手術(shù)部位醫(yī)院感染與控制課件

2024/6/20Dr.GaoXiaodong1復(fù)旦大學(xué)附屬中山醫(yī)院上海市院內(nèi)感染質(zhì)量控制中心高曉東23SSI是外科醫(yī)生的“災(zāi)難〞！2024/6/20Dr.GaoXiaodong42024/6/20Dr.GaoXiaodong5SSI＝皮膚軟組織感染Skin/skinstructureinfectionsthat:Involvedeep,softtissueRequiresurgicalinterventionAreassociatedwithsignificantunderlyingdiseasethatcomplicatetheresponsetotreatmentCellulitisAbscessUlcercSSSIDefinition2024/6/20Dr.GaoXiaodong6淺表切開(kāi)

Superficialincisional

深部切口

Deepincisional器官和腔隙Organ/Space表皮皮下組織深部軟組織器官間隙淺表感染深部感染器官間隙感染2024/6/20Dr.GaoXiaodong7表淺切口感染2024/6/20Dr.GaoXiaodong8以下情況不歸屬淺部切口感染2024/6/20Dr.GaoXiaodong9深部切口感染2024/6/20Dr.GaoXiaodong10器官/腔隙感染2024/6/20Dr.GaoXiaodong11國(guó)外不同部位切口SSI發(fā)生率*美國(guó)1986-1996年NNIS監(jiān)測(cè)數(shù)據(jù)未將淺表與深部切口感染分開(kāi)統(tǒng)計(jì)美國(guó)*英國(guó)2024/6/20Dr.GaoXiaodong12國(guó)內(nèi)不同部位切口SSI發(fā)生率中國(guó)中國(guó)上海市2024/6/20Dr.GaoXiaodong13SSI一種重要的醫(yī)院感染2024/6/20Dr.GaoXiaodong14背景Background2024/6/20Dr.GaoXiaodong152024/6/20Dr.GaoXiaodong16興旺國(guó)家的SSI發(fā)生率研究SSI發(fā)生率(%)美國(guó)國(guó)家醫(yī)院感染監(jiān)測(cè)系統(tǒng)(NNIS)報(bào)道數(shù)據(jù)2024/6/20Dr.GaoXiaodong17開(kāi)展中國(guó)家的SSI發(fā)生率研究SSI發(fā)生率(%)2024/6/20Dr.GaoXiaodong182024/6/20Dr.GaoXiaodong19結(jié)腸切除術(shù)胃/食管手術(shù)膽囊切除術(shù)脾切除術(shù)闌尾切除術(shù)矯形手術(shù)疝修補(bǔ)術(shù)經(jīng)腹子宮切除術(shù)剖腹產(chǎn)術(shù)甲狀腺切除術(shù)乳腺切除術(shù)SSI發(fā)生率(%)2024/6/20Dr.GaoXiaodong20切口的清潔程度SSI發(fā)生率(%)178所醫(yī)院醫(yī)院感染危險(xiǎn)因素調(diào)查分析.2024/6/20Dr.GaoXiaodong21我國(guó)2001年的全國(guó)性醫(yī)院感染橫斷面調(diào)查：SSI構(gòu)成比為7.04%；2003年我國(guó)醫(yī)院SSI占醫(yī)院感染的10.55%，僅次于呼吸道感染和泌尿道感染，在外科居第2位上海市18所綜合性醫(yī)院1999年10月份出院的所有病例，隨訪數(shù)據(jù)顯示SSI占院內(nèi)感染的9.16%我國(guó)的SSI發(fā)生率研究2024/6/20Dr.GaoXiaodong222003年上海市57708例次醫(yī)院感染構(gòu)成情況SSI構(gòu)成比＝5.5%2024/6/20Dr.GaoXiaodong23SSI的主要病原菌AdaptedfromMangramAJetal.InfectControlHospEpidemiol.1999;20:247-278.*CoNS=coagulase-negativestaphylococci.Percent2024/6/20Dr.GaoXiaodong24RelativeDistributionofBacteria

FromSuperficialtoDeepInfectionsStaphylococcusStreptococcusGram-negativeBacilliAnaerobesSuperficialinfectionDeepinfectionNicholsRL,etal.ClinInfectDis.2001;33(suppl2):S84-S93.252024/6/20Dr.GaoXiaodong26目前我國(guó)SSI監(jiān)測(cè)存在的問(wèn)題2024/6/20Dr.GaoXiaodong27美國(guó)NNIS已經(jīng)采用

目標(biāo)性監(jiān)測(cè)NNISSystemAURICUHRNSurgicalPatient抗菌藥物應(yīng)用和耐藥性AntimicrobialUseandResistance成人與兒童ICUIntensiveCareUnit(Adult/Pediatric)高危新生兒HighRiskNursery(NICU)28“真實(shí)的〞感染率常規(guī)監(jiān)測(cè)增強(qiáng)監(jiān)測(cè)YokoeDS,etal,EmergInfectDis2004;10,1924-1930BolonMk,etal,ClinInfectDis2021;48:1223-1229膝關(guān)節(jié)髖關(guān)節(jié)血管外科冠脈搭橋2024/6/20Dr.GaoXiaodong29SSI的損失不可低估2024/6/20Dr.GaoXiaodong30SSI造成的損失2024/6/20Dr.GaoXiaodong31SSI增加了治療本錢(qián)治療總本錢(qián)(美元)SSI患者在門(mén)診、急診、X線檢查、醫(yī)療設(shè)備使用、家庭衛(wèi)生效勞利用、抗生素治療、再次入院等醫(yī)療資源消耗上都要明顯高于非感染患者3382美元2024/6/20Dr.GaoXiaodong32一項(xiàng)SSI患者住院時(shí)間和治療本錢(qián)/費(fèi)用的歸因研究：平均每位SSI住院天數(shù)10.2天，直接由感染引起的醫(yī)療費(fèi)用為3937美元SSI增加了治療本錢(qián)2024/6/20Dr.GaoXiaodong33SSI：預(yù)防為上美國(guó)醫(yī)院拯救十萬(wàn)生命運(yùn)動(dòng)始于2004年12月14日目的是改善操作規(guī)程，在2006年6月前防止100,000住院病人不必要的死亡發(fā)起創(chuàng)議的醫(yī)院超過(guò)2000所預(yù)防三種主要的醫(yī)院感染SSIVAPCA-BSI2024/6/2034Dr.GaoXiaodong零感染是什么樣子的？0DeepSternalCABGSSIin24months!WhatDoesZeroLookLike?2024/6/2035Dr.GaoXiaodong2024/6/20Dr.GaoXiaodong36局部關(guān)于SSI的數(shù)據(jù)2024/6/20Dr.GaoXiaodong37SSI–

影響因素手術(shù)麻醉患者類別組織灌注量糖尿病備皮溫度吸煙部位/時(shí)間/類型吸氧濃度營(yíng)養(yǎng)不良縫線質(zhì)量肥胖血腫疼痛高齡預(yù)防性抗菌藥物輸血身體狀況機(jī)械壓力藥物感染放療/化療術(shù)前住院時(shí)間長(zhǎng)2024/6/20Dr.GaoXiaodong38預(yù)防SSI的bundle2024/6/2039Dr.GaoXiaodong40Prospective,Randomized,6-CenterClinicalTrialof849PatientsPopulation:adultpatientsscheduledforabdominalornon-abdominalclean-contaminatedsurgeryRandomization:hospital-stratifiedIntervention:preoperativeskincleansingwith:ChloraPrep?(2%chlorhexidinegluconate-70%isopropylalcohol=CA)26-mlapplicators;OR10%povidone-iodine(PI)scrubandpaintEvaluation:SSIwasassessedbyblindedevaluators

Darouiche,etal.NEnglJMed2021;362:18-2648ProportionofPatientswithSurgical-SiteInfection,AccordingtoTypeofInfection(Intention-to-TreatPopulation).TypeofInfectionChlorhexidine-Alcohol(N=409)no.(%)Povidone-Iodine(N=440)no.(%)RelativeRisk(95%CI)P-ValueAnysurgical-siteinfection39(9.5)71(16.1)0.59(0.41-0.85)0.004Superficialincisionalinfection17(4.2)38(8.6)0.48(0.28-0.84)0.008Deepincisionalinfection4(1.0)13(3.0)0.33(0.11-1.01)0.05Organ-spaceinfection18(4.4)20(4.6)0.97(0.52-1.80)>0.99Sepsisfromsurgical-siteinfection11(2.7)19(4.3)0.62(0.30-1.29)0.2649APROSPECTIVE,RANDOMIZED,MULTICENTERCLINICALTRIALOF2%CHLORHEXIDINEGLUCONATE/70%ISOPROPYLALCOHOL(Alc-CHG)VSPOVIDONE-IODINE(PI)FORPREVENTIONOFSSIPatients>18years,undergoingclean/clean-contaminatedprocedures(gastrointestinal,thoracic,urologicandgynecologic)N=820surgicalpatients:400Alc-CHGvs.420PI:1randomizationPatientsmonitoredfor30dayspost-opOverallrateofSSIwassignificantlyreducedinAlc-CHGvs.PIgroups:9.8vs.16.9,p<0.003Significantdifference(p<0.01)insuperficialincisionalsiterate:4.3%(A-CHG)v.8.6%(PI)–ratefordeepincisional1%v.3%NosignificantdifferencefororganspaceinfectionNosignificantadverseeventsnotedduringthestudyineithergroupAlc-CHGsuperiortoPIinreducingtheriskofSSIinclean/clean-contaminatedproceduresDairouche,NEJM2021;362:18-26WhattodoaboutMRSA?ConflictingStudiesRegardingPreopScreeningLargerandomizedcrossovertrialusinguniversalscreeningofspecialtyv.generalsurgicalpatientsforMRSA.MRSApatientsreceiveddecolonizationandperiopvanco.NodifferenceinSSIrates.Smallercontrolledtrialscreenedpatients,treatedwithdecolonizationanddailyCHGbaths.Excluded“simpleprocedures.〞ReducedS.aureusSSIratesby60%.Screeninggenerallyrestrictedtomorecomplexprocedures(i.e.implants,CVsurgery)HarbathJAMA2021;299:1149BodeNEJM2021;362:92024/6/20Dr.GaoXiaodong45外科抗生素預(yù)防性應(yīng)用2024/6/20Dr.GaoXiaodong46ClassenDC,etal..NEnglJMed1992;326:281IncisionHoursbeforeincisionHoursafterincisionAntibioticAdministered2024/6/20Dr.GaoXiaodong47結(jié)論：抗生素應(yīng)該在皮膚切開(kāi)前半小時(shí)或麻醉誘導(dǎo)開(kāi)始時(shí)2847例選擇性清潔或清潔污染切口2024/6/20Dr.GaoXiaodong48ProphylacticAntibioticUse

1988-1998??*#*pre-opnurseresponsible,checklist#standingorderinO.R.?removestandingorder?replacestandingorderBurke.ClinInfectDis2001;33(suppl2):S782024/6/20Dr.GaoXiaodong49干預(yù)措施定義，入選與剔除論文標(biāo)準(zhǔn)最后入選：28篇9478例病人總計(jì)：?jiǎn)未伪葘掖蔚腛R為1.12(0.89,1.42;P=0.33)Beta-lactam(21)：OR=1.10(0.90,1.33)非beta-lactam(7)：OR=0.65(0.34,1.23),P=0.13婦產(chǎn)科(10,N=1480)：OR=1.14(0.62,2.09)其他科(19)：OR=1.03(0.82,1.28).P=0.75盲法評(píng)價(jià)(15)：OR=1.24(0.95,1.63)非盲評(píng)價(jià)(13)：OR=0.91(0.71,1.17).P=0.10多劑>24h(16)：OR=1.03(0.77,1.36)多劑<24h(12)：OR=1.03(0.76,1.40).P=0.95Single-vsMultiple-DoseSurgicalProphylaxis:SystematicReviewMcDonaldMetal.AustNZJSurg.1998;68:388–396.Adaptedwithpermissionfrom

BlackwellSynergy?1998.Allstudies,fixedAllstudies,randomMulti>24hMulti<24hFavorssingledoseFavorsmultipledose5151抗菌藥物應(yīng)用>3天比例2024/6/20Dr.GaoXiaodong52內(nèi)容分值評(píng)估方法扣分標(biāo)準(zhǔn)1．自查2查看記錄，了解是否按要求查2007年10月份和2008年4月份2次沒(méi)有查扣2分；僅查1次扣1分。沒(méi)有按要求查4月和10月，每錯(cuò)1次扣0.5分。2．上報(bào)2查看匯總表，有沒(méi)有按要求及時(shí)上傳到“市院內(nèi)感染質(zhì)控中心內(nèi)部交流網(wǎng)”相應(yīng)的目錄沒(méi)有上傳，每次扣1分。沒(méi)有按要求上傳內(nèi)容、文件格式，或規(guī)定時(shí)間內(nèi)上傳，每次每項(xiàng)扣0.5分。最多扣2分。4．總結(jié)、分析和反饋2自查數(shù)據(jù)是否總結(jié)并向醫(yī)院領(lǐng)導(dǎo)和所在科室反饋沒(méi)有總結(jié)分析，扣2分；有數(shù)據(jù)總結(jié)但沒(méi)有結(jié)果分析，扣1分；沒(méi)有向主管院長(zhǎng)反饋扣0.5分，沒(méi)有向手術(shù)科室反饋扣0.5分。本項(xiàng)最多扣2分。5．帶藥入手術(shù)室2計(jì)算圍術(shù)期抗菌藥物帶入手術(shù)室率（沒(méi)有帶入手術(shù)室但術(shù)后也不用則按帶入計(jì)算）帶入率：71～90％，扣0.5分；51～70％，扣1.0分；31～50％，扣1.5分；<31％，扣2.0分6．預(yù)防使用時(shí)間2計(jì)算圍術(shù)期抗菌藥物使用時(shí)間>3天的比例11～30％，扣0.5分；31～50％，扣1.0分；51～70％，扣1.5分；>71％，扣2.0分53532024/6/20Dr.GaoXiaodong5404812AlexanderJWetal.ArchSurg.1983;118:347–352.Hair-RemovalTechniquesandSSIsInfection,%Discharge30-DayFollow-up5.2%

(14/271)8.8%

(23/260)6.4%

(17/266)10%

(26/260)4%

(10/250)7.5%

(18/241)1.8%

(4/226)3.2%

(7/216) PM AM PM AM

Razor Razor Clipper Clipper2024/6/20Dr.GaoXiaodong562024/6/20Dr.GaoXiaodong572024/6/20Dr.GaoXiaodong583M被皮器2024/6/2059Dr.GaoXiaodong2024/6/20Dr.GaoXiaodong60住院時(shí)間2024/6/20Dr.GaoXiaodong61溫度控制2024/6/20Dr.GaoXiaodong62溫度控制KurzA,etal.N.EnglJMed.19962024/6/20Dr.GaoXiaodong63患者加溫2024/6/20Dr.GaoXiaodong64電熱毯2024/6/20Dr.GaoXiaodong65倡導(dǎo)正常體溫6.012.701.580.000.001.002.003.004.005.006.007.00TimeFrame7/04-12/051/06-9/067/03-6/041/6/03在美國(guó)Mercy醫(yī)院所見(jiàn)VAP降為零2024/6/2066Dr.GaoXiaodong2024/6/2067Dr.GaoXiaodongSSIsandGlucoseConcentrations012345678100–150150–200200–250250–300Day1BloodGlucose(mg/dL)DeepI