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Lancet:强化终末消毒措施对控制院内获得性耐药菌和艰难梭菌感染是否有效呢?

发布日期:2018-06-11来源:Lancet发布人:感控雏鹰

针对性增强房间终末消毒在防控医院范围内获得性多重耐药菌和艰难梭菌感染的有效性:一项交叉设计的多中心聚类随机对照试验的二次分析(BETR消毒)

背景

医院环境是病原体传播的来源。在一项多中心,随机对照试验中,强化消毒策略对全院感染发病率的影响效果尚未调查清楚。我们旨在评估四种消毒策略对全院范围内获得性多重耐药菌和艰难梭菌在增强终末房间(BETR)消毒研究中的益处的有效性。

方法

我们对BETR消毒研究的结果进行了预先指定的二次分析,这是一项实用的多中心交叉整群随机试验,评估了美国东南部9家医院的4种不同的终端房间的消毒策略。患有特定感染或定植(由于目标生物体艰难梭菌,耐甲氧西林金黄色葡萄球菌,耐万古霉素肠球菌(VRE)或多重耐药不动杆菌属)的房间被安排分别采用四种终末消毒策略之一:标准消毒(季铵消毒剂,除艰难梭菌外,使用10%次氯酸盐[漂白剂]; 参考); 标准消毒和消毒紫外线(UV-C),但使用漂白剂和UV-C的艰难梭菌除外(UV策略); 10%次氯酸盐(漂白策略); 和漂白剂和UV-C(漂白和紫外线策略)。我们随机分配每个医院的战略顺序(1:1:1:1),每个消毒策略使用7个月,包括1个月的试用期和6个月的数据收集。预先确定的次要结果是全院范围内医院获得目标细菌的发生率(以每10 000患者日有目标生物体的医院获得性感染患者数量计算),以及全院范围内每一种医院获得性目标细菌的发生率。BETR消毒已注册,编号NCT01579370。

发现

2012年4月至2014年7月期间,共有271 740名独立患者,入院人数为375918人。符合所有入选标准的314610名入选者(参考研究期间n = 73 071,紫外线研究期间n = 81621,漂白研究期间n = 78760,漂白剂和紫外线研究期间n = 81158 )。研究期间发生了2681例院内感染或定植病例。标准消毒与所有目标多药耐药病原菌的三种增强终末消毒策略在全医院范围内的目标微生物采集风险无显着差异(紫外线研究期相对风险[RR] 0.89,95%CI 0.79-1.00; p = 0.052;漂白研究期0.92,0.79-1.08; p = 0.32;漂白和UV研究期0.99,0.89-1.11; p = 0.89)。艰难梭菌(RR 0.89,95%CI 0.80-0.99; p = 0.031)和VRE(0.056,0.31-0.996; p = 0.048)。

解释

在高风险的目标房间使用紫外线加强房间的终末消毒,可以导致全院范围内艰难梭菌和VRE的发病率下降。增强终末消毒能够克服标准消毒策略的局限性,并且是降低获得多重耐药性病原菌和艰难梭菌风险的潜在策略。


Effectiveness of targeted enhanced terminal room disinfection on hospital-wide acquisition and infection with multidrug-resistant organisms and Clostridium difficile: a secondary analysis of a multicentre cluster randomised controlled trial with crossover design (BETR Disinfection)


Background

The hospital environment is a source of pathogen transmission. The effect of enhanced disinfection strategies on the hospital-wide incidence of infection has not been investigated in a multicentre, randomised controlled trial. We aimed to assess the effectiveness of four disinfection strategies on hospital-wide incidence of multidrug-resistant organisms and Clostridium difficile in the Benefits of Enhanced Terminal Room (BETR) Disinfection study.

Methods

We did a prespecified secondary analysis of the results from the BETR Disinfection study, a pragmatic, multicentre, crossover cluster-randomised trial that assessed four different strategies for terminal room disinfection in nine hospitals in the southeastern USA. Rooms from which a patient with a specific infection or colonisation (due to the target organisms C difficile, meticillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci (VRE), or multidrug-resistant Acinetobacter spp) was discharged were terminally disinfected with one of four strategies: standard disinfection (quaternary ammonium disinfectant, except for C difficile, for which 10% hypochlorite [bleach] was used; reference); standard disinfection and disinfecting ultraviolet light (UV-C), except for C difficile, for which bleach and UV-C was used (UV strategy); 10% hypochlorite (bleach strategy); and bleach and UV-C (bleach and UV strategy). We randomly assigned the sequence of strategies for each hospital (1:1:1:1), and each strategy was used for 7 months, including a 1-month wash-in period and 6 months of data collection. The prespecified secondary outcomes were hospital-wide, hospital-acquired incidence of all target organisms (calculated as number of patients with hospital-acquired infection with a target organism per 10?000 patient days), and hospital-wide, hospital-acquired incidence of each target organism separately. BETR Disinfection is registered with ClinicalTrials.gov, number NCT01579370.

Findings

Between April, 2012, and July, 2014, there were 271740 unique patients with 375918 admissions. 314610 admissions met all inclusion criteria (n=73071 in the reference study period, n=81621 in the UV study period, n=78760 in the bleach study period, and n=81158 in the bleach and UV study period). 2681 incidenct cases of hospital-acquired infection or colonisation occurred during the study. There was no significant difference in the hospital-wide risk of target organism acquisition between standard disinfection and the three enhanced terminal disinfection strategies for all target multidrug-resistant organisms (UV study period relative risk [RR] 0.89, 95% CI 0.79–1.00; p=0.052; bleach study period 0.92, 0.79–1.08; p=0.32; bleach and UV study period 0.99, 0.89–1.11; p=0.89). The decrease in risk in the UV study period was driven by decreases in risk of acquisition of C difficile (RR 0.89, 95% CI 0.80–0.99; p=0.031) and VRE (0.56, 0.31–0.996; p=0.048).

Interpretation

Enhanced terminal room disinfection with UV in a targeted subset of high-risk rooms led to a decrease in hospital-wide incidence of C difficile and VRE. Enhanced disinfection overcomes limitations of standard disinfection strategies and is a potential strategy to reduce the risk of acquisition of multidrug-resistant organisms and C difficile.

简译人:感控雏鹰