中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
6期
489-493
,共5页
张青%王东浩%张文芳%白长森%郑珊%刘坤彬%李丁%张鹏
張青%王東浩%張文芳%白長森%鄭珊%劉坤彬%李丁%張鵬
장청%왕동호%장문방%백장삼%정산%류곤빈%리정%장붕
导管相关性血流感染%实体肿瘤%阳性时间差%导管半定量培养
導管相關性血流感染%實體腫瘤%暘性時間差%導管半定量培養
도관상관성혈류감염%실체종류%양성시간차%도관반정량배양
Catheter-related bloodstream infection%Solid tumor%Differential time to positivity%Semi quantitative catheter tip culture
目的：评估血培养阳性时间差法（DTTP）对重症加强治疗病房（ICU）实体肿瘤患者静脉导管相关性血流感染（CRBSI）诊断的应用价值。方法采用回顾性病例对照研究方法，收集2011年8月至2014年3月天津医科大学肿瘤医院ICU送检的615例患者615对中心静脉导管血和外周静脉血培养标本，采用DTTP法和（或）导管尖端半定量培养法进行培养。中心静脉导管与外周静脉血培养分离出相同病原菌且DTTP≥2 h（120 min）时诊断为CRBSI；导管尖端半定量培养菌落数≥15 cfu诊断为CRBSI。以临床诊断为依据，比较DTTP和导管尖端半定量培养两种实验室检查方法对CRBSI诊断的可靠性；并绘制受试者工作特征曲线（ROC），评估两种方法单用或联用对CRBSI的诊断价值。结果615例患者配对血培养标本中，有440例因外周静脉和中心静脉导管血培养皆为阴性而被排除CRBSI；有8例外周静脉血培养阳性而中心静脉导管血培养阴性，提示导管为非感染源；有57例中心静脉导管血培养阳性而外周静脉血培养阴性而被排除；有68例因多处留置导管和重复采集标本而被排除。42例中心静脉导管和外周静脉血培养均为阳性的标本中，有2例因检出不同菌种被排除，有10例因没有导管尖端标本送检被排除，13例确诊为非CRBSI。在17例确诊为CRBSI的配对中心静脉导管和外周静脉血培养标本中，有14例患者中心静脉导管和外周静脉配对血培养DTTP≥120 min，漏诊3例；而导管尖端半定量培养法阳性者有13例，漏诊4例；其中有2例患者同时被两种方法漏诊。DTTP法与导管尖端培养法单用及联用诊断CRBSI的ROC曲线下面积（AUC）分别为0.912、0.882和0.941。单用DTTP法诊断CRBSI的敏感度、特异度、阳性预测值和阴性预测值分别为82.35%、92.31%、93.33%和80.00%，均高于单用导管尖端培养法（分别为76.47%、84.62%、86.67%和73.33%）；而两种方法联合诊断CRBSI的特异度和阳性预测值可达100%，敏感度（88.24%）和阴性预测值（86.67%）也有所提高，但与单独应用DTTP法比较差异无统计学意义（χ2＝0.00，P＝1.00；χ2＝0.00，P＝0.98；χ2＝0.00，P＝0.98；χ2＝0.00，P＝0.98）。结论 DTTP法诊断ICU实体肿瘤患者CRBSI具有可接受的敏感度及较好的特异度和阳性预测值，可推荐用于辅助诊断CRBSI；如将DTTP与其他临床症状结合并进行综合分析，不仅可避免不必要的导管移除，也可帮助患者及时获得最佳治疗时间和方案。
目的：評估血培養暘性時間差法（DTTP）對重癥加彊治療病房（ICU）實體腫瘤患者靜脈導管相關性血流感染（CRBSI）診斷的應用價值。方法採用迴顧性病例對照研究方法，收集2011年8月至2014年3月天津醫科大學腫瘤醫院ICU送檢的615例患者615對中心靜脈導管血和外週靜脈血培養標本，採用DTTP法和（或）導管尖耑半定量培養法進行培養。中心靜脈導管與外週靜脈血培養分離齣相同病原菌且DTTP≥2 h（120 min）時診斷為CRBSI；導管尖耑半定量培養菌落數≥15 cfu診斷為CRBSI。以臨床診斷為依據，比較DTTP和導管尖耑半定量培養兩種實驗室檢查方法對CRBSI診斷的可靠性；併繪製受試者工作特徵麯線（ROC），評估兩種方法單用或聯用對CRBSI的診斷價值。結果615例患者配對血培養標本中，有440例因外週靜脈和中心靜脈導管血培養皆為陰性而被排除CRBSI；有8例外週靜脈血培養暘性而中心靜脈導管血培養陰性，提示導管為非感染源；有57例中心靜脈導管血培養暘性而外週靜脈血培養陰性而被排除；有68例因多處留置導管和重複採集標本而被排除。42例中心靜脈導管和外週靜脈血培養均為暘性的標本中，有2例因檢齣不同菌種被排除，有10例因沒有導管尖耑標本送檢被排除，13例確診為非CRBSI。在17例確診為CRBSI的配對中心靜脈導管和外週靜脈血培養標本中，有14例患者中心靜脈導管和外週靜脈配對血培養DTTP≥120 min，漏診3例；而導管尖耑半定量培養法暘性者有13例，漏診4例；其中有2例患者同時被兩種方法漏診。DTTP法與導管尖耑培養法單用及聯用診斷CRBSI的ROC麯線下麵積（AUC）分彆為0.912、0.882和0.941。單用DTTP法診斷CRBSI的敏感度、特異度、暘性預測值和陰性預測值分彆為82.35%、92.31%、93.33%和80.00%，均高于單用導管尖耑培養法（分彆為76.47%、84.62%、86.67%和73.33%）；而兩種方法聯閤診斷CRBSI的特異度和暘性預測值可達100%，敏感度（88.24%）和陰性預測值（86.67%）也有所提高，但與單獨應用DTTP法比較差異無統計學意義（χ2＝0.00，P＝1.00；χ2＝0.00，P＝0.98；χ2＝0.00，P＝0.98；χ2＝0.00，P＝0.98）。結論 DTTP法診斷ICU實體腫瘤患者CRBSI具有可接受的敏感度及較好的特異度和暘性預測值，可推薦用于輔助診斷CRBSI；如將DTTP與其他臨床癥狀結閤併進行綜閤分析，不僅可避免不必要的導管移除，也可幫助患者及時穫得最佳治療時間和方案。
목적：평고혈배양양성시간차법（DTTP）대중증가강치료병방（ICU）실체종류환자정맥도관상관성혈류감염（CRBSI）진단적응용개치。방법채용회고성병례대조연구방법，수집2011년8월지2014년3월천진의과대학종류의원ICU송검적615례환자615대중심정맥도관혈화외주정맥혈배양표본，채용DTTP법화（혹）도관첨단반정량배양법진행배양。중심정맥도관여외주정맥혈배양분리출상동병원균차DTTP≥2 h（120 min）시진단위CRBSI；도관첨단반정량배양균락수≥15 cfu진단위CRBSI。이림상진단위의거，비교DTTP화도관첨단반정량배양량충실험실검사방법대CRBSI진단적가고성；병회제수시자공작특정곡선（ROC），평고량충방법단용혹련용대CRBSI적진단개치。결과615례환자배대혈배양표본중，유440례인외주정맥화중심정맥도관혈배양개위음성이피배제CRBSI；유8예외주정맥혈배양양성이중심정맥도관혈배양음성，제시도관위비감염원；유57례중심정맥도관혈배양양성이외주정맥혈배양음성이피배제；유68례인다처류치도관화중복채집표본이피배제。42례중심정맥도관화외주정맥혈배양균위양성적표본중，유2례인검출불동균충피배제，유10례인몰유도관첨단표본송검피배제，13례학진위비CRBSI。재17례학진위CRBSI적배대중심정맥도관화외주정맥혈배양표본중，유14례환자중심정맥도관화외주정맥배대혈배양DTTP≥120 min，루진3례；이도관첨단반정량배양법양성자유13례，루진4례；기중유2례환자동시피량충방법루진。DTTP법여도관첨단배양법단용급련용진단CRBSI적ROC곡선하면적（AUC）분별위0.912、0.882화0.941。단용DTTP법진단CRBSI적민감도、특이도、양성예측치화음성예측치분별위82.35%、92.31%、93.33%화80.00%，균고우단용도관첨단배양법（분별위76.47%、84.62%、86.67%화73.33%）；이량충방법연합진단CRBSI적특이도화양성예측치가체100%，민감도（88.24%）화음성예측치（86.67%）야유소제고，단여단독응용DTTP법비교차이무통계학의의（χ2＝0.00，P＝1.00；χ2＝0.00，P＝0.98；χ2＝0.00，P＝0.98；χ2＝0.00，P＝0.98）。결론 DTTP법진단ICU실체종류환자CRBSI구유가접수적민감도급교호적특이도화양성예측치，가추천용우보조진단CRBSI；여장DTTP여기타림상증상결합병진행종합분석，불부가피면불필요적도관이제，야가방조환자급시획득최가치료시간화방안。
Objective To determine the value of differential time to positivity ( DTTP ) of blood culture for the diagnosis of catheter-related bloodstream infection ( CRBSI ) in patients with solid tumors in intensive care unit ( ICU ). Methods A retrospective study was conducted. 615 pairs of peripheral vein blood cultures and instantaneous catheter tip blood culture of 615 patients admitted to ICU of Tianjin Medical University Cancer Institute and Hospital were collected from August 2011 to March 2014. The DTTP method and ( or ) semi quantitative culture of catheter tip were compared. CRBSI was diagnosed when both cultures were positive for the same microorganism and DTTP ≥2 hours ( 120 minutes ). The result of this procedure was compared with that of organism obtained using the semi quantitative culture of blood at catheter tip with≥15 cfu. Based on the clinical diagnosis, the reliability of two kinds of laboratory examination was compared for the diagnosis of CRBSI by plotting receiver operator characteristic curve ( ROC curve ). Results The result of 615 cases suspected of having CRBSI were analyzed during the study period. Of these, 440 episodes were excluded because cultures were negative for blood obtained through peripheral vein and central vein. Eight episodes were excluded because only peripheral vein blood culture was positive and 57 episodes were excluded because of only central vein blood culture was positive, 68 pairs of blood cultures were excluded due to the presence of multiple catheters and repeated blood withdrawals. Two cases of polymicrobial cultures were excluded from the final analysis due to the difficulty in determining the time of positive result for each individual microorganism. Ten cases in 42 cases of suspected cases of CRBSI were excluded from analysis because catheter was not removed, therefore culture from catheter tip could not be obtained. Using the DTTP method, 14 out of 17 CRBSI cases were diagnosed with DTTP≥120 minutes, while 3 cases were missed;the semi quantitative catheter tip culture was positive in 13 cases, and in 4 cases it was neglected. In 2 cases of CRBSI it was missed by both methods. The area under the ROC curve ( AUC ) of DTTP, catheter tip culture and the combination method was 0.912, 0.882 and 0.941 for diagnosis of CRBSI, respectively. Validity values for the diagnosis of CRBSI for DTTP were:sensitivity 82.35%, specificity 92.31%, positive predictive value 93.33%and negative predictive value 80.00%, and they were higher than those of the catheter tip culture method only ( 76.47%, 84.62%, 86.67% and 73.33%). The specificity and positive predictive CRBSI combination of the two methods in the diagnosis value were up to 100%, the sensitivity ( 88.24%) and negative predictive value ( 86.67%) was also increased, but no significant differences were found with DTTP method (χ2=0.00, P=1.00;χ2=0.00, P=0.98;χ2=0.00, P=0.98;χ2=0.00, P=0.98 ). Conclusions DTTP can be a valid method recommended for CRBSI diagnosis in critically ill patients with acceptable sensitivity, good specificity as well as positive predictive value. DTTP combined with other clinical symptoms can not only avoid unnecessary catheter withdrawal, but it also can help obtain the optimal treatment time and strategy.
