ratio, 2.95 [95% CI 1.73~5.03]; p < 0.001). The infection densities of various vascular accesses were as follows: 0.11 per 1000 catheter-times for the Taiwan was reported to have the highest incidence and prevalence of end-stagerenal disease (ESRD). Thus, healthcare workers need to have in-depth knowledge on dialysis-related complications, such as healthcare-associated infections .A retrospective study was conducted between 2006 and 2016, and we evaluatedvarious healthcare-associated infections including bloodstream and vascular accessrelatedinfections according to the definition of the Centers for Disease Control, Taiwan. Totally, there were 466, 861 person-times of hemodialysis during theseyears. Hemodialysis-related infections occurred 345 times in 276 subjects, and theincidence density was 0.74 per 1000 patient-times, including 0.56 of bloodstreaminfection cases and 0.17‰ of vascular access-related infection cases. The riskratio (RR) of inpatients was 12.46 (95% confidence interval [CI] 10.08~15.41)compared with that of outpatients (p < 0.001). Approximately 23.1% of theidentified pathogens were methicillin-resistant Staphylococcus aureus (MRSA),which was prevalent before 2012 and became less predominant afterward (31.6%vs. 13.5%; odds ratio, 2.95 [95% CI 1.73~5.03]; p < 0.001). The infection densitiesof various vascular accesses were as follows: 0.11 per 1000 catheter-times for the arteriovenous fistula, 0.81‰ for the arteriovenous graft, 4.26‰ for the permanentcentral venous catheter (CVC), and 5.57‰ for the temporary double lumen CVC.The following are the RRs of these vascular accesses: arteriovenous graft, 7.4 (95%CI 4.13~13.25); permanent CVC, 39.1 (95% CI 23.18~65.86); and temporary CVC, The early establishment of arteriovenous fistula and skin preparation using chlorhexidine gluconate are recommended with increasing prevalence of MRSA infection. Lastly, healthcare workers should be aware that ESRD subjects hospitalized for acute illnesses are at risk of acquiring hemodialysis-related infections.