住院兒童醫療照護相關感染流行病學、醫療利用及死亡情形探討

Abstract

兒童因生長發展階段免疫功能尚未成熟，且在疾病型態上較少見慢性或退化性疾病，故住院中因醫療照護導致的感染部位、菌種及抗藥性情形與成人不同。因此，本研究目的為探討不同年齡層之兒童醫療照護相關染流行病學、醫療利用及死亡情形。 本研究以回溯性研究方法，分析某醫學中心於2010年1月至2014年9月住院兒童的醫療照護相關感染資料。醫療照護相關感染定義依美國疾病管制中心2008年公佈之定義監測。研究期間共發生423人次醫療照護相關感染。研究結果以統計套裝軟體SPSS 17.0版進行資料分析，包括描述性統計、卡方檢定、邏輯式迴歸及存活分析。 研究結果，住院兒童感染部位以血流感染186人次最多(44.0%)。感染的分離菌種主要是革蘭氏陰性菌(59.3%)，為最常造成住院兒童血流、尿路及呼吸道感染的菌種。次之，革蘭氏陽性菌(28.6%)，主要造成手術及皮膚部位感染。整體抗藥性趨勢，oxacillin抗藥性之CoNS (ORCoNS)及S. aureus (ORSA)有升高趨勢；對carbapenem抗藥性之A. baumannii (IRAB) 於2012年後感染趨勢明顯下降。 醫療照護相關感染對住院兒童醫療利用的影響，加護病房別及身上有兩種以上侵入性管路對總住院日數(>30日)有顯著影響。新生兒(出生≦30天)、男性、外科、使用呼吸器對感染至出院日數(>30日)有顯著影響。 醫療照護相關感染住院兒童死亡情形，以Cox迴歸分析存活的相關因素顯示，嬰兒期(>30天~<1歲)、學齡前期(1歲~4歲)及青少年期之死亡風險分別是新生兒(出生≦30天)的4.68、0.83及6.05倍。男性的死亡風險是女性2.77倍。科別部分，外科較內科減少0.16倍的死亡風險。疾病與治療狀態方面，有使用治療藥物死亡風險較無使用者高2.46倍。 本研究同時發現，住院兒童感染抗藥性葡萄球菌仍是上升趨勢，建議臨床人員確實執行手部衛生、接觸防護，感染管制人員則應提供教育訓練，定期分析感染資料，以期及時發現群聚或群突發的可能。藉由此研究，了解不同科別及診斷兒童在住院期間發生感染的分佈，後續可進一步針對這些族群，如兒童血液腫瘤或腦瘤、進行重大手術兒童的感染及預後作流行病學分析。進而，針對不同族群特性及感染部位訂定降低感染事件發生的相關政策，避免感染事件的發生導致後續醫療資源的耗用。

Because of the immunological naivety and having fewer chronic or degenerative organ system disorders, young children present more often with congenital or acquired immune deficiencies as well as congenital syndromes than adults. Therefore, the nosocomial pathogens, most common healthcare associated infection (HAI) sites and antimicrobial-resistant organisms in children differ from those reported among adults. The purpose of the study is to explore the epidemiology and the impact of HAI on medical utility and death among hospitalized children. A retrospective design was conducted for the study. The definition of HAI for the study is based on the definitions defined by the Centers for Disease Control and Prevention in 2008. The population consists of patients under 18 years old, who were hospitalized at a medical center from January 2010 to September 2014. A total of 423 person times were found to have HAI during their hospitalization. The collected data were analyzed by using SPSS (ver. 17) for descriptive statistics, chi-square test, logistic regression and Cox regression. Results: The most frequent sites of infections in hospitalized children were bloodstream infection (44.0%). Bacteria were responsible for gram-negative organisms 59.3% and gram-positive organisms 28.6%. Bloodstream infection, urinary tract infection and respiratory tract infection were most commonly gram-negative organisms. Surgical site infection and skin and soft tissue infection were most commonly gram-positive organisms. The proportion of infections caused by methicillin-resistant coagulase-negative Staphylococcus (CoNS) and Staphylococcus aureus (S. aureus) has increased from 2010 to 2014。 In logistic regression analysis, intensive care unit and use two kinds of invansive procedure are two independent predictors of length of stay. Then age (neonates), sex (men), surgical, and ventilator use are independent predictors of onset infection to discharge. The predictive factors for mortality related to HAI (p &lt; 0.05 in the Cox regression model) are: age (>30day~<1year、1~4years、15~18years), sex (men), surgical and use of antibiotics or steroids. Conclusions: We found large differences in HAI frequency and microbial epidemiology in this study. Clinical monitoring of HAIs and bacterial resistance profiles are required in all pediatric units. Describing the epidemiology of HAIs in the hospital enabled us to establish infection occurrence, distribution, and expected incidence, as well as to recognize trends and keep track of possible outbreaks.