（戰(zhàn)略管理）降低感染率的圍手術(shù)期策略

（戰(zhàn)略管理）降低感染率的圍手術(shù)期策略TheJournalofBoneandJointSurgery(American).2010;92:232-239.PerioperativeStrategiesforDecreasingInfectionAComprehensiveEvidence-BasedApproach降低感染率的圍手術(shù)期策略：綜合性循證醫(yī)學(xué)路徑JosephA.Bosco,III,MD1,JamesD.Slover,MD,MS1andJanetP.Haas,RN,PhD21DepartmentofOrthopaedicSurgery,NYUHospitalforJointDiseases,NewYorkUniversityLangoneMedicalCenter,301East17thStreet,NewYork,NY10003.E-mailaddressforJ.A.BoscoIII:joseph.bosco@.E-mailaddressforJ.D.Slover:james.slover@2InfectionPreventionandControl,WestchesterMedicalCenter,100WoodsRoad,MacyPavilionSW246,Valhalla,NY10595.E-mailaddress:Haasj@AnInstructionalCourseLecture,AmericanAcademyofOrthopaedicSurgeonsIntroduction引言Surgicalsiteinfectionsassociatedwithorthopaedicsurgicalproceduresaredevastatingcomplications.Theyincreasemorbidity,mortality,andcostandresultinoutcomesthatareworsethanthoseinuninfectedcases1.Decreasingtheincidenceofsurgicalsiteinfectionsisnotonlyofinteresttopatientsandsurgeons,itisalsoamajorfocusofseveralgroupsofinterestedparties.Theserangefrompayers,includingtheCentersforMedicareandMedicaidServices(CMS,Baltimore,Maryland),toinstitutionsrepresentedbytheSurgicalCareImprovementProject(SCIP),amultiple-institutionpartnershipbetweenmajorpublicandprivatehealth-careorganizations,includingtheJointCommissiononAccreditationofHealthcareOrganizations(OakbrookTerrace,Illinois).Decreasingtheincidenceofsurgicalsiteinfectionsis,andwillcontinuetobe,amajorfocusinmedicine.對于骨科手術(shù)而言，手術(shù)部位的感染是一種毀滅性的并發(fā)癥，往往會導(dǎo)致致殘率、致死率以及醫(yī)療費用的增加，并且與沒有發(fā)生感染的病例相比，最終的治療結(jié)果通常也會更差【1】。減少手術(shù)部位的感染率，不僅對患者和醫(yī)生都很有意義，也是利益相關(guān)的各方非常關(guān)注的問題。如出資方，包括醫(yī)療保險與醫(yī)療輔助服務(wù)中心（CMS，Baltimore,Maryland）；以外科醫(yī)療改良項目（SCIP）為代表的相關(guān)機構(gòu)；介于大眾公共機構(gòu)與私人醫(yī)療保健機構(gòu)之間的多機構(gòu)合作組織，包括醫(yī)療機構(gòu)評審聯(lián)合委員會（JCAHO，OakbrookTerrace,Illinois）等。減少手術(shù)部位的感染率現(xiàn)在是，將來也仍會是，醫(yī)學(xué)領(lǐng)域關(guān)注的焦點問題。Toeffectivelypreventsurgicalsiteinfections,theclinicianmustconsiderpreoperative,intraoperative,andpostoperativefactorsandinterventions.Preoperativestrategiesforreductionofinfectionratesincludeidentificationofhigh-riskpatients,screeninganddecolonizationofpatientswithmethicillin-sensitiveStaphylococcusaureusandmethicillin-resistantStaphylococcusaureuscolonization,preoperativepreparationofthepatientwithchlorhexidinegluconate,utilizationofproperhair-removaltechniques,andaddressingpreexistingdentalandnutritionalissuespriortosurgery.為了有效地防止手術(shù)部位的感染，臨床醫(yī)生必須審慎地考慮到手術(shù)前、手術(shù)中以及手術(shù)后的相關(guān)因素和干預(yù)措施。降低感染的術(shù)前策略包括識別高風(fēng)險的患者，對甲氧西林敏感的金黃色葡萄球菌和耐甲氧西林的金黃色葡萄球菌定植的患者進行篩查，并清除定植菌，術(shù)前應(yīng)用洗必泰葡萄糖酸鹽進行清洗，應(yīng)用合適的方法去除毛發(fā)，術(shù)前妥善處理先前存在的牙齒及營養(yǎng)相關(guān)的問題。Thereareavarietyofperioperativestrategiesthatcanandshouldbeemployedtodecreasetheriskofsurgicalsiteinfections.Intraoperativeinterventionsthathavebeenshowntodecreasesurgicalsiteinfectionratesincludetheproperselection,timing,anddosesofprophylacticantibioticsandutilizationofbestpracticesforhandhygieneandsurgicalsitepreparation.Maintainingasterileoperating-roomenvironmentbydecreasingoperating-roomtraffic,monitoringforbreaksinsteriletechnique,anddecreasingtheuseofflashsterilizationisvital.Finally,postoperativestrategiesforthereductionofsurgicalsiteinfectionratesincludetheproperuseanddurationinsituofurinarycathetersandsurgicaldrains;standardizationofwoundcare;useofantibiotic-impregnatedbandages;and,perhapsmostimportantly,maintenanceofproperhandhygiene,isolationprecautions,androomcleaning.有多種圍手術(shù)期的策略可以并且必須應(yīng)用以減少手術(shù)部位的感染。術(shù)中的一些干預(yù)因素已經(jīng)證實可以降低手術(shù)部位的感染率，包括選擇合適的種類、時機和劑量預(yù)防性應(yīng)用抗生素，手衛(wèi)生及術(shù)區(qū)消毒均采用最優(yōu)化的方案。通過減少手術(shù)室的穿行、監(jiān)視有無違反無菌技術(shù)的操作、減少快速消毒的應(yīng)用對于維持手術(shù)的無菌環(huán)境是至關(guān)重要的。最后，降低手術(shù)部位感染率的術(shù)后策略包括合理地應(yīng)用和維持原有的導(dǎo)尿管和術(shù)區(qū)引流管，對創(chuàng)口進行標準化護理；應(yīng)用抗生素浸潤的繃帶，以及，可能最為重要的是，保持正確的手衛(wèi)生、隔離預(yù)防和室內(nèi)清潔。PreoperativeConsiderations術(shù)前注意事項Althougheveryprecautionshouldbetakentopreventinfectionforallorthopaedicpatients,theidentificationofhigh-riskpatientsenablesclinicianstoprovidemaximalpreventionstrategiesforthem.Furthermore,theidentificationofpatientsathighriskforinfectionallowsappropriatepreoperativecounselingforshareddecision-makingandestablishesappropriatepatientexpectationsregardingsurgicalrisks.雖然對于所有骨科患者，都應(yīng)該采用各種預(yù)防措施以防止感染，但臨床醫(yī)生識別出高風(fēng)險的患者后，便可針對其制定最大限度的防范策略。此外，識別出感染的高風(fēng)險患者后可進行適當(dāng)?shù)男g(shù)前告知談話，這樣可與患者共同制定治療決策，并使患者對于手術(shù)風(fēng)險樹立合理的期望值。Numeroushigh-riskpatientpopulationsandriskfactorsthatplacepatientsathighriskforinfectionaftertotaljointreplacementorspinesurgeryhavebeendescribedintheliterature.Someofthesefactorscanbemodified,whileotherscannot.Anexplanationoftheriskfactorsthatcannotbemodifiedshouldbeincludedwhenpatientsarecounseledabouttheirincreasedriskofinfectionwiththeproposedsurgicalprocedure.Inthisway,patientswillmorecompletelyunderstandtherisksandbenefitswhendecidingonsurgery.Twocommonfactorsthatcannotbemodifiedandthatincreasetheriskofinfectionwithjointreplacementareahistoryofinfectioninthejoint2andahistoryofsteroidinjectionintothejoint3.Factorsthatcannotbemodifiedthatincreasetheriskofinfectioninpatientsundergoingspinesurgeryincludetrauma-relatedsurgery4,useofinstrumentation5,andlumbar6andposterior4surgery.對于關(guān)節(jié)置換術(shù)和脊柱手術(shù)的感染，有很多高風(fēng)險患者人群以及相關(guān)的危險因素使患者具有較高感染風(fēng)險的情況，在以往的文獻中都有論述。在這些因素中，有些事可以改善的，而有些則無法改變。對于無法控制的危險因素，在對患者進行術(shù)前告知談話時，應(yīng)向其說明這樣會增加感染的風(fēng)險。這樣，患者在決定做手術(shù)時便可更全面地認識到相關(guān)的風(fēng)險和益處。有兩個無法控制的因素，既往關(guān)節(jié)感染病史【2】和既往關(guān)節(jié)內(nèi)類固醇注射史【3】，通常會增加關(guān)節(jié)置換手術(shù)的感染風(fēng)險。而對于進行脊柱手術(shù)的患者而言，會增加感染的風(fēng)險并且無法控制的因素包括創(chuàng)傷相關(guān)的手術(shù)【4】，需要應(yīng)用內(nèi)置物【5】，以及腰椎【6】和后路【4】手術(shù)。Otherfactorsthatincreasetheriskofinfectionarepotentiallymodifiableand,therefore,providetheopportunityforpatientoptimizationpriortoelectiveorthopaedicprocedures.Forexample,patientswithinflammatoryarthritis7,sickle-celldisease8,diabetes9,renalfailure10,andhumanimmunodeficiencyvirus(HIV)11haveincreasedinfectionrateswithjointreplacement.Althoughtheseriskfactorscannotbeeliminated,theriskscanbeminimized.Forexample,patientswithinflammatoryarthritisshouldhaveapreoperativeconsultationwiththeirrheumatologistaboutreducingordiscontinuingimmunosuppressivemedicationsperioperatively.Patientswithsickle-celldiseaseshouldbescreenedforskinulcerationsorpotentialsourcesofosteomyelitis,whichcancauseseedingofthesiteofaprostheticjoint.DiabeticpatientsshouldhavetheirhemoglobinA1Clevelscheckedandnormalized(to<6.9%,whichreflectslong-termglucosecontrol)priortosurgery;consultationwithanendocrinologistmaybenecessary.Patientswithrenalfailurecertainlyshouldhavetheirrenalfunctionoptimizedpriortosurgery,andpatientswithHIVshouldbeplacedonregimensthatachieveanundetectableviralload,ifpossible,priortojointreplacement.Malnutritionisassociatedwithanincreasedriskofinfection;therefore,preoperativeoptimization,withtheassistanceofanutritionistifnecessary,isbeneficial12.其他的一些可能增加感染風(fēng)險的因素通常都是可以控制的，因此，對于骨科的擇期手術(shù)而言，術(shù)前通?？梢允瓜嚓P(guān)的因素達到最優(yōu)化的狀態(tài)。例如，患者合并有炎癥性的關(guān)節(jié)炎【7】，鐮狀細胞性貧血癥【8】，糖尿病【9】，腎功能衰竭【10】和人免疫缺陷癥病毒（HIV）感染【11】會增加關(guān)節(jié)置換的感染率，雖然這些風(fēng)險因素?zé)o法消除，但相關(guān)的風(fēng)險則可以降至最低。比如，患者炎癥性關(guān)節(jié)炎的患者，可以在術(shù)前請風(fēng)濕科醫(yī)生進行診治，在圍手術(shù)期盡量減少或停用免疫抑制類藥物。如患者合并有鐮狀細胞性貧血癥，則應(yīng)仔細篩查皮膚潰瘍或骨髓炎的潛在病源，否則容易導(dǎo)致播散至關(guān)節(jié)假體處引起感染。糖尿病患者應(yīng)檢查其血紅蛋白A1C水平，在術(shù)前調(diào)至正常（<6.9%，可反映長期的血糖控制情況），必要時請內(nèi)分泌科醫(yī)生會診。腎功能衰竭的患者當(dāng)然也應(yīng)在術(shù)前將腎功能調(diào)整至最佳水平，而感染HIV的患者，在關(guān)節(jié)置換之前，如果可能的話應(yīng)通過藥物治療使其病毒載量達到檢測不到的程度。營養(yǎng)不良也會增加感染的風(fēng)險，因此，必要時在營養(yǎng)師的幫助下，在術(shù)前進行優(yōu)化也是很有好處的【12】。Smokingandobesityincreasetheriskofinfectionwithspinesurgery13.Althoughthesefactorsareoftendifficulttomodify,patientsshouldbecounseledthatabenefitofsmokingcessationandweightreductionisadecreasedriskofinfectionwithspinesurgery.Patientsconsideringorplanningsurgicalweight-losstreatments,suchasgastricbypasssurgery,probablyshouldbeadvisedtopursuetheseproceduresfirsttoreducetheriskofinfectionatthesitesofhardwareorprosthesesasabenefitfromweightloss.Workingwithpatientsandtheappropriateconsultantstooptimizethesefactorspriortosurgerymayimprovepatientoutcomesbyloweringtheriskofinfectionwithhigh-riskjoint-replacementandspineprocedures.吸煙和肥胖會增加脊柱手術(shù)感染的風(fēng)險【13】。雖然這些因素通常難以控制，但仍然應(yīng)該告知患者，戒煙以及減輕體重對于降低脊柱手術(shù)感染的風(fēng)險具有重要意義。如果患者正在考慮或計劃通過手術(shù)來減輕體重，如胃旁路手術(shù)，那么應(yīng)該建議患者先做減肥手術(shù)，因為這樣對于置入內(nèi)固定物或假體的部位可以減少感染的風(fēng)險。與患者充分溝通，提出合理化的建議，在手術(shù)前盡量優(yōu)化這些因素，對這些關(guān)節(jié)置換和脊柱手術(shù)的高風(fēng)險人群而言，可以改善臨床結(jié)果，降低感染的風(fēng)險。Anotherimportantpreoperativeconsiderationispreoperativebathing.Preoperativebathinghasbeenusedtoreducethebacterialloadoftheskinpriortosurgerybecauseskinpreparationimmediatelybeforesurgerydoesnotcompletelysterilizetheskin.Inaddition,directcontaminationcanoccuratthetimeofsurgery.ArecentCochranereviewwasperformedtoassesstheinformationintheliteratureregardingpreoperativebathingwithantisepticsforthepreventionofsurgicalsiteinfection14.Chlorhexidinegluconateisthemostcommonlyusedantisepticforpreoperativebathing.TheCochranereviewrevealedevidencethatthebacterialloadofresidentskinfloraisreducedbyuseofchlorhexidinegluconatepreparationsforpreoperativebathing.Repeated,consecutivetreatmentsreducethisloadprogressivelyovertime.However,concernsaboutthedevelopmentofresistantorganismsandhypersensitivityremain.Therefore,theauthorsofthereviewconcludedthatthereisnoclearevidencethatpreoperativebathingwithchlorhexidinegluconateissuperiortopreoperativebathingwithotherproducts,suchasbarsoap,forreducingtheincidenceofsurgicalsiteinfection.手術(shù)前另一個重要的注意事項便是術(shù)前洗澡。由于術(shù)前即刻的皮膚消毒并不能完全殺滅所有細菌，因而通常都通過術(shù)前洗澡以減少皮膚的細菌接種量。此外，如果術(shù)前不洗澡，手術(shù)時也可能發(fā)生直接的污染。最近的一項Cochrane綜述對術(shù)前應(yīng)用消毒劑洗澡預(yù)防手術(shù)部位感染的相關(guān)信息進行了評價【14】。洗必泰葡萄糖酸鹽是術(shù)前洗澡時應(yīng)用最多的消毒劑。Cochrane綜述的相關(guān)證據(jù)顯示術(shù)前洗澡時應(yīng)用洗必泰葡萄糖酸鹽進行消毒可使體表常居菌的細菌接種量明顯減少。隨著時間的延長，反復(fù)、持續(xù)地洗浴可使該接種量進行性地下降。然而，這樣做也有產(chǎn)生耐藥菌及出現(xiàn)過敏反應(yīng)的風(fēng)險。因此，上文作者的結(jié)論認為，為了減少手術(shù)部位感染的發(fā)生率，在術(shù)前洗澡時，并沒有明確的證據(jù)證實應(yīng)用洗必泰葡萄糖酸鹽優(yōu)于其他的產(chǎn)品，如肥皂等。Hairremovalhasbeenusedtraditionallytokeephairfromcontaminatingthewound.Morerecently,hairremovalhasallowedsurgeonstoapplyocclusivedressingstotheskinperioperativelytokeepskinflorafromdirectlycontaminatingthewound.Threemethodsusedforhairremovalincludetraditionalrazors,clippers,andhair-removalcreamsordepilatories.Hairlesssurgicalsitescanmakethesurgeryandapplicationofdressingsandprotectivedrapingeasier,buttheuseofrazorstoshavethesurgicalsiteincreasestheriskofintroducingprimaryinfectionsthroughmicroscopicinjuriestotheskin.TheCentersforDiseaseControlandPrevention(CDC)recommendthathairremovalbeminimizedandthat,whenitisnecessary,electricclippersordepilatoriesbeusedratherthanrazors15.ACochranereviewoftheliteratureonhairremovalpriortosurgerysupportedtheCDCrecommendationsandaddedthathairremovalcanbedoneonthedayofthesurgery16.以往術(shù)前通常都要求去除毛發(fā)以避免污染創(chuàng)口，而最近則傾向于讓外科醫(yī)生在術(shù)前應(yīng)用密閉的敷料覆蓋皮膚，從而防止皮膚菌群直接污染創(chuàng)口。傳統(tǒng)的去毛方式主要有三種：剃毛、剪毛和脫毛膏或脫毛藥物。手術(shù)部位去毛后通?？墒故中g(shù)操作更為方便，并使貼膜和防護膜的應(yīng)用也更為簡便，但應(yīng)用剃刀刮除手術(shù)部位的毛發(fā)會對皮膚產(chǎn)生微小的損傷，通過這些損傷局部原發(fā)感染的風(fēng)險會明顯增加。疾病預(yù)防和控制中心（CDC）建議，應(yīng)盡量避免去毛，如果實在必要，也應(yīng)該應(yīng)用電動剪毛刀或脫毛劑，而應(yīng)避免應(yīng)用剃毛刀【15】。有學(xué)者對術(shù)前去毛相關(guān)的文獻進行了Cochrane綜述，其結(jié)論與CDC所推薦的方案一致，此外，去毛應(yīng)該手術(shù)當(dāng)天進行【16】。Dentalcareisanotherpreoperativeissuetobediscussedwithhigh-riskorthopaedicpatients.Allpatients,butparticularlythoseathighriskforinfection,shouldbeencouragedtomaintaingooddentalhealthbeforeandaftersurgery.Bacteremiafromadentalinfectioncancauseacutehematogenousinfectionatthesiteofatotaljointreplacement.Evidenceshowsthatthemostcriticalperiodisthefirsttwoyearsaftersurgery17.TheAmericanAcademyofOrthopaedicSurgeons(AAOS)inconjunctionwiththeAmericanDentalAssociation(ADA)developedguidelinesforantibioticprophylaxisforpatientswithatotaljointreplacementwhorequiredentalprocedures18.Patientsareidentifiedasbeingathighorlowriskdependingontheirmedicalcomorbidities.Dentalproceduresarecategorizedashighorlowriskdependingontheriskofbacteremia.Allpatientsshouldreceiveantibioticprophylaxisforhigh-riskdentalproceduresfortwoyearsafterthejointreplacement,andhigh-riskpatientsshouldreceiveprophylaxisforhigh-riskdentalproceduresforlife.Antibioticregimensareincludedintherecommendations(TableI).術(shù)前處理牙科的疾病對于高風(fēng)險的骨科患者而言也是一個值得探討的問題。對于所有患者，而感染風(fēng)險較高的患者尤其，應(yīng)鼓勵其在手術(shù)前后保持良好的口腔衛(wèi)生。源自牙齒感染的菌血癥可導(dǎo)致全關(guān)節(jié)置換部位的急性血源性感染。有證據(jù)表明，臨界期通常為手術(shù)后的頭兩年【17】。美國骨科醫(yī)師學(xué)會（AAOS）聯(lián)合美國牙科協(xié)會（ADA）對全關(guān)節(jié)置換的患者進行牙科手術(shù)時預(yù)防性應(yīng)用抗生素制定了指南【18】。按照內(nèi)科合并癥的情況將患者分為高或低風(fēng)險人群；按照菌血癥的風(fēng)險將牙科手術(shù)分為高風(fēng)險或低風(fēng)險手術(shù)。關(guān)節(jié)置換術(shù)后2年內(nèi)的所有患者在進行高風(fēng)險的牙科手術(shù)時，都應(yīng)該預(yù)防性地應(yīng)該抗生素，而對于高風(fēng)險的患者而言，關(guān)節(jié)置換術(shù)后的任何時間行高風(fēng)險牙科手術(shù)時都應(yīng)該預(yù)防性應(yīng)用抗生素。其推薦的方案中也包括了抗生素的用法（表1）。Antibiotics抗生素Perioperativeprophylacticantibioticsareeffectiveinreducingtherateofsurgicalsiteinfectionsinhigh-riskorthopaediccases.Ina2002meta-analysisofspinefusionsurgery,Barker19reportedthatuseofantibiotictherapyforsuchproceduresisbeneficialevenwhentheinfectionrateswithoutantibioticsarelow.Similarstudieshavedemonstratedtheefficacyofpreoperativeantibioticsingeneralorthopaedicsurgeryandbeforetotaljointreplacement20,21.對高風(fēng)險的骨科患者而言，圍手術(shù)期預(yù)防性應(yīng)用抗生素可有效地降低手術(shù)部位的感染率。在2002年一項關(guān)于脊柱融合手術(shù)的meta分析中，Barker【19】指出，在這樣的手術(shù)中應(yīng)用抗生素是有益的，即使在不用抗生素時感染率也較低的情況下依然如此。其他類似的研究也證實，在普通的骨科手術(shù)和全關(guān)節(jié)置換手術(shù)之前應(yīng)用抗生素都有著良好的效果【20,21】。Thechoiceofantibioticforpatientswithalowriskofmethicillin-resistantStaphylococcusaureuscolonizationiseithercefazolin(1to2gadministeredintravenously)orcefuroxime(1.5gadministeredintravenously).Thesedosesmustbeadjustedforchildren.Forpatientswithabeta-lactamallergy,clindamycin(600mgadministeredintravenously)orvancomycin(1.0gadministeredintravenously)shouldbeusedinlieuofcephalosporins.Patientswhoarecolonizedwithmethicillin-resistantStaphylococcusaureusareathighriskforcolonization(e.g.,nursinghomeresidents),orhavehadapreviousmethicillin-resistantStaphylococcusaureusinfectionhaveanincreasedriskforthedevelopmentofaninfectionwithmethicillin-resistantStaphylococcusaureus22,23.Prophylaxiswithvancomycin(1.0gadministeredintravenously)shouldbeconsideredforthesepatients24.對于耐甲氧西林金黃色葡萄球菌定植風(fēng)險較低的患者選擇抗生素時，頭孢唑啉（1-2g靜脈內(nèi)給藥）或頭孢呋辛（1.5g靜脈內(nèi)給藥）都是可以考慮的，應(yīng)用于兒童時劑量應(yīng)作相應(yīng)的調(diào)整。如果患者對β-內(nèi)酰胺類藥物過敏，可用克林霉素（600mg靜脈內(nèi)給藥）或萬古霉素（1.0g靜脈內(nèi)給藥）代替頭孢菌素。如患者居住在耐甲氧西林金黃色葡萄球菌較多的環(huán)境中，發(fā)生菌群定植的風(fēng)險往往較高（如敬老院的住戶），而曾經(jīng)感染上述耐甲氧西林金黃色葡萄球菌的患者則發(fā)生耐甲氧西林金黃色葡萄球菌感染的風(fēng)險會明顯增加【22,23】，對這些患者應(yīng)用考慮預(yù)防性應(yīng)用萬古霉素（1.0g靜脈內(nèi)給藥）【24】。Thepropertiminganddurationofantibioticprophylaxisareimperativeforsafetyandeffectiveness.Ingeneral,antibiotictherapyshouldbestartedwithinonehourpriortothesurgicalincision,andthedrugsshouldbecompletelyinfusedpriortotourniquetinflation.Theexceptiontothisrecommendationisvancomycin,theadministrationofwhichmaybestarteduptotwohourspriortothesurgicalincision.Thisallowsaslowerinfusionanddecreasesthelikelihoodofredmansyndrome.Redmansyndromeoccurswhenhypersensitivitytovancomycincausesdegranulationofmastcellsandareleaseofhistamine.Thehistamineleadstohypotensionandfacialflushing.Redmansyndromeispreventedbytheslowadministrationofvancomycinoveraperiodofonetotwohours.預(yù)防性應(yīng)用抗生素注意合適的時機和持續(xù)時間對于其安全性和有效性都是非常關(guān)鍵的。通常應(yīng)在做手術(shù)切口之前的一個小時內(nèi)應(yīng)用抗生素，并且止血帶充氣之前藥物必須輸注完畢。對這一建議而言，萬古霉素是個例外，其開始給藥的時間應(yīng)提前至做手術(shù)切口之前兩個小時，這樣可以緩慢輸注，減少紅人綜合征的發(fā)生率。萬古霉素過敏時可導(dǎo)致肥大細胞脫顆粒并釋放組胺從而出現(xiàn)紅人綜合征，組胺可導(dǎo)致低血壓和顏面部發(fā)紅。應(yīng)用萬古霉素時緩慢輸注，輸注時間達1-2小時可防止發(fā)生紅人綜合征。Antibiotictreatmentshouldbestoppedwithintwenty-fourhoursafterwoundclosure.Administrationofprophylacticantibioticsforlongerthantwenty-fourhourshasnotbeendemonstratedtobeeffectiveandmayactuallyleadtosuperinfectionwithdrug-resistantorganisms25.Repeatdosingwithantibioticsisrecommendedduringsurgicalproceduresthatlastforlongerthanfourhoursorwhenthereis>1500mLofbloodloss26.抗生素應(yīng)在創(chuàng)口閉合后的24小時之內(nèi)停藥。沒有證據(jù)表明預(yù)防性應(yīng)用抗生素超過24小時是有效的，并且事實上還有可能導(dǎo)致耐藥菌的二重感染【25】。而如果手術(shù)持續(xù)時間較長，超過4小時或術(shù)中出血量大于1500ml，則推薦在術(shù)中重復(fù)給藥一次【26】。Werecommendthat,inordertoensuretheproperselectionandtimingofantibioticprophylaxis,thechoiceofantibioticsanddurationofadministrationbeincorporatedintothesurgical"time-out."Rosenbergetal.reportedthatcompliancewiththepropertimingandselectionofantibioticsincreasedfrom65%to99%whentheprotocolwasincorporatedintothetime-out27.在預(yù)防性應(yīng)用抗生素時為了確保合理選擇抗生素并確定適當(dāng)?shù)慕o藥時機，我們推薦，將選擇抗生素和確定給藥持續(xù)時間都歸入到手術(shù)的“time-out”（手術(shù)劃刀前暫停核對各項信息）方案中。Rosenberg等曾報道，將相關(guān)的內(nèi)容并入到“time-out”方案中之后，選擇抗生素以及用藥時間的符合率由65%增加到99%【27】。SurgicalHandAntisepsis術(shù)者手部消毒Theobjectiveofapreoperativehandscrubistoremoveorkillasmanybacteriaaspossiblefromthehandsofthesurgicalteam.Aqueousscrubsolutionsconsistingofwater-basedsolutionsofeitherchlorhexidinegluconateorpovidone-iodinehavebeentraditionallyused.術(shù)前洗手的目的是為了盡可能多地去除或殺死手術(shù)人員手部的細菌。通常應(yīng)用的液態(tài)洗滌劑大多為洗必泰葡萄糖酸鹽或聚維酮碘的水溶液。TheauthorsofarecentCochranereview28foundalcohol-basedrubscontainingethanol,isopropanol,orn-propanoltobeaseffectiveasaqueoussolutionsforpreventingsurgicalsiteinfectionsinpatients29.Hajipouretal.30reportedthatalcoholrubsweremoreeffectivethaneitherchlorhexidinegluconateoriodine-basedscrubsforreducingbacterialcolony-formingunits(CFUs)onthehandsofsurgeons.Otherinvestigatorsreportedthattheuseofscrubbrusheshadnopositiveeffectonasepsisandmayactuallyincreasetheriskofinfectionasaresultofskindamage31.Onthebasisofthisevidence,therecommendedprocedureforpreoperativesurgicalhandantisepsisisthat,precedingthefirstscrubofthedayorwhenthehandsaregrosslycontaminated,thesurgicalteamshouldwashwithsoapandwater,useanailpicktocleanunderthenails,anddrywithpapertowels.Theyshouldthenuseanalcohol-basedrubforthreeminutes32.Analcohol-basedrubshouldbeusedforeachsubsequentcase.Theuseofscrubbrushesisnotrecommended.有學(xué)者最近的一項Cochrane綜述【28】發(fā)現(xiàn)，含有乙醇、異丙醇或正丙醇的酒精擦劑與水溶液相比，對于預(yù)防患者手術(shù)部位的感染具有類似的效果【29】。Hajipour等【30】報道酒精擦劑比洗必泰葡萄糖酸鹽或含碘洗滌劑都更為有效，因為前者可減少術(shù)者手上的細菌菌落形成單位（CFU）。另外還有學(xué)者報道應(yīng)用毛刷對于手部消毒并沒有明顯的效果，并且事實上由于會損傷皮膚反而會增加感染的風(fēng)險【31】。根據(jù)這些證據(jù)，術(shù)者術(shù)前手部消毒推薦的方式為，在當(dāng)天初次刷洗之前或手部嚴重污染時，手術(shù)人員應(yīng)該用肥皂和水洗手，并用指甲簽將指甲下方的污物清理干凈，然后用紙巾擦干。然后，術(shù)者再用含酒精的擦劑涂抹3分鐘【32】。后續(xù)的手術(shù)每次都應(yīng)該用含酒精的擦劑進行涂抹，但不推薦應(yīng)用毛刷進行刷洗。SurgicalSitePreparation手術(shù)部位的消毒Chlorhexidinegluconate-basedsolutionshavesupplantedalcoholandiodine-basedsolutionsforsurgicalsitepreparation.Ostranderetal.33examinedtheresidualamountsofbacteriaonfeetpreparedwithachlorhexidinegluconate,iodine/isopropylalcohol,orchloroxylenolscrub.Theyfoundthatchlorhexidinegluconatewassuperiortotheothertwopreparationsolutionsinreducingoreliminatingbacteriafromthefeetpriortosurgery.Chlorhexidinegluconateskinpreparationwassuperiortoeither70%alcoholoriodineindecreasinginfectionassociatedwiththeplacementofcentralvenouscathetersandthedrawingofbloodforculture34,35.Thus,thecurrentevidence-basedrecommendationsandbest-practiceguidelinescallfortheuseofchlorhexidinegluconate-basedsolutionsforsurgicalsitepreparationandplacementofcentralvenouscatheters.手術(shù)部位的消毒液，洗必泰葡萄糖酸鹽溶液已經(jīng)替代酒精和含碘的溶液。Ostrander等【33】對洗必泰葡萄糖酸鹽、碘/異丙醇或氯二甲苯酚的擦劑消毒足部后，檢測殘余的細菌數(shù)量，結(jié)果發(fā)現(xiàn)在術(shù)后減少或消除足部細菌的功效上洗必泰葡萄糖酸鹽優(yōu)于其他兩種消毒劑。而在置入中央靜脈導(dǎo)管和抽血樣做培養(yǎng)等操作時，應(yīng)用洗必泰葡萄糖酸鹽進行皮膚消毒，相比70%的酒精或碘劑，均可減少感染的發(fā)生率【34,35】。因此，在術(shù)區(qū)消毒以及置入中央靜脈導(dǎo)管時，基于現(xiàn)有證據(jù)的建議和最佳操作指南都提倡應(yīng)用洗必泰葡萄糖酸鹽溶液。DecreasingtheRiskofSurgicalSiteInfectionRelatedtotheOperating-RoomEnvironment降低手術(shù)部位感染相關(guān)的手術(shù)室環(huán)境Althoughthearcanedetailsoftechniquesusedtosterilizesurgicalinstrumentsarebeyondtheexpectedknowledgeofmostorthopaedicsurgeons,manyofasurgeon'sactionscanadverselyaffectsterilizationandincreasetheriskofsurgicalsiteinfections.Flashsterilizationisaprocedureusedbyoperating-roomstafftosterilizeinstrumentsorimplantswithsteam,onanas-neededbasis.Flashsterilizationisnotequivalenttosterilizationincentralprocessing36,37.Incentralsterileprocessing,instrumentsareproperlycleanedandalllumensareinspected;theinstrumentsarethensterilizedandallowedtodrycompletely,afterwhichtheyaredeliveredinclosedcontainersthatensuremaintenanceofsterility.Mostimportantly,theprocessisperformedbytrained,focusedprofessionals.Theentireprocesstakesthreetofourhours.Flashsterilizationshouldbeusedonlyfordroppedinstrumentsorinanemergencysituation.Preventablereasonsforflashsterilizationincludeaninsufficientquantityofinstruments,loanerinstrumentsand/orinstrumentsnotdeliveredintimeforproperprocessing,andinaccurateorincompletesurgicalbookingrequiringtheemergency,unplanneduseofinstrumentsand/orimplants.雖然手術(shù)器械滅菌方法中很多不為人知的操作細節(jié)并不是大多數(shù)骨科醫(yī)生都期望掌握的知識，但外科醫(yī)生的很多做法卻可對滅菌過程產(chǎn)生負面的影響，并會增加手術(shù)部位感染的風(fēng)險。快速滅菌是手術(shù)室工作人員常用的一種對手術(shù)器械或內(nèi)置物的滅菌方式，在一些必要的基座之上，應(yīng)用蒸汽?？焖贉缇⒉荒艿韧谥醒霚缇^程【36,37】。在中央滅菌處理中，手術(shù)器械先用適當(dāng)?shù)姆椒ㄇ謇砀蓛簦瑢λ袃?nèi)腔都進行徹底的檢查，然后在對器械進行滅菌，并可使其完全干燥，最后手術(shù)器械在運送過程中必須保持密閉的包裝，以確保維持其無菌的狀態(tài)。最為重要的是，這些操作都由經(jīng)過專業(yè)訓(xùn)練的人員完成，整個過程需要3-4小時。快速滅菌只有在術(shù)中器械掉落或緊急狀況下方可應(yīng)用。有些因素是可以避免進行快速滅菌的，包括手術(shù)器械數(shù)量不足，應(yīng)用替代性器械和/或器械沒有按照合適的操作規(guī)程按時送達，手術(shù)預(yù)約錯誤或不完善需要緊急處理，非計劃性地應(yīng)用手術(shù)器械和/或內(nèi)置物等。Toreducetheincidenceofflashsterilization,werecommendanincreaseinphysicianawarenessabouttheinadequacyofthetechnique;improvementintheaccuracyofsurgicalbooking;mandatingcooperationfromvendorstoensuretimelydeliveryofequipment,includingfinancialpenaltiesforlatedelivery;purchaseofmorefrequentlyflash-sterilizeditems;surgicalschedulingtoaccommodateandmitigateequipmentshortages;and,finally,generationofincidentreportswhenaflash-sterilizedimplantisusedinapatient.Adoptingthesepoliciesandproceduresleadstoadecreaseintheincidenceofflashsterilization38.為了減少快速滅菌，我們建議增強對臨床醫(yī)師的宣傳和培訓(xùn)，使其充分認識到這一方法的不足；提高手術(shù)預(yù)約單的準確性；要求供貨商密切配合，確保相關(guān)設(shè)備及時交付到位，對于延遲送達的應(yīng)考慮適當(dāng)給予經(jīng)濟懲罰；對于以往經(jīng)常進行快速滅菌的器械適當(dāng)增加購買數(shù)量；通過調(diào)整手術(shù)安排以適應(yīng)和緩解設(shè)備上的不足，最后，快速滅菌的內(nèi)置物應(yīng)用于患者后應(yīng)寫出相關(guān)的事件報告。采用這些策略和規(guī)程可有效降低快速滅菌的使用率【38】。PowderlessGlovesTraditionally,surgicalglovescontainedpowdertoaidinthemanufacturingprocessandtomakedonningeasier.Thepowderwaseithertalcorlycopodiumspores.Becauseofconcernsaboutgranulomaformationandadhesionsassociatedwiththeuseofthesesubstances,cornstarchisnowthepowderofchoice39.However,cornstarchisnotbenign.Itcausesforeign-bodygranulomaformationanddelayedwound-healingandcandecreasetheamountofbacteriarequiredtocauseaclinicallyapparentinfection40.Cornstarchalsoleadstoincreasedlatexsensitivityinhealth-careworkers.Type-Iandtype-IVhypersensitivityreactionstolatexproteininhospitalstaffleadtoincreasesinsicktimeanddecreasedjobsatisfaction41.Powderlessglovesdecreasestaffabsenteeismandeliminatethepotentialforforeign-bodygranulomaformation.Theseglovescost25%morethanpowderedgloves,buttheaddedexpenseismitigatedbyincreasedproductivityoftheoperating-roomstaff41.無粉手套以往外科手套都是有粉的，這樣在制造過程中便于操作，同時也可使穿戴更為方便，粉末的成分為滑石粉或石松子。由于考慮到應(yīng)用這些粉末可能會形成肉芽腫以及粘連，因此目前一般都選用玉米淀粉【39】。然而，玉米淀粉也不是沒有任何危險的，其可導(dǎo)致創(chuàng)口延遲愈合或形成異物性肉芽腫，并且它可使通常出現(xiàn)感染相關(guān)臨床表現(xiàn)所需的細菌數(shù)量減少【40】。玉米淀粉還會使醫(yī)務(wù)人員對橡膠的敏感度增加。醫(yī)院的工作人員對乳膠蛋白的I型和IV型過敏反應(yīng)會使不適時間延長，并使工作的滿意度下降【41】。無粉手套可減少工作人員的缺勤狀況，且可避免向體外形成肉芽腫的潛在可能。這些手套比有粉手套貴25%，但由此增加的費用會隨著手術(shù)室工作人員工作效率的提高而減少【41】。Antiseptic-CoatedSuturesTheuseofantiseptic-coatedsutureshasgeneratedincreasedinterest.Thesesuturesaretypicallycoatedwiththeantiseptictriclosan.Edmistonetal.demonstratedtheeffectivenessofcoatedsuturesininhibitingbacterialgrowthandcontaminationinaninvitromodel42.Inarandomizedcontrolledtrial,Rozzelleetal.reportedasignificantreductioninsurgicalsiteinfectionratesfollowingcerebralspinal-fluid-shuntsurgerywiththeuseofantiseptic-coatedsuturesascomparedwiththeratefollowingthesameprocedurewithouttheuseofsuchsutures43.Thesesuturescost7%to10%morethantheiruncoatedcounterparts.Toourknowledge,nocost-effectivenessanalysishasbeenpublished;however,theuseofthesesuturesinhigh-riskpatientsmaybejustified.具有抗菌表層的縫線應(yīng)用具有抗菌表層的縫線越來越被人們所重視，這種縫線通常涂有一層抗菌的三氯生。Edmiston等曾報道，在體外實驗中，這種有涂層的縫線可有效抑制細菌的繁殖和污染【42】。在另一項隨機對照試驗中，Rozzelle等報道在腦脊液分流術(shù)后應(yīng)用具有抗菌表層的縫線與沒有應(yīng)用這種縫線的病例相比，手術(shù)部位的感染率明顯下降【43】。這種縫線相比沒有涂層的類似縫線要貴7%至10%。據(jù)我們所知，目前尚未發(fā)表相關(guān)的效價分析，但是在高風(fēng)險的患者中應(yīng)用這樣的縫線還是合理的。Operating-RoomTrafficMaintainingadisciplinedoperating-roomculturecanreducetheriskofsurgicalsiteinfections.Unnecessaryoperating-roomtrafficincreasestherateofinfections44.Inastudyofspinesurgery,Olsenetal.reportedthattwoormoreresidentsparticipatingintheoperativeprocedurewasanindependentriskfactorforsurgicalsiteinfections,withanoddsratioof2.245.Babkinetal.foundthattherateofsurgicalsiteinfectionsassociatedwithleftkneereplacementswas6.7timeshigherthanthatassociatedwithrightkneereplacementsperformedduringthesametimeperiodandinthesameoperatingrooms46.Whenthedoorontheleftsideoftheoperatingroomwaslocked,preventingingressoregress,thesurgicalsiteinfectionrateassociatedwiththeleftkneereplacementsrapidlydecreasedtothatassociatedwiththerightkneereplacements,afindingthatsupportstheimportanceoflimitingoperating-roomtraffic.手術(shù)室的交通在手術(shù)室保持遵守職業(yè)規(guī)范的習(xí)慣可減少手術(shù)部位感染的風(fēng)險，在手術(shù)室內(nèi)不必要的穿行會使感染率增加【44】。在一項有關(guān)脊柱手術(shù)的研究中，Olsen等報道在手術(shù)過程中2個或更多的人員加入進去是手術(shù)部位感染的一個獨立的風(fēng)險因素，優(yōu)勢比2.245。Babkin等發(fā)現(xiàn)，在相同時期內(nèi)在同一手術(shù)間進行手術(shù)，左膝關(guān)節(jié)置換手術(shù)部位感染的發(fā)生率為由膝關(guān)節(jié)置換的6.7倍【46】，而當(dāng)手術(shù)室左側(cè)的門鎖上以后，避免進出，左膝關(guān)節(jié)置換的術(shù)區(qū)感染率便很快下降到與右膝關(guān)節(jié)置換相當(dāng)?shù)乃?，這一發(fā)現(xiàn)也證實了限制手術(shù)室交通的重要性。DrainsandBloodTransfusionsWhethertousedrainsattheendoforthopaedicsurgicalproceduresisadecisionthatsurgeonsmakeonthebasisoftheirtraining,opinions,andpersonalexperience,inadditiontoresearchfindings.ArecentCochranereviewonthistopicthatincludedfindingsfromthirty-sixstudies(5464patients)revealedthattheuseofcloseddrainsreducedbruisingandtheneedforreinforcementofdressings47.However,theuseofcloseddrainswasalsoassociatedwithanincreasedneedfortransfusion,ariskfactorthatisdiscussedbelow.Therewasnodifferenceinsurgicalsiteinfectionratesbetweendrainedandundrainedwounds.Theauthorsconcludedthatclosedsuctiondrainswereofdoubtfulbenefit.創(chuàng)口引流與輸血在骨科手術(shù)臨結(jié)束時是否放置引流管除了參考相關(guān)的研究結(jié)果以外，還需要術(shù)者根據(jù)他們所接受的訓(xùn)練、觀點以及個人的經(jīng)驗來決定。最近有一項針對這一問題的Cochrane綜述，共納入了36項研究（5464例患者），結(jié)果顯示應(yīng)用封閉式引流可減少瘀傷，同時還可減少加包輔料的需要【47】。不過，應(yīng)用封閉式引流會相應(yīng)地增加輸血的需求，風(fēng)險因子如下文所述。是否放置創(chuàng)口引流對于手術(shù)部位的感染率并沒有明顯的差異。作者的結(jié)論認為閉合負壓引流的有效性仍不確定。Inadditiontothedoubtfulbenefitofsurgicaldrainsinorthopaedicprocedures,theyareassociatedwithamorefrequentneedforbloodtransfusion.Bloodtransfusioncarriesthegeneralriskofinfectionwithblood-bornepathogens,suchasHIVorhepatitis,andwithotherbacteriaorparasites.Thisriskisverysmall,althoughstillpresent,intheUnitedStatesandotherdevelopedcountriesthathaverigoroustestingproceduresfordonatedblood48.Themoreimmediateriskassociatedwithtransfusionissurgicalsiteinfectionandanincreasedlengthofhospitalstay49.Transfusionofbloodinducesimmunomodulationthatcanleadtoanincreasedriskofinfectionatthesurgicalsite50.Talbotetal.reporteda3.2-foldincreaseinthepost-sternotomyinfectionrateamongpatientswhohadhadatransfusioncomparedwiththerateamongthosewhohadnot51.Inastudyofcardiacsurgery,Boweretal.reportedthattherateofinfectioninpatientswhohadhadatransfusionwasalmosttwiceashighasthatinpatientswhohadnot52.Weberetal.foundthatpatientswhohadhadatransfusionafterhiparthroplastyhadanincreasedlengthofhospitalstay,evenwhentheauthorscontrolledforsurgicalsiteinfection49.Strategiestodecreasetheneedfortransfusionincludepreoperativeassessmentofhemoglobinlevelsandthehematocritandprescriptionofdrugstoimprovetheseparameters,ifindicated,aswellastheuseofanalgorithmthatdependsonsymptomaticanemia,ratherthanhemoglobinandhematocritresultsalone,todeterminetransfusionneed.在骨科手術(shù)中放置引流除了其好處仍不確定以外，往往輸血的需求相應(yīng)地也會更多一些。輸血會帶來感染血液傳播的相關(guān)病原體的風(fēng)險，例如HIV、肝炎，以及其他細菌或寄生蟲。這種風(fēng)險雖然仍然存在，但非常小，在美國及其他發(fā)達國家，對于捐獻的血液都有一個嚴格的檢測程序【48】。與輸血相關(guān)的更為直接的風(fēng)險辨識手術(shù)部位的感染和住院時間的延長【49】。輸血會引起免疫調(diào)節(jié)，進而導(dǎo)致術(shù)區(qū)感染的風(fēng)險增加【50】。Talbot等報道，胸骨切開術(shù)后的感染率，輸過血的患者比未曾輸血的患者要高3.2倍【51】。在一項有關(guān)心臟手術(shù)的研究中，Bower等報道輸血的患者其感染率幾乎是沒有輸血的患者的兩倍【52】。Weber等發(fā)現(xiàn)，盡管術(shù)者控制了術(shù)區(qū)的感染，但髖關(guān)節(jié)置換術(shù)后輸血的患者住院時間會明顯延長【49】。減少輸血相關(guān)需求的策略包括術(shù)前評估血紅蛋白的水平及紅細胞壓積，如果符合指征可給予適當(dāng)?shù)乃幬镏委熞愿纳七@些參數(shù)，不能僅僅只根據(jù)血紅蛋白和紅細胞壓積的結(jié)果，而應(yīng)該參照繼發(fā)性貧血的相關(guān)策略來決定是否有必要輸血。PostoperativeWoundManagementTheCDCrecommendsmaintainingsurgicaldressingsfortwenty-fourtoforty-eighthourspostoperatively53.Somesurgeonsuseathree-dayrule,keepingtheoriginalsurgicaldressinginplaceforseventy-twohours.Thereislittleevidencethatkeepingdressingsonforanextradayortwodecreasestheinfectionrisk;however,ifthedressingisnotcleananddry,itmaybecomeasourceofmicrobesclosetotheincision.Perhapsasimportantasthedurationthatthedressingisinplaceisensuringtheproperprocessforpostoperativewoundmanagement.Thesurgeonshouldreviewpoliciesandprocedurestodeterminewhochangesdressings(e.g.,nurses,orphysiciansonly),underwhatcircumstancestheyarechanged,andiftheyareeverreinforcedratherthanchanged.Thebasicconceptofinfectionpreventionistokeepthewoundcleananddry.Soiledorblood-soakeddressingsshouldberemovedimmediatelyratherthanreinforced.Ifdressingsdonotstayintact,useofadifferentproductmaybewarranted.術(shù)后創(chuàng)口的處理CDC推薦術(shù)后24至48小時內(nèi)維持手術(shù)的敷料【53】。有些外科醫(yī)生采用三天原則，72小時內(nèi)將最初的手術(shù)敷料保持在原位。很少有證據(jù)認為維持原來的敷料多一或兩天會增加感染的風(fēng)險，然而，如果敷料并不干燥、清潔，則可能成為緊鄰切口的微生物來源。術(shù)后采用合理的操作規(guī)程來處理創(chuàng)口，可能同敷料保持在原位的時間同等重要。術(shù)者應(yīng)對相關(guān)的方法和操作程序進行檢查，以確定由誰來更換敷料（例如護士，或者只安排醫(yī)生），在什么情況下他們應(yīng)該進行更換，或者他們只是增加敷料而不是更換。預(yù)防感染的基本概念辨識保持創(chuàng)口干燥和清潔。污染或血液浸透的敷料必須立即更換，而不能加包。如果敷料不能保持其整體性，那么應(yīng)用不同種類的敷料也是允許的。Amultidisciplinarygroupshouldevaluatecurrentpracticesanddiscusswaystooptimizepostoperativewoundcare.Somebasicissuesareensuringthatanaseptictec