U. H a r t e n a u e r , B. Thiilig, P. L a w i n , W. F e g e l e r

Infection Surveillance and Selective Decontamination of the Digestive Tract (SDD) in Critically Ill Patients- Results of a Controlled Study Summary: All ICU patients were continuously monitored for infections according to a standard protocol by the physician in charge and an infection control nurse during the first quarter of five consecutive years (1980-1984). The number of patients surveyed was 1,009. The average age was 45.5 years and the average period of stay about four days. 733 patients (72.6%) were intubated and artificially ventilated for three days. A fatal outcome resulted in 13.2% of all patients. 1,129 nosocomial infections were registered in 331 patients, which means an infection rate of 32.8%. The most frequent nosocomial infections were those of the respiratory tract (24.3%). Wound infections developed in 16.6%. The urinary tract was affected in 8.8%. Nosocomial septicaemias were observed in 8.7%. Catheterassociated infections were found in 6.7% of the patients. A fatal outcome resulted in 26% of the patients with nosocomial infections and in 6.9% of the non-infected patients, respectively. There was no significant reduction in nosocomial infections over the five-year

period in our ICU. Therefore, a study was designed to evaluate the concept of selective decontamination of the digestive tract (SDD) in critically ill patients in our two surgical/traumatological ICUs. A prospective, consecutive, placebo-controlled study in two ICUs was carried out during four six-month periods. 200 patients who were intubated for at least three days, required intensive care for a minimum of five days, and belonged to either class III or IV according to the "Therapeutic Intervention Scoring System" were included in the study. They received either placebo or a prophylaxis regimen, consisting of polymyxin E, tobramycin and amphotericin B. The rates of nosocomial bronchopulmonary infections (ICU I and II) and urinary tract infections (ICU II) were significantly reduced. There was no significant reduction in wound infection, septicaemia and mortality rates. Selective flora suppression is effective in reducing infection rates in critically ill patients without development of resistant strains.

Zusammenfassung: Infektionsi~erwachung und selektive Darmdekontamination (SDD) in der operativen Intensivmedizin - Ergebnisse einer kontrollierten prospektiven Studie. Zur Dokumentation nosokomialer Infektionen auf einer Intensivstation wurden in einer t~iglichen gemeinsamen Infektionsvisite von Untersucher und Hygienefachschwester alle infektionsrelevanten Daten auf einem zuvor entwickelten Erhebungsbogen erfaBt. Ausgewertet wurden die jeweils ersten Quartale (FebruarApril) der Jahre 1980-1984. Die Untersuchung schlol3 1009 Patienten ein. Das mittlere Lebensalter betrug 45,5 Jahre, die mittlere Behandlungsdauer 3,9 Tage. 733 Patienten (72,6%) muBten w/ihrend der Intensivtherapie im Mittel 3 Tage lang beatmet werden. Die Mortalit/it im gesamten Beobachtungszeitraum betrug 13,2%. Uber den gesamten Zeitraum wurden insgesamt 1129 nosokomiale Infektionen (NI) bei 331 Patienten beobachtet. Das entsprach einer Infektionsrate von 32,8%. Die h/iufigsten registrierten Infektionen bezogen auf die Anzahl insgesamt infizierter Patienten waren bronchopulmonale (BPI)(24,3%), Wund- (WI) (16,6%) und Harnwegsinfektionen (HWI) (8,8%). Hinzu kamen Septik/imien (SI) (8,7%) und mit intravasa-

len Kathetern assoziierte Infektionen (ZVI) (6,7%). Nosokomial infizierte verstarben viermal h/iufiger (26%) als nicht infizierte Patienten (6,9%). W/ihrend der 5j/ihrigen Infektionsfiberwachung konnten die Infektionsraten nicht signifikant reduziert werden. Daher wurde eine einj/ihrige prospektive, konsekutive, plazebokontrollierte Studie auf zwei Intensivtherapiestationen (ICU) durchgefiihrt, mit der das Konzept der selektiven Florasuppression 0berpriift werden sollte. 200 Patienten erfiillten die Aufnahmekriterien (mindestens drei Tage Intubation und fiinf Tage Intensivtherapie, Klasse III oder IV im ,,Therapeutic Intervention Scoring System"). Die Patienten erhielten entweder Plazebo oder Prophylaxeregime aus Polymyxin E, Tobramycin und Amphotericin B. Die Raten der Bronchopneumonien (ICU I und II) und Harnwegsinfektionen (ICU II) wurden signifikant reduziert. Wundinfektionen, Septik/imien und Mortalit/it wurde nicht signifikant vermindert. Resistenzentwicklungen oder Zunahmen multiresistenter St/imme wurden nicht beobachtet. Damit stellt selektive Florasuppression ein hochwirksames Verfahren zur Infektionsprophylaxe in der operativen Intensivmedizin dar.

Introduction

Priv.-Doz. Dr. med./_1. Hartenauer, Dr. med. B. Th////g, Prof. Dr. reed. P. Lawin, Klinik und Poliklinik for An/isthesiologie und operative Intensiv-

The Clinic for Anesthesiology and surgical Intensive Care of the University Hospital of Miinster (FRG) comprises apart from the central anesthesia service - three intensive care units. Multiple trauma patients and patients after

medizin, Westf~ilische Wilhelms-Universit/it MOnster, Albert-Schweitzer-Str. 33, D-4400 MOnster; Dr. med. W. Fegeler, Institut fOr Medizinische Mikrobiologie, Westf~lische Wilhelms-Universit/it MOnster, Domagkstr. 10, D-4400 MOnster, FR Germany.

S 22

Infection 18 (1990) Suppl. 1 © MMV Medizin Verlag GmbH M0nchen, M0nchen 1990

U. Hartenauer et al.: Selective Digestive Decontamination in ICU elective surgery who need intensive care, are admitted to one of those three units. Infections in critically ill patients in our intensive care unit II were studied over a five-year period. All the patients in the first quarter of each of five consecutive years (1980-1984) were continuously monitored for infections according to a standard protocol. Definitions and criteria for infections complied with those of the CDC and the algorithms of the SENIC project [1]. The first quarter of 1980 was analysed retrospectively, the subsequent years were examined prospectively. Of the 1,009 patients surveyed, 60% were males and 40% females; the average age was 45.5 years, the average duration of stay approximately four days. One third of the patients came from the neurosurgical department; 10% came from different surgical fields because of multiple trauma and the rest were admitted after orthopaedic or other surgical procedures. Nearly half of the patients underwent surgical procedures before or during their stay in the intensive care unit. 733 patients (73%) were intubated and artificially ventilated for three days. In all, 1,129 nosocomial infections were registered in 331 patients: 26% of the patients with nosocomial infections died, 6.9% of the uninfected patients died. Figures and tables for the following data have been published elsewhere [2]. Respiratory tract infections (RTIs), wound infections and urinary tract infections (UTIs) were the most frequent, followed by septicaemia and catheter-related infections. Mechanical ventilation increased the rates of RTI and mortality: only two thirds of the pulmonary infections were successfully treated with antibiotics. Patients developing septicaemia had RTIs in approximately 90% of cases, and a concomitant nosocomial superficial or deep (intraabdominal) wound infection in approximately 75%. Intubation and tracheostomy increased the frequency of septicaemia fourfold and sevenfold, respectively. I. v. catheter-related infection rates increased with the duration of catheter insertion and with the number of catheters per patient. UTIs occurred with the same frequency as in other departments of the same hospital, and were more frequent in patients with a urinary catheter. There was no significant reduction in nosocomial infections over the five-year period in our intensive care unit; rates were similar in a second ICU, opened in 1984, which differs from the first only in building construction. Hygienic measures can help only in eliminating "germ" reservoirs. However, 80% of all infections in intensive care are endogenous and therefore new and original strategies which affect the sources of endogenous infection should be evaluated. Therefore a study was designed to evaluate the concept of selective decontamination of the digestive tract (SDD) in critically ill patients in our two surgical/traumatological intensive care units. The first application of this technique to an intensive care unit was reported by Stoutenbeek and coworkers in 1983 [3]. SDD is defined as selective elimina-

tion of potentially pathogenic microorganisms from both the oral and intestinal microflora by topical nonabsorbable antibiotics. However, the term "selective decontamination of the digestive tract" is open to question. The term decontamination is used mostly in conjunction with disinfection of inanimate objects and not for flora modulation. Moreover, the term "decontamination of the digestive tract" suggests that only the intestinal flora is treated and although this may be the case in leukaemic patients, in intensive care patients the oropharyngeal microflora is of utmost importance. Therefore, we prefer the term "selective flora suppression" as the more appropriate one. The objective of the present study was to investigate the concept of selective flora suppression in severly ill patients in two surgical ICUs. The aim was to clarify whether selective flora suppression offers advantages over conventional restrictive antibiotic policy as far as microbial colonization, infection, mortality and development of resistance are concerned. Patients and Methods

Study design: This investigation took the form of a one-year prospective, consecutive, placebo-controlled study in two ICUs (Figure 1). Verum was given for six months and then placebo and vice versa. ICU I dealt with patients undergoing cardiothoracic surgery and neurosurgery, ICU II with general surgery and multiple trauma patients. Patients: The evaluation included patients who were intubated for at least three days, required intensive care for five days or more and who fell into categories III or IV of the "Therapeutic Intervention Scoring System" (TISS [4]). Methods of evaluation: In evaluating the clinical findings, the results were compared only within each ICU. The microbiological results of the placebo periods were combined and compared with the verum periods. Antibiotic regimen: All patients expected to require intensive care for more than one day were given the prophylaxis regimen (PTA) described by Van Saene et al. [5] or placebo. The PTA regimen consists of a solution containing 100 mg polymyxin E, 80 mg tobramycin and 500 mg amphotericin B. The patients either drank the solution or it was applied via the nasogastric tube four times a day. A sticky paste (carboxymethyl cellulose) was also applied to the oropharyngeal cavity at the same time, and contained the same substances in a concentration of 2%. This local antimicrobial prophylaxis was continued until the patient was transferred to a general ward. For prophylaxis of exogenous or primarily en-

I

ICU

Placebo: 61

×

ICU II I

monthsl 0

Placebo: 40

]

I

I

6

12

Figure 1: Study design and patient groups in intensive care units (ICU) I and II. After six months verum was exchanged for placebo and vice versa.

Infection 18 (1990) Suppl. 1 © MMV MedizinVerlag GmbH Miinchen, Miinchen 1990

S 23

U. Hartenauer et al.: Selective Digestive Decontamination in ICU dogenous early infections, cefotaxime (6 g/day) was given to patients for four days who, on admission to the ICU, were not receiving parenteral antibiotics for any other reason. Infections were treated according to the regulations of a restrictive antibiotic policy. Life-threatening infections were initially treated with a combination of a cephalosporin (cefotaxime, ceftazidime) and tobramycin. Metronidazole was added if there was any reason to suspect anaerobic involvement. If indicated, however, further antibiotics were used, e. g. penicillins, vancomycin or erythromycin. Medical and nursing care and other study-related measures: All patients had central venous and arterial lines, transurethral or suprapubic urinary catheters and nasogastric tubes. If there was any sign of local infection at the entry site or if patients developed fever of unknown origin, arterial and venous catheters were removed. If nasotracheal intubation was expected to last for longer than ten days, tracheostomy was performed. All patients received stress ulcer prophylaxis with 1 mg/kg BW/h cimetidine and three times 10 mg pirenzepine/day. Patients with lst-3rd degree craniocerebral trauma received triamcinolone, which was tapered off the following nine days. All patients underwent daily physical examination and chest Xray for signs of infection. Infection-related problems were discussed twice weekly at clinical/microbiological conferences. Detailed findings were documented daily in a nosocomial infection work sheet. The "Simplified Acute Physiology Score" (SAPS [6]), "Hospital Trauma Index-Injury Severity Score" (HTI-ISS [7]) and the TISS [4]) were calculated. Microbiological examinations: Samples were obtained from oropharyngeal and anal swabs, tracheobronchial secretions, urine and stool. These were taken before the first administration of PTA and then twice weekly. Samples were cultured on blood, MacConkey and yeast agar and were enriched in dextrose bouillon. All Enterobacteriaceae and Pseudomonadaceae, summarized as aerobic gram-negative bacilli in the following, were biochemically differentiated (API 20E, API 20NE) and tested for resistance. If isolated as a monoculture, organisms constituting part of the physiological microflora were also tested for resistance, as were those with special pathogenicity in intensive care patients (e. g. coagulase-negative staphylococci). Definitions: Bronchopulmonary infection was diagnosed on the following: new pulmonary infiltrates on X-ray, purulent tracheobronchial secretions and one of the following features: positive physical signs, hyperthermia or hypothermia, leucocytosis or leucopenia, a fall in arterial partial oxygen pressure. Urinary tract infection (UTI) was diagnosed on the following: presence of at least 103 colony-forming units in transurethral catheter urine or positive bacteriological findings in suprapubic urine samples, with at least five leucocytes per high power field. Septicemia was defined as follows: microbiological findings in bloodculture, coupled with hyperdynamic or hypodynamic sepsis. Microbiological findings had to be demonstrated twice for coagulase-negative staphylococci. Catheter-associated septicemia was defined as septicemia, but the identical organisms had to be isolated from t h e t i p o f the intravasal catheter. Statistical analysis~ The Chi-square test was used for statistical analyses; to facilitate comparison, percentages were used even if the absolute figures were lower than 100.

Results 200 p a t i e n t s m e t t h e i n c l u s i o n criteria. 111 w e r e t r e a t e d in I C U I (50 in t h e v e r u m g r o u p a n d 61 in t h e p l a c e b o g r o u p )

S 24

Table 1: Distribution of the patients in ICU I and II according to the referring, hospital. ~.

.~

Cardiothoracic Surgery Neurosurgery Anesthesia* Maxillary surgery ENT Urology Gynaecology Orthopaedics Total E~;'~~1~r¢~

~;t~"

General surgery "Polytrauma.... Total

22 19 6 1 1 1 0 0 50 " ~~ J ~

~l'~~

' ~ l ; ~

39 10 49

23 27 4 3 0 0 22 2 61 ~'!~;~ ';~"

~'" ' E ~

30 10 40

Anesthesia: referral of patient from external intensive care unit. "Polytrauma": admission following interdisciplinaryemergency treatment.

Table 2: Patient data. The days on respirator are given as a percentage of ICU days.

Patients (n) Male/female Age (years) ICU days Days on respirator (%) SAPS (lst day)

50 32/18 53 + / - 17.4 11.9+/-6.5 87 9.6+/-3

61 29/32 55 + / - 18.4 13.1+/-10.8 85.3 10.1+/-3.3

Patients (n) Male/female Age (years) ICU days Days on respirator (%) SAPS (lst day) HTI-ISS

49 38/11 52+./-16.5 13.2 + / - 8.7 80.4 9.3+/-2.8 39+/-13.1

40 33/7 54+/-16.7 16.5 + / - 10.4 89.9 8.2+/-2.4 39.3+/-12.5

and 89 in ICU II (49 in the verum group and 40 in the placebo group) (Table 1). The distribution of the patients in the verum and placebo groups was comparable with regard to sex, age, stay, days on respirator, SAPS and HTI-ISS (Table 2). Colonization

The microbiological results in both verum periods were nearly identical. The same applies to both placebo periods. This enabled pooling of the results to form one verum group and one placebo group. 2,581 of 5,108 microbiological samples were taken as routine examinations (mouth, anal and wound swabs and samples of tracheobronchial secretions) (Table 3). A total of 9,326 bacterial strains were isolated. Almost the same number of samples was collected in placebo and verum groups.

Infection 18 (1990) Suppl. 1 © MMV Medizin Verlag GmbH Miinchen, Miinchen 1990

U. Hartenauer et al.: Selective Digestive Decontamination in ICU Table 3: Proportion of Enterobacteriaceae and Pseudomonadaceae (aerobic gram-negative bacilli) of the total number of strains isolated from each test material. Total number of bacterial strains isolated from the respective test material = 100%.

Mouth swabs Tracheobronchial secretions Anal swabs Wound swabs Total

9%

811

23.9%

1243

12.7% 28.8% 14.6%

536 1163 370

35.2% 42.3% 26.9%

810 1498 253

18.9%

3795

35.6%

5531

Evaluation of all organisms cultured revealed that aerobic gram-negative bacilli accounted for 18.9% of the strains in the verum group, almost half of that for the same group of organisms in the placebo group at 35.6%. Differences for mouth swabs and traCheobronchial secretions were more pronounced (Table 3).

The course of colonization with aerobic gram-negative bacilli is reflected in the number of colonized patients per day. In Figures 2-7, the number of investigations per day corresponds to the number of patients. A period of 14 days was chosen for this analysis. On day one, the mouth swabs from the verum and placebo group showed almost the same incidence of aerobic gramnegative bacilli. From day two onwards, only very few or no aerobic gram-negative bacilli at all were cultured. It is clear from Figures 2 and 3 that aerobic gram-negative bacilli accounted for between one third and one half of samples investigated on any given day. The incidence of aerobic gram-negative bacilli also decreased in the anal swabs from the verum group, and this was particularly marked from day eight onwards. Regardless of the day of investigation, aerobic gram-negative bacilli were demonstrable in the vast majority of anal swabs in the placebo group (Figures 4 and 5). With regard to tracheobronchial secretions, the trend in both groups was similar up to day four. After this, samples n Number ol examln=a=!=lonsc_osre_spo_nd~.tothe number otp~_atie.nts

Number of examinations oorrespoods to the number of patients

100-

94 . . . . . .

:.....................................

:..............................................

100 •

93

........................

.................

::. . . . . .

50 50

~1

28 28

24 24

19 1~,1.16

,,

Day 0

1

2 ] 3

4

"

6

7

8

'

10

14

11

12113114

I

o

31

3

2

2

0

1

1

t

0

2

2

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t

3 3 12 10 9 11 15 13 12 19 ..... 24 L,!PLP___t 16 5 ..... 16 l ......... t3 J..... 4 j ~44 1 ~4% 0 __J

1

without

without Enterobaeterlaceae and/or Pseudomonada~eae with

m

il

:

L_...~___.

I~B

with

10 3

11 6 a3 L ~3

Enterobecterlaceae and/or Peeudomonadaceae

Figure 2: Mouth swabs in the verum group (ICU I and II). Proportion of samples with and without aerobic gram-negative bacilli.

Figure 4: Anal swabs in the verum group (ICU I and II). Proportion of samples with and without aerobic gram-negative bacilli.

n Number of examinations corresponds to the number of patients

n Number ol examinations oorresponds to the number of patients a s ..........................................................................................................................

100 "

100

-

150. ^~

29

29 32 (-~7~ ~

28

Day F ~

15 15 lO 18

8

13 12

9

7

5

8

4

6

10

11

6 I ......... 9 .........

6

6

7

10

7

3 !

without with

14:8

10

Enterobacteriaoeaeand/or Pseudomonadaceae

Figure 3: Mouth swabs in the placebo group (ICU I and II). Proportion of samples with and without aerobic gram-negative bacilli.

m

20

20

20

18

-m

19

2z

3

4

5

6

7

8

9

10

11

12

13 [ 14

~3

26

17

26

16

15

17

12

14

11

17

11

without I~1

31 1B ~

with

Enterobacterlaoeae

9

a n d / o r Paeudomonadaceae

Figure 5: Anal swabs in the placebo group (ICU I and II). Proportion of samples with and without aerobic gram-negative bacilli.

Infection 18 (1990) Suppl. 1 © MMV Medizin Verlag GmbH Miinchen, Miinchen 1990

S 25

U. Itartena~er et al.: Selective Digestive Decontamination in ICU n N u m b e r ot examinations oorresponds to the number of patients

100

....

........................................

50-

................................ -I~1

23

23

26

"~

20

~1~/1~1 ~tl~al~TlZOl~Zl la / ~ / 8 / 9 without

with

Enlerobaoterlaceae

i1~1 7 /

and/or Pseudomonadaceaa

Figure 6: Tracheobronchial secretions in the verum group (ICU I and II). Proportion of samples with and without aerobic gramnegative bacilli. N u m b e r of examinations corresponds to the n u m b e r o! patients

aureus. Bronchopulmonary Infections

98 100

6O 22 I ~

24 ~

^~ 17

18 ,

,I,rllet without with

ttl~Ol

~u :

17 ~

18 ~-~

16 .

-^ ~u

10

~ "~

12

~ I~=1 . ItOl ~ I ~ I z I 4 / ~

Enterobaoterlaoeae and/or Pseudomonadaceae

Figure 7: Tracheobronchial secretions in the placebo group (ICU I and II). Proportion of samples with and without aerobic gram-negative bacilli.

with aerobic gram-negative bacilli were only found occasionally in the verum group, whilst aerobic gram-negative bacilli were isolated from at least one third of the samples from the placebo group (Figures 6 and 7). Aerobic gram-negative bacilli were isolated from 12 mouth swabs from nine patients of the verum group between days five and 14 (Figures 2 and 3). In one case, primary, persistent colonization with a Pseudomonas rnaltophilia strain resistant to polymyxin E and tobramycin was present, and in another case primary, persistent colonization with Morganella morganii. In two further patients, two organisms isolated at baseline, Escherichia call and M. morganii were eliminated. ICU-acquired secondary, persistent colonization with Enterobacter cloacae was observed in another patient. Pseudomonas aeruginosa, E. cloacae, M. morganii and E. call were present in only one sample in three cases and not in the following samples. In the ninth patient in this group, P. aeruginosa was isolated only once; further samples were not available and thereS 26

fore no conclusion could be drawn on persistence. None of these nine patients showed signs of bronchopulmonary infection. Aerobic gram-negative bacilli were isolated from tracheabronchial secretions in 16 samPles from 12 patients between days five and 14. In one patient, as in the corresponding mouth swab, primary, persistent P. mattophilia was isolated, which was also resistant to polymyxin E and tobramycin. In three further patients, the following organisms isolated at baseline were eliminated: P. aeruginosa, M. morganii and E. coll. Secondary colonization persisted in four cases: E. cloacae (one patient), Citrobacter freundii (one patient), P. aeruginosa (two patients). E. call was isolated from only one sample in one patient and in no further samples. Aerobic gram-negative bacilli (Proteus morganii, Proteus mirabilis, C. freundii and P. aeruginosa) were isolated from the last tracheobronchial sample obtained in four patients. Two patients developed bronchopneumonia caused by Legionella pneumophila and Staphylococcus

The rate of nosocomial bronchopneumonia was significantly reduced in both ICUs: from 45.6% to 10% in ICU I (Table 4) and from 45% to 10% in ICU II (Table 5). None of the five cases of pneumonia in the verum group in ICU I was caused by aerobic gram-negative bacilli. This was, however, the case in 75% of cases of pneumonia in the placebo group. Amongst the three causative gram-positive microorganisms in the verum group were two strains of S. aureus (one tobramycin-resistant) and enterococci. The diagnosis "legionellosis" was made twice serologically. In one case, however, a clear increase in titre was not observed. Also in ICU II, none of the five cases of pneumonia in the verum group was caused by aerobic gram-negative bacilli. Two were caused by S, aureus or coagulasenegative staphylococci, two again by L. pneumophila. Candida albicans pneumonia occurred in a patient who had Table 4: Nosocomial bronchopulmonary infections (BPI) and organisms isolated from tracheobronchial secretions in patients in ICU I.

BPI 5/50 (10%)* Staphylococcus aureus 2 Coagulase-negative staphylococci 0 Enterococcus faecalis 1 Pseudomonas aeruginosa 0 Pseudomonas maltophilia 0 Enterobacter Spp. 0 Proteus spp. 0 Citrobacter spp. 0 Acinetobacter spp. 0 Klebsiella spp. 0 Legionella pneumophila 2 Total 5

28/61 (45.6%) 6 4 3 13 1 5 4 3 3 2 0 44

* p < 0.001

Infection 18 (1990) Suppl. 1 © MMV Medizin Verlag GmbH Miinchen, Miinchen 1990

U. Itartenauer et al.: Selective Digestive Decontamination in ICU Table 5: Nosocomial bronchopuimonary infections (BPI) and organisms isolated from tracheobronchial secretions in patients in ICU II.

Table 9: Septicemia including catheter-associated septicemia and organisms isolated in patients in ICU 11.

Septicemia BPI

8/49 (16.3%)

3/40 (7.5%)

Staphylococcus aureus

3

0

2

Coagulase-negative staphylococci

1

1

i

1

0 0 0

1 7 3

Pseudomonus aeru~nosa Acinetobacter calcoaceticus Candida albicans

1 0 3

1 1 0

Total

8

3

0 0

2 3

0 2 1

1 0 0

0 5

1 21

5/49 (10%)*

18/40 (45%)

Staphylococcus aureus

1

Coagulase-negative staphylococci Enterococcus faecalis Pseudomonas aeruginosa Pseudomonas maltophilia Enterobacter spp. Proteus spp. Acinetobacter calcoaceticus Legionella pneumophila Candida albicans

Cytomegalovirus(CMV) Total *p