防控产碳青霉烯酶的肠杆菌科细菌新观点
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摘要
产碳青霉烯酶的肠杆菌科细菌(carbapenemase producing Enterobacteriaceae,CPE)已成为全球公共卫生的一项重大挑战,可能将感染患者置于无法医治的风险中。由于对碳青霉烯类抗菌药物耐药,可用治疗方法常常极为有限。为了防止CPE在医疗机构中的出现和传播,许多国际指南在循证医学的基础上提出了新的防控策略。该文介绍了一些已被证明有效的防控关键策略:首先是通过主动筛查,尽早识别CPE携带者;在等待微生物筛查结果时,疑似CPE携带者在单人病房进行预防性隔离,同时医务人员执行接触隔离。主动的监测培养和及时的预防性隔离将限制CPE在医院内的出现和传播。其次,整合强化院内基础感染防控措施的最佳实践至关重要,包括全面实施手卫生、正确使用个人防护用品、通过抗菌药物管理减少抗菌药物滥用、有效的环境清洁和消毒、员工教育和反馈、开展医院感染监测。这种整体方法能有效减少CPE在医疗机构内的立足点。
Carbapenemase producing Enterobacteriaceae(CPE) has emerged as a significant global public health challenge and placing infected patients at risk of potentially untreatable infections. When resistance to carbapenems occurs, there are often few alternative treatments available. Numerous international guidelines have performed systematic and evidence review to identify new strategies to prevent the entry and spread of CPE in healthcare settings. Several key strategies have been shown to be highly effective. Firstly a new strategy that is proven to be effective is the early identification of the CPE carrier patients through active surveillance cultures. While waiting for the screening results,suspected CPE carriers will be put on preemptive isolation in single room and healthcare worker will at the same time practice contact precautions. The active surveillance culture and prompt preemptive isolation will limit the entry and spread of CPE from getting into hospital. Secondly, it is of utmost importance to incorporate enforcement of the basic infection prevention and control best practices in the hospital including, full compliance to hand hygiene, appropriate use of personal protective equipment, execute antibiotic stewardship program to control abuse of antibiotics, effective environmental cleaning and decontamination, staff education and feedback, as well as surveillance of healthcareassociated infections. Such a holistic approach has been shown to be effective in inhibiting CPE from gaining foothold in t he hospital.
Carbapenemase producing Enterobacteriaceae(CPE) has emerged as a significant global public health challenge and placing infected patients at risk of potentially untreatable infections. When resistance to carbapenems occurs, there are often few alternative treatments available. Numerous international guidelines have performed systematic and evidence review to identify new strategies to prevent the entry and spread of CPE in healthcare settings. Several key strategies have been shown to be highly effective. Firstly a new strategy that is proven to be effective is the early identification of the CPE carrier patients through active surveillance cultures. While waiting for the screening results,suspected CPE carriers will be put on preemptive isolation in single room and healthcare worker will at the same time practice contact precautions. The active surveillance culture and prompt preemptive isolation will limit the entry and spread of CPE from getting into hospital. Secondly, it is of utmost importance to incorporate enforcement of the basic infection prevention and control best practices in the hospital including, full compliance to hand hygiene, appropriate use of personal protective equipment, execute antibiotic stewardship program to control abuse of antibiotics, effective environmental cleaning and decontamination, staff education and feedback, as well as surveillance of healthcareassociated infections. Such a holistic approach has been shown to be effective in inhibiting CPE from gaining foothold in t he hospital.
引文
1World Health Organization. Guidelines for the prevention and control of carbapenem-resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in health care facilities.Licence:CC BY-NC-SA 3.0 IGO. Geneva:World Health Organization, 2017.
2 Magiorakos AP, Burns K, Rodríguez Ba?o J, et al. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings:guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control, 2017, 6:113.
3Public Health England. Acute trust toolkit for the early detection,management and control of carbapenemase-producing Enterobacteriaceae. London:Public Health England, 2013.https://assets.publishing.service.gov.uk/government/uploads/syste m/uploads/attachment_data/file/329227/Acute_trust_toolkit_for_the_early_detection.pdf.
4Health Protection Scotland. Toolkit for the early detection,management and control of carbapenemase-producing Enterobacteriaceae in Scottish acute settings.(2018-11-20)[2019-01 -01]. https://www.hps.scot.nhs.uk/haiic/amr/resourcedetail.aspx?id=478.
5 Centers for Disease Control and Prevention. Facility guidance for control of carbapenem resistant Enterobacteriaceae(CRE):November 2015 update-CRE toolkit 2015. Atlanta:Centers for Disease Control and Prevention, 2015. https://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf.
6Public Health Agency of Canada. Carbapenem resistant Gramnegative bacilli, 2010.(2012-01-26)[2019-01-01]. https://www.health.gov.nl.ca/health/publichealth/cdc/infectioncontrol/carbapenem_resistant_patient.pdf.
7Australian Commission on Safety and Quality in Health Care.Recommendations for the control of multi-drug resistant Gramnegatives:carbapenem resistant Enterobacteriaceae(October2013). Sydney:ACSQHC, 2013.
8French CE, Coope C, Conway L, et al. Control of carbapenemaseproducing Enterobacteriaceae outbreaks in acute settings:an evidence review. J Hosp Infect, 2017, 95(1):3-45.
9Otter JA, Burgess P, Davies F, et al. Counting the cost of an outbreak of carbapenemase-producing Enterobacteriaceae:an economic evaluation from a hospital perspective. Clin Microbiol Infect, 2017, 23(3):188-196.
10Feldman N, Adler A, Molshatzki N, et al. Gastrointestinal colonization by KPC-producing Klebsiella pneumoniae following hospital discharge:duration of carriage and risk factors for persistent carriage. Clin Microbiol Infect, 2013, 19(4):E190-E196.
11Zimmerman FS, Assous MV, Bdolah-Abram T, et al. Duration of carriage of carbapenem-resistant Enterobacteriaceae following hospital discharge. Am J Infect Control, 2013, 41(3):190-194.
12Schwartz-Neiderman A, Braun T, Fallach N, et al. Risk factors for carbapenemase-producingcarbapenem-resistant Enterobacteriaceae(CP-CRE)acquisition among contacts of newly diagnosed CP-CRE patients. Infect Control Hosp Epidemiol, 2016,37(10):1219-1225.
13European Committee on Antimicrobial Susceptibility Testing.EUCAST guidelines for detection of resistance mechanisms and specific resistances of clinical and/or epidemiological importance EUCAST, V?xj?. 2013. http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Resistance_mechanisv1.0_20131211.pdf.
14Clinical and Laboratory Standards Institute(CLSI). Performance standards for antimicrobial susceptibility testing; twenty-second informational supplement. Wayne, PA:CLSI2012.
2 Magiorakos AP, Burns K, Rodríguez Ba?o J, et al. Infection prevention and control measures and tools for the prevention of entry of carbapenem-resistant Enterobacteriaceae into healthcare settings:guidance from the European Centre for Disease Prevention and Control. Antimicrob Resist Infect Control, 2017, 6:113.
3Public Health England. Acute trust toolkit for the early detection,management and control of carbapenemase-producing Enterobacteriaceae. London:Public Health England, 2013.https://assets.publishing.service.gov.uk/government/uploads/syste m/uploads/attachment_data/file/329227/Acute_trust_toolkit_for_the_early_detection.pdf.
4Health Protection Scotland. Toolkit for the early detection,management and control of carbapenemase-producing Enterobacteriaceae in Scottish acute settings.(2018-11-20)[2019-01 -01]. https://www.hps.scot.nhs.uk/haiic/amr/resourcedetail.aspx?id=478.
5 Centers for Disease Control and Prevention. Facility guidance for control of carbapenem resistant Enterobacteriaceae(CRE):November 2015 update-CRE toolkit 2015. Atlanta:Centers for Disease Control and Prevention, 2015. https://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf.
6Public Health Agency of Canada. Carbapenem resistant Gramnegative bacilli, 2010.(2012-01-26)[2019-01-01]. https://www.health.gov.nl.ca/health/publichealth/cdc/infectioncontrol/carbapenem_resistant_patient.pdf.
7Australian Commission on Safety and Quality in Health Care.Recommendations for the control of multi-drug resistant Gramnegatives:carbapenem resistant Enterobacteriaceae(October2013). Sydney:ACSQHC, 2013.
8French CE, Coope C, Conway L, et al. Control of carbapenemaseproducing Enterobacteriaceae outbreaks in acute settings:an evidence review. J Hosp Infect, 2017, 95(1):3-45.
9Otter JA, Burgess P, Davies F, et al. Counting the cost of an outbreak of carbapenemase-producing Enterobacteriaceae:an economic evaluation from a hospital perspective. Clin Microbiol Infect, 2017, 23(3):188-196.
10Feldman N, Adler A, Molshatzki N, et al. Gastrointestinal colonization by KPC-producing Klebsiella pneumoniae following hospital discharge:duration of carriage and risk factors for persistent carriage. Clin Microbiol Infect, 2013, 19(4):E190-E196.
11Zimmerman FS, Assous MV, Bdolah-Abram T, et al. Duration of carriage of carbapenem-resistant Enterobacteriaceae following hospital discharge. Am J Infect Control, 2013, 41(3):190-194.
12Schwartz-Neiderman A, Braun T, Fallach N, et al. Risk factors for carbapenemase-producingcarbapenem-resistant Enterobacteriaceae(CP-CRE)acquisition among contacts of newly diagnosed CP-CRE patients. Infect Control Hosp Epidemiol, 2016,37(10):1219-1225.
13European Committee on Antimicrobial Susceptibility Testing.EUCAST guidelines for detection of resistance mechanisms and specific resistances of clinical and/or epidemiological importance EUCAST, V?xj?. 2013. http://www.eucast.org/fileadmin/src/media/PDFs/EUCAST_files/Resistance_mechanisv1.0_20131211.pdf.
14Clinical and Laboratory Standards Institute(CLSI). Performance standards for antimicrobial susceptibility testing; twenty-second informational supplement. Wayne, PA:CLSI2012.