내과계중환자실환자에서 Chlorhexidine-silver Sulfadiazine Coated Catheter 의중심정맥관감염에대한연구 울산대학교의과대학서울아산병원호흡기내과정영주, 고윤석, 임채만, 이재승, 유미현, 오연목, 심태선, 이상도, 김우성, 김동순, 김원동, 홍상범 The Central Venous Catheter-related Infection of Chlorhexidinesilver Sulfadiazine Coated Catheters in Medical ICU Young Ju Jung, M.D., Younsuck Koh, M.D., Chae-Man Lim, M.D., Jae Seung Lee, M.D.,Mi Hyun Yu, M.D., Yeon Mok Oh, M.D., Tae Sun Shim, M.D., Sang Do Lee, M.D., Woo Sung Kim, M.D., Dong Soon Kim, M.D., Won Dong Kim, M.D., Sang- Bum Hong, M.D. Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Background : Central venous catheters(cvcs) area major source of nosocomial infection. Chlorhexidine-silver sulfadiazine coated catheters (CHSS) were developed to reduce the rate of CVC infection. However, the clinical effectiveness of CHSS in comparison wth non-coated catheter (NCC) remains to be evaluated. Methods : From January 2004 to December 2004 in medical intensive care unit (ICU) of Asan Medical Center, CVCs were inserted in 446 cases. We retrospectively analyzed characteristics of patients and catheterization,the catheterrelated infection rate and colonization, microbiologic findings, and insertion sites (subclavian, jugular, femoral) according to the type of inserted CVCs (NCC: 187 cases, CHSS: 259 cases). Catheter related infection is defined as catheter related bacteremia and catheter related non-bacteremic sepsis. Results : 1) The mean age of the patients in each group was 62±16 years, 63±15 years (p=0.42), and sex ratio 94:50, 141:69 (p=0.9) in NCC and CHSS. Duration of ICU admission (29±37, 26±44 p=0.42), duration of mechanical ventilation (17±22, 15±19 p=0.17), and APACHE III score at the time of CVC insertion (81±34, 82±37 p=0.61) were not different between both groups. 2) Mean duration of catheterization was 118 in NCC and 119 in CHSS (p=0.98). Number of catheter-days was 2176 days in NCC and 3035 days in CHSS. Catheter-related infection occurred in 9 (4.8%) cases receiving NCC and 4 cases (1.5%) receiving CHSS. Catheterrelated infection incidence per 1000 catheter-days was 4.1 and 1.3, respectively (p=0.04). CHSS was associated with a significant reduction of infection in jugular catheters regarding to insertion sites (p=0.01). 3) Microorganisms causing infection were Staphylococcus aureus (n=3), Candida (n=3), coagulase-negative Staphylococci (n=2), and Klebsiella (n=1) in NCC, and Candida species (n=2), coagulase-negative Staphylococci (n=2), Proteus (n=1) in CHSS. Conclusion : CHSS has significantly reduced the episodes of infection compared to NCC in jugular catheterization in medical ICU. (Tuberc Respir Dis 2005; 59: 389-396) Key words : Central venous Catheter, Bacteremia, Nosocomial infection 서 현대의학의발달에따라최근각종침습적인수기의사용이보편화되고있고, 중환자들에게중심정맥 론 Address for correspondence : Sang-Bum Hong, M.D. Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center 388-1 Pungnap-2 Dong, Songpa-gu, Seoul, 138-736, Korea Phone : 02-3010-3893 Fax : 02-3010-6968 E-mail : sbhong@amc.seoul.kr Received : Jul. 8. 2005 Accepted : Sep. 6. 2005 관은삽입후장기간유치가가능하며, 수액요법, 고영양요법, 항암치료및중심정맥압의측정을이용한혈액학지표의감시등을위하여자주사용된다. 그러나중심정맥관의삽입및장기적인유치는피부의방어벽을깨뜨려미생물의침입경로가되어, 원내감염의주요원인인중심정맥관관련혈류감염 (catheter related bloodstream infection) 이증가하게되었다 1. 중환자실환자에서원내감염이발생하면환자의전반적인사망률이 35% 증가하고중환자실입원기간이 8일정도연장되는것을포함하여총 32일의입원기간이늘어난다 2. 국내보고에의하면국내중환자실 389
YJ Jung et al. : Central venous catheter infection 감염률은연환자일수 1000일당 10.18건, 중환자실에입원한환자에서중심정맥관관련혈류감염은 1000 catheter-days 당 2.12건이었다 3. 또한중환자실에서발생하는패혈증의원인중 25% 는카테터감염이며, 원발성균혈증의 80% 까지카테터감염과관련이있는것으로보고되었다 4,5. 이러한중심정맥관관련패혈증을줄이기위해카테터삽입시철저한방어벽 (barrier precaution) 을사용하고카테터조작의무균적인방법뿐아니라항생제가 coating된카테터의사용에대해연구들이진행되었다. Antimicrobial impregnated catheter의효능에대한연구에서 non-impregnanted catheter에비해카테터세균집락은 46%, 카테터관련혈류감염증은 40% 감소시켰다고보고하였으나 6-8, 다른연구에서는 antimicrobial impregnated catheter가카테터관련혈류감염증의감소및환자예후의호전을보여주지못했다 4,9,10. 국내에서는중심정맥관관련감염을감소시키기위한 chlorhexidine-silver sulfadiazine coated catheter (CHSS) 사용에대한보고가없는실정이다. 그래서본연구는 CHSS 사용이 non-coated catheter (NCC) 에비하여중심정맥관관련감염증이감소하는지여부를알아보고자하였다. 대상및방법 1. 대상 2004년 1월부터 12월까지 12개월간울산대학교의과대학서울아산병원내과계중환자실에입원하여 48시간이상중심정맥관을삽입받았던 446 예를대상으로의무기록을후향적인방법으로조사하였다. NCC가사용된군은 187 예, CHSS은 259 예였다. 2. 방법 1) 카테터선택중심정맥관은환자들중에서활력징후가불안한 상태여서혈액학적지표의관찰이필요하였거나, 총정맥영양공급이필요한경우에시행되었고, 시술자는카테터의종류를모르고시술하였었다 1. 2) 환자의특성두군의환자들에서연령, 성, 기저질환, 입원기간, 중환자실입원기간, 인공호흡기사용일수등에대해조사하였다. 두군사이중증도를비교하기위해중환자실입원당시와카테터삽입당시의 APACHE (Acute Physiology, Age, Chronic Health Evaluation) III score, 카테터삽입시항생제사용유무를조사하였다. 3) 카테터삽입과제거중환자실에입원하여중심정맥관을삽입받는모든환자들에서철저한방어벽 (barrier precaution) 을갖추고쇄골하정맥, 내경정맥, 대퇴정맥을통해시행되었다. 의무기록을통하여삽입위치와평균카테터삽입일수등을조사하였다. 중심정맥관제거이유는환자가사망하거나호전되어더이상필요하지않을경우, 막히거나저절로빠지는등기능이상이있는경우, 중심정맥관과연관된감염이의심될때, 다른명백한감염원없이혈류감염이있을때, 그리고카테터삽입부위의국소적인염증징후가있는경우로나누어조사하였다 11. 4) 세균검사 38도이상의열이나거나저혈압징후가있는경우에환자에서말초혈액과중심정맥관을통한혈액세균배양의시행유무, 그리고혈액배양시행이후혈액배양검사에결과에따라서혹은즉시중심정맥관을제거하고카테터 tip의세균배양을실시하였는지등을조사하였다. 그리고중심정맥관의사용이더이상필요없게되었을때나기능이상이있는경우에제거된카테터에서 tip 배양검사결과를조사하였다. 그러나, 환자가사망하거나카테터감염징후가없었던경우등에서는세균검사가시행되지못했다. 카테터 tip 배양은무균적으로제거한카테터를 390
Tuberculosis and Respiratory Diseases Vol. 59. No. 4, Oct. 2005 5cm 정도로잘라 rolling method ( 반정량적배양 ) 으로시행되었고, 양성배양은균집락수가 15개이상인경우로정의하였다 12,13. 5) 정의 4,13 (1) 카테터관련혈류감염증 (definite catheter re lated bloodstream infection) : 카테터 tip 배양과혈액배양에서같은세균이동정된경우이다 (2) 비균혈성카테터관련패혈증 (non-bacteremic catheter-related sepsis) : 패혈증을설명할다른원인없이혈액배양검사는음성이나카테터 tip 배양은양성이고항생제치료등을바꾸지않았음에도카테터제거 48시간이후에모든증상이나징후가호전된경우로정의하였다. 6) 통계적분석두그룹사이에통계적차이성은범주형변수인경우카이제곱 (chi-square) 검사를이용하여양측검증을하였고연속형변수인경우 t-test로검정하였다. p 값 0.05이하를유의한것으로판정하였고통계 분석은 window 용 SPSS 프로그램 (SPSS 11.0, SPSS Inc,Chiago,Illinoi,USA) 을이용하였다. 결과 1. 대상환자의특성 (Table 1) NCC 군의평균연령은 62±16세였고, CHSS 군은평균연령이 61±16세였다 (p=0.42). 남자는각각 65.3%, 67.1% 이었다 (p=0.90). 두군모두에서기저질환은호흡기질환및암등의질환이많았고입원기간, 중환자실입원기간, 인공호흡기사용기간은차이가없었다. 중환자실입실당시 APACHE III 점수와중심정맥관삽입시 APACHE III 점수역시차이가없었고중심정맥관삽입시대부분환자에서항생제를사용하고있었다. 2. 대상카테터특성 (Table 2) 삽입된카테터은 NCC 군에서 1 예를제외하고 Table 1. Characteristics of the Patients between two groups Non-coated catheter (n=187) CH-SS* coated catheter (n= 259) No. of patients 144 210 Sex ratio 94:50 141:69 p=0.90 Mean Age(yr) 62 ± 16 61 ± 16 p=0.42 Underlying disease Pulmonary Cardiovascular Gastrointestinal Cancer Neurologic Other Duration of Admission 58 ± 78 46 ± 63 p=0.07 Duration of ICU admission 29 ± 37 26 ± 44 p=0.42 Duration of Mechanical ventilation 17 ± 22 15 ± 19 p=0.17 APACHE III at ICU admission 80 ± 33 82 ± 36 p=0.59 APACHE III at CVC insertion 81 ± 34 82 ± 37 p=0.61 Ongoing antibiotics at CVC insertion (n, %) 177 (95%) 251 (97%) P=0.23 * CH-SS: Chlorhexidine-silver sulfadiazine No: Number ICU :Intensive care unit APACHE III: Acute Physiology, Age, Chronic Health Evaluation III CVC: Central venous catheter 70 9 18 17 8 14 109 15 27 30 10 23 p=0.10 391
YJ Jung et al. : Central venous catheter infection Table 2. Characteristics of catheters between two groups Non-coated catheter (n=187) CH-SS *coated catheter (n= 259) No. of lumen Two Three 1 186 Order of catheter, Second or more (n,%) 26 (18.0%) 39 (18.6%) p=0.50 Insertion site (n,%) Subclavian Internal jugular Femoral Mechnical complication Pneumothorax Arterial puncture 98 (52.4%) 71 (38.0%) 18 (9.6%) 0 259 161 (62.2%) 87 (33.6%) 11 (4.2%) 1 1 2 3 Subsequent catheter exchange none none Cause of catheter removal (n, %) No longer use 79 (42%) 148 (57%) Malfunction 8(4%) 7(3%) Suspicious infection 90 (48%) 98 (38%) Unexplained bloodstream infection 9(5%) 6(2%) Insertion site infection 1(1%) 0 * CH-SS: Chlorhexidine-silver sulfadiazine No: Number p=0.24 p=0.03 p=0.47 p=0.02 모두 triple lumen catheter가사용되었다. 1 개이상의카테터가사용된예는 NCC 군 26 (18.0%), CHSS 군 39 (18.6%) 로차이가없었다 (p=0.5). 삽입위치에있어서 NCC 군에서는쇄골하정맥 52.4%, 내경정맥 38.0%, 대퇴정맥 9.6%, CHSS 군은 62.2%, 33.6%, 4.2% 으로차이를보였다 (p=0.03). 중심정맥관삽입시발생하는합병증의빈도에서는차이가없었다. CHSS 군에서는카테터의사용이필요하지않아제거한경우 (48%) 가많았고 NCC 군은카테터관련감염증이의심되어제거한예 (57%) 가많았다 (p=0.02). 3. 중심정맥관감염과집락화의빈도 (Table 3) NCC 군에서총중심정맥과삽입일수는 2176일, CHSS 군에서는 3035일이고, 두군에서평균중심정맥관삽입일수는각각 11±8 일, 11±9 일이었다 (p= 0.98). NCC 군에서중심정맥관이더이상필요없어제거한 79 예중 17 예 (21.5%) 에서 tip 배양검사가시행되었고, 중심정맥관감염이의심된경우에는 90 예중 83 예 (92%) 에서 tip 배양검사가시행되었다. CHSS 군에서는각각 148 예중 34 예 (22.9%) 그리고, 98 예중 87 예 (88.8%) 에서검사가시행되었다. 중심정맥관세균집락화의빈도는 NCC 군에서전체중심정맥관중 67%, CHSS 군에서 47% 에서 tip 배양검사가시행되었고각각 9건 (4.8%), 8건 (3.1%) 에서배양양성균주가확인되었다. NCC, CHSS 군에서 1000 catheter-day 당각각 4.1, 2.6의집락화가있었다 (p=0.50). 삽입위치별로시행한집락화발생빈도는두군사이에서차이가없었다. 중심정맥관감염의빈도는 NCC 군에서 non-bact eremic sepsis 1건, definite catheter related bloods tream infection 8건, 총 9건 (4.8%) 의감염이있었고 CHSS 군에서는 definite catheter related bloodstream infection 4건 (1.5%) 의감염이발생하였다. 즉, CHSS 군에서 1000 catheter-day 당 1.3 으로 NCC 군 4.1 보다낮은빈도로감염이발생하였다 (p=0.04). 삽입위치따른감염발생빈도에있어서쇄골하정맥, 대퇴정맥으로삽입한경우에는두군사이에서차이가없었으나, 내경정맥으로삽입한경우는 CHSS 군에서 NCC 군에비해중심정맥관감염이적게발생하였다 (p=0.01). 392
Tuberculosis and Respiratory Diseases Vol. 59. No. 4, Oct. 2005 Table 3. Catheter colonization and infection between two groups Non-coated catheter (n=187) CH-SS* coated catheter (n= 259) No. of catheter days 2176 3035 Duration of catheterization (days:median) 11 ± 8 11 ± 9 p=0.98 Culture frequency of removed catheter (n,%) No longer use Malfunction Suspicious infection Unexplained bloodstream infection Insertion site infection Catheter colonization No. of catheter colonized Incidence, per 1000 catheter-days Colonization due to insertion site Subclavian Internal jugular Femoral Catheter related infection Non-bacteremic sepsis Bloodstream infection No. of catheter infected Incidence, per 1000 catheter-days Infection due to insertion site Subclavian Internal jugular Femoral * CH-SS: Chlorhexidine-silver sulfadiazine No: Number 17/79 (21.5%) 2/8 83/90 (92%) 1/9 1/1 9 (4.8%) 4.1 2/98 5/71 1/18 1 8 9 (4.8%) 4.1 3/98 5/71 1/18 34/148 (22.9%) 0/7 87/98 (88.8%) 2/6 0/0 p=0.19 p=0.10 p=0.02 p=0.76 p=0.24 8 (3.1%) 2.6 p=0.50 2/161 6/87 0/11 p=0.61 p=0.97 p=0.73 0 4 4 (1.5%) 1.3 p=0.04 3/161 0/87 1/11 p=0.53 p=0.01 p=0.72 4. 중심정맥관감염의원인균 (Table 4) NCC 군에서감염의원인균주로 methicillin resis tant Staphylococci, Candida species 가각각 3 예로가장많았고, methicillin resistant coagulase-negative Staphylococci 2 예, 그람음성간균으로 Klebsillae pneumonia (ESBL) 가 1 예에서배양되었다. 집락화에서는 Candida species 6 예로가장많이집락화되었고 methicillin resistant Staphylococci 3 예, methicillin resistant coagulase-negative Staphylococci, Candida 가동시에배양된 1 예도있었다. CHSS 군에서는중심정맥관감염의원인균으로 Table 4. Microorganisms associated with colonization or infection of catheters Gram-positive cocci S. aureus Coagulase-negative staphylococci Non-coated catheter (n=187) Infected Colonised 3 3 2 1 CH-SS* coated catheter (n= 259) Infected Colonised 0 4 2 1 Gram-negative bacilli 1 0 1 2 Candida spp 3 6 2 2 Total 9 9 5 9 * CH-SS: Chlorhexidine-silver sulfadiazine One infection and one colonization in the CHSS-coated group were polymicrobial; one colonization in the non-coated group were polymicrobial. 393
YJ Jung et al. : Central venous catheter infection methicillin resistant coagulase-negative Staphylococci, Candida species 각각 2 예, Proteus mirabilis가 1 예자랐고 1 예에서 methicillin resistant coagulasenegative Staphylococci, Candida species가동시에자랐다. 집락화에서는 methicillin resistant Staphylococci 4 예로가장많았고, Candida species 2 예이외에그람음성간균으로 Klebsillae pneumonia (ESBL), En terobacter cloacae가각각 1 예에서보고되었다. 고찰본연구는 chlorhexidine-silver sulfadiazine coated catheter (CHSS) 가중심정맥관감염을감소시켰음을보여준연구이다. 중심정맥관의감염은원내에서주로발생하며, 이에대한예방및치료는병원감염관리에서매우중요하다. 중심정맥관감염증의원인으로중심정맥관의세균집락이가장흔하고, 주위피부로부터상재균이가장많은원인을차지하게된다. 대개중심정맥관삽입 1주이내에피부로부터중심정맥관외부를따라균주가이동하여중심정맥관에서집락화되어균혈증의요인이되며, 설치후 1주가지나면중심정맥관내강으로침입한균주가 biofilm을형성하면서집락화되는경우가많아주위피부의균주뿐만아니라의료진의손이나수액제제등에의해서도감염될수있다. 따라서피부상재균이나그람양성구균외에도환자의기저질환이나병원환경등여러요인에의해그람양성간균등에의해서도균혈증발생이가능하다고보고되고있다 14-16. 본연구에사용된 CHSS은카테터바깥표면에 chlorhexidine-silver sulfadiazine이도포되어주변조직이나피부에병원감염으로전파된균주에대해서서히억제효과를보이게되고이러한작용으로중심정맥관제거시집락화를감소시키고결과적으로집락화의감소가카테터관련혈류감염의감소와연관이있다고보고하고있다 6,12. 하지만이러한카테터관련혈류감염의감소효과는 2주이내로삽입기간이짧아야하며본연구에서는평균삽입기간이 11일로이러한결과와일치한다 5. Maki 등이 CHSS 사용시 NCC 에비해집락화는 24.1% 에서 13.5% 로감소하였고, 1000 catheter-day 당 7.6에서 1.6으로중심정맥관감염의감소를보고하였다12. 본연구에서중심정맥관집락화의빈도가 NCC, CHSS 군에서각각 9건 (4.8%), 8건 (3.1%) 으로기존의연구보다낮은집락화의빈도를보이며두군사이에차이가없었으나, 그에비해 NCC, CHSS 군에서 1000 catheter-day 당각각 4.1, 1.3 의감염이발생하여두군간차이가있었다. 즉, 집락화의빈도는차이가없었으나중심정맥관감염은감소하였다. 원인으로는본연구가후향적인방법으로시행되어중심정맥관관련감염증이의심되는경우를제외하고는카테터 tip 검사가되지않아정확한집락화의빈도를알수없었을것으로사료되며또한, 집락화의빈도뿐아니라동시에전반적인카테터감염이낮은것도전향적으로모든환자에서카테터배양검사가시행되지못한점을고려해야한다. 그러므로 CHSS 에서집락화의빈도가감소여부에대해서는향후전향적인추가연구가필요하겠다. 국내병원감염률에대한다기관연구에따르면내과계중환자실에서병원감염률은연환자일수 1000 일당 16.18건이었으며 NNIS (National Nosocomial Infections Surveillance) 기준에서정의된내과계중환자실의중심정맥관감염증은 1000 catheter-day 당 7.12건으로 17, 외국보고에서는 1000 catheter-day 당 3.3건이상이면항생제가도포된 catheter를사용할것을추천하고있고 10,12,18, 본연구는상기제안이국내에서도적용될수있는가능성을보여주었으며중심정맥관감염률이높은중환자실에서는 antimicrobial impregnated catheter의사용을고려해볼수있을것이다. 이전연구에서삽입위치에따른감염률은쇄골하정맥이가장낮고, 내경정맥, 대퇴정맥순으로감염률이증가하였다 18,19. 본연구에서쇄골하정맥에서는두카테터사이에감염률의차이가없었고대퇴정맥은삽입빈도가적어감염률의차이가없었으나 anti microbial impregnated catheter에서내경정맥삽입시중심정맥관감염률이 7% 에서 0% 로감소하였다. Antimicrobial impregnated catheter와삽입위치에 394
Tuberculosis and Respiratory Diseases Vol. 59. No. 4, Oct. 2005 따른감염률의차이에대해서는보고된적이없으나감염률이높은곳일수록차이가날가능성을보여주었다. 다른연구에서도 CHSS에서 NCC에비해집락화는 13.1% 에서 3.7% 로감소하였으나, 1000 catheterday당 5.2에서 2.0으로중심정맥관감염의감소는차이가없었다 4. 이러한중심정맥관감염률감소에있어서차이가없는것은집락화에비해중심정맥관감염률이낮아서차이가없는것으로설명하였다. 본연구에서두군에서삽입위치의빈도가차이가있었지만, 삽입위치차이가있는곳은쇄골하정맥이었으며내경정맥삽입빈도는양군에서차이가없었다. 결론적으로, 내과계중환자실환자에서중심정맥삽입시 NCC에비해 CHSS 사용시중심정맥관감염율이감소하였으며, 특히삽입위치가내경정맥일때유의한감소를보였다. 중심정맥관감염을줄이기위해가능한쇄골하정맥에중심정맥관을삽입을고려해야하겠고증심정맥관감염율이높은위치에삽입하거나감염률이높은병원에서는 CHSS 사용을고려해볼수있을것으로판단된다. 그러나향후 CHSS 에서중심정맥관감염을더정확히평가하기위한전향적인추가연구가필요하겠다. 요약목적 : 중환자실환자에서중심정맥관관련감염증은원내감염의주요부분을차지한다. 이러한중심정맥관관련감염증을감소시키기위하여 chlorhexidine-sil ver sulfadiazine coated catheter (CHSS) 사용에대한임상적유용성에대해서는논란의여지가있지만, 국내에서는아직이와관련된보고가없었다. 본연구는 non-coated catheter (NCC) 와 CHSS의중심정맥관관련감염증의차이를비교하고자하였다. 대상및방법 : 2004년 1월부터 12월까지 12개월간서울아산병원내과계중환자실에입원하여 48시간이상중심정맥관을삽입하였던 446 예을대상으로하였다. NCC (n=187) 과 CHSS (n=259) 에서중심정맥관과환자의특성, 중심정맥관삽입위치, 평균삽입일수, 집락화 중심정맥관관련감염증의빈도, 및원인균등에대하여후향적인방법으로조사하였다. 결과 : 1) NCC와 CHSS에서환자군의나이 (62±16, 63± 15; p=0.42) 세, 성비 (94:50, 141:69; p=0.9), 중환자실재원일수 (29±37, 26±44 ;p=0.42) 일, 인공호흡기사용기간 (17±22, 15±19; p=0.17) 일, 카테터삽입시 APACHE III 점수는 (81±34, 82±37; p=0.61) 차이가없었다. 2) 평균카테터삽입기간은 NCC 11±8 일, CHSS 11±9 일이었고 (p=0.98), 총카테터일수는 NCC 2176 일, CHSS 3035 일이었다. NCC와 CHSS에서카테터감염발생환자는각각 9명 (4.8%), 4명 (1.5%) 으며, 1000 catheter-day당감염건수는 4.1건, 1.3건이었다 (p=0.04). 삽입위치에서는내경정맥삽입시 CHSS 에서 NCC 보다중심정맥관관련감염증이감소하였다 (p=0.01). 3) 중심정맥관관련감염증에서동정된균은 NCC 에서 Stazfphylococcus aureus 3명, Candida species 3명, coagulase-negative Staphylococci 2명, Klebsiella 1명, 이었고 CHSS는 coagulase-negative Staphylococci 2명, Candida species 2명, Proteus 1명이었다. 결론 : 내과계중환자실환자에서중심정맥관삽입시 NCC에비해 CHSS에서중심정맥관감염율이감소하였으며, 특히삽입위치가내경정맥일때유의한감소를보였다 참고문헌 1. Kim JY, Song JH, Jeong JS, Seo EJ, Pai CH. Epidermiologic features of central venous catheter infection. J Korean Soc Chemother 1993;11:56-62. 2. Pittet D, Tarara D, Wenzel RP. Nosocomial blood stream infection in critically ill patients: excess length of stay, extra costs, and attributable mortality. J Am Med Assoc1994;271:1598-601. 3. Park ES, Park MR, Kim JE, Choi JS, Jin HY, Song YG, et al. Multicenter ICU surveillance study for nosocomial infection in Korea. Korean Soc Nosocomial Infect Control 2003;8:23-33. 4. Brun-Buisson C, Doyon F, Sollet JP, Cochard JF, 395
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