臺灣博碩士論文加值系統

本篇研究的目標在於分析成人加護病房、呼吸照護中心與呼吸照護病房所整合的呼吸照護系統中的院內感染的發生率、感染部位、致病微生物的種類與其比率。研究的資料來自中台灣某大學附設醫院的醫院院內感染管制監測系統，研究的期間為2003年到2006年，而收案的定義是使用被許多國家採用的美國疾病管制局（Centers for Disease Control and Prevention）的標準與方法。成人加護病房的院內感染發生率（incidence）是14.0/1000 patient-days，呼吸照護中心為10.3/1000 patient-days，而呼吸照護病房為5.0/1000 patient-days。在三個單位中最常見的感染型態分別是泌尿道感染、血流感染與肺炎。在加護病房當中最常被分離培養出來的致病微生物為非發酵性格蘭氏陰性桿菌（nonfermentative gram-negative bacilli, 33.0%）、腸內菌科（Enterobacteriaceae, 26.5%）、念珠菌屬（Candida spp., 18.2%）、金黃色葡萄球菌（Staphylococcus aureus, 8.9%）、凝固酵素陰性葡萄球菌（coagulase-negative Staphylococci, 4.9%）以及腸球菌屬（Enterococci, 4.5%）。雖然呼吸照護中心與呼吸照護病房的院內感染致病微生物的主要種類與加護病房的結果相類似，但是分佈的型態是不一樣的。若是呼吸照護病房與加護病房比較，金黃色葡萄球菌在呼吸照護病房的院內感染比例是高於加護病房（odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.7），並且腸球菌屬（OR 2.2; 95% CI, 1.4 to 3.5）與腸內菌科（OR 2.2; 95% CI, 1.7 to 2.8）也是比較容易在呼吸照護病房當中得到。但是凝固酵素陰性葡萄球菌（OR 0.3; 95% CI, 0.1 to 0.8）、非發酵性格蘭氏桿菌（OR 0.5; 95% CI, 0.4 to 0.7）與念珠菌屬（OR 0.2; 95% CI, 0.1 to 0.3）則在呼吸照護病房中的院內感染比例較低。此外，具有抗藥性的細菌在呼吸照護病房當中也相當嚴重的，其中methicillin抗藥性金黃色葡萄球菌（OR 4.9; 95% CI, 1.1 to 22.0）與產生extended-spectrum β-lactamase的腸內菌科（OR 4.1; 95% CI, 2.2 to 7.5）均證實呼吸照護病房比加護病房中更容易得到。這個研究的結果顯示呼吸照護中心的感染型態與致病微生物的分佈是接近加護病房的，但是呼吸照護病房中的院內感染特色是內源性的細菌的浮現以及抗藥性菌種比例的增多，然而感染的密度是在呼吸照護系統中最低且接近一般病房，不過反覆發生的院內感染是被注意到的問題。這也顯示當我們面對在此一呼吸照護系統中的院內感染時，選擇經驗性抗生素療法是受到許多的侷限。

The objectives of this study were to investigates the incidence of nosocomial infections (NIs) and the distribution of resistant nosocomial pathogens in critical and long-term care respiratory care units, including adult intensive care units (ICUs), respiratory care center (RCC) and respiratory care ward (RCW). The Centers for Disease Control and Prevention’s definitions and methods were used to collect the NIs data in adult ICUs, RCC and RCW at an 1100-bed university-affiliated hospital from 2003 to 2006. The overall NI incidences were 14.0, 10.3 and 5.0 per 1000 patient-days for adult ICUs, RCC and RCW, respectively. Urinary tract infections, bloodstream infections and pneumonias most commonly occurred. The frequently reported micro-organisms in adult ICUs were nonfermentative gram-negative bacilli (33.0%), Enterobacteriaceae (26.5%), Candida spp. (18.2%), Staphylococcus aureus (8.9%), coagulase-negative Staphylococci (4.9%) and Enterococci (4.5%). As compared with ICUs patients, RCW patients had a higher proportion of NIs caused by S. aureus (odds ratio [OR], 1.9; 95% confidence interval [CI], 1.3 to 2.7), Enterococci ( OR 2.2; 95% CI, 1.4 to 3.5) and Enterobacteriaceae ( OR 2.2; 95% CI, 1.7 to 2.8), at the same time, a lower proportion of coagulase-negative Staphylococci (OR 0.3; 95% CI, 0.1 to 0.8), nonfermentative gram-negative bacilli ( OR 0.5; 95% CI, 0.4 to 0.7) and Candida spp. ( OR 0.2; 95% CI, 0.1 to 0.3). Additionally, RCW patients had higher chances of infection caused by methicillin-resistant S. aureus (OR 4.9; 95% CI, 1.1 to 22.0) and extended-spectrum β-lactamase Enterobacteriaceae (OR 4.1; 95% CI, 2.2 to 7.5) when compared with ICU patients. Limited options for treating RCW patients with NIs have been a challenge due to a high prevalence of multidrug-resistant organisms. These pathogens were often endogenous and associated with decreased host defenses and broad-spectrum antibiotic uses during the period of prior prolonged hospitalization.

目 錄……………………………………………………………………1
中文摘要 ………………………………………………………………3
英文摘要 ………………………………………………………………5
第 壹 章 緒 論………………………………………………………7
第一節前言………………………………………………………………7
第二節 名詞解釋………………………………………………………9
第三節 研究架構………………………………………………………15
第貳章 材料和方法 …………………………………………………18
第一節 研究對象 ……………………………………………………18
第二節 院內感染收案方法 …………………………………………19
第三節 細菌學試驗 …………………………………………………21
第四節 資料分析 ……………………………………………………22
第參章結果……………………………………………………………23
第一節 院內感染率的結果……………………………………………23
第二節 不同院內感染部位所佔比率之比較…………………………24
第三節 各單位病房內的院內感染致病微生物分佈…………………25
第四節 各單位病房院內感染致病微生物的比較……………………28
第五節 院內感染致病微生物之抗藥性………………………………31
第肆章 討論……………………………………………………………34
第一節 院內感染發生率逐步下降但感染率逐步上升………………35
第二節泌尿道感染是最常見的感染部位，其次是血流感染與肺炎…38
第三節 加護病房院內感染致病微生物分佈與國外研究有所不同……39
第四節 呼吸照護中心的院內感染致病微生物分佈相近於加護病房…42
第五節 隨著患者由加護病房下轉至呼吸照護病房而浮現內源性致病微生物的重要性與致病微生物的抗藥性……………………………43
第伍章 結論與建議……………………………………………………47
參考文獻 ………………………………………………………………49
圖表及其他附錄 ………………………………………………………63
表1: 各單位的院內感染發生率………………………………………63
表2：依照感染部位分類之院內感染分佈……………………………64
表3：院內感染致病微生物的分佈……………………………………65
表4：院內感染致病微生物的分佈……………………………………66
表5：各單位病房指標性高抗藥性致病微生物的比較………………67

1.Stauffer JL, Fayter NA, Graves B, Cromb M, Lynch JC, Goebel P, (1993) Survival following mechanical ventilation for acute respiratory failure in adult men. Chest 104: 1222-1229
2.Daly BJ, Rudy EB, Thompson KS, Happ MB, (1991) Development of a special care unit for chronically critically ill patients. Heart Lung 20: 45-51
3.Lemaire F, (1993) Difficult weaning. Intensive Care Med 19 Suppl 2: S69-73
4.Carson SS, Bach PB, Brzozowski L, Leff A, (1999) Outcomes after long-term acute care. An analysis of 133 mechanically ventilated patients. Am J Respir Crit Care Med 159: 1568-1573
5.Wagner DP, (1989) Economics of prolonged mechanical ventilation. Am Rev Respir Dis 140: S14-18
6.Ely EW, Meade MO, Haponik EF, Kollef MH, Cook DJ, Guyatt GH, Stoller JK, (2001) Mechanical ventilator weaning protocols driven by nonphysician health-care professionals: evidence-based clinical practice guidelines. Chest 120: 454S-463S
7.MacIntyre NR, (2002) Bringing scientific evidence to the ventilator weaning and discontinuation process: evidence-based practice guidelines. Respir Care 47: 29-30
8.MacIntyre NR, Cook DJ, Ely EW, Jr., Epstein SK, Fink JB, Heffner JE, Hess D, Hubmayer RD, Scheinhorn DJ, (2001) Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest 120: 375S-395S
9.Vincent JL, (2003) Nosocomial infections in adult intensive-care units. Lancet 361: 2068-2077
10.Klevens RM, Edwards JR, Tenover FC, McDonald LC, Horan T, Gaynes R, (2006) Changes in the epidemiology of methicillin-resistant Staphylococcus aureus in intensive care units in US hospitals, 1992-2003. Clin Infect Dis 42: 389-391
11.Gaynes R, Edwards JR, (2005) Overview of nosocomial infections caused by gram-negative bacilli. Clin Infect Dis 41: 848-854
12.Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, Hooton TM, (1985) The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 121: 182-205
13.Edmond MB WR (2005) Organization for infection control. In: GL M (ed) Mandell, Douglas, and Bennett’s Principles and practice of infectious diseases Churchill Livingstone, Philadelphia, pp. 3323-3325
14.Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM, (1988) CDC definitions for nosocomial infections, 1988. Am J Infect Control 16: 128-140
15.Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG, (1992) CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Am J Infect Control 20: 271-274
16.Emori TG, Culver DH, Horan TC, Jarvis WR, White JW, Olson DR, Banerjee S, Edwards JR, Martone WJ, Gaynes RP, et al., (1991) National nosocomial infections surveillance system (NNIS): description of surveillance methods. Am J Infect Control 19: 19-35
17.Shlaes DM, Gerding DN, John JF, Jr., Craig WA, Bornstein DL, Duncan RA, Eckman MR, Farrer WE, Greene WH, Lorian V, Levy S, McGowan JE, Jr., Paul SM, Ruskin J, Tenover FC, Watanakunakorn C, (1997) Society for Healthcare Epidemiology of America and Infectious Diseases Society of America Joint Committee on the Prevention of Antimicrobial Resistance: guidelines for the prevention of antimicrobial resistance in hospitals. Infect Control Hosp Epidemiol 18: 275-291
18.Laplane R, Begue P, Bricout F, Lasfargues G, (1977) [Bacterial infections caused by multi-resistant organisms at the Hopital Trousseau in 1974. Incidence, origin and prevention]. Ann Med Interne (Paris) 128: 401-403
19.Wright MO, (2005) Multi-resistant gram-negative organisms in Maryland: a statewide survey of resistant Acinetobacter baumannii. Am J Infect Control 33: 419-421
20.Steinberg JP DRC (2000) Other gram-negative bacilli. In: GL M (ed) Mandell, Douglas, and Bennett’s Principles and practice of infectious diseases. Churchill Livingstone, Philadelphia, pp. 2459–2474
21.Horan TC GR (2004) Surveillance of nosocomial infections. In: CG M (ed) Hospital Epidemiology and Infection Control. Lippincott-Williams & Wilkins, Philadelphia, pp. 1659-1702
22.National Committee for Clinical and Laboratory Standards. Performance standards for antimicrobial susceptibility testing; 17th informational supplement (M100-S17). Wayne, PA: National Committee for Clinical and Laboratory Standards, 2007.
23.Seneff MG, Zimmerman JE, Knaus WA, Wagner DP, Draper EA, (1996) Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest 110: 469-479
24.Gracey DR, Viggiano RW, Naessens JM, Hubmayr RD, Silverstein MD, Koenig GE, (1992) Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clin Proc 67: 131-136
25.Scheinhorn DJ, Chao DC, Stearn-Hassenpflug M, LaBree LD, Heltsley DJ, (1997) Post-ICU mechanical ventilation: treatment of 1,123 patients at a regional weaning center. Chest 111: 1654-1659
26.Chang SC TC, Wang JT, et al., (2004) Nosocomial Infections in Medical Centers and Regional Hospitals between 1999 and 2002 in Taiwan. . Infect Control J 14: 1- 11
27.Freeman J TI (2004) Modern quantitative epidemiology in the hospital. In: CG M (ed) Hospital Epidemiology and Infection Control. Lippincott-Williams & Wilkins, Philadelphia, pp. 19-48
28.Su J, Lin CY, Chen PJ, Lin FJ, Chen SK, Kuo HT, (2006) Experience with a step-down respiratory care center at a tertiary referral medical center in Taiwan. J Crit Care 21: 156-161
29.Cook DJ, Walter SD, Cook RJ, Griffith LE, Guyatt GH, Leasa D, Jaeschke RZ, Brun-Buisson C, (1998) Incidence of and risk factors for ventilator-associated pneumonia in critically ill patients. Ann Intern Med 129: 433-440
30.Kollef MH, (2004) Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 32: 1396-1405
31.Cavalcanti M, Ferrer M, Ferrer R, Morforte R, Garnacho A, Torres A, (2006) Risk and prognostic factors of ventilator-associated pneumonia in trauma patients. Crit Care Med 34: 1067-1072
32.Vincent JL, Bihari DJ, Suter PM, Bruining HA, White J, Nicolas-Chanoin MH, Wolff M, Spencer RC, Hemmer M, (1995) The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA 274: 639-644
33.Fridkin SK, Gaynes RP, (1999) Antimicrobial resistance in intensive care units. Clin Chest Med 20: 303-316, viii
34.Williams RE, (1963) Healthy carriage of Staphylococcus aureus: its prevalence and importance. Bacteriol Rev 27: 56-71
35.Thompson RL, Cabezudo I, Wenzel RP, (1982) Epidemiology of nosocomial infections caused by methicillin-resistant Staphylococcus aureus. Ann Intern Med 97: 309-317
36.Foster TJ, (2004) The Staphylococcus aureus "superbug". J Clin Invest 114: 1693-1696
37.Sista RR, Oda G, Barr J, (2004) Methicillin-resistant Staphylococcus aureus infections in ICU patients. Anesthesiol Clin North America 22: 405-435, vi
38.Huang YC, Hwang KP, Chen PY, Chen CJ, Lin TY, (2007) Prevalence of methicillin-resistant Staphylococcus aureus nasal colonization among Taiwanese children in 2005 and 2006. J Clin Microbiol 45: 3992-3995
39.Creech CB, 2nd, Kernodle DS, Alsentzer A, Wilson C, Edwards KM, (2005) Increasing rates of nasal carriage of methicillin-resistant Staphylococcus aureus in healthy children. Pediatr Infect Dis J 24: 617-621
40.Fredricks DN, (2001) Microbial ecology of human skin in health and disease. J Investig Dermatol Symp Proc 6: 167-169
41.Roth RR, James WD, (1988) Microbial ecology of the skin. Annu Rev Microbiol 42: 441-464
42.Pfaller MA, Herwaldt LA, (1988) Laboratory, clinical, and epidemiological aspects of coagulase-negative staphylococci. Clin Microbiol Rev 1: 281-299
43.Richards MJ, Edwards JR, Culver DH, Gaynes RP, (1999) Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med 27: 887-892
44.Streit JM, Jones RN, Sader HS, Fritsche TR, (2004) Assessment of pathogen occurrences and resistance profiles among infected patients in the intensive care unit: report from the SENTRY Antimicrobial Surveillance Program (North America, 2001). Int J Antimicrob Agents 24: 111-118
45.Hoban DJ, Biedenbach DJ, Mutnick AH, Jones RN, (2003) Pathogen of occurrence and susceptibility patterns associated with pneumonia in hospitalized patients in North America: results of the SENTRY Antimicrobial Surveillance Study (2000). Diagn Microbiol Infect Dis 45: 279-285
46.(2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171: 388-416
47.Connie R. Mahon GM (2000) Enterobacteriaceae. In: Connie R. Mahon GM (ed) Textbook of diagnostic microbiology. Saunders, Philadelphia, pp. 463-514
48.Halwani M, Solaymani-Dodaran M, Grundmann H, Coupland C, Slack R, (2006) Cross-transmission of nosocomial pathogens in an adult intensive care unit: incidence and risk factors. J Hosp Infect 63: 39-46
49.Grundmann H, Barwolff S, Tami A, Behnke M, Schwab F, Geffers C, Halle E, Gobel UB, Schiller R, Jonas D, Klare I, Weist K, Witte W, Beck-Beilecke K, Schumacher M, Ruden H, Gastmeier P, (2005) How many infections are caused by patient-to-patient transmission in intensive care units? Crit Care Med 33: 946-951
50.Selden R, Lee S, Wang WL, Bennett JV, Eickhoff TC, (1971) Nosocomial klebsiella infections: intestinal colonization as a reservoir. Ann Intern Med 74: 657-664
51.De Louvois J, (1969) Serotyping and the Dienes reaction on Proteus mirabilis from hospital infections. J Clin Pathol 22: 263-268
52.Beezhold DW, Slaughter S, Hayden MK, Matushek M, Nathan C, Trenholme GM, Weinstein RA, (1997) Skin colonization with vancomycin-resistant enterococci among hospitalized patients with bacteremia. Clin Infect Dis 24: 704-706
53.Gould IM, (2002) Antibiotic policies and control of resistance. Curr Opin Infect Dis 15: 395-400
54.Chow JW, Yu VL, Shlaes DM, (1994) Epidemiologic perspectives on Enterobacter for the infection control professional. Am J Infect Control 22: 195-201
55.Morris JG, Jr., Shay DK, Hebden JN, McCarter RJ, Jr., Perdue BE, Jarvis W, Johnson JA, Dowling TC, Polish LB, Schwalbe RS, (1995) Enterococci resistant to multiple antimicrobial agents, including vancomycin. Establishment of endemicity in a university medical center. Ann Intern Med 123: 250-259
56.Shlaes DM, Binczewski B, Rice LB, (1993) Emerging antimicrobial resistance and the immunocompromised host. Clin Infect Dis 17 Suppl 2: S527-536
57.Rello J, Ausina V, Ricart M, Castella J, Prats G, (1993) Impact of previous antimicrobial therapy on the etiology and outcome of ventilator-associated pneumonia. Chest 104: 1230-1235
58.Lucet JC, Paoletti X, Lolom I, Paugam-Burtz C, Trouillet JL, Timsit JF, Deblangy C, Andremont A, Regnier B, (2005) Successful long-term program for controlling methicillin-resistant Staphylococcus aureus in intensive care units. Intensive Care Med 31: 1051-1057
59.Blot SI, Vandewoude KH, Hoste EA, Colardyn FA, (2002) Effects of nosocomial candidemia on outcomes of critically ill patients. Am J Med 113: 480-485
60.Garnacho-Montero J, Garcia-Garmendia JL, Barrero-Almodovar A, Jimenez-Jimenez FJ, Perez-Paredes C, Ortiz-Leyba C, (2003) Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis. Crit Care Med 31: 2742-2751
61.Harbarth S, Garbino J, Pugin J, Romand JA, Lew D, Pittet D, (2003) Inappropriate initial antimicrobial therapy and its effect on survival in a clinical trial of immunomodulating therapy for severe sepsis. Am J Med 115: 529-535
62.Heyland DK, Cook DJ, Griffith L, Keenan SP, Brun-Buisson C, (1999) The attributable morbidity and mortality of ventilator-associated pneumonia in the critically ill patient. The Canadian Critical Trials Group. Am J Respir Crit Care Med 159: 1249-1256
63.Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH, (2000) The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest 118: 146-155
64.Iregui M, Ward S, Sherman G, Fraser VJ, Kollef MH, (2002) Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia. Chest 122: 262-268
65.Kollef MH, (2000) Inadequate antimicrobial treatment: an important determinant of outcome for hospitalized patients. Clin Infect Dis 31 Suppl 4: S131-138
66.Tenover FC, (2006) Mechanisms of antimicrobial resistance in bacteria. Am J Med 119: S3-10; discussion S62-70
67.Tenover FC, McGowan JE, Jr., (1996) Reasons for the emergence of antibiotic resistance. Am J Med Sci 311: 9-16
68.Marshall C, Wesselingh S, McDonald M, Spelman D, (2004) Control of endemic MRSA-what is the evidence? A personal view. J Hosp Infect 56: 253-268
69.Monnet DL, (1998) Methicillin-resistant Staphylococcus aureus and its relationship to antimicrobial use: possible implications for control. Infect Control Hosp Epidemiol 19: 552-559
70.Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR, Boyce JM, Farr BM, (2003) SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. Infect Control Hosp Epidemiol 24: 362-386
71.Kuo LC, Yu CJ, Kuo ML, Chen WN, Chang CK, Lin HI, Chen CC, Lu MC, Lin CH, Hsieh WF, Chen LW, Chou Y, Huang MS, Lee CH, Chen SC, Thai SL, Chen PC, Chen CH, Tseng CC, Chen YS, Hsiue TR, Hsueh PR, (2008) Antimicrobial resistance of bacterial isolates from respiratory care wards in Taiwan: a horizontal surveillance study. Int J Antimicrob Agents 31: 420-426