哈佛医学院波士顿儿童医院挑战儿科肠衰竭人群中心导管相关血流感染48小时排除规则的初步回顾研究

　　虽然肠外营养已经彻底改变肠衰竭患者的管理，但是中心导管相关血流感染（CLABSI）仍然是这一人群发病和死亡的主要原因。

　　为了描述CLABSI在儿科肠衰竭中的特征，并确定血培养出现阳性的时间，美国哈佛医学院、波士顿儿童医院对2012年1月1日～2012年12月31日进行疑似CLABSI评估的肠衰竭儿童开展了队列回顾研究。

　　结果共确诊60例肠衰竭患者，其中16例患者发生33次CLABSI，感染率为1.5次/1000导管日。有或无CLABSI的患者之间，年龄、生长指标、导管天数无显著差异。85%的CLABSI患者记录到发热。与无CLABSI的患者相比，这些患者出现的中性粒细胞百分比和C反应蛋白水平增加。培养物出现阳性的平均时间为13.2小时，97%的培养物24小时内出现阳性。

　　因此，该研究数据表明大部分发生CLABSI的儿科肠衰竭患者培养物24小时内出现阳性，无发热和白细胞增加未必表示无感染。这些发现可能支持临床实践指南，有利于怀疑CLABSI时缩短住院时间；然而，建议在任何实践改变之前，应对该人群CLABSI进行前瞻分析，以确定安全性和适应证。

JPEN J Parenter Enteral Nutr. 2016;40(4):567-73.

Challenging the 48-Hour Rule-Out for Central Line-Associated Bloodstream Infections in the Pediatric Intestinal Failure Population: A Retrospective Pilot Study.

Chang MI, Carlson SJ, Nandivada P, O'Loughlin AA, Potemkin AK, Cowan E, Mitchell PD, Gura KM, Puder M.

Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

INTRODUCTION: While parenteral nutrition (PN) has revolutionized the management of patients with intestinal failure (IF), central line-associated bloodstream infections (CLABSIs) remain a leading cause of mortality and morbidity in this population. The objective of this study is to characterize the presentation of CLABSIs in pediatric IF and to determine the time to positivity of blood cultures.

METHODS: A retrospective cohort study of children with IF who presented to our institution for evaluation of a possible CLABSI from January 1, 2012, to December 31, 2012, was performed.

RESULTS: Sixty patients with IF were identified. There were 33 cases of CLABSI in 16 patients, with a rate of 1.5 infections per 1000 catheter days. There were no significant differences in age, growth parameters, or catheter days between patients with or without CLABSI. Fever was documented in 85% of patients with CLABSI. These patients demonstrated an increased percentage of neutrophils and higher C-reactive protein levels compared with patients without CLABSI. The mean time to culture positivity was 13.2 hours, and 97% of cultures were positive within 24 hours.

CONCLUSION: Our data suggest that most pediatric patients with IF who have CLABSI develop positive cultures within 24 hours, and the absence of fever and leukocytosis does not necessarily indicate the absence of infection. These findings may support clinical practice guidelines in favor of shorter hospital stay when CLABSI is suspected; however, a prospective analysis of CLABSI in this population is recommended to determine the safety and appropriate setting prior to any practice change.

PMID: 25567785

DOI: 10.1177/0148607114567897