中心靜脈導管病人使用含CHG抗菌敷料與一般防水透氣敷料,哪一種敷料對降低的導管相關血流感染的效果較佳?Using CHG antibacterial dressings and Standard polyurethane dressings, which dressing is more effective in reducing catheter-related bloodstream infections for patients with central venous catheters?

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2020-07-22 已刊登
新刊登 綜 整 預防/治療/介入類型

作  者

鄭麗華* 陳淑賢 胡瑞桃 余文彬

實證知識類別

A 類:實證健康照護綜整

PICO

治療/預防性問題

治療/介入措施

其他 other

科別

  • 重症護理 Critical Care Nursing

中文關鍵詞

中心靜脈導管、CHG抗菌敷料、導管相關血流感染

英文關鍵詞

Central venous catheter CHG antibacterial dressing Central-Line Associated Bloodstream Infection(CLABSI).

機構名稱

長庚醫療財團法人基隆長庚紀念醫院

申請單位

護理部門

中文摘要

形成臨床提問:
裝置中心靜脈導管病人照護時,使用一般防水透氣敷料覆蓋,目的為建立物理性安全屏障,以降低細菌侵入機會,主要可預防導管相關血流感染(Central Line-associated Bloodstream Infection, CLABSI),臨床市面上推出含CHG抗菌敷料(chlorhexidine gluconate, CHG),可降低皮膚菌叢感染之敷料。此含CHG抗菌敷料,可於市面上醫療器材店購買,護理人員常面臨病人或家屬是否需要購買此抗菌敷料,幫助降低感染發生。鑑此,擬以實證手法瞭解含CHG抗菌敷料與一般防水透氣敷料(簡稱OP site)之CLABSI感染率進行比較。
文獻搜尋的方法與分析:
本文以情境臨床提問形成PICO,利用主要關鍵字:【P】central venous catheters。【I】chlorhexidine gluconate-impregnated dressings。【C】polyurethane dressings。【O】central line-associated bloodstream infection,以「or」、「and」及括號串聯進行搜尋,使用PubMed、Cochrane Library和EMBASE等資料庫,不設限年份及與語言,得到英文文獻共76篇,篩選系統性回顧文獻(Systematic Review, SR)及隨機分派試驗( Randomized Clinical Trial, RCT)優先評讀,最後以證據等級較高的1篇SR(2015)與1篇RCT(2019)進行評讀。
文獻的品質評讀:
評讀文獻,一篇為Systematic Reviews(2015)證據等級為Level 1(治療型)及1篇RCT 採用Cochrane (2016) RoB 2.0 評讀文獻品質為Low risk of bias (L)。研究對象皆為接受中心靜脈導管病人且大於18 歲,介入措施是含CHG抗菌敷料於導管照護;控制組接受一般防水透氣敷料。結果比較兩種敷料的導管相關血流感染率,SR統合分析結果無顯著差異(Z=1.78, p=0.08, RR 0.65, 95%CI: 0.40-1.05),RCT研究兩組比較結果無差異( p= 1.00),顯示與一般防水透氣敷料相比,使用含CHG抗菌敷料並無顯著較低的導管相關血流感染率。
結論與建議:
放置中心靜脈導管病人,於系統性回顧文獻結果顯示相較使用一般防水透氣敷料每一千人中有27人有血流感染發生,而使用含CHG抗菌敷料每一千人中有16人有血流感染發生,兩者相比則無顯著統計差異。藉由此實證文獻的搜尋,並沒有足夠的證據支持何種敷料可以有效降低導管相關血流感染。未來有待更多嚴謹的隨機試驗,控制隨機分配與隱匿偏差,提供臨床參考。

英文摘要

Ask an answerable question (PICO):
In the care of patients with central venous catheters, use standard polyurethane dressings to cover. The purpose is to establish a physical safety barrier to reduce the chance of bacterial invasion, mainly to prevent catheter-related bloodstream infection (Central Line-associated Bloodstream Infection, CLABSI). Fixed function to prevent slippage of the catheter, prevent skin allergies and prevent skin flora. The clinical market has introduced CHG antibacterial dressings (chlorhexidine gluconate, CHG) that can reduce skin flora (Staphylococcus Epidermidis or Staphylococcus Aureus) infection. This antibacterial dressing containing CHG can be purchased from medical equipment stores in the market. Nursing staff often face whether patients or family members need to purchase this antibacterial dressing to help reduce the occurrence of infections. In view of this, we intend to use methods of evidenced-based to understand the comparison of CLABSI infection rates between CHG antibacterial dressings and standard polyurethane dressings (OP site).
The Method and Analysis of Literature Review:
PICO is formed from situational clinical questions, using the main keyword: [P] central venous catheters.【I】chlorhexidine gluconate-impregnated dressings. [C] Polyurethane dressings. [O] Central line-associated bloodstream infection. The search strategy with "or", "and" and brackets in series, using PubMed, Cochrane Library, EMBASE and other databases, regardless of year and language. A total of 76 articles in English were obtained. Priority is given to the screening of Systematic Reviews and randomized trials. Finally, 1 Systematic Reviews (2015) and 1 RCT (2019) with higher evidence levels are used for evaluation.
Critical Appraisal:
Among the two articles reviewed, Systematic Reviews (2015) used the CASP and Oxford research evidence to use grade classification to evaluate the level of evidence as Level 1 (Therapeutic type); and 1 RCT used Cochrane (2016) RoB 2.0 to evaluate the quality of the literature It is low risk of bias (L). The subjects of the study were patients who received central venous catheters and were older than 18 years of age. The interventional measures included CHG antibacterial dressings in catheter care; the control group received polyurethane dressings. Results Comparing the catheter-related bloodstream infection rates of the two dressings, there was no significant difference in the results of the integrated analysis of the SR study (Z=1.78, P=0.08, RR 0.65, 95%CI: 0.40-1.05), and there was no difference between the two groups in the RCT study. (P=1.00), showing that compared with polyurethane dressings, the use of CHG-containing antibacterial dressings does not have a significantly lower catheter-related bloodstream infection rate.
Conclusions and Recommendations:
The patients of central venous catheters that compared with the use of general waterproof and breathable dressings, 27 people have bloodstream infections per 1,000 people. However, 16 people out of every 1,000 people who used CHG antibacterial dressings had bloodstream infections, and there was no significant statistical difference between the two. Based on this empirical literature search, there is not enough evidence to support which dressings can effectively reduce catheter-related bloodstream infections. In the future, more rigorous randomized trials are needed to control random allocation and concealed allocation and provide clinical reference.