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1、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,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
2、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
3、NNIS调查手术时间的75%百分位,ASA术前评估,常见手术的T时间点,SSI危险分类: 手术种类和T时间点,SSI的诊断,SSI的微生物学,SSI的微生物学,SSI的微生物学,预防性抗生素,使用何种抗生素抗生素 vs. 安慰剂1GC vs. 2GC2GC 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 trialsby Bruce Kreter and Mark Wood
4、sJ 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,2GC较优,1GC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2GC (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2GC 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-infe
5、ction prophylaxis in cardiac surgery: comparison of single-dose ceftriaxone and cefamandole in repeat doses Schweiz Rundsch Med Prax. 1989 May 30;78(22):643-5Neidhart P, Velebit V, Gunning K, Suter PM. A comparative study of cefamandole and ceftriaxone as prophylaxis in cardiac surgery. Infection 19
6、90 Mar-Apr;18(2):101-4.,氨基糖甙的作用,Efficacy of cefazolin, cefamandole, and gentamicin as prophylactic agents in cardiac surgery: results of a prospective, randomized, double-blinded trial in 1030 patientsby Allen B. Kaiser, et alAnn. Surg 1987; 206: 791-7,氨基糖甙的作用,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
7、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
8、 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,
9、 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
10、) 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 (p = 0.04)术后平均LOS: 万古霉素组最低 (10.1天; p 0.01), 头孢唑啉组最高 (12.9天)医院获得性MRSCoN在皮肤表面的定植无万古霉素耐药葡萄球菌或肠球菌的定植或感染,Maki DG, Bohn MJ, Stolz SM, et al. Comparative study of cefazolin, cefamandole, and vancomycin for surgical prophylaxis in cardiac and vascular op
11、erations. A double-blind randomized trial,预防性使用万古霉素 vs. 3GC,头孢曲松 (n = 97)单一剂量2 gm总感染率13.4%SSI 4% (n = 4),万古霉素 (n = 103)500 mg IV q6h x 48 h总感染率10.7%SSI 5% (n = 5),Salminen US, Viljanen TUT, Valtonen VV, et al. Ceftriaxone versus vancomycin prophylaxis in cardiovascular surgery. JAC 1999; 44: 287-90,
12、本研究说明, 至少在万古霉素耐药葡萄球菌感染率较低的医院中, 心脏外科手术应用单一剂量头孢曲松即可达到足够的效果,心脏外科手术预防性应用万古霉素的适应证,降低人工瓣膜置换或人工血管植入手术后移植物MRSCoN或肠球菌感染的危险性近期应用广谱抗生素治疗的患者进行任何心血管手术MRS或肠球菌外科感染率很高的医院中任何心血管手术,预防性抗生素的时机,短程 (1 剂至2 天) Vs. 长程 (3 至 6天),长程较优,短程较优,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2GC (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
13、,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
14、0.05 protocol 2 vs. 1 or 3: p 0.05 protocol 1 vs. 2 or 3,Maher KO, VanDerElzen K, Bove EL, et al. A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients,患儿心脏手术后的预防性抗生素,接受心脏手术的患儿预防性抗生素可能需要应用到胸腔引流管拔除时,Maher KO, VanDerElzen K, Bove EL, et al. A retrospec
15、tive review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients,高危患者心脏手术后长程预防性抗生素,前瞻性, 随机研究接受心脏手术的高危患者, 即手术后低心排需要强心药物和IABP支持,研究组(n = 28),对照组(n = 25),头孢唑啉x 24 h,替卡西林/克拉维酸x 48 h,小剂量万古霉素,停用 IABP,围手术期,出院,Niederhuser U, Vogt M, Vogt P, et al. Cardiac surgery in a high-risk gr
16、oup of patients: is prolonged postoperative antibiotic prophylaxis effective? J Thorac Cardiovasc Surg 1997;114:162-8,高危患者心脏手术后长程预防性抗生素,结果早期病死率: 25% (7/28) vs. 32% (8/25), p = 0.397明确感染: 50% vs. 68%, p = 0.265肺炎 (n=22); 全身性感染 (n=8); 胸骨伤口深部感染 (n=2)凝固酶阴性葡萄球菌菌血症 (5 vs.3)共计1158次细菌培养中 (血培养, n = 389; 血管内导
17、管, n = 208; 支气管吸取物, n = 411; IABP, n = 42; 伤口分泌物, n = 108), 322 (28%)次细菌生长, 两组间无显著差异血管内导管和IABP (13 vs. 11),Niederhuser U, Vogt M, Vogt P, et al. Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective? J Thorac Cardiovasc Surg 1997;114:162-8,高危患者
18、心脏手术后长程预防性抗生素,结果对于心脏手术的高危患者, 采用长程预防性抗生素及小剂量万古霉素和替卡西林克拉维酸不能减少感染并发症小剂量万古霉素不能降低革兰阳性球菌引起血管内导管定植和感染,Niederhuser U, Vogt M, Vogt P, et al. Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective? J Thorac Cardiovasc Surg 1997;114:162-8,短程 vs. 长程预防,*单一剂
19、量头孢呋肟预防; *阿莫西林和奈替米星联合应用4天,Kriaras I, Michalopoulos A, Michalis A, et al. Antibiotic prophylaxis in cardiac surgery. J Cardiovasc Surg (Torino). 1997; 38 (6): 605-10,长程预防性抗生素对心脏手术后肺炎的影响,Carrel TP, Eisinger E, Vogt M, et al. Pneumonia after cardiac surgery is predictable by tracheal aspirates but cann
20、ot be prevented by prolonged antibiotic prophylaxis,心血管手术后长程预防性抗生素,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,心血管手术后长程预防性抗生素,Ha
21、rbarth 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
22、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
23、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
24、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 0.05LOS 16.5 vs. 10.2 天, P 0.05结论择期手术患者长程使用 PAT 增加 CDT 阳性的风险,Kreisel D, Savel TG, Silver AL, Cunningham JD. Surgical antibiotic p
25、rophylaxis and Clostridium difficile toxin positivity. Arch Surg. 1995 Sep; 130 (9): 989-93,局部抗生素和SSI,目的围手术期应用莫匹罗星清除鼻咽部携带的金黄色葡萄球菌是否能够有效预防SSI试验设计随机, 双盲, 安慰剂对照试验莫匹罗星(n = 315)安慰剂(n = 299)从入院时开始使用, 直至手术当日,Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM. Surgical Site Infections in Orthopedic Surgery:
26、 The Effect of Mupirocin Nasal Ointment in a Double-Blind, Randomized, Placebo-Controlled Study. Clin Infect Dis 2002; 35: 3538,局部抗生素和SSI,Kalmeijer MD, Coertjens H, van Nieuwland-Bollen PM. Surgical Site Infections in Orthopedic Surgery: The Effect of Mupirocin Nasal Ointment in a Double-Blind, Rand
27、omized, Placebo-Controlled Study. Clin Infect Dis 2002; 35: 3538,预防性抗生素应用现状,90% (193/215) 应用预防性抗生素择期手术和急诊手术无差异与缺乏证据的手术相比, 推荐使用经验性抗生素的手术应用预防性抗生素的比例较高 (96 vs. 74%, P = 0.000006)尽管缺乏证据, 部分手术中仍然普遍应用抗生素几乎50%的手术中第一剂预防性抗生素未在正确时机应用21%的病例预防性抗生素 24 h非标准抗生素方案非常普遍,Finkelstein R, Reinhertz G, Embom A. Surveillan
28、ce 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.
29、 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1GC94%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 sur
30、vey 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, Burk
31、e 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
32、. 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 s
33、tudy. 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
34、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
35、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. Inf
36、ect Control Hosp Epidemiol. 2003 Jan; 24 (1): 13-6.,改进预防性抗生素应用的方法,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
37、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 1GC (n = 32, 43%) 或 2GC (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
38、 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
39、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 card
40、iac 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,Kriaras I, Michalopoulos A, Turina M, Geroulanos S. Evolution of antimicrobial prophylaxis
41、 in cardiovascular surgery.,心脏外科术后感染,结果总感染率4.5 5.7%SSI1.1% (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(1GC, 2GC, 或 3GC)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.,
