1、血培养: 临床医生应该知道的,北京协和医院杜斌,Conflicts of Interest,Speaker fee or consultation fee from the following pharmaceutical companiesGSKEli lillyPfizerSanofi-AventisXian JasenMSDBayerWyeth,危重病患者的全身性感染,Brun-Buisson C, Doyon F, Carlet J, et al. Incidence, risk factors, and outcome of severe sepsis and septic shoc
2、k in adults: a multicenter prospective study in intensive care units; French ICU Group for Severe Sepsis. JAMA 1995; 274: 968-974,血行性感染: 概述,在医院获得性感染中所占比例逐渐增加 200,000例血行性感染/年病死率40 50%,血行性感染的致病菌,Michael B. Edmond, Sarah E. Wallace, Donna K. McClish, et al. Nosocomial Bloodstream Infections in United S
3、tates Hospitals: A Three-Year Analysis. Clin Infect Dis 1999; 29: 239-44.Lyytikainen O, Lumio J, Sarkkinen H, et al. Nosocomial Bloodstream Infections in Finnish Hospitals during 19992000. Clin Infect Dis 2002; 35: e14-9,血培养: 临床意义,Perez A, Herranz M, Segura M, et al. Epidemiologic impact of blood cu
4、lture practices and antibiotic consumption on pneumococcal bacteraemia in children. Eur J ClinMicrobiol Infect Dis 2008; 27: 717-724,Navarre vs. Majorca (2000 2004)Occult bacteraemiaRR 11.8 (4.7 29.7)Bacteraemic pneumoniaRR 2.6 (1.5 4.4)MeningitisRR 0.8 (0.2 2.8),血培养: 临床意义,Perez A, Herranz M, Segura
5、 M, et al. Epidemiologic impact of blood culture practices and antibiotic consumption on pneumococcal bacteraemia in children. Eur J ClinMicrobiol Infect Dis 2008; 27: 717-724,内容,菌血症的危险因素,年龄 30岁OR 2.0795% CI 1.19 3.60心率 90 bpmOR 1.9095% CI 1.13 3.17体温 37.8COR 2.4295% CI 1.41 4.14白细胞计数 12,000/LOR 2.4
6、095% CI 1.41 4.10应用中心静脉插管OR 1.8995% CI 1.02 3.50LOS 10天OR 2.0295% CI 1.25 3.24Hosmer-Lemeshow拟和优度检验2.99 (P = .981)ROC AUC0.7186,Jaimes F, Arango C, Ruiz G, et al. Predicting bacteremia at the bedside. Clin Infect Dis. 2004 Feb 1;38(3):357-62. Epub 2004 Jan 13.,菌血症的预测指标,Peduzzi P, et al. Predictors o
7、f bacteremia and Gram-negative bacteremia in patients with sepsis. Arch Intern Med 1992; 152: 529-535,菌血症的预测指标,Peduzzi P, et al. Predictors of bacteremia and Gram-negative bacteremia in patients with sepsis. Arch Intern Med 1992; 152: 529-535,菌血症: 预测指标,主要标准,次要标准(每项1分),怀疑心内膜炎(3分)体温 39.4C (103.0F) (3分
8、)留置血管内导管(2分),体温38.3 39.3C (101.0 102.9F)年龄 65岁寒战呕吐低血压(收缩压 18,000杆状核 5%血小板 2.0 mg/dL,Shapiro NI, Wolfe RE, Wright SB, et al. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med 2008; 35(3): 255-264,菌血症: 预测指标,Shapiro NI, Wolfe RE, Wright SB, et al. Who needs a
9、 blood culture? A prospectively derived and validated prediction rule. J Emerg Med 2008; 35(3): 255-264,菌血症: 预测指标,Shapiro NI, Wolfe RE, Wright SB, et al. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med 2008; 35(3): 255-264,鉴别菌血症患者,发热是重要的临床指标BT 38.5C, 低体温
10、, 白细胞增加, 低血压, 意识障碍警惕体温正常的菌血症鉴别引起体温升高的其他疾病内科危重病患者更为复杂,Shafazand S, Weinacker AB. Blood cultures in the critical care unit. Chest 2002; 122: 1727-1736,内容,血培养阳性率的影响因素,血液屏障细菌数量少间断性菌血症血液成分中的杀菌机制(溶酶体, 补体, 中性粒细胞, 抗体)临床和实验室因素采血量抗生素使用血培养数目血培养时机培养时间培养环境培养基,Shafazand S, Weinacker AB. Blood cultures in the crit
11、ical care unit. Chest 2002; 122: 1727-1736,提高血培养阳性率的措施,Shafazand S, Weinacker AB. Blood cultures in the critical care unit. Chest 2002; 122: 1727-1736,留取血培养前应对皮肤进行充分消毒避免仅留取一套血培养; 24小时内应在不同静脉穿刺部位留取2或3套培养(包括需氧和厌氧瓶)每个培养瓶应至少留取10 mL血标本如从静脉导管留取血标本, 应同时经外周静脉留取, 以帮助鉴别污染菌及真正的致病菌应根据临床情况及微生物实验室的建议使用适当的培养基和收集系统
12、如有可能, 应在应用抗生素前留取血标本. 如果已经使用抗生素, 当抗生素血药浓度达到谷值时留取培养可能提高阳性率,提高血培养阳性率,何时留取血培养皮肤消毒穿刺部位留取血培养次数留取血标本量送检时间是否需要常规留取厌氧培养,采集血培养的时机,菌血症为间断性细菌入血后30 60分钟出现发热寒战NHS应用抗生素之前体温高峰后尽快留取,采集血培养的时机,菌血症发生1 2小时后出现发热寒战1培养的时机体温高峰后尽早留取血培养临床研究结果不支持2,Chandrasekar PH, Brown WJ. Clinical issues of blood cultures. Arch Intern Med 19
13、94; 154: 841-849Li J, Plorde JJ, Carlson LG. Effects of volume and periodicity on blood cultures. J. Clin. Microbiol 1994; 32: 2829-31.,抗生素治疗前后血培养的阳性率,139名患者,抗生素治疗前,抗生素治疗过程中,开始抗生素治疗,83名患者(60%)血培养阴性或分离出污染菌,0/83 (0%)分离到致病菌,56名患者(40%)分离到致病菌,26/56 (45%)分离到致病菌,25名患者(45%)分离到致病的葡萄球菌,19/25 (76%)分离到葡萄球菌,14名患
14、者(25%)分离到致病的链球菌,5/14 (36%)分离到链球菌,17名患者(30%)分离到革兰阴性杆菌,2/17 (12%)分离到革兰阴性杆菌,1/139 (0.72%)分离到新的致病菌,Grace CJ, Lieberman J, Pierce K, et al. Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy. Clin Infect Dis 2001; 32: 1651-5,临床意义,应用抗生素前进行血培养分离到致病菌的可能性增加2.2倍在开始抗生素治疗
15、最初72小时内, 连续进行血培养的结果, 可以根据应用抗生素前血培养的结果预测极少分离到新的致病菌医生可以等待应用抗生素前的血培养结果回报后, 再进行新的血培养,Grace CJ, Lieberman J, Pierce K, et al. Usefulness of Blood Culture for Hospitalized Patients Who Are Receiving Antibiotic Therapy. Clin Infect Dis 2001; 32: 1651-5,血培养: 留取血标本的时机,对于血流动力学不稳定的患者, 应当在应用抗生素前留取2套血培养,Shafazan
16、d S, Weinacker AB. Blood cultures in the critical care unit. Chest 2002; 122: 1727-1736,应用抗生素后的血培养,应当在抗生素达到谷浓度时留取血培养未经过深入研究缺乏临床实用性,Chandrasekar PH, Brown WJ. Clinical issues of blood cultures. Arch Intern Med 1994; 154: 841-849Mylotte JM, Tayara A. Blood cultures: clinical aspects and controversies.
17、 Eur J ClinMicrobiol Infect Dis 2000; 19: 157-163,吸附抗生素的血培养瓶,Flayhart D, Borek AP, Wakefield T, et al. Comparison of BACTEC PLUS blood culture media to BacT/Alert FA blood culture media for detection of bacterial pathogens in samples containing therapeutic levels of antibiotics. J ClinMicrobiol 2007
18、; 45(3): 816-821,吸附抗生素的血培养瓶,Flayhart D, Borek AP, Wakefield T, et al. Comparison of BACTEC PLUS blood culture media to BacT/Alert FA blood culture media for detection of bacterial pathogens in samples containing therapeutic levels of antibiotics. J ClinMicrobiol 2007; 45(3): 816-821,血培养: 皮肤消毒减少污染,没有
19、明确证据提示应使用何种消毒剂能够减少假阳性结果使用皮肤消毒包装及含有乙醇的消毒剂可能有帮助,Malani A, Trimble K, Parekh V, et al. Review of clinical trials of skin antiseptic agents used to reduce blood culture contamination. Infect Control Hosp Epidemiol 2007; 28: 892-895,皮肤消毒: 洗必太 vs. 酒精,McLellan E, Townsend R, Parsons HK. Evaluation of Chlor
20、aPrep (2% chlorhexidinegluconate in 70% isopropyl alcohol) for skin antisepsis in preparation for blood culture collection. J Infect 2008; 57: 459-463,皮肤消毒: 洗必太 vs. 碘仿,ARR = 3.7%; RRR = 45%; NNT = 28,Suwanpimolkul G, Pongkumpai M, Suankratay C. A randomized trial of 2% chlorhexidine tincture compare
21、d with 10% aqueous povidone-iodine for venipuncture site disinfection: effects on blood culture contamination rates. J Infect 2008; 56: 354-359,采集血培养的方法,皮肤消毒后通过静脉穿刺留取动脉血 vs. 静脉血对于多数病原菌没有差异动脉血对播散性真菌感染的检出率稍高,采集血培养的方法: 更换针头,不推荐将血标本注入血培养瓶前更换针头增加针头刺伤的危险轻度降低细菌污染的危险性,Spitalnic SJ, Woolard RH, Mermel LA. Th
22、e significance of changing needles when inoculating blood cultures: a meta-analysis. Clin Infect Dis 1995;21:1103-6,采集血培养的方法: 血培养次数,第二套或第三套血培养能够增加致病菌的检出率有助于识别污染,血培养次数与阳性率,Lee A, Mirret S, Reller LB, et al. Detection of bloodstream infections in adults: How many blood cultures are needed? J ClinMicro
23、biol 2007; 45(11): 3546-3548,血培养次数,Shafazand S, Weinacker AB. Blood cultures in the critical care unit. Chest 2002; 122: 1727-1736,血培养次数,Shafazand S, Weinacker AB. Blood cultures in the critical care unit. Chest 2002; 122: 1727-1736,多数情况下, 24小时内无需留取超过2 3套血培养从2 3个不同部位留取血标本应当留取1次以上的血培养有助于鉴别真正菌血症和细菌污染,
24、采集血培养的次数,血培养之间的时间间隔并不明确同时, 间隔2小时, 间隔24小时采血并无差异,Li J, Plorde JJ, Carlson LG. Effects of volume and periodicity on blood cultures. J ClinMicrobiol 1994; 32: 2829-2831,采集血培养的方法: 采血量,成人菌血症时血液中细菌密度 103cfu/mL推荐留取20 30 ml血液血标本每增加1 ml, 培养检出率增加3%,Mermel LA, Maki DG. Detection of bacteremia in adults: consequ
25、ences of culturing an inadequate volume of blood. Ann Intern Med 1993; 119: 270-272,血培养: 采血量,The higher the volume of blood cultured the higher the yield of blood cultures Washington II JA,Washington JA. Blood cultures: principles and techniques. Mayo Clin Proc 1975; 50: 91-95Washington JA. Evolving
26、 concepts on the laboratory diagnosis of septicemia. Infect DisClinPract 1993; 2: 65-69Washington JA II, Ilstrup DM. Blood cultures: issues and controversies. Rev Infect Dis 1986; 8: 792-802,血培养: 采血量,Donnino MW, Goyal N, Terlecki TM, et al. Inadequate blood volume collected for culture: a survey of
27、health care professionals. Mayo Clin Proc 2007; 82(9): 1069-1072,血培养: 采血量,Donnino MW, Goyal N, Terlecki TM, et al. Inadequate blood volume collected for culture: a survey of health care professionals. Mayo Clin Proc 2007; 82(9): 1069-1072,79% 10 mLMean (SD) 6.0 (9.0) mLMedian (IQR) 5 (2, 5) mL,血培养:
28、采血量,Donnino MW, Goyal N, Terlecki TM, et al. Inadequate blood volume collected for culture: a survey of health care professionals. Mayo Clin Proc 2007; 82(9): 1069-1072,血培养: 采血量,Donnino MW, Goyal N, Terlecki TM, et al. Inadequate blood volume collected for culture: a survey of health care profession
29、als. Mayo Clin Proc 2007; 82(9): 1069-1072,结论大部分医务人员不了解血培养时推荐的最佳采血量,血培养: 采血量与阳性率,Bouza E, Sousa D, Rodriguez-Creixems M, et al. Is the volume of blood cultured still a significant factor in the diagnosis of bloodstream infections? J ClinMicrobiol 2007; 45(9): 2765-2769,OR 0.98795%CI 0.976 0.998P 0.0
30、18,OR 1.0495%CI 1.001 1.08P 0.018,血培养: 采血量,Weinstein MP, Mirrett S, Wilson ML, et al. Controlled evaluation of 5 versus 10 milliliters of blood cultured in aerobic BacT/Alert blood culture bottles. J ClinMicrobiol 1994; 32(9): 2103-2106,血培养: 培训的重要性,Connell TG, Rele M, Cowley D, et al. How reliable i
31、s a negative blood culture result? Volume of blood submitted for culture in routine practice in a Childrens hospital. Pediatr 2007; 119: 891-896,* 采血量足够指1个月龄以下 0.5 mL, 1 36个月龄者 1.0 mL， 36个月龄者 4.0 mL* 若采血量 1周(19.6 1.6 days)85%接受输血治疗(9.5 0.8 U)静脉采血解释输血量差异的49%,Corwin HL, Parsonnet KC, Gettinger A. RBC
32、transfusion in the ICU. Chest 1995; 108: 767-771,危重病患者的贫血,设计: 前瞻性观察研究背景和患者: 西欧145个ICU的1136名患者结果: 最初24小时内采血次数4.6 (3.2)次45.9%的患者采血 5次采血量10.3 (6.6) ml/次24小时内采血量41.1 (39.7) mLSOFA评分与采血次数(r = 0.34; p 0.001)及采血量(r = 0.28; p 0.001)相关,Vincent JL, Baron JF, Reinhart K, et al. Anemia and blood transfusion in
33、critically ill patients. JAMA 2002; 288(12): 1499-1507,血培养的技术细节: 采血量,理论上6个培养瓶, 总量35 42 mL, 最好为同时取血1实际2或3个培养瓶, 每次抽血20 30 mL2, 3缺乏实际可操作性,LamyB, Roy P, Carret G, et al. What is the relevance of obtaining multiple blood samples for culture? A comprehensive model to optimize the strategy for diagnosing b
34、acteremia. Clin Infect Dis 2002; 35: 842-50.Washington JA, Ilstrup DM. Blood cultures: issues and controversies. Rev Infect Dis 1986; 8: 792-802.Wilson ML, Weinstein MP. General principles in the laboratory detection of bacteremia and fungemia. Clin Lab Med 1994; 14: 69-82.,血培养: 标本运送与处理时间,血培养运送时间不超过
35、4小时1实际平均运送时间为10.4小时2,Garcia, L. S. (ed.). 2007. 2007 update: clinical microbiology procedures handbook, 2nd ed. ASM Press, Washington, DC.Kerremans JJ, Verboom P, Stijnen T, et al . Rapid identification and antimicrobial susceptibility testing reduce antibiotic use and accelerate pathogendirected an
36、tibiotic use. J. Antimicrob. Chemother. 2008; 61: 428-435,血培养: 标本运送时间影响因素,Kerremans JJ, van derBij AK, Goessens W, et al. Needle-to-incubator transport time: logistic factors influencing transport time for blood culture specimens. J ClinMicrobiol 2009; 47(3): 819-822,血培养: 延迟送达细菌室,Jardine LA, Sturges
37、s BR, Inglis GDT, et al. Neonatal blood cultures: Effect of delayed entry into the blood culture machine and bacterial concentration on the time to positive growth in a simulated model. J Paediatr Child Health 2009,血培养: 延迟送达细菌室,Saito T, Iinuma Y, Takakura S, et al. Delayed insertion of blood culture
38、 bottles into automated continuously monitoring blood culture systems increases the time from blood sample collection to the detection of microorganisms in bacteremic patients. J Infect Chemother 2009; 15: 49-53,血培养: 延迟送达细菌室,血培养瓶延迟送达细菌室显著延长培养阳性所需时间与放置在自动化血培养机器中的培养瓶相比, 室温保存的培养瓶中细菌生长速度缓慢如果血培养标本在室温下保存超
39、过15.5 h, 则目前实行的36 h安全范围(报告培养结果为阴性前)可能过短,Jardine LA, Sturgess BR, Inglis GDT, et al. Neonatal blood cultures: Effect of delayed entry into the blood culture machine and bacterial concentration on the time to positive growth in a simulated model. J Paediatr Child Health 2009,厌氧菌培养: 临床意义,Grohs P, Maina
40、rdi JL, Podglajen I, et al. Relevance of routine use of the anaerobic blood culture bottle. J ClinMicrobiol 2007; 45(8): 2711-2715,厌氧菌培养: 临床意义,Grohs P, Mainardi JL, Podglajen I, et al. Relevance of routine use of the anaerobic blood culture bottle. J ClinMicrobiol 2007; 45(8): 2711-2715,厌氧培养阳性, 需氧培养
41、阴性:143株菌, 来自137 (2.7%)名患者厌氧菌52株, 来自48名患者兼性厌氧菌(肠杆菌科, 葡萄球菌, 链球菌, 肠球菌)91株, 来自91名患者,厌氧菌培养: 临床意义,Grohs P, Mainardi JL, Podglajen I, et al. Relevance of routine use of the anaerobic blood culture bottle. J ClinMicrobiol 2007; 45(8): 2711-2715,厌氧菌培养: 临床意义,Grohs P, Mainardi JL, Podglajen I, et al. Relevance
42、 of routine use of the anaerobic blood culture bottle. J ClinMicrobiol 2007; 45(8): 2711-2715,肠杆菌科链球菌/肠球菌属金黄色葡萄球菌,厌氧菌培养: 临床意义,Grohs P, Mainardi JL, Podglajen I, et al. Relevance of routine use of the anaerobic blood culture bottle. J ClinMicrobiol 2007; 45(8): 2711-2715,13.7%的患者厌氧培养阳性, 需氧培养阴性其中2/3的患
43、者, 分离细菌并非严格厌氧菌厌氧培养的作用不仅限于分离严格厌氧菌即使需氧和厌氧培养均为肠杆菌科, 厌氧培养较需氧培养更早呈阳性,厌氧菌培养: 临床意义,Riley JA, Heiter BJ, Bourbeau PP. Comparison of recovery of blood culture isolates from two BacT/ALERT FAN aerobic blood culture bottles with recovery from one FAN aerobic bottle and one FAN anaerobic bottle. J ClinMicrobiol
44、 2003; 41(1) 213-217,*other than E. coli,厌氧菌培养: 临床意义,Riley JA, Heiter BJ, Bourbeau PP. Comparison of recovery of blood culture isolates from two BacT/ALERT FAN aerobic blood culture bottles with recovery from one FAN aerobic bottle and one FAN anaerobic bottle. J ClinMicrobiol 2003; 41(1) 213-217,*o
45、ther than Enterobacteriaceae,厌氧菌培养: 临床意义,Riley JA, Heiter BJ, Bourbeau PP. Comparison of recovery of blood culture isolates from two BacT/ALERT FAN aerobic blood culture bottles with recovery from one FAN aerobic bottle and one FAN anaerobic bottle. J ClinMicrobiol 2003; 41(1) 213-217,支持常规使用FAN厌氧培养瓶
46、使用厌氧培养瓶的影响因素细菌和真菌检出率检出细菌和真菌种类培养基使用的血培养系统,厌氧菌培养: 临床意义,Iwata K, Takahashi M. Is anaerobic blood culture necessary? If so, who needs it? Am J Med Sci 2008; 336(1): 58-63,17,775份血培养,2,132培养阳性(12.0%),953株为厌氧培养(44.7%),234株为污染菌(24.5%),719株细菌来自410名患者,363名患者需氧培养阳性,47名患者需氧培养阴性,厌氧菌培养: 临床意义,Iwata K, Takahashi M
47、. Is anaerobic blood culture necessary? If so, who needs it? Am J Med Sci 2008; 336(1): 58-63,厌氧菌培养: 临床意义,Iwata K, Takahashi M. Is anaerobic blood culture necessary? If so, who needs it? Am J Med Sci 2008; 336(1): 58-63,多数患者无需进行厌氧培养以下患者应进行厌氧培养临床怀疑严格厌氧菌导致的菌血症严重免疫功能抑制临床评估未能发现菌血症来源,血培养: 三天以上没有意义,Bourbeau PP, Foltzer M. Routine incubation of BacTALERT FA and FN blood culture bottles for more than 3 days may not be necessary. J ClinMicrobiol 2005; 43(5): 2506-2509,
