臺灣博碩士論文加值系統

血液腫瘤病人由於接受細胞毒性化學治療誘發中性粒細胞減少，造成免疫力低下，增加醫療照護相關血流感染的風險。侵入性醫療裝置如中心靜脈導管，是血液腫瘤科病人不可避免的醫療處置，但卻也是血流感染(BSI)重要危險因子。導管置入點為細菌進入人體的途徑，造成病人局部和全身性感染，而皮膚菌叢常移生於置入之導管進而發生血流感染，因此置入導管前皮膚清潔消毒是預防感染之重要措施。回顧國外多篇研究，每日使用含2% Chlorhexidine (CHG) 浸漬紙巾擦拭浴，可以有效降低醫療照護相關血流感染，且為國外之醫療常規。但在國內則尚未有相關研究。
目的：為釐清每日以較高濃度2% CHG抗菌劑沐浴相較於每日使用一般常規抗菌潔膚露(劑)沐浴是否可減少皮膚菌叢引起血流感染(SKIN_BSI)、中心靜脈導管相關血流感染(CLABSI_CVC)，進而降低醫療照護相關血流感染(HABSI)之發生率，以提升病人之存活率。
方法：本研究為前瞻性介入性研究，研究期間為2015年12月~2016年6月。研究對象為二個血液腫瘤單位住院病人，符合受納者條件者，經同意並簽屬受試者同意書，於住院期間每日使用含2%CHG抗菌劑沖洗浴或含2%CHG浸漬紙巾擦拭浴為實驗組；每日使用一般常規抗菌潔膚露(劑)沐浴之血液腫瘤科住院病人，將回溯性利用電子病歷紀錄收集其相關人口學資料、臨床資料及實驗室檢查資料等為對照組。比較二組first SKIN_BSI、first CLABSI_CVC及first HABSI之發生率。
結果：總計485人為實驗組，408人為對照組，利用Chi_score檢定，實驗組first SKIN_BSI發生率相較對照組減少65.5% (1.0 vs 2.9每1000住院人日, P=0.012)，有顯著差異；實驗組first CLABSI_CVC發生率相較對照組減少61% (6.6 vs 16.9每1000住院人日, P=0.005)，有顯著差異；實驗組first HABSI 發生率相較對照組減少35% (7.8 vs 12.0 每1000住院人日, P=0.035) ，有顯著差異。以邏輯斯迴歸分析，經調整干擾變項後，結果顯示實驗組病人可因介入措施使得發生first SKIN_BSI之風險，顯著下降70% (OR=0.3, P=0.02)；first CLABSI_CVC之比例，顯著下降68% (HR=0.32, P=0.009)；first HABSI之風險，顯著下降59% (OR=0.41, P=0.002)，但對腸道來源之大腸桿菌(Escherichia coli)及克雷伯氏肺炎菌(Klebsiella pneumoniae) 菌血症（作為對照指標）則無預防效果 (OR=0.993, P=0.99)。
結論：每日使用含2% CHG抗菌劑進行沖洗浴，主要加強病人皮膚清潔外，並能對皮膚菌叢有殺菌及抑菌之作用，而結果顯示研究期間病人SKIN_BSI、CLABSI_CVC之發生率明顯下降，進而降低整體HABSI。使用2% CHG沐浴，提供一種相對簡單、省成本又安全的策略，建議此措施可推行於血液腫瘤科病人，以預防血流感染。

Background
Hematology patients undergoing immunocompromising cytotoxic chemotherapy are at risk for healthcare-associated infections. It remains unclear whether daily bathing with 2% chlorhexidine can reduce the risk. The aim of this study is to compare the incidence of healthcare-associated bloodstream infection (HABSI) between patients using of 2% CHG daily bath and those using general antibacterial cleansers daily bath.
Methods
This was a single-arm prospective interventional study. Patients admitted to two hematological units during the period from December 2015 to June 2016 were the study population. We recruited patients to receive 2% CHG daily bath (intervention group). Those who refused to participate were provided with general antibacterial cleansers daily bath (control group). The incidence rate of skin flora-related bloodstream infection (SKIN_BSI), central venous catheter (CVC)-associated bloodstream infection (CLABSI_CVC), and HABSI of the intervention group were compared with that of the control group.
Results
In total, 485 patients were enrolled as the intervention group, and the other 408 patients served as control group. Compared with the control group, the incidence rate of first SKIN_BSI was reduced by 65.5% (1.0 vs 2.9 per 1,000 patient-day, p=0.012), the incidence rate of first CLABSI_CVC was reduced by 61% (6.6 vs 16.9 per 1,000 patient-day, P = 0.005) and the incidence rate of first HABSI was reduced by 35% (7.8 vs 12.0 per 1,000 patient-day, P=0.035) in the intervention group. After adjusting for effects of confounding variables by logistic regression, the 2% CHG daily bath reduces the risk of first SKIN_BSI by 70% (adjusted OR=0.3, P=0.02), the risk of first CLABSI_CVC by 68% (adjusted OR=0.32, P=0.01), and the risk of first HABSI by 59% (adjusted OR=0.41, P=0.002). In contrast, the risk of gut-origin bacteremia, such as Escherichia coli and Klebsiella pneumoniae-related bloodstream infection, did not change (adjusted OR=0.99, P=0.99).
Conclusion
Daily bathing with 2% CHG is effective in reducing skin flora-related bloodstream infection and cathether-related bacteremia. We recommend routine adoption of this simple and low-cost intervention to reduce BSI among patients with hematological malignancy.

第一章 導論 1
第一節 實習單位特色與簡介 1
第二節 研究背景與動機 3
第三節 文獻回顧 4
第四節 研究目的 11
第二章 方法 12
第一節 研究架構 12
第二節 研究設計 12
第三節 研究指標 13
第四節 資料來源 15
第五節 資料收集 16
第六節 資料分析 20
第三章 結果 21
第一節 研究個案特性分析 21
第二節 單變量分析 22
第三節 多變量分析 26
第四章 討論 27
第一節 研究成效分析及探討 27
第二節 研究限制 29
第五章 結論及建議 30
參考文獻 31
附錄一 血流感染收案定義
附錄二 研究受訪者說明及同意書
附錄三 2%CHG沐浴產品說明、使用方式及流程
附錄四 IRB審核通過文件

1.de Naurois, J., et al., Management of febrile neutropenia: ESMO Clinical Practice Guidelines. Ann. Oncol, 2011. 21, Suppl 5:v252-6.
2.Apostolopoulou, E., et al., Infection Probability Score, APACHE II and KARNOFSKY scoring systems as predictors of bloodstream infection onset in hematology-oncology patients. Bmc Infectious Diseases, 2010. 10.
3.O''Grady, et al., Guidelines for the Prevention of Intravascular Catheter-Related Infections. Healthcare Infection Control Practices Advisory Committee (HICPAC), 2011.
4.Huoi, C., et al., Incidence of Hospital-Acquired Pneumonia, Bacteraemia and Urinary Tract Infections in Patients with Haematological Malignancies, 2004-2010: A Surveillance-Based Study. Plos One, 2013. 8(3).
5.Brunelli, S.M., et al., Clinical and economic burden of bloodstream infections in critical care patients with central venous catheters. Journal of Critical Care, 2016. 35: p. 69-74.
6.Kaur, M., et al., Incidence, risk factors, microbiology of venous catheter associated bloodstream infections - A prospective study from a tertiary care hospital. Indian Journal of Medical Microbiology, 2015. 33(2): p. 248-254.
7.Leistner, R., et al., Costs and prolonged length of stay of central venous catheter-associated bloodstream infections (CVC BSI): a matched prospective cohort study. Infection, 2014. 42(1): p. 31-36.
8.Kao, H.-F., et al., Chlorhexidine for the prevention of bloodstream infection associated with totally implantable venous ports in patients with solid cancers. Supportive Care in Cancer, 2014. 22(5): p. 1189-1197.
9.Bashir, M.H., L.K.M. Olson, and S.-A. Walters, Suppression of regrowth of normal skin flora under chlorhexidine gluconate dressings applied to chlorhexidine gluconate-prepped skin. American Journal of Infection Control, 2012. 40(4): p. 344-348.
10.Weber, D.J. and W.A. Rutala, Central Line-Associated Bloodstream Infections: Prevention and Management. Infectious Disease Clinics of North America, 2011. 25(1): p. 77-102.
11.Munoz-Price, L.S., et al., Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital. Infect Control Hosp Epidemiol, 2009. 30(11): p. 1031-5.
12.Climo, M.W., et al., Effect of Daily Chlorhexidine Bathing on Hospital-Acquired Infection. New England Journal of Medicine, 2013. 368(6): p. 533-542.
13.Cassir, N., et al., Chlorhexidine daily bathing: Impact on health care–associated infections caused by gram-negative bacteria. American Journal of Infection Control, 2015. 43(6): p. 640 - 643
14.Reasbeck, P.G. and S. Fiockhart, Effectiveness of a care bundle to reduce central line-associated bloodstream infections. Medical Journal of Australia, 2015. 203(3): p. 138-138.
15.Chen, W.S., et al., Effects of daily bathing with chlorhexidine and acquired infection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: a meta-analysis. Journal of Thoracic Disease, 2013. 5(4): p. 518-524.
16.Montecalvo, M.A., et al., Chlorhexidine Bathing to Reduce Central Venous Catheter-associated Bloodstream Infection: Impact and Sustainability. American Journal of Medicine, 2012. 125(5): p. 505-511.
17.Dixon, J.M. and R.L. Carver, Daily chlorohexidine gluconate bathing with impregnated cloths results in statistically significant reduction in central line-associated bloodstream infections. American Journal of Infection Control, 2010. 38(10): p. 817-821.
18.Evans, H.L., et al., Effect of Chlorhexidine Whole-Body Bathing on Hospital-Acquired Infections Among Trauma Patients. Archives of Surgery, 2010. 145(3): p. 240-246.
19.Seyman, D., et al., Weekly chlorhexidine douche: does it reduce healthcare-associated bloodstream infections? Scandinavian Journal of Infectious Diseases, 2014. 46(10): p. 697-703.
20.Donskey, C.J. and A. Deshpande, Effect of chlorhexidine bathing in preventing infections and reducing skin burden and environmental contamination: A review of the literature. American Journal of Infection Control, 2016. 44(5): p. E17-E21.
21.Lo Menzo, S., et al., New Insight on Epidemiology and Management of Bacterial Bloodstream Infection in Patients with Hematological Malignancies. Mediterranean Journal of Hematology and Infectious Diseases, 2015. 7.
22.行政院衛生福利部疾病管制署, 醫療照護相關感染監測定義. 2009: p. 15-22.
23.Arefian, H., et al., Economic Evaluation of Interventions for Prevention of Hospital Acquired Infections: A Systematic Review. Plos One, 2016. 11(1).
24.Cook, E., D. Marchaim, and K.S. Kaye, Building a Successful Infection Prevention Program: Key Components, Processes, and Economics. Infectious Disease Clinics of North America, 2011. 25.
25.Zimlichman, E., et al., Health Care-Associated Infections A Meta-analysis of Costs and Financial Impact on the US Health Care System. Jama Internal Medicine, 2013. 173(22): p. 2039-2046.
26.Hsu, V., Prevention of Health Care-Associated Infections. American Family Physician, 2014. 90(6): p. 377-382.
27.McAlearney, A.S., et al., Preventing Central Line-Associated Bloodstream Infections: A Qualitative Study of Management Practices. Infection Control and Hospital Epidemiology, 2015. 36(5): p. 557-563.
28.WHO, Guidelines on Hand Hygiene in Health Care. 2009.
29.Pages, J., et al., Comparison of alcoholic chlorhexidine and povidone-iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study. Intensive Care Medicine, 2016. 42(9): p. 1418-1426.
30.Cassir, N., et al., Insights into bacterial colonization of intensive care patients'' skin: the effect of chlorhexidine daily bathing. European Journal of Clinical Microbiology & Infectious Diseases, 2015. 34(5): p. 999-1004.
31.Suner, A., et al., Assessment of bloodstream infections and risk factors in an intensive care unit. Turkish Journal of Medical Sciences, 2015. 45(6): p. 1243-1250.
32.Trethon, A., et al., Characteristic of nosocomial bloodstream infections at a hungarian cardiac surgical centre. Acta Microbiologica Et Immunologica Hungarica, 2012. 59(2): p. 271-283.
33.Glied, S., et al., Trends in mortality, length of stay, and hospital charges associated with health care-associated infections, 2006-2012. American Journal of Infection Control, 2016. 44(9): p. 983-989.
34.Zhao, X., et al., Risk factors for hospital-acquired infection in cancer patients in a central Chinese hospital. American Journal of Infection Control, 2016. 44(9): p. E163-E165.
35.Puhto, T., et al., Point prevalence and risk factors for healthcare-associated infections in primary healthcare wards. Infection, 2011. 39(3): p. 217-223.