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中国循证儿科杂志

中国循证儿科杂志 ›› 2020, Vol. 15 ›› Issue (2): 87-95.

• 论著 • 上一篇    下一篇

基于标准集束化中心静脉导管干预策略观察儿科95万个导管日的每1 000个导管日可减少3例导管相关血流感染发生的系统评价和Meta分析

康琼芳1a，王颖雯1b，王瑞1c，王文超1d，顾莺1d，张玉侠2，张崇凡1c   

  1. 1 复旦大学附属儿科医院 上海，201102，a 肿瘤外科，b 血液肿瘤科，c 临床指南制作和评价中心，d 护理部；
    2 复旦大学附属中山医院 上海，200032
  • 收稿日期:2020-03-28 修回日期:2020-04-18 出版日期:2020-04-25 发布日期:2020-04-25
  • 通讯作者: 张崇凡；张玉侠

Reduction of three cases of central line-associated bloodstream infections per 1000 catheter days by standardized central line bundles based on the observation of 950 thousand catheter days: A systematic review and meta-analysis

KANG Qiong-fang1a, WANG Ying-wen1b, WANG Rui1c, WANG Wen-chao1d, GU Ying1d, ZHANG Yu-xia2, ZHANG Chong-fan1c   

  1. 1 Children's Hospital of Fudan University, Shanghai 201102, China, a. Department of Surgical Oncology, b. Department of Hematology and Oncology, c. Center for Clinical Practice Guideline Development and Evaluation, d. Nursing Department; 2 Nursing Department, Zhongshan Hospital of Fudan University, Shanghai 200032, China
  • Received:2020-03-28 Revised:2020-04-18 Online:2020-04-25 Published:2020-04-25
  • Contact: ZHANG Chong-fan; ZHANG Yu-xia

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摘要： 目的 基于标准集束化中心静脉导管干预策略（简称标准集束化策略）对儿童中心静脉导管相关血流感染（CLABSI）文献进行系统评价和Meta分析，为预防和控制儿童CLABSI提供最佳证据体。方法 纳入同时符合以下标准的文献。①年龄<18岁的NICU和PICU住院患儿。②标准集束化策略：a.手卫生；b.置管过程中最大无菌屏障；c.浓度＞0.5%的氯己啶、碘、碘伏作为皮肤消毒剂；d.每日评估导管的必要性，及时拔除不必要的导管；e.根据患儿特点选择最佳置管部位（非股静脉）；至少满足上述5条中的前4条。③以1 000个导管日CLABSI发生事件数作为结局指标。④干预性研究的文献。;⑤文献语种不限。在Ovid-MEDLINE、Ovid-EMBASE、Web-of-science 、Cochrane 图书馆、中国生物医学文献数据库、中国知网、维普和万方数据库中进行检索，检索时间为2003年1月1日至2019年12月31日。采用ROBINS-I对纳入文献进行偏倚风险评价。结果 中英文数据库共检索到9 708篇文献，其他文献来源2篇，41篇文献进入本文分析，来自于20个国家，美国最多共18篇，均为历史对照研究。标准集束化策略为后时段干预措施，前时段干预措施不限。30篇研究场所为NICU，10篇研究场所为PICU，1篇研究场所为NICU和PICU。累计952 584个导管日，其中前时段干预措施442 296个导管日，后时段干预措施510 288个导管日。41篇文献中，低、中和高偏倚风险分别为11篇（27%）、18篇（44%）和12篇（29%）。标准集束化策略后可降低NICU+PICU患儿CLABSI发生事件数（I 2=81%，随机效应模型），RR=0.40（95%CI：0.33～0.48），绝对效应值：每1 000个导管日可减少 3（4～3）例CLABSI；可以降低NICU新生儿CLABSI发生事件数（I 2=85%，随机效应模型），RR=0.36（95%CI：0.29～0.45）；可以降低PICU患儿CLABSI发生事件数(I 2=27%，固定效应模型)，RR=0.54（95%CI：0.42～0.69）。结论 标准化集束化策略下每1 000个导管日可减少 3~4例CLABSI。

Abstract: Objective To conduct a systematic review and meta-analysis of the literature on central line-associated bloodstream infections (CLABSI) in children based on a standardized central line bundle so as to provide the best evidence for the prevention and control of CLABSI in children. Methods Literature that met all of the following criteria was included: a. Populations were NICU and PICU patients younger than 18 years old; b. A standardized central line bundle was used as the intervention which referred to hand hygiene, maximal sterile barrier precautions, skin disinfectants of >0.5% chlorhexidine, iodine or iodophor, daily audits to assess whether each central line was still needed and ly removal of unnecessary central lines and the best insertion site (except femoral vein) based on individual patient characteristics and the first four of the above requirements about the bundle should be met at least; c. The outcome was the number of CLABSI events within 1,000 catheter days; d. The literature belonged to studies of interventions; e. There were no limits to the language of literature. Literature was searched in the database of Ovid-MEDLINE, Ovid-EMBASE, Web of science, Cochrane Library and China Biology Medicine (CBM), CNKI, VIP and Wanfang from January 1st, 2003 to December 31st, 2019. The risk of bias for eligible studies was assessed according to Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). Results A total of 9,708 literature was retrieved including 2 articles from other sources. Forty-one studies from 20 countries were included with 30 for NICU,10 for PICU and 1 for both, 18 of which were historical control studies from America with standardized central line bundles as the post-intervention and no limits to pre-interventions. There was a total of 952,584 catheter days, including 442,296 for pre-interventions and 510,288 for the post-interventions. Among 41 included literature, studies with low, moderate, serious risk of bias accounted for 27% (11 studies), 44% (18 studies) and 29%(12 studies) respectively. The standardized central line bundle could reduce the number of CLABSI events in both NICU and PICU patients［I 2=81%, random effect model, RR=0.40 (95% CI: 0.33-0.48), absolute effect value: 3 fewer per 1,000 catheter days (from 4 fewer to 3 fewer)］. For the intervention site of NICU, the number of CLABSI events in neonates can be reduced ［I 2=85%, random effect model, RR=0.36 (95% CI: 0.29-0.45), absolute effect value: 3 fewer per 1,000 catheter days (from 4 fewer to 3 fewer)］. For the intervention site of PICU, the number of CLABSI events in children can be reduced ［I 2=27%, fixed effect model, RR=0.54 (95% CI: 0.42-0.69), absolute effect value: 4 fewer per 1,000 catheter days (from 5 fewer to 3 fewer)］. Conclusion Standardized central line bundles (at least including hand hygiene, maximal sterile barrier precautions, skin disinfectants of >0.5% chlorhexidine, iodine or iodophor and daily audits and ly removal of unnecessary central lines) for pediatric patients could reduce 3 to 4 cases of CLABSI per 1,000 catheter days.