依赖肠外营养的儿科患者中心导管相关血行感染处理过程

　　中心导管相关血行感染（CLABSI）是家庭肠外营养（HPN）的重要并发症，早期诊断、早期治疗能有效改善临床预后。

　　为提供诊断CLABSI的循证医学证据，波士顿儿童医院、贝斯以色列女执事医疗中心对42个机构开展调查，在22个经常诊断CLABSI的机构中，比较公认的诊断指标是微生物血培养和全血细胞计数。此外，临床症状和体征可为诊断提供依据，如发热、疲乏、心动过速等，但各机构间差别较大。

JPEN J Parenter Enteral Nutr. 2016;40(4):129-131.

Processes for Ruling Out Central Line-Associated Bloodstream Infections in Parenteral Nutrition-Dependent Pediatric Patients.

Bennet S. Cho; Kathleen M. Gura; Alexis K. Potemkin; Alison O'Loughlin; Prathima Nandivada; Lorenzo Anez-Bustillos; Meredith A. Baker; Duy T. Dao; Mark Puder; Gillian L. Fell.

Boston Children's Hospital, Boston, MA, USA; Beth Israel-Deaconess Medical Center, Boston, MA, USA.

Purpose: Parenteral nutrition (PN) is a life-sustaining therapy in pediatric patients with intestinal failure (IF) who are unable to absorb nutrients enterally. Patients who require long-term PN have central venous catheters for delivery of home PN (HPN). Central line-associated bloodstream infection (CLABSI) is the most common complication of HPN. Delays in diagnosis and treatment of CLABSI can result in sepsis, multisystem organ failure, and death. Given the potential gravity of CLABSI, there is a low threshold to admit and empirically treat HPN patients who present with concern for CLABSI. Certain CLABSI rule-out practices, such as obtaining microbial blood cultures, are evidence based, while other practices, such as length of inpatient admission for CLABSI rule-out, are not. The purpose of this study is to assess CLABSI rule-out practices at pediatric IF and HPN programs in the United States to determine what information would be nationally applicable to aide in defining and refining best CLABSI rule-out practices.

Methods: A 5-question electronic survey of CLABSI rule-out practices for pediatric HPN patients was sent to directors of 42 pediatric HPN or IF programs in the United States. Survey questions asked about the presence of an institutional protocol for managing CLABSI evaluation, admission practices and laboratory values obtained, and the top 3 presenting signs and symptoms felt to be most concerning for CLABSI based on institutional experience. Responses were not linked to particular institutions.

Results: Twenty-two of 42 programs responded. Fifteen (68%) have a protocol for CLABSI evaluation, while the remaining 7 (32%) have no specific protocol but general agreement among physicians on CLABSI rule-out management. Twelve programs (55%) always admit patients with suspected CLABSI; 9 (41%) usually admit patients; and 1 (4%) usually does not admit patients. Of the 21 programs that usually or always admit patients to rule-out CLABSI, 19 (90%) admit for 48 hours, and 2 (10%) admit for longer than 48 hours. At presentation for CLABSI evaluation, all programs obtain microbial blood cultures and complete blood counts; 18 (82%) obtain blood chemistries; 14 (64%) obtain liver panels; and 11 (50%) obtain C-reactive protein levels. All programs reported fever among the top 3 signs or symptoms most concerning for CLABSI. Respondents reported other signs and symptoms among the top 3 most concerning for CLABSI at variable frequencies, including leukocytosis (48%), fatigue (38%), tachycardia (33%), elevated C-reactive protein (29%), thrombocytopenia (14%), elevated liver function tests (14%), changes in ostomy output (5%), leukopenia (5%), and respiratory distress (5%).

Conclusions: Based on responses from 22 of 42 pediatric IF and HPN programs in the United States, it appears that while some CLABSI rule-out practices, including obtaining microbial blood cultures and complete blood count values, are widely agreed on, the majority of CLABSI rule-out practices, as well as perceptions of signs and symptoms most concerning for CLABSI, are variable among institutions. This study highlights a need for data-driven evidence to guide admission practices and define laboratory values, presenting signs, and patient symptoms important for risk-stratifying HPN patients at presentation for CLABSI evaluation. Development of an evidence-based standard of care may improve the quality of care and safety for this patient population.

Financial support: National Institutes of Health grant T35 HL 110843 (B.S.C.), National Institutes of Health grant F32DK104525-01 (G.L.F.).