神经外科病人导尿管相关尿路感染高危因素分析及相应预防护理措施探讨
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摘要
导尿管相关尿路感染(catheter-associate urinary tract infections，CAUTI)是指病人在留置导尿后，或者拔除导尿管48小时之内，泌尿系统发生的感染[1]。留置导尿是临床上常用的一种操作技术，它不仅是观察病情的需要，也是治疗某些疾病的主要措施，其最常见、最重要的并发症是CAUTI,也是全球范围内最为常见的医院感染之一。CAUTI不仅影响病人救治成功率，也是造成病人住院时间延长、住院费用大幅增加的主要原因。
目前临床上控制CAUTI感染率的主要措施是强化无菌操作、使用无菌设备、使用广谱抗生素等等，虽然使CAUTI的发生率大幅下降，但还是不能从根本上克服感染的发生[2]。因此明确CAUTI发病的各种高危因素，并针对高危因素探讨预防CAUTI的护理措施，才能从根本上降低导尿管相关尿路感染的发生，对病人救治成功率和生活质量的提高具有重要的理论和实际意义。目的：
本课题主要研究神经外科病人住院期间导尿或留置导尿后发生导尿管相关尿路感染的高危因素，并探讨具有针对性的预防护理措施，为临床上降低CAUTI的发生率提供可靠的理论依据。方法：
选取在吉林大学中日联谊医院神经外科住院导尿或留置导尿的病人中开展横断面病例调查研究，采用整群抽样的调查方法收集2011年11月1日0:00～24:00所有住院病人的信息，填写《导尿管相关尿路感染调查病例登记表》，采用床旁调查和在院病例相结合的方法对神经外科全部病人进行调查分析。纳入标准：该院神经外科具有导尿或者留置导尿的所有住院病人，包括当日所有出院、转科、死亡的住院病人，但不包括当日新入院的病人。调查内容包括性别、年龄、当前诊断、既往病史、实验室检查情况（血常规、尿常规、尿培养）、临床症状等、抗菌药物使用情况、基础疾病等情况。CAUTI诊断标准根据2001年中华人民共和国卫生部下发的《医院感染诊断标准》和卫生部在2010年下发的《导尿管相关尿路感染预防与控制技术指南(试行)》，CAUTI的诊断依据病例或者该院医院感染办公室相关人员判断。调查数据采用Excel建库，使用SPSS19.0统计软件进行分析,各组间率的比较采用卡方检验，以P＜0.05为差异有统计学意义。考虑到某些危险因素之间可存在相互作用，再将有显著统计学意义及可能的相关因素纳入Logistic进行多元素回归分析，找出与CAUTI相关的高危因素。
结果：
1.调查日当天吉林大学中日联谊医院神经外科住院病人中，共有68人在住院期间进行了导尿或留置导尿，CAUTI的感染率为28.57%，导尿管的使用率为46.03%。
2.导尿管相关尿路感染的病人平均住院天数(13.35±4.28),明显高于非感染病人的平均住院天数(5.62±3.93)。留置尿管天数分别为[1,3),[3,7),[7,14),,导尿管相关尿路感染的感染率分别为9.1%，16.67%，37.5%，64.71%。导尿或者留置导尿的病人年龄分别为＜30,[30,40),[40,50),[50,60),≥60岁，导尿管相关尿路感染的感染率分别为12.5%,20%,30.77%,33.33%,47.37%。病人使用抗菌药物天数分别为[1,3),[3,5),≥5天，导尿管相关尿路感染的感染率分别为13.64%,15.38%，57.17%。该院神经外科住院病人中所患疾病种类位于前三位的是脑出血，颅脑损伤，和颅内肿瘤，导尿管相关尿路感染的感染率分别为36.36%，28.57%，30.00%。
3.多因素非条件logistic回归分析结果显示影响导尿管相关尿路感染的高危因素包括病人留置尿管时间≥7天、集尿袋更换时间（1天或≥7天）、糖尿病、住院天数、使用抗菌药物≥5天。
结论：
1.随着神经外科住院病人留置尿管时间的延长，导尿管相关尿路感染的感染率也随之增加。
2.病人使用集尿袋更换的最佳时间是2～4天，CAUTI的感染率最低为17.64%；病人每天更换集尿袋CAUTI的感染率是36.67%；更换时间≥7天CAUTI的感染率是50.00%。
3.针对该院神经外科使用的是Folley's硅胶导尿管，最佳的更换时间是每2周更换一次。
4.使用抗菌药物≥5天，CAUTI感染率明显增加。病人伴有糖尿病，会使导尿管相关尿路感染感染率升高。
Catheter-associate urinary tract infections (CAUTI) are urinary system that the patientswith indwelling catheter or48hours after catheter removing, are infected. Retention ofcatheterization is a common operation technique, it is not only the clinical needing, but alsothe main measure of treatment for some certain diseases, the most important complication isthe CAUTI. During the catheter exist, and the CAUTI is also the most common healthcare-associated infections in the global scope. CAUTI affects the reasons that the patienttreatment successful rate, as well as cause the patient stay hospital long, the cost increase.
The main clinical control measures of CAUTI morbidity are strengthening the asepticoperation, using sterile equipment antibiotics and so on. The incidence of CAUTI decreasedsignificantly, but it cannot from go up at all infections. Therefore, controlling various riskfactors of CAUTI incidence, recommending CAUTI prevention nursing measures, canreduce the incidence of urinary tract infection of patients, treatment success rate andimproving the quality of life.Objective：
The surveys were focused on the patients during catheterization or retention ofcatheterization risk factors of CAUTI, and to suggest the corresponding preventive nursingmeasures, in order to reduce the occurrence of CAUTI and provide a scientific basis.Methods：
The Point Prevalence Surveys were carried out in the patients with Catheterization orretention of catheterization in neurosurgery of Changchun City Hospital. The surveyscollected all the hospitalized patients' information with Catheterization or retention ofcatheterization in neurosurgery on January1,2011. The method of combination of all thepatients in the investigation were investigated and analyzed in neurosurgery. Inclusioncriteria: the patients have a catheterization or retention of catheterization. The investigationcontent included the patient's sex, age, current diagnosis, past medical history, laboratoryexamination (blood, urine, urine culture, clinical symptoms), the use of antibacterial drugs,underlying diseases and so on.
The patients that meet the inclusion criteria in this study were randomly divided intotwo groups. The occurrence of CAUTI patients were the case group, and the other patientswere a control group. The data used Excel database, and SPSS17.0statistics software, thegroup was compared using the chi-square test, P＜0.05for the difference was statisticallysignificant. Considering that some risk factors may be present between interaction, there willbe significant and the possible factors related to incorporate Logistic multi-elementregression analysis, to identify high risk factors associated with CAUTI.
Results：
1. The patients in this survey of Changchun City in neurosurgery were189,68in themduring hospitalization were catheterization or retention of catheter. The use of urinarycatheter rate was46.03%.
2. The average hospitalization days of Catheter associated urinary tract infection groupwere (13.35±4.28).It is significantly higher than the average hospitalization days of thenon-infection group(5.62±3.93). The days of indwelling catheter [1,3),[3,7),[7,14), catheterassociated urinary tract infection incidence rates were9.1%,16.67%,37.5%,64.71%. The ageof catheterization and retention of catheterization patients were <30,[30,40),[40,50),[50,60),≥60years old, and the catheter associated urinary tract infection incidence rates were12.5%,20%,30.77%,33.33%,47.37%. The days of patients use of antimicrobial drugs [1,3),[3,5),≥5days, and the catheter associated urinary tract infection incidence rates were13.64%,15.38%,57.17%. The three top of neurosurgical disease types were cerebralhemorrhage, traumatic brain injury, intracranial tumor, and the catheter associated urinarytract infection incidence rates were36.36%,28.57%,30%.
3. The risk factors of catheter associated urinary tract infection include the patient's daywith ureter≥7days; replacing urine collection bag's time (1days or≥7days); BPH;hospitalization days; the use of antibacterial drugs≥5days.
Conclusion：
1. The patient's time in the Neurosurgery with indwelling catheter prolonged, and thecatheter associated urinary tract infection rate also increased.
2. The best time of the patient's urine collection bag replacement is2to4days. thepatient daily replacement of urine collection bags or more than7days to replace the urinecollection bag, that will make the indwelling catheter patients the incidence of CAUTI weresignificantly increased.
3. The suitable replacement time of Folley's latex catheter in neurosurgery, is every2 weeks.
4. The average time stay in neurosurgery, that the patients in catheter associated urinarytract infection's group was (13.35±4.28) days. the average time stay in neurosurgery, that thepatients in catheter associated urinary tract disinfection's group was (5.62±3.93) days. theinfection group's average time stay in neurosurgery was higher than disinfection's7.73days.Patients with diabetes mellitus, or Hyperplasia of prostate, will increased the catheterassociated urinary tract infection's rate.
5. The research group suggested that strict implementation of aseptic technique;shortening the duration of indwelling catheter; rational administration of antibiotics; tryingto keep the catheter drainage device closed. At the same time, the research for reducingincidence rate of CAUTI intervention study provided a theoretical basis.
目前临床上控制CAUTI感染率的主要措施是强化无菌操作、使用无菌设备、使用广谱抗生素等等，虽然使CAUTI的发生率大幅下降，但还是不能从根本上克服感染的发生[2]。因此明确CAUTI发病的各种高危因素，并针对高危因素探讨预防CAUTI的护理措施，才能从根本上降低导尿管相关尿路感染的发生，对病人救治成功率和生活质量的提高具有重要的理论和实际意义。目的：
本课题主要研究神经外科病人住院期间导尿或留置导尿后发生导尿管相关尿路感染的高危因素，并探讨具有针对性的预防护理措施，为临床上降低CAUTI的发生率提供可靠的理论依据。方法：
选取在吉林大学中日联谊医院神经外科住院导尿或留置导尿的病人中开展横断面病例调查研究，采用整群抽样的调查方法收集2011年11月1日0:00～24:00所有住院病人的信息，填写《导尿管相关尿路感染调查病例登记表》，采用床旁调查和在院病例相结合的方法对神经外科全部病人进行调查分析。纳入标准：该院神经外科具有导尿或者留置导尿的所有住院病人，包括当日所有出院、转科、死亡的住院病人，但不包括当日新入院的病人。调查内容包括性别、年龄、当前诊断、既往病史、实验室检查情况（血常规、尿常规、尿培养）、临床症状等、抗菌药物使用情况、基础疾病等情况。CAUTI诊断标准根据2001年中华人民共和国卫生部下发的《医院感染诊断标准》和卫生部在2010年下发的《导尿管相关尿路感染预防与控制技术指南(试行)》，CAUTI的诊断依据病例或者该院医院感染办公室相关人员判断。调查数据采用Excel建库，使用SPSS19.0统计软件进行分析,各组间率的比较采用卡方检验，以P＜0.05为差异有统计学意义。考虑到某些危险因素之间可存在相互作用，再将有显著统计学意义及可能的相关因素纳入Logistic进行多元素回归分析，找出与CAUTI相关的高危因素。
结果：
1.调查日当天吉林大学中日联谊医院神经外科住院病人中，共有68人在住院期间进行了导尿或留置导尿，CAUTI的感染率为28.57%，导尿管的使用率为46.03%。
2.导尿管相关尿路感染的病人平均住院天数(13.35±4.28),明显高于非感染病人的平均住院天数(5.62±3.93)。留置尿管天数分别为[1,3),[3,7),[7,14),,导尿管相关尿路感染的感染率分别为9.1%，16.67%，37.5%，64.71%。导尿或者留置导尿的病人年龄分别为＜30,[30,40),[40,50),[50,60),≥60岁，导尿管相关尿路感染的感染率分别为12.5%,20%,30.77%,33.33%,47.37%。病人使用抗菌药物天数分别为[1,3),[3,5),≥5天，导尿管相关尿路感染的感染率分别为13.64%,15.38%，57.17%。该院神经外科住院病人中所患疾病种类位于前三位的是脑出血，颅脑损伤，和颅内肿瘤，导尿管相关尿路感染的感染率分别为36.36%，28.57%，30.00%。
3.多因素非条件logistic回归分析结果显示影响导尿管相关尿路感染的高危因素包括病人留置尿管时间≥7天、集尿袋更换时间（1天或≥7天）、糖尿病、住院天数、使用抗菌药物≥5天。
结论：
1.随着神经外科住院病人留置尿管时间的延长，导尿管相关尿路感染的感染率也随之增加。
2.病人使用集尿袋更换的最佳时间是2～4天，CAUTI的感染率最低为17.64%；病人每天更换集尿袋CAUTI的感染率是36.67%；更换时间≥7天CAUTI的感染率是50.00%。
3.针对该院神经外科使用的是Folley's硅胶导尿管，最佳的更换时间是每2周更换一次。
4.使用抗菌药物≥5天，CAUTI感染率明显增加。病人伴有糖尿病，会使导尿管相关尿路感染感染率升高。
Catheter-associate urinary tract infections (CAUTI) are urinary system that the patientswith indwelling catheter or48hours after catheter removing, are infected. Retention ofcatheterization is a common operation technique, it is not only the clinical needing, but alsothe main measure of treatment for some certain diseases, the most important complication isthe CAUTI. During the catheter exist, and the CAUTI is also the most common healthcare-associated infections in the global scope. CAUTI affects the reasons that the patienttreatment successful rate, as well as cause the patient stay hospital long, the cost increase.
The main clinical control measures of CAUTI morbidity are strengthening the asepticoperation, using sterile equipment antibiotics and so on. The incidence of CAUTI decreasedsignificantly, but it cannot from go up at all infections. Therefore, controlling various riskfactors of CAUTI incidence, recommending CAUTI prevention nursing measures, canreduce the incidence of urinary tract infection of patients, treatment success rate andimproving the quality of life.Objective：
The surveys were focused on the patients during catheterization or retention ofcatheterization risk factors of CAUTI, and to suggest the corresponding preventive nursingmeasures, in order to reduce the occurrence of CAUTI and provide a scientific basis.Methods：
The Point Prevalence Surveys were carried out in the patients with Catheterization orretention of catheterization in neurosurgery of Changchun City Hospital. The surveyscollected all the hospitalized patients' information with Catheterization or retention ofcatheterization in neurosurgery on January1,2011. The method of combination of all thepatients in the investigation were investigated and analyzed in neurosurgery. Inclusioncriteria: the patients have a catheterization or retention of catheterization. The investigationcontent included the patient's sex, age, current diagnosis, past medical history, laboratoryexamination (blood, urine, urine culture, clinical symptoms), the use of antibacterial drugs,underlying diseases and so on.
The patients that meet the inclusion criteria in this study were randomly divided intotwo groups. The occurrence of CAUTI patients were the case group, and the other patientswere a control group. The data used Excel database, and SPSS17.0statistics software, thegroup was compared using the chi-square test, P＜0.05for the difference was statisticallysignificant. Considering that some risk factors may be present between interaction, there willbe significant and the possible factors related to incorporate Logistic multi-elementregression analysis, to identify high risk factors associated with CAUTI.
Results：
1. The patients in this survey of Changchun City in neurosurgery were189,68in themduring hospitalization were catheterization or retention of catheter. The use of urinarycatheter rate was46.03%.
2. The average hospitalization days of Catheter associated urinary tract infection groupwere (13.35±4.28).It is significantly higher than the average hospitalization days of thenon-infection group(5.62±3.93). The days of indwelling catheter [1,3),[3,7),[7,14), catheterassociated urinary tract infection incidence rates were9.1%,16.67%,37.5%,64.71%. The ageof catheterization and retention of catheterization patients were <30,[30,40),[40,50),[50,60),≥60years old, and the catheter associated urinary tract infection incidence rates were12.5%,20%,30.77%,33.33%,47.37%. The days of patients use of antimicrobial drugs [1,3),[3,5),≥5days, and the catheter associated urinary tract infection incidence rates were13.64%,15.38%,57.17%. The three top of neurosurgical disease types were cerebralhemorrhage, traumatic brain injury, intracranial tumor, and the catheter associated urinarytract infection incidence rates were36.36%,28.57%,30%.
3. The risk factors of catheter associated urinary tract infection include the patient's daywith ureter≥7days; replacing urine collection bag's time (1days or≥7days); BPH;hospitalization days; the use of antibacterial drugs≥5days.
Conclusion：
1. The patient's time in the Neurosurgery with indwelling catheter prolonged, and thecatheter associated urinary tract infection rate also increased.
2. The best time of the patient's urine collection bag replacement is2to4days. thepatient daily replacement of urine collection bags or more than7days to replace the urinecollection bag, that will make the indwelling catheter patients the incidence of CAUTI weresignificantly increased.
3. The suitable replacement time of Folley's latex catheter in neurosurgery, is every2 weeks.
4. The average time stay in neurosurgery, that the patients in catheter associated urinarytract infection's group was (13.35±4.28) days. the average time stay in neurosurgery, that thepatients in catheter associated urinary tract disinfection's group was (5.62±3.93) days. theinfection group's average time stay in neurosurgery was higher than disinfection's7.73days.Patients with diabetes mellitus, or Hyperplasia of prostate, will increased the catheterassociated urinary tract infection's rate.
5. The research group suggested that strict implementation of aseptic technique;shortening the duration of indwelling catheter; rational administration of antibiotics; tryingto keep the catheter drainage device closed. At the same time, the research for reducingincidence rate of CAUTI intervention study provided a theoretical basis.
引文
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