摘要
第一部分ICU住院患者医院感染相关因素的调查研究目的了解综合性ICU病房医院感染情况及发展特点,分析引起医院感染的相关危险因素,为采取干预措施降低医院感染的发生率提供科学依据。方法采用回顾性调查和前瞻性监测的方法,对2007年以前的资料采用回顾性调查的方法、对2007年以后的资料采用前瞻性监测的方法,收集2004年1月～2010年12月某三级教学医院综合性ICU所有住院患者的病例资料,对资料进行分类比较,资料分析采用卡方检验。
结果在7年内,共监测重症监护病房入住患者2060例,发生医院感染662例,911例次,感染发生率为32.14%,感染例次率为44.22%%。下呼吸道为主要感染部位,占65.09%%,其次为泌尿道感染占9.88%%。662例感染病例中,共检出菌株1 439株,革兰阴性菌1033株,占71.79%,居首位的是铜绿假单胞菌,其次为鲍曼不动杆菌。死亡病例的医院感染率(41.58%),高于非死亡病例的医院感染率(27.69%%),P＜0.05。不同病种医院感染发生率最高的是复合外伤(50.89%%),其次为肺部感染(49.02%)和脑血管病(48.24%%)。经卡方检验,ICU医院感染的发生与患者的性别、住院天数、病情分级、个别病种、基础疾病数量、侵袭性操作和免疫抑制剂的使用有很大的关系,而不同年龄段医院感染发生率无统计学意义。
结论ICU病人是医院感染高发人群,应加强对综合ICU的医院感染监管力度,从而逐步降低医院感染的发生率。ICU病人医院感染部位以下呼吸道感染为主,病原菌分布以革兰阴性菌感染为主。患有复合外伤、肺部感染、脑血管病和呼吸疾病的患者应重点监测。男性患者医院感染的发生率高于女性(P<0.05),随病情严重程度的增加、伴有基础疾病种类的增多,感染发生率逐渐增加(P＜0.05)。医院感染发生率随着住院时间的延长而显著升高(P<0.05)。
ICU患者是医院感染的易感人群,应加强对ICU的目标性监测,并采取有效措放降低医院感染发生率、提高医疗质量。
第二部分I CU住院患者医院感染的直接经济损失调查研究目的研究ICU住院患者因医院感染所造成的直接经济损失,分析ICU住院患者医院感染直接经济损失的相关因素。
方法采用回顾性调查和前瞻性监测的方法,调查2004年1月至2010年12月某三级甲等教学医院综合性ICU病房的的住院患者,共收集病例2 060例。按条件1：1配比,共成功配对182对(发生医院感染的患者为病例组,未发生医院感染的患者为对照组),比较它们的住院费用和住院天数的差别。
结果病例组住院总费用中位数每例为91 977.12元,对照组为31 015.78元,病例组显著高于对照组(P<0.05)；费用的增加主要是药费和治疗费；ICU医院感染直接经济损失因感染部位的不同而异,发生单一部位感染的,以呼吸道感染的经济损失最高(48472.17元),而多部位感染直接经济损失更加严重；ICU医院感染直接经济损失排在前三位的疾病种类为循环系统疾病、消化系统疾病和肿瘤术后；男性患者医院感染直接经济损失高于女性患者；ICU医院感染直接经济损失与患者病情严重程度有关,病情分级为E级的医院感染直接经济损失最高(68 250.54元)。病例组中位数每例患者住院天数为17.0天,对照组为6.0天,两组间差异有统计学意义(P<0.05)。多部位的感染对住院时间的延长更为显著,每例延长26.0天(P<0.05)。
结论ICU患者医院感染大大增加了医疗费用支出,延长了住院天数,降低了病床周转率,其费用支出远高于非医院感染患者,做好ICU患者医院感染监控工作可获得巨大经济效益和社会效益。
Part I The investigation about Influencing Factors of Nosocomial Infection in ICU
Objective Investigating the actual state and the characteristics of nosocomial infections (NI) in integrated ICU and analysing the related risk factors of NI in order to supply scientific evidences for intervening measures and reduce the incidence of NI in integrated ICU.
Methods NI of all the integrated ICU inpatients in a tertiary teaching hospital from January 2004 to December 2010 were retrospectively studied and prospectively surveyed (The inpatients before 2007 were retrospectively studied and the inpatients after 2007 were prospectively surveyed). Through Chi-square test, the data was classified and compared.
Results Of the 2060 integrated ICU inpatients investigated during 7 years, 662 patients and 911 cases suffered from NI with infection. Hospital infection rate was 32.14% and the infection case-rate was 44.22%. Lower respiratory tract infection ranked first in nosocomial infection, followed by the urinary tract. Of 662 infected cases,1 439 strains were detected of which 1033 strains were Gram-negative bacteria (71.79%). Pseudomonas aeruginosa ranked first, followed by Acinetobacter baumannii. The infection rate of the integrated ICU inpatients who was dead was 41.5%. Which was higher than that was not dead (27.69%). Of all the inpatients in ICU, the NI rates in the patients with complex trauma, lung infection and cerebrovascular disease were 50.89%、49.02%、48.24% respectively. After Chi-square test, that was known different sex, length stay, disease grading, some kinds of disease, the amount of primary disease, invasive operation and immunosuppressant, but no statistical significance was among the difference from hospital infection rate of patients with different age. Conclusions We should take effective measures to reduce the morbidity of NI of the patients in ICU because they are the high risk population. We should pay more attentions to the patients with the disease as follows: complex trauma, lung infection, cerebrovascular disease, and respiratory disease. The hospital infection rate in men was higher than in women (P<0.05). And it increased gradually along with the severity of illness, the amount of the previous diseases and the hospitalization time (P<0.05).
The patients in ICU are susceptible population of nosocomial infection. We should pay much more attention to monitor the main factors and take effective measure to reduce the incidence of infection and improve the medical quality.
PartⅡStudy on Direct Economic Losses of Nosocomial Infections in ICU
Objective To evaluate the direct economic costs of nosocomial infections in ICU, to analyse the related factors.
Methods The retrospective study and prospectively surveyed were conducted and according to the mate conditions,182 pairs of cases (patients with nosocomial infection were described as infection group and patients without nosocomial infection were described as control group) that were collected in a tertiary teaching hospital during from January 2004 to December 2010. The direct economic losses and the time of hospitalization were analyzed. Results The median of total hospitalization expenses of each case were 91 977.12 and 31 015.78 Yuan in infection and control group respectively, infection group was significantly higher than control group (P<0.05).The main increased expenses of hospitalization were medicine cost and therapy costs.The direct economic loss varied from infection sites,the loss from respiratory tract was higher than other single infection. The loss from mulriple infection was heaviest.The direct economic loss of nosocomial infection of patients with circulatory system diseases ranked first, followed by patients with digestive system disease and patients after tumor surgery.The direct economic loss of men is higher than women. The direct economic loss varied from severity of disease. The loss of E grade is highest. The median of hospitalization days of each patient in infection group and control group were 17.0 and 6.0 days respectively, there was significant difference between them(P<0.05). The extension of hospitalization days of patients with multilocation infection was 26.0 days.
Conclusions Nosocomial infections of ICU inpatients during hospitalization caused significant increase in the medical expense of managing the underlying disease which led to hospitalization of the patients and reduced the tumover rate of patient bed, and cost of nosocomial infection was much more than that for common nosocomial infections. Good measures of controlling nosocomial infection could bring tremendous social and economic benefits.
引文
[1]王东浩,王伟,王勇强,等.重症监护病房获得性细菌感染临床调查[J].中华医院感染学杂志,2004,14(2)：151-153.
[2]张彦华,杨营军.医院感染与医疗纠纷的相关性[J].中国现代药物应用,2009,12：200-201.
[3]Ciorlia LA, Zanetta DM. Hepatitis B in healthcare workers:prevalence, vaccination and relation to occupational factors[J]. Braz J Infect Dis, 2005,9(5):384-389.
[4]吴安华,任南,文细毛,等.159所医院医院感染现患率调查结果与分析[J].中国感染控制杂志,2005,4(1)：12-17.
[5]居丽雯,胡必杰.医院感染学[M].上海：复旦大学出版社,2006：1.
[6]申正义.全球医院感染控制概况[C].预防医学学科发展蓝皮书(2006卷),2006.
[7]夏祥碧,刘力克.恶性肿瘤医院感染影响因素的病例对照分析[J].中华医院感染学杂志,2003,13(4)：315-317.
[8]王小岩,朱会英,孙立贵,等.糖尿病并发医院感染的危险因素研究[J].中华医院感染学杂志,2005,15(3)：282-284.
[9]Roder BL, Nielsen SL, Magnussen P, et al. Antibiotic usage in an intensive care unit in a Danish university hospital[J]. J Antimicrob Chemother,1993,32(4):633-642.
[10]Gavazzi G, Krause KH. Ageing and infection [J]. The Lancet Infect Dis, 2002,2(11):659-666.
[11]Farr BM. Preventing vascular catheter-related infections:current controversies[J]. Clin Infect Dis,2001,33(10):1733-1738.
[12]陈吉.肠道细菌移位的研究进展[J].肠外与肠内营养,2004,11(5)：309-312.
[13]谢扬,张志宏,李颖.重症颅脑损伤医院感染因素的研究[J].中华医院感染学杂志,2004,14(3)：269-271.
[14]王宝华.全麻气管插管后与下呼吸道感染关系探讨[J].中华医院感染学杂 志,2002,12(4)：286.
[15]何瑾玢,李卿,江金燕.101例普外科手术切口感染调查及分析[J].中华医院感染学杂志,2002,12(2)：110-111.
[16]赵松立,周达生.综合医院外科手术疾病住院日影响因素研究[J].中国卫生资源,2001,4(6)：252-253.
[17]吴风波,王福明,郑新华,等.医院感染经济损失的病例对照研究[J].中华医院感染学杂志,1996,6(2)：83.
[18]Iribarren B 0, Alvarez C A, Rodriguez C C, et al. Cost and outcome of hip's arthroplasty nosocomial infection. Case and control study [J]. Rev Chilena Infectol,2007,24(2):125-130.
[19]Warren DK, Shukla SJ, Olsen MA, et al. Outcome and attributable cost of ventilator-associated pneumonia among intensive care unit patients in a suburban medical center[J]. Crit Care Med,2003,31(5):1582-1583.
[20]Wisplinghoff H, Cornely 0 A, Moser S, et al. Outcomes of nosocomial blood stream infections in adult neutropenic patients:a prospective cohort and matched case-control study [J]. Infect Control Hosp Epidemiol, 2003,24(12):905-911.
[21]Orsi G B, Distefano L, Noah N. Hospital-acquired, laboratory-confirmed bloodstream infection:increased hospital stay and direct costs[J]. Infect Control Hosp Epidemiol,2002,23(4):190-197.
[22]刘振声,金大鹏,陈增辉.医院感染管理学[M].北京：军事医学科学出版社,2000：15-25.
[23]江敏,李长福,郜红梅,等.4种类型医院感染的经济损失病例对照研究[J].中国感染控制杂志,2009,8(5)：325-330.
[24]易文华,张永成,张柔玲.医院感染经济损失病例对照研究[M].中华医院感染学杂志,2006,16(10)：1140-1142.
[25]Lauria FN, Angeleti C. The impact of nosocomial infections on hospital care costs [J]. Infection,2003,31:36-37.
[26]Kumasaka K, Yanai M. Costs and benefits in hospital infection control [J]. Nippon Rinsho,2002,60:2230-2235.
[27]Yalcin AN. Socioeconomic burden of nosocomial infections.Ind J Med Sci.2003,4(4):284-285.
[28]卫生部.医院感染诊断标准(试行)[S].北京：卫生部办公厅(卫医发[2001]2号),2001.
[29]任玲,周宏,郑雯,等.医院感染目标性监测与全面综合性监测方法的对比研究[J].中华医院感染学杂志,2006,16(9)：995-997.
[30]陈蜀岚,陈先云.医院ICU呼吸道感染状况调查分析[J].预防医学情报杂志,2008,24(7)：515-517.
[31]王力红,马文晖,张京利,等.APACHEII评分与医院感染相关性研究[J].中华医院感染学杂志,2007,17(6)：651-653.
[32]向阳.脑血管病患者医院感染分析[J].河北医学,2007,13(2)：214-216.
[33]齐晓红.医院感染现患率统计分析[J].中国医院统计,2002,9(3)：165-167.
[34]张志臣,张元媛,张秀銮,等.呼吸机医院感染预防管理模式[J].中国消毒学杂志,2007,24(3)：286-287.
[35]范珊红,金霞、吕桂芝,等.综合性医院医院感染患病率及危险因素调查[J].中国感染控制杂志,2010,9(4)：245-247.
[36]顾克菊,王津存,贾淑梅,等.重症监护病房医院感染流行病学调查[J].中国感染控制杂志.2003,2(1)：14-16.
[37]汪得喜,裘建章,张辛.不动杆菌肺炎及其治疗的临床回顾[J].中华医院感染学杂志,2000,10(2)：104-106.
[38]Richards MJ, Edwards JR, Culver DH, et al. Nosocomialinfections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System[see comments][J]. Crit Care Med,1999, 27(5):887-892.
[39]李立伟.2001—2006年住院病人死亡情况分析[J].中国医院统计,2007,14(4)：358-359.
[40]Erbay H, Yalcin AN, Serin S, et al. Nosocomial infections in intensive care unit in a Turkish university hospital:a 2-year survey[J]. Intensive Care Med,2003,29(9):1482-1488.
[41]黄金平.泌尿系统疾病患者医院感染直接经济损失对照研究[J].中华医院感染学杂志,2009,19(15)：1973.
[42]蒋景华,陈文光,章泽豹,等.脑梗死患者医院感染经济损失的对照研究[J].中华医院感染学杂志,2007,17(3)：272-273.
[43]秦颖,孙俊.剖胸术后手术部位感染的直接经济损失评价[J].中国感染控制杂志,2009,8(6)：400-402.
[44]刘一新,孔萍,孙代艳.综合性医院医院感染经济损失病例对照研究[J].中华医院感染学杂志,2002,12(9)：660-661.
[45]邱听光,邓颖珍,李淑霞.恶性肿瘤医院感染医疗费用及抗感染药物分析[J].中国医院统计,2002,9(1)：21-23.
[46]崔少罡,自玲,常城,等.剖胸术后切口感染经济损失病例对照分析[J].中华医院感染学杂志,2002,12(2)：87-88.
[47]黄小红,覃金爱,韦志福,等.高血压脑出血医院感染经济损失的对照研究[J].中华医院感染学杂志,2002,12(7)：481-482,503.
[48]杨学岭,赵敬东.医院感染经济损失的病例对照研究[J].中华医院感染学杂志,2003,13(10)：922-924.
[49]王斐,王建斌,吴俊霞.脑梗塞医院感染经济损失的病例对照研究[J].中华医院感染学杂志,2002,12(7)：483—484.
[50]韩雪玲,胡淑芳,华梅,等.神经外科院内感染经济损失病例对照研究[J].西北国防医学杂志,2005,26(5)：374-375.
[51]徐秀芝脑出血患者医院感染经济损失病例对照研究[J].2009,21(11)：78,82.
[52]杨武,李武英,贺桂菊,等.医院感染经济损失的1：1病例对照研究[J].中华医院感染学杂志,1998,8(4)：193.
[53]王力红,石海鸥,张京利.重症监护患者医院感染前瞻性研究[J].中华医院感染学杂志,2002,12(4)：268-270.
[54]李小宇,郑爱平,单沙林.危重症患者抗生素相关性腹泻的临床分析[J].实用预防医学,2002,9(4)：346-347.
[55]Cuellar LE, Fernandez-Maldonado E, Rosenthal VD, et al. Device-associated nosocomial infections in limited-resources countries: findings of the International Nosocomial infection Control Consortium [J]. Rev Panam Salud Publica,2008,24(1):16-24.