Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial.
Effect of body surface decolonisation on bacteriuria and candiduria in intensive care units: an analysis of a cluster-randomised trial.
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体表去定植对重症监护室菌尿和念珠菌尿的影响：整群随机试验分析。
DOI：
10.1016/s1473-3099(15)00238-8
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发表时间：
2016
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作者：
Huang,SusanS;Septimus,Edward;Hayden,MaryK;Kleinman,Ken;Sturtevant,Jessica;Avery,TaliserR;Moody,Julia;Hickok,Jason;Lankiewicz,Julie;Gombosev,Adrijana;Kaganov,RebeccaE;Haffenreffer,Katherine;Jernigan,JohnA;Perlin,JonathanB;
研究背景尿路感染（UTIs）是常见的卫生保健相关感染。细菌尿通常先于UTI，通常用抗生素治疗，特别是在医院重症监护室（ICU）。2013年，一项群集随机试验（REDUCE MRSA试验[随机评价去殖民化与普遍清除以根除MRSA]）显示，体表去殖民化减少了所有病原体的血流感染。我们的目的是进一步评估非殖民化的影响，对细菌尿和念珠菌尿症的患者入院ICUs.MethodsWe做了一个二次分析的三组，43家医院（集群）的患者在74成人ICU的群集随机试验。包括的三组是耐甲氧西林金黄色葡萄球菌（MRSA）筛查和分离，氯己定和莫匹罗星靶向去克隆化（MRSA携带者的筛查、分离和去克隆化），氯己定和莫匹罗星通用去克隆化（无筛查，所有患者去克隆化）。方案包括洗必泰清洗会阴和近端6英寸（15·24 cm）的导尿管。同一家医院的ICU被分配了相同的策略。结果包括高水平菌尿（≥50 000菌落形成单位[CFU]/mL）伴任何尿路病原体、高水平念珠菌尿（≥50 000 CFU/mL）和任何菌尿伴尿路病原体。 性别特异性分析是事先规定的。比例风险模型评估了各组之间结局减少的差异，比较了18个月的干预期和12个月的基线期。 高水平菌尿的干预与基线风险比（HR）为1.02（95%CI 0·88-1·18）筛查或隔离，0·88（0.76 - 1.02）用于有针对性的非殖民化，（0·77-1·00）普遍非殖民化（组间无差异，p= 0.26），无性别特异性降低（男性的HR：筛查或隔离为1.09 [95%CI 0.85 - 1.40]，目标去殖民化为1.01 [0.79 - 1.29]，普遍去殖民化为0.78 [0.63 - 0.98]，p= 0.12;妇女人力资源：筛选和分离为0·97 [0·80-1·17]，靶向去定殖为0·83 [0·70-1·00]，普遍去定殖为0·93 [0·79-1·09]，p=0·49）。高水平念珠菌尿症的HR在筛选和分离组为1.14（0.95 - 1.37），靶向去殖组为0.99（0.83 - 1.18），普遍去殖组为0.83（0.70 - 0.99）（p= 0.05）。性别间的差异是由于普遍去殖民化组中男性的减少（HR：筛选或隔离组为1·21 [95% CI 0·88-1·68]，靶向去殖民化组为1·01 [0·73-1·39]，普遍去殖民化组为0·63 [0·45-0·89]，p=0·02）。在普遍去殖民化组中，任何CFU/mL的菌尿也减少了（筛选或分离的HR为1·01 [0·81-1·25]，靶向去定殖的HR为1·04 [0·83-1·30]，普遍去定殖的HR为0·74 [0·61-0·90]，p=0·04）。解释ICU患者每天洗一次洗必泰浴和短时间洗必泰浴的普遍去殖民化。鼻用莫匹罗星可作为男性患者的潜在预防策略，因为它可显著降低念珠菌尿和任何菌尿，但对女性无效。美国卫生与公众服务部作为制定有效性决策证据（DECIDE）计划，CDC预防中心计划的一部分。
BackgroundUrinary tract infections (UTIs) are common health-care-associated infections. Bacteriuria commonly precedes UTI and is often treated with antibiotics, particularly in hospital intensive care units (ICUs). In 2013, a cluster-randomised trial (REDUCE MRSA Trial [Randomized Evaluation of DecolonizationvsUniversal Clearance to Eradicate MRSA]) showed that body surface decolonisation reduced all-pathogen bloodstream infections. We aim to further assess the effect of decolonisation on bacteriuria and candiduria in patients admitted to ICUs.MethodsWe did a secondary analysis of a three-group, cluster-randomised trial of 43 hospitals (clusters) with patients in 74 adult ICUs. The three groups included were either meticillin-resistantStaphylococcus aureus(MRSA) screening and isolation, targeted decolonisation (screening, isolation, and decolonisation of MRSA carriers) with chlorhexidine and mupirocin, and universal decolonisation (no screening, all patients decolonised) with chlorhexidine and mupirocin. Protocol included chlorhexidine cleansing of the perineum and proximal 6 inches (15·24 cm) of urinary catheters. ICUs within the same hospital were assigned the same strategy. Outcomes included high-level bacteriuria (≥50 000 colony forming units [CFU]/mL) with any uropathogen, high-level candiduria (≥50 000 CFU/mL), and any bacteriuria with uropathogens. Sex-specific analyses were specified a priori. Proportional hazards models assessed differences in outcome reductions across groups, comparing an 18-month intervention period to a 12-month baseline period.Findings122 646 patients (48 390 baseline, 74 256 intervention) were enrolled. Intervention versus baseline hazard ratios (HRs) for high-level bacteriuria were 1·02 (95% CI 0·88–1·18) for screening or isolation, 0·88 (0·76–1·02) for targeted decolonisation, and 0·87 (0·77–1·00) for universal decolonisation (no difference between groups, p=0·26), with no sex-specific reductions (HRs for men: 1·09 [95% CI 0·85–1·40] for screening or isolation, 1·01 [0·79–1·29] for targeted decolonisation, and 0·78 [0·63–0·98] for universal decolonisation, p=0·12; HRs for women: 0·97 [0·80–1·17] for screening and isolation, 0·83 [0·70–1·00] for targeted decolonisation, and 0·93 [0·79–1·09] for universal decolonisation, p=0·49). HRs for high-level candiduria were 1·14 (0·95–1·37) for screening and isolation, 0·99 (0·83–1·18) for targeted decolonisation, and 0·83 (0·70–0·99) for universal decolonisation (p=0·05). Differences between sexes were due to reductions in men in the universal decolonisation group (HRs: 1·21 [95% CI 0·88–1·68] for screening or isolation, 1·01 [0·73–1·39] for targeted decolonisation, and 0·63 [0·45–0·89] for universal decolonisation, p=0·02). Bacteriuria with any CFU/mL was also reduced in men in the universal decolonisation group (HRs 1·01 [0·81–1·25] for screening or isolation, 1·04 [0·83–1·30] for targeted decolonisation, and 0·74 [0·61–0·90] for universal decolonisation, p=0·04).InterpretationUniversal decolonisation of patients in the ICU with once a day chlorhexidine baths and short-course nasal mupirocin could be a potential preventive strategy in male patients because it significantly decreases candiduria and any bacteriuria, but not for women.FundingHAI Program from AHRQ, US Department of Health and Human Services as part of the Developing Evidence to Inform Decisions about Effectiveness (DEcIDE) program, CDC Prevention Epicenters Program.