心脏外科术后手术部位感染.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,心脏外科术后手术部位感染,北京协和医院加强医疗科,杜斌,手术部位感染的后果,SSI,患者与对照组患者住院日,(,LOS),及医疗费用,手术种类,病例对数目,每例,SSI,患者,LOS,延长中位数,每例,SSI,医疗费用增加中位数,CABG,20,11.0,$,3,856,阑尾切除术,7,10.0,$,3,945,结肠手术,29,6.0,$,2,671,剖腹探查,19,22.0,$,9,964,椎板切除术,24,10.5,$,3,273,椎骨融合,20,20.5,$,11,001,ORIF,8,11.5,$3,623,关节置换,23,4.0,$,2,714,血管手术,11,16.0,$,5,595,心脏外科手术后的手术部位感染,流行病学,危险因素,诊断,微生物学,普通外科手术,SSI,的,危险因素,SSI,发生率11.4%(254/2,237),预防使用抗生素的正确率,63.5%,SSI,的独立预测因素,年龄,(,OR=1.2,每,增加10岁,),伤口分类,(,清洁沾染,OR=6.4;,污染,OR=3.7;,感染,OR=9.3),抗生素预防(,OR=0.5),手术前住院日(,OR=1.1,每增加3天,),手术持续时间(,OR=1.5,每,增加60分钟,),恶性肿瘤(,OR=1.7),急诊手术(,OR=1.99),手术前住,ICU,时间(,OR=2.6),手术前,2,h,应用抗生素预防,(,OR=5.3),Lizan,-Garcia M,Garcia-Caballero J,Asensio,-Vegas A.Risk factors for surgical-wound infection in general surgery:a prospective study.Infect Control Hosp,Epidemiol,1997 May;18(5):310-5,SSI,的危险因素,NNIS,危险指数,污染或感染手术,美国麻醉师学会(,ASA),术前评估为,3,4,或5,手术时间超过75百分位,时间点(,T),指,根据,NNIS,调查手术时间的75%百分位,ASA,术前评估,外科患者生理状态分级,Class I,健康,Class II,具有全身性疾病，但无功能障碍,A patient with mild systemic disease resulting in no functional limitations,Class III,具有严重全身性疾病，限制日常活动，但无功能障碍,A patient with severe systemic disease that limits activity,but is not incapacitating,Class IV,具有严重全身性疾病，持续威胁生命,A patient with severe systemic disease that is a constant threat to life,Class V,濒死状态，无望存活24小时,A moribund patient not likely to survive 24 hours,常见手术的,T,时间点,手术,T,时间点(,hour),CABG,5,胆道,肝脏,或胰腺手术,4,开颅手术,4,头颈部手术,4,结肠手术,3,人工关节置换手术,3,血管外科手术,3,经腹或经,阴道子宫切除术,2,脑室转流,2,疝修补术,2,阑尾切除术,1,截肢手术,1,剖宫产,1,SSI,危险分类:手术种类和,T,时间点,危险分类,手术种类,T,时间点(,hr),0,1,2,3,结肠手术,3,3.2,8.5,16.0,22.0,血管外科手术,3,1.6,2.1,6.1,14.8,胆囊切除手术,2,1.4,2.0,7.1,11.5,器官移植,7,0.0,4.4,6.7,18.0,SSI,的诊断,SSI,的微生物学,手术,SSI,常见致病菌,手术,常见致病菌,所有移植物,或假体的植入术,心脏,神经外科,乳腺,金黄色葡萄球菌,;,凝固酶阴性葡萄球菌,眼科,资料有限,;但在前节,切除术,玻璃体切除术等常用,金黄色葡萄球菌,;,凝固酶阴性葡萄球菌,;,链球菌;革兰阴性杆菌,骨科,全关节置换术,闭合性骨折或应用骨钉,骨板,其他内固定装置,无移植物或装置的功能修复手术,创伤,金黄色葡萄球菌,;,凝固酶阴性葡萄球菌,;,革兰阴性杆菌,SSI,的微生物学,手术,SSI,常见致病菌,手术,常见致病菌,非心脏胸科手术,胸外科手术,(,肺叶切除术,肺切除术,肺楔形切除,其他非心脏纵隔手术),胸腔闭式引流术,金黄色葡萄球菌,;,凝固酶阴性葡萄球菌,;,肺炎链球菌;革兰阴性杆菌,血管外科手术,金黄色葡萄球菌,;,凝固酶阴性葡萄球菌,阑尾切除术,革兰阴性杆菌;厌氧菌,胆管,结肠直肠,胃十二指肠,头颈部,(经口咽部,粘膜切口的大手术,),革兰阴性杆菌,;,链球菌;口咽部厌氧菌,(如,消化链球菌,),妇产科,革兰阴性杆菌;肠球菌;,B,族链球菌,;,厌氧菌,泌尿科,如果尿液无菌,抗生素可能无效,革兰阴性杆菌,SSI,的微生物学,NNIS,手术部位感染分离的致病菌,1986,to 1996,分离致病菌的百分比,致病菌,1986 1989,(,n=16,727),1990 1996,(,n=17,671),金黄色葡萄球菌,17,20,凝固酶阴性葡萄球菌,12,14,肠球菌属,13,12,大肠杆菌,10,8,铜绿假单胞菌,8,8,肠杆菌属,8,7,奇异变形杆菌,4,3,肺炎克氏菌,3,3,其他链球菌属,3,3,白色念珠菌,2,3,D,族链球菌,(,非肠球菌),-,2,其他革兰阳性需氧菌2,脆弱拟杆菌,-,2,预防性抗生素,使用何种抗生素,抗生素,vs.,安慰剂,1,GC vs.2GC,2GC vs.3GC,氨基糖甙类抗生素的作用,万古霉素的作用,何时使用,疗程如何,预防性抗生素,Antibiotic prophylaxis for,cardiothoracic,operations meta-analysis of thirty years of clinical trials,by Bruce,Kreter,and Mark Woods,J,Thorac Cardiovasc Surg,1992;104:590-9,仅,入选前瞻性,随机,盲法,及对照研究,预防性抗生素,Versus,安慰剂对照,预防性抗生素较优,安慰剂较优,头孢唑啉,Versus,头孢呋肟或头孢孟多,2,GC,较优,1,GC,较优,心脏外科的预防性抗生素,结论,预防性抗生素,安慰剂,SSI,减少5倍,2,GC(,头孢孟多和头孢呋肟,),头孢唑啉,SSI,降低1.5倍,预防性抗生素,48,小时无益,心脏外科中2,GC vs.3GC,头孢曲松,2,gm,单剂,vs.SSI,相似,头孢孟多,多剂量,头孢曲松,vs.,SSI,相似,头孢孟多,Badel,P,Schmuziger,M.Anti-infection prophylaxis in cardiac surgery:comparison of single-dose,ceftriaxone,and,cefamandole,in repeat doses,Schweiz Rundsch,Med,Prax,.1989 May 30;78(22):643-5,Neidhart,P,Velebit,V,Gunning K,Suter,PM.A comparative study of,cefamandole,and,ceftriaxone,as prophylaxis in cardiac surgery.Infection 1990 Mar-Apr;18(2):101-4.,氨基糖甙的作用,Efficacy of,cefazolincefamandole,and,gentamicin,as prophylactic agents in cardiac surgery:results of a prospective,randomized,double-blinded trial in 1030 patients,by Allen B.Kaiser,et al,Ann.,Surg,1987;206:791-7,氨基糖甙的作用,预防性抗生素,胸骨正中切口的患者,胸骨伤口感染,(%),血管供体切口的患者,血管供体部位感染(%),头孢唑啉,255,3(1.2),239,4(1.7),头孢唑啉 庆大霉素,253,6(2.4)*,236,2(0.8),头孢孟多,259,2(0.8),246,0(0),头孢孟多 庆大霉素,263,0(0)*,242,0(0),所有头孢唑啉组,508,9(1.8)*,475,6(1.3)*,所有头孢孟多组,522,2(0.4)*,488,0(0)*,联合庆大霉素,516,6(1.2),478,2(0.4),不联合庆大霉素,514,5(1.0),485,4(0.8),总计,1030,11(1.1),963,6(0.6),氨基糖甙的作用,结论,心脏外科中庆大霉素不应作用预防性抗生素使用,头孢孟多,头孢唑啉,针对胸骨和血管供体部位的深部感染,CABG,中预防性抗生素的药代动力学研究,头孢呋肟(,n=30),每日一次,体外循环过程中加用一剂,单一剂量,血清水平 2,mg/L x 8 hr,万古霉素(,n=30),每日一次,体外循环过程中加用一剂,单一剂量,血清水平 4,mg/L x 24 hr,结论:,单一剂量的头孢呋肟,(3,g,或 1.5,g),或,万古霉素,(1.5,g),可以使血清浓度在,CABG,手术后数小时达到并维持足以预防感染的水平,Vuorisalo,S,Pokela,R,Syrjala,H.Is single-dose antibiotic prophylaxis sufficient for coronary artery bypass surgery?An analysis of,peri,-and postoperative serum,cefuroxime,and,vancomycin,levels.J Hosp Infect.1997 Nov;37(3):237-47.,预防性使用万古霉素,vs.1GC,万古霉素和利福平替代头孢唑啉作为,CABG,预防性抗生素,手术部位感染率(每100例手术,),10.5(95%,CI,8.2 13.3)to 4.9(95%CI,3.2 7.1),P .001,估计12个月内节约$576,655(澳元),Spelman,D,Harrington G,Russo P,Wesselingh,S.Clinical,microbiological,and economic benefit of a change in antibiotic prophylaxis for cardiac surgery.Infect Control Hosp,Epidemiol,.2002 Jul;23(7):402-4.,预防性使用万古霉素,vs.,头孢菌素,接受心脏或大血管手术的321名成年患者,随机化,头孢唑啉,头孢孟多,或万古霉素,结果,SSI:,万古霉素组 3.7%(4),vs.,头孢唑啉组 12.3%(14),vs.,头孢孟多组,11.5%(13);,p=0.05,万古霉素组心脏外科手术后无胸部伤口感染发生,(,p0.04),术后,平均,LOS:,万古霉素组最低,(10.1,天;,p,安慰剂,SSI,减少5倍,2,GC(,头孢孟多和头孢呋肟,),头孢唑啉,SSI,降低1.5倍,预防性抗生素,48,小时无益,患儿心脏手术后的预防性抗生素,术前,手术,留置胸腔引流管,留置,CVC,POD 2,Protocol 1*,(n=786),Protocol 2*,(n=1095),Protocol 3*,(n=2039),头孢唑啉,*,开胸,患者手术后应用万古霉素和庆大霉素直至胸腔引流管拔除,Maher KO,VanDerElzen,K,Bove,EL,et al.,A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients,头孢唑啉,头孢唑啉,患儿心脏手术后的预防性抗生素,:,p 0.05 protocol 2 vs.1 or 3,:,p 48,h),1.6,0.027,1.1 2.6,年龄 65 岁,1.3,0.022,1.0 1.6,CABG/,心,瓣膜联合手术,2.7,0.002,1.4 5.1,CABG,后抗生素治疗,1.8,0.054,1.0 3.3,Harbarth,S,Samore,MH,Lichtenberg,D,Carmeli,Y.Prolonged Antibiotic Prophylaxis After Cardiovascular Surgery and Its Effect on Surgical Site Infections and,Antimicrobial,Resistance.,Circulation,.2000;101:2916-2921,预防性抗生素对抗生素耐药的影响,37例,血管外科手术患者,阿莫西林克拉维酸,x 3,天,(,group 1),氧氟沙,星+甲硝唑,x 3,天(,group 2),氧氟沙,星+甲硝唑,x 1,天(,group 3),17,例未行手术或未应用抗生素患者,(,对照组),结果,第1和2组皮肤葡萄球菌对下列抗生素的敏感性显著下降,:,邻氯青霉素(12.8%,vs.23.6%),和氧氟沙星(0.5%,vs.85%),第3组,结果介于1和2组之间,分子生物学分型提示患者社区来源的敏感菌株被医院获得的耐药菌株(遗传学不相关)所替代,结论,长程预防性抗生素可导致耐药菌定植,应尽量避免,Terpstra,S,Noordhoek,GT,Voesten,HGJ,et al.Rapid emergence of resistant,coagulase,-negative staphylococci on the skin after antibiotic prophylaxis,ICU,中,抗生素预防的费用及合并症,61%的预防性抗生素医嘱超过1天,超过1天的预防性抗生素总费用达,$44,893,应用预防性抗生素超过4天的患者更容易发生菌血症和导管感染,Namias,N,Harvill,S,Ball S,McKenney,MG,Salomone,JP,Civetta,JM.Cost and morbidity associated with antibiotic prophylaxis in the ICU.J Am,Coll Surg,.1999 Mar;188(3):225-30,预防性抗生素的副作用,回顾性病例对照研究,病例,(,n=23):,应用预防性抗生素,(,PAT),的择期手术患者且难辨梭状芽孢杆菌毒素,(,CDT),阳性,对照(,n=39):,年龄,性别和手术相匹配,结果,PAT,错误 83%,vs.44%,OR 5.1(1.10 23.64),手术至最后一剂抗生素的平均时间间隔,3.1,vs.1.7,天,P 0.05,LOS 16.5 vs.10.2,天,P 24,h,非,标准抗生素方案非常普遍,Finkelstein R,Reinhertz,G,Embom,A.Surveillance of the use of antibiotic prophylaxis in surgery.,Isr,J Med,Sci,1996 Nov;32(11)1093-7,预防性抗生素应用现状,81%,至 94%的病例应用预防性抗生素,适时应用抗生素,手术前,2,hrs,应用抗生素,Silver A,Eichorn,A,Kral,J,Pickett G,Barie,P,Pryor V,Dearie,MB.Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures.The Antibiotic Prophylaxis Study Group.Am J,Surg,1996 Jun;171(6):548-52,髋,关节骨折患者不正确应用预防性抗生素,时机,过迟(手术后 2,hrs)70%(247/352),过早或在手术中,10%,直至手术结束才应用首剂,39%(91/231),抗生素的选择,胃肠外应用1,GC94%,疗程,手术后 24,hrs78%,不,正确应用预防性抗生素的预测指标,没有预防性抗生素的书面医嘱,非,教学医院,手术时间较短,Zoutman,D,Chau,L,Watterson,J,Mackenzie T,Djurfeldt,M.A Canadian survey of prophylactic antibiotic use among hip-fracture patients.Infect Control Hosp,Epidemiol,1999 Nov;20(11):752-5,1.,Platt R,Zaleznik,DF,Hopkins CC,et al.,Perioperative,antibiotic prophylaxis for,herniorrhaphy,and breast surgery.N,Engl,J Med.1990;322:153-160.2.,Matuschka,PR,Cheadle,WG,Burke JD,Garrison RN.A new standard of care:administration of preoperative antibiotics in the operating room.Am,Surg,.1997;63:500-503.3.Silver A,Eichorn,A,Kral,J,et al.Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures.The Antibiotic Prophylaxis Study Group.Am J,Surg,.1996;171:548-552.4.Finkelstein R,Reinhertz,G,Embom,A.Surveillance of the use of antibiotic prophylaxis in surgery.,Isr,J Med,Sci,.1996;32:1093-1097.5.,Lizan,-Garcia M,Garcia-Caballero J,Asensio,-,Vegis,A.Risk factors for surgical wound infection in general surgery:a prospective study.Infect Control Hosp,Epidemiol,.1997;18:310-315.6.,Zoutman,D,Chau,L,Watterson,J,et al.A Canadian survey of prophylactic antibiotic use among hip-fracture patients.Infect Control Hosp,Epidemiol,.1999;20:752-755.,不正确的预防性抗生素,改进预防性抗生素应用时机的方法,Louisville,退伍军人医疗中心,由不同人员应用手术前抗生素,病房护士,1992,至 1994,手术室麻醉医生,1995,正确的时机,手术前抗生素在切开皮肤前1小时内应用,Matuschka,PR,Cheadle,WG,Burke JD,Garrison RN.A new standard of care:administration of preoperative antibiotics in the operating room.Am,Surg,1997 Jun;63(6):500-3,改进预防性抗生素应用的方法,目的:,评价自动手术中报警对长时间心脏手术应用第二剂预防性抗生素的影响,设计,:,随机,对照,评估者设盲试验,患者:接受超过4小时心脏外科手术的患者,手术前已经预防性应用头孢唑啉,干预:,报警组(,n=137):,在术前预防性应用抗生素后225分钟,手术室计算机自动发出声音和视觉报警信号,.30,分钟后,要求巡回护士提醒是否已经应用第二剂预防性抗生素,对照组(,n=136),历史对照组(,n=480):,研究前6个月,Zanetti,G,Flanagan HL,Jr,Cohn LH,et al.Improvement of,intraoperative,antibiotic prophylaxis in prolonged cardiac surgery by automated alerts in the operating room.Infect Control Hosp,Epidemiol,.2003 Jan;24(1):13-6.,改进预防性抗生素应用的方法,报警组,(,n=137),对照组,(,n=136),历史对照组,(,n=480),手术中再次,应用抗生素,68%(93)*40%(55),27%(129)*,SSI,4%(5),6%(8),10%(48),*,adjusted OR 3.31;95%CI 1.97 to 5.56;P .0001 vs.control group,*P .001 vs.control group,P=.42 vs.control group,P=.02 vs.historical control group,Zanetti,G,Flanagan HL,Jr,Cohn LH,et al.Improvement of,intraoperative,antibiotic prophylaxis in prolonged cardiac surgery by automated alerts in the operating room.Infect Control Hosp,Epidemiol,.2003 Jan;24(1):13-6.,预防性抗生素的现状,心脏外科,德国,围手术期预防,除4家医院外,所有其他医院,(94%)均,应用,1,GC(n=32,43%),或 2,GC(n=38,51%),常常应用,24,小时(,n=60,81%),预防性抗生素从不超过3天,74%,的医院,(,n=55),对,所有心脏手术均使用相同的预防性抗生素,而26%,的医院(,n=19),在,部分患者改变预防性抗生素,多,见于心脏移植,预防性抗生素的改变,根据药敏结果(,n=63,85%),根据固定的时间表,(,n=7,10%),从不,改变,(,n=4,5%),Markewitz,A,Schulte HD,Scheld,HH.Current practice of,peri,-and postoperative antibiotic therapy in cardiac surgery in Germany.Working Group on,Cardiothoracic,Surgical Intensive Care Medicine of the German Society for Thoracic and Cardiovascular Surgery.,Thorac Cardiovasc Surg,.1999 Dec;47(6):405-10.,预防性抗生素的现状,心脏外科,德国,手术后的经验性治疗,总计应用29种不同的抗生素,分属8个种类,一线,二线和三线治疗间无显著差异,以下情况除外,-,内酰胺,类抗生素(碳青霉烯类除外)的应用逐渐减少,从一线的,60%,下降到三线的,23%,糖肽类,抗生素应用逐渐增加,从一线的,5%,升高到三线的,18%,ICU,和普通病房应用相同抗生素,:,N=41(55%),预防和手术后治疗选择相同的抗生素,:,N=9(12%),联合治疗:,N=12(16%),Markewitz,A,Schulte HD,Scheld,HH.Current practice of,peri,-and postoperative antibiotic therapy in cardiac surgery in Germany.Working Group on,Cardiothoracic,Surgical Intensive Care Medicine of the German Society for Thoracic and Cardiovascular Surgery.,Thorac Cardiovasc Surg,.1999 Dec;47(6):405-10.,心脏外科术后感染,Year,Pt No.,头孢唑啉,头孢呋肟,头孢曲松,阿莫西林+奈替米星,4-,day,1-,day,2-,day,1-,shot,2-,shot,1-,shot,4-,day,1980 1981,566,1982 1983,512,1984 1987,883,1994 1995,1009,Kriaras,I,Michalopoulos,A,Turina,M,Geroulanos,S.Evolution of,antimicrobial,prophylaxis in cardiovascular surgery.,心脏外科术后感染,结果,总感染率,4.5 5.7%,SSI,1.1%(Range 0.4 2.5%),全身性感染0.8%(,Range 0.4 1.6%),肺炎2.0%(,Range 0.7 2.9%),泌尿系感染0.4%(,Range 0.0 1.4%),中心静脉插管相关性感染0.4%(,Range 0.0 1.0%),30,天病死率1.3%(,Range 0.4 2.0%),Kriaras,I,Michalopoulos,A,Turina,M,Geroulanos,S.Evolution of,antimicrobial,prophylaxis in cardiovascular surgery.,心脏外科术后感染,总结,尽管采用预防性抗生素(,1,GC,2GC,或 3,GC),不同,疗程长短也不尽相同,但感染率均较低,(,range 4.5 5.7%),由于单一剂量抗生素已成功用于心血管外科的预防,因此术后无须使用抗生素,除非术中或术后感染明确,或发生严重的围手术期并发症,Kriaras,I,Michalopoulos,A,Turina,M,Geroulanos,S.Evolution of,antimicrobial,prophylaxis in cardiovascular surgery.,