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通过去定植降低MRSA携带者出院后的感染风险
Decolonization to Reduce Postdischarge Infection Risk among MRSA Carriers


Susan S. Huang ... 其他 • 2019.02.14
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• 治疗MRSA菌血症的新型联合疗法? • 通过出院后MRSA去定植预防感染

根除耐药菌的去定植策略预防出院后感染有价值吗?CLEAR试验答案并不clear

 

张怡,张文宏*

复旦大学附属华山医院感染科

*通讯作者

 

自20世纪80年代,去定植(decolonization)的感染防控概念开始引入医院,作为院内感染防控的一大措施。对于耐甲氧西林金葡萄球菌(methicillin-resistant Staphylococcus aureus,MRSA)等常见定植于人体皮肤的病原体,去定植措施包括:氯己定擦浴、氯己定漱口、抗菌软膏局部应用等;对于耐碳青霉烯类肠杆菌科(carbapenem-resistant enterobacteriaceae,CRE)等常见定植于肠道的病原体,去定植措施主要有选择性消化道(selective digestive tract decontamination,SDD)和口咽去定植治疗(selective oropharyngeal decontamination,SOD)等措施。

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摘要


背景

有耐甲氧西林金黄色葡萄球菌(MRSA)定植的住院患者出院后的感染风险高。

 

方法

我们在有MRSA定植的患者(携带者)中开展了一项比较出院后卫生教育与教育+去定植的多中心、随机、对照试验。去定植包括每月2次,每次使用氯己定漱口水、氯己定盆浴或淋浴以及鼻用莫匹罗星5日,共治疗6个月。对每例参与者随访1年。主要结局为按照美国疾病控制和预防中心(CDC)标准定义的MRSA感染。次要结局包括临床判定的MRSA感染、任何原因感染和感染相关住院。在符合方案人群(被随机分组、符合纳入标准并且生存至参与者纳入试验的住院结束后)和实际治疗人群(as-treated population,按照依从性分层的参与者)中,利用比例风险模型进行了所有分析。

 

结果

在符合方案人群中,教育组1,063例参与者中的98例(9.2%)和去定植组1,058例参与者中的67例(6.3%)出现了MRSA感染;84.8%的MRSA感染导致了住院治疗。教育组23.7%的参与者和去定植组19.6%的参与者出现了任何原因感染;85.8%的感染导致了住院治疗。与教育组相比,在去定植组中,MRSA感染的风险显著较低(风险比,0.70;95%置信区间[CI],0.52~0.96;P=0.03;每预防1例感染所需治疗的患者数量,30;95% CI,18~230);MRSA感染风险较低导致因MRSA感染住院的风险较低(风险比,0.71;95% CI,0.51~0.99)。去定植组中发生临床判定的任何原因感染(风险比,0.83;95% CI,0.70~0.99)和感染相关住院(风险比,0.76;95% CI,0.62~0.93)的可能性较低;由于未预设多重比较校正,因此对次要结局疗效的解读应谨慎。在实际治疗分析中,完全依从治疗方案的去定植组参与者的MRSA感染率比教育组低44%(风险比,0.56;95% CI,0.36~0.86),任何原因感染率低40%(风险比,0.60;95% CI,0.46~0.78)。4.2%的参与者出现了副作用(均为轻度)。

 

结论

与单独教育相比,出院后使用氯己定和莫匹罗星进行MRSA去定植使MRSA感染风险降低30%(由AHRQ Healthcare相关感染计划[AHRQ Healthcare-Associated Infections Program]等资助;在ClinicalTrials.gov注册号为NCT01209234)。





作者信息

Susan S. Huang, M.D., M.P.H, Raveena Singh, M.A., James A. McKinnell, M.D., Steven Park, M.D., Ph.D., Adrijana Gombosev, M.S., Samantha J. Eells, M.P.H., Daniel L. Gillen, Ph.D., Diane Kim, B.S., Syma Rashid, M.D., Raul Macias-Gil, M.D., Michael A. Bolaris, M.D., Thomas Tjoa, M.P.H., M.S., Chenghua Cao, M.P.H., Suzie S. Hong, M.S., Jennifer Lequieu, B.S., Eric Cui, B.S., Justin Chang, B.S., Jiayi He, M.S., Kaye Evans, B.A., Ellena Peterson, Ph.D., Gail Simpson, M.D., Philip Robinson, M.D., Chester Choi, M.D., Charles C. Bailey, Jr., M.D., James D. Leo, M.D., Alpesh Amin, M.D., Donald Goldmann, M.D., John A. Jernigan, M.D., Richard Platt, M.D., Edward Septimus, M.D., Robert A. Weinstein, M.D., Mary K. Hayden, M.D., and Loren G. Miller, M.D., M.P.H. for the Project CLEAR Trial
From the Division of Infectious Diseases (S.S. Huang, R.S., S.P., D.K., S.R., T.T., C. Cao, S.S. Hong, J.L., E.C., J.C., J.H.), the Health Policy Research Institute (S.S. Huang), and the Department of Medicine (A.A.), University of California Irvine School of Medicine, and the Institute for Clinical and Translational Science (A.G.) and the Department of Statistics (D.L.G.), University of California Irvine, Irvine, the Infectious Disease Clinical Outcomes Research Unit, Division of Infectious Diseases, Los Angeles Biomedical Research Institute at Harbor–UCLA Medical Center, Torrance (J.A.M., S.J.E., R.M.-G., M.A.B., L.G.M.), the Department of Pathology and Laboratory Medicine, University of California Irvine School of Medicine, Orange (K.E., E.P.), Ventura County Medical Center, Ventura (G.S.), the Division of Infectious Disease, Hoag Hospital, Newport Beach (P.R.), the Division of Infectious Disease, St. Mary Medical Center (C. Choi), and MemorialCare Health System (J.D.L.), Long Beach, and the Division of Infectious Disease, Mission Hospital, Mission Viejo (C.C.B.) — all in California; the Institute of Healthcare Improvement, Cambridge (D.G.), and the Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care, Boston (R.P.) — both in Massachusetts; the Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta (J.A.J.); Texas A&M Health Science Center, Houston (E.S.); and Cook County Health and Hospitals System (R.A.W.) and the Division of Infectious Diseases, Rush University Medical Center (R.A.W., M.K.H.), Chicago. Address reprint requests to Dr. Huang at the University of California Irvine School of Medicine, Division of Infectious Diseases, 100 Theory, Suite 120, Irvine, CA 92617, or at sshuang@uci.edu.

 

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