心臟外科術(shù)后手術(shù)部位感染圖文

1、心臟外科術(shù)后手術(shù)心臟外科術(shù)后手術(shù)部位感染圖文部位感染圖文手術(shù)部位感染的后果手術(shù)部位感染的后果SSI患者與對(duì)照組患者住院日患者與對(duì)照組患者住院日(LOS)及醫(yī)療費(fèi)用及醫(yī)療費(fèi)用手術(shù)種類手術(shù)種類病例對(duì)數(shù)目病例對(duì)數(shù)目每例每例SSI患者患者LOS延長(zhǎng)延長(zhǎng)中位數(shù)中位數(shù)每例每例SSI醫(yī)療費(fèi)用增醫(yī)療費(fèi)用增加中位數(shù)加中位數(shù)CABG2011.0$3,856闌尾切除術(shù)710.0$3,945結(jié)腸手術(shù)296.0$2,671剖腹探查1922.0$9,964椎板切除術(shù)2410.5$3,273椎骨融合2020.5$11,001ORIF811.5$3,623關(guān)節(jié)置換234.0$2,714血管手術(shù)1116.0$5,595心臟外科

2、手術(shù)后的手術(shù)部位感染心臟外科手術(shù)后的手術(shù)部位感染流行病學(xué)危險(xiǎn)因素診斷微生物學(xué)普通外科手術(shù)普通外科手術(shù)SSI的危險(xiǎn)因素的危險(xiǎn)因素SSI發(fā)生率11.4% (254/2,237)預(yù)防使用抗生素的正確率63.5%SSI的獨(dú)立預(yù)測(cè)因素n年齡 (OR = 1.2, 每增加10歲)n傷口分類 (清潔沾染, OR = 6.4; 污染, OR = 3.7; 感染, OR = 9.3)n抗生素預(yù)防 (OR = 0.5)n手術(shù)前住院日 (OR = 1.1, 每增加3天)n手術(shù)持續(xù)時(shí)間 (OR = 1.5, 每增加60分鐘)n惡性腫瘤 (OR = 1.7)n急診手術(shù) (OR = 1.99)n手術(shù)前住ICU時(shí)間 (OR

3、 = 2.6)n手術(shù)前 2 h應(yīng)用抗生素預(yù)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):310-5SSI的危險(xiǎn)因素的危險(xiǎn)因素 NNIS危險(xiǎn)指數(shù)危險(xiǎn)指數(shù)污染或感染手術(shù)美國(guó)麻醉師學(xué)會(huì)(ASA)術(shù)前評(píng)估為3, 4或5手術(shù)時(shí)間超過75%百分位n時(shí)間點(diǎn)(T)指根據(jù)NNI

4、S調(diào)查手術(shù)時(shí)間的75%百分位ASA術(shù)前評(píng)估術(shù)前評(píng)估外科患者生理狀態(tài)分級(jí)外科患者生理狀態(tài)分級(jí)Class I健康Class II具有全身性疾病，但無功能障礙A patient with mild systemic disease resulting in no functional limitationsClass III具有嚴(yán)重全身性疾病，限制日?；顒?dòng)，但無功能障礙A patient with severe systemic disease that limits activity, but is not incapacitatingClass IV具有嚴(yán)重全身性疾病，持續(xù)威脅生命A patie

5、nt with severe systemic disease that is a constant threat to lifeClass V瀕死狀態(tài)，無望存活24小時(shí)A moribund patient not likely to survive 24 hours常見手術(shù)的常見手術(shù)的T時(shí)間點(diǎn)時(shí)間點(diǎn)手術(shù)T時(shí)間點(diǎn) (hour)CABG5膽道, 肝臟, 或胰腺手術(shù)4開顱手術(shù)4頭頸部手術(shù)4結(jié)腸手術(shù)3人工關(guān)節(jié)置換手術(shù)3血管外科手術(shù)3經(jīng)腹或經(jīng)陰道子宮切除術(shù)2腦室轉(zhuǎn)流2疝修補(bǔ)術(shù)2闌尾切除術(shù)1截肢手術(shù)1剖宮產(chǎn)1SSI危險(xiǎn)分類危險(xiǎn)分類: 手術(shù)種類和手術(shù)種類和T時(shí)間點(diǎn)時(shí)間點(diǎn)危險(xiǎn)分類危險(xiǎn)分類手術(shù)種類手術(shù)種類T時(shí)

6、間點(diǎn)時(shí)間點(diǎn) (hr)0123結(jié)腸手術(shù)結(jié)腸手術(shù)33.28.516.022.0血管外科手術(shù)血管外科手術(shù)31.62.16.114.8膽囊切除手術(shù)膽囊切除手術(shù)21.42.07.111.5器官移植器官移植70.04.46.718.0SSI的診斷的診斷SSI的微生物學(xué)的微生物學(xué)手術(shù)手術(shù), SSI常見致病菌常見致病菌手術(shù)手術(shù)常見致病菌常見致病菌所有移植物, 或假體的植入術(shù)心臟神經(jīng)外科乳腺金黃色葡萄球菌; 凝固酶陰性葡萄球菌眼科資料有限; 但在前節(jié)切除術(shù), 玻璃體切除術(shù)等常用金黃色葡萄球菌; 凝固酶陰性葡萄球菌; 鏈球菌;革蘭陰性桿菌骨科全關(guān)節(jié)置換術(shù)閉合性骨折或應(yīng)用骨釘, 骨板, 其他內(nèi)固定裝置, 無移植物或

7、裝置的功能修復(fù)手術(shù)創(chuàng)傷金黃色葡萄球菌; 凝固酶陰性葡萄球菌; 革蘭陰性桿菌SSI的微生物學(xué)的微生物學(xué)手術(shù)手術(shù), SSI常見致病菌常見致病菌手術(shù)手術(shù)常見致病菌常見致病菌非心臟胸科手術(shù)胸外科手術(shù)(肺葉切除術(shù), 肺切除術(shù), 肺楔形切除, 其他非心臟縱隔手術(shù))胸腔閉式引流術(shù)金黃色葡萄球菌; 凝固酶陰性葡萄球菌; 肺炎鏈球菌; 革蘭陰性桿菌血管外科手術(shù)金黃色葡萄球菌; 凝固酶陰性葡萄球菌闌尾切除術(shù)革蘭陰性桿菌; 厭氧菌膽管結(jié)腸直腸胃十二指腸頭頸部(經(jīng)口咽部粘膜切口的大手術(shù))革蘭陰性桿菌; 鏈球菌; 口咽部厭氧菌(如消化鏈球菌)婦產(chǎn)科革蘭陰性桿菌; 腸球菌; B族鏈球菌; 厭氧菌泌尿科如果尿液無菌, 抗生

8、素可能無效革蘭陰性桿菌SSI的微生物學(xué)的微生物學(xué)NNIS手術(shù)部位感染分離的致病菌, 1986 to 1996分離致病菌的百分比分離致病菌的百分比致病菌致病菌1986 1989(n = 16,727)1990 1996(n = 17,671)金黃色葡萄球菌1720凝固酶陰性葡萄球菌1214腸球菌屬1312大腸桿菌108銅綠假單胞菌88腸桿菌屬87奇異變形桿菌43肺炎克氏菌33其他鏈球菌屬33白色念珠菌23D族鏈球菌 (非腸球菌)-2其他革蘭陽(yáng)性需氧菌2預(yù)防性抗生素預(yù)防性抗生素使用何種抗生素n抗生素 vs. 安慰劑n1GC vs. 2GCn2GC vs. 3GCn氨基糖甙類抗生素的作用n萬古霉素的

9、作用何時(shí)使用療程如何預(yù)防性抗生素預(yù)防性抗生素Antibiotic prophylaxis for cardiothoracic operations meta-analysis of thirty years of clinical trialsby Bruce Kreter and Mark WoodsJ Thorac Cardiovasc Surg 1992;104:590-9僅入選前瞻性, 隨機(jī), 盲法, 及對(duì)照研究預(yù)防性抗生素預(yù)防性抗生素 Versus 安慰劑對(duì)照安慰劑對(duì)照0.11101001000Goodman1986, OxacillinGoodman1968, PCNG/Stre

10、pFekety 1969,PCN GFekety 1969,MethicillinFong 1979,MethicillinSummaryOdds RatioOdds Ratio預(yù)防性抗生素較優(yōu)預(yù)防性抗生素較優(yōu)安慰劑較優(yōu)安慰劑較優(yōu)頭孢唑啉頭孢唑啉 Versus 頭孢呋肟或頭孢孟多頭孢呋肟或頭孢孟多0.1110100Slama 1986,CefamandoleKaiser 1987,CefamandoleGeroulanos1987,CefuroximeGentry 1988,CefuroximeGentry 1988,CefamandoleConklin 1988,CefuroximeDoeb

11、belling1990,CefuroximeSummary OddsRatioOdds Ratio2GC較優(yōu)較優(yōu)1GC較優(yōu)較優(yōu)心臟外科的預(yù)防性抗生素心臟外科的預(yù)防性抗生素結(jié)論預(yù)防性抗生素 安慰劑nSSI減少5倍2GC (頭孢孟多和頭孢呋肟) 頭孢唑啉nSSI降低1.5倍預(yù)防性抗生素 48小時(shí)無益心臟外科中心臟外科中2GC vs. 3GC頭孢曲松, 2 gm單劑vs.SSI相似頭孢孟多, 多劑量頭孢曲松vs.SSI相似頭孢孟多Badel P, Schmuziger M. Anti-infection prophylaxis in cardiac surgery: comparison of si

12、ngle-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 1990 Mar-Apr;18(2):101-4.氨基糖甙的作用氨基糖甙的作用Efficacy of cefaz

13、olin, 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預(yù)防性抗生素胸骨正中切口的患者胸骨傷口感染(%)血管供體切口的患者血管供體部位感染 (%)頭孢唑啉2553 (1.2)2394 (1.7)頭孢唑啉 慶大霉素2536

14、(2.4)*2362 (0.8)頭孢孟多2592 (0.8)2460 (0)頭孢孟多 慶大霉素2630 (0)*2420 (0)所有頭孢唑啉組5089 (1.8)*4756 (1.3)*所有頭孢孟多組5222 (0.4)*4880 (0)*聯(lián)合慶大霉素5166 (1.2)4782 (0.4)不聯(lián)合慶大霉素5145 (1.0)4854 (0.8)總計(jì)103011 (1.1)9636 (0.6)氨基糖甙的作用氨基糖甙的作用結(jié)論心臟外科中慶大霉素不應(yīng)作用預(yù)防性抗生素使用頭孢孟多 頭孢唑啉n針對(duì)胸骨和血管供體部位的深部感染CABG中預(yù)防性抗生素的藥代動(dòng)力學(xué)研究中預(yù)防性抗生素的藥代動(dòng)力學(xué)研究頭孢呋肟 (

15、n = 30)每日一次體外循環(huán)過程中加用一劑單一劑量血清水平 2 mg/L x 8 hr萬古霉素 (n = 30)每日一次體外循環(huán)過程中加用一劑單一劑量血清水平 4 mg/L x 24 hr結(jié)論結(jié)論:單一劑量的頭孢呋肟單一劑量的頭孢呋肟 (3 g 或或 1.5 g) 或萬古霉素或萬古霉素 (1.5 g)可以使血清濃度在可以使血清濃度在CABG手術(shù)后數(shù)小時(shí)達(dá)到并手術(shù)后數(shù)小時(shí)達(dá)到并維持足以預(yù)防感染的水平維持足以預(yù)防感染的水平Vuorisalo S, Pokela R, Syrjala H. Is single-dose antibiotic prophylaxis sufficient for c

16、oronary artery bypass surgery? An analysis of peri- and postoperative serum cefuroxime and vancomycin levels. J Hosp Infect. 1997 Nov;37(3):237-47. 預(yù)防性使用萬古霉素預(yù)防性使用萬古霉素 vs. 1GC萬古霉素和利福平替代頭孢唑啉作為CABG預(yù)防性抗生素手術(shù)部位感染率 (每100例手術(shù))n10.5 (95% CI, 8.2 13.3) to 4.9 (95% CI, 3.2 7.1), P .001估計(jì)12個(gè)月內(nèi)節(jié)約$576,655 (澳元)Spel

17、man 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. 預(yù)防性使用萬古霉素預(yù)防性使用萬古霉素 vs. 頭孢菌素頭孢菌素接受心臟或大血管手術(shù)的321名成年患者隨機(jī)化n頭孢唑啉, 頭孢孟多, 或萬古霉素結(jié)果nSSI: 萬古霉素組 3.7% (4)

18、 vs. 頭孢唑啉組 12.3% (14) vs. 頭孢孟多組 11.5% (13); p = 0.05u萬古霉素組心臟外科手術(shù)后無胸部傷口感染發(fā)生 (p = 0.04)n術(shù)后平均LOS: 萬古霉素組最低 (10.1天; p -2 -2-1012345678910 10hours before / after incisionSurgical Site Infection %短程短程 (1 劑至劑至2 天天) Vs. 長(zhǎng)程長(zhǎng)程 (3 至至 6天天)0.010.11101001000Conte, 1972Goldman, 1977Austin, 1980Hillis, 1983SummaryOd

19、ds Ratio長(zhǎng)程較優(yōu)長(zhǎng)程較優(yōu)短程較優(yōu)短程較優(yōu)心臟外科的預(yù)防性抗生素心臟外科的預(yù)防性抗生素結(jié)論預(yù)防性抗生素 安慰劑nSSI減少5倍2GC (頭孢孟多和頭孢呋肟) 頭孢唑啉nSSI降低1.5倍預(yù)防性抗生素 48小時(shí)無益患兒心臟手術(shù)后的預(yù)防性抗生素患兒心臟手術(shù)后的預(yù)防性抗生素術(shù)前術(shù)前手術(shù)手術(shù)留置胸腔引流管留置胸腔引流管留置留置CVCPOD 2Protocol 1*(n = 786)Protocol 2*(n = 1095)Protocol 3*(n = 2039)頭孢唑啉頭孢唑啉*開胸患者手術(shù)后應(yīng)用萬古霉素和慶大霉素直至胸腔引流管拔除Maher KO, VanDerElzen K, Bove E

20、L, et al. A retrospective review of three antibiotic prophylaxis regimens for pediatric cardiac surgical patients 頭孢唑啉頭孢唑啉頭孢唑啉頭孢唑啉患兒心臟手術(shù)后的預(yù)防性抗生素患兒心臟手術(shù)后的預(yù)防性抗生素2.042.186.5818.86.511.679.35.0205101520Surgical Site InfectionSSI in Pts with Open ChestBSISurgical Site Infection (per 100 operations) or BSI

21、 (per1000 patient-days)Protocol 1Protocol 2Protocol 3: p 0.05 protocol 2 vs. 1 or 3: p 48 h)1.60.0271.1 2.6年齡年齡 65 歲歲1.30.0221.0 1.6CABG/心瓣膜聯(lián)合手術(shù)心瓣膜聯(lián)合手術(shù)2.70.0021.4 5.1CABG后抗生素治療后抗生素治療1.80.0541.0 3.3Harbarth S, Samore MH, Lichtenberg D, Carmeli Y. Prolonged Antibiotic Prophylaxis After Cardiovascular

22、Surgery and Its Effect on Surgical Site Infections and Antimicrobial Resistance. Circulation. 2000;101:2916-2921預(yù)防性抗生素對(duì)抗生素耐藥的影響預(yù)防性抗生素對(duì)抗生素耐藥的影響37例血管外科手術(shù)患者n阿莫西林克拉維酸 x 3 天 (group 1)n氧氟沙星 + 甲硝唑 x 3 天 (group 2)n氧氟沙星 + 甲硝唑 x 1 天 (group 3)17例未行手術(shù)或未應(yīng)用抗生素患者 (對(duì)照組)結(jié)果n第1和2組皮膚葡萄球菌對(duì)下列抗生素的敏感性顯著下降: 鄰氯青霉素(12.8% vs.

23、23.6%)和氧氟沙星(0.5% vs. 85%)n第3組結(jié)果介于1和2組之間n分子生物學(xué)分型提示患者社區(qū)來源的敏感菌株被醫(yī)院獲得的耐藥菌株(遺傳學(xué)不相關(guān))所替代結(jié)論n長(zhǎng)程預(yù)防性抗生素可導(dǎo)致耐藥菌定植, 應(yīng)盡量避免Terpstra S, Noordhoek GT, Voesten HGJ, et al. Rapid emergence of resistant coagulase-negative staphylococci on the skin after antibiotic prophylaxis ICU中抗生素預(yù)防的費(fèi)用及合并癥中抗生素預(yù)防的費(fèi)用及合并癥61%的預(yù)防性抗生素醫(yī)囑超過1

24、天超過1天的預(yù)防性抗生素總費(fèi)用達(dá)$44,893應(yīng)用預(yù)防性抗生素超過4天的患者更容易發(fā)生菌血癥和導(dǎo)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 預(yù)防性抗生素的副作用預(yù)防性抗生素的副作用回顧性病例對(duì)照研究n病例 (n = 23): 應(yīng)用預(yù)防性抗生素 (PAT) 的擇期手術(shù)患者且難辨梭狀芽孢桿

25、菌毒素 (CDT)陽(yáng)性n對(duì)照 (n = 39): 年齡, 性別和手術(shù)相匹配結(jié)果nPAT錯(cuò)誤 83% vs. 44%, OR 5.1 (1.10 23.64)n手術(shù)至最后一劑抗生素的平均時(shí)間間隔 3.1 vs. 1.7天, P 0.05nLOS 16.5 vs. 10.2 天, P 24 h非標(biāo)準(zhǔn)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預(yù)防性抗生素應(yīng)用

26、現(xiàn)狀預(yù)防性抗生素應(yīng)用現(xiàn)狀81% 至 94% 的病例應(yīng)用預(yù)防性抗生素適時(shí)應(yīng)用抗生素n手術(shù)前 2 hrs 應(yīng)用抗生素46%60%73%0%20%40%60%80%動(dòng)脈瘤修補(bǔ)動(dòng)脈瘤修補(bǔ)髖關(guān)節(jié)置換髖關(guān)節(jié)置換結(jié)腸切除結(jié)腸切除適時(shí)應(yīng)用抗生素比例適時(shí)應(yīng)用抗生素比例sSilver 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 Pr

27、ophylaxis Study Group. Am J Surg 1996 Jun;171(6):548-52髖關(guān)節(jié)骨折患者不正確應(yīng)用預(yù)防性抗生素髖關(guān)節(jié)骨折患者不正確應(yīng)用預(yù)防性抗生素時(shí)機(jī)n過遲 (手術(shù)后 2 hrs)70% (247/352)n過早或在手術(shù)中10%n直至手術(shù)結(jié)束才應(yīng)用首劑39% (91/231)抗生素的選擇n胃腸外應(yīng)用1GC94%療程n手術(shù)后 24 hrs78%不正確應(yīng)用預(yù)防性抗生素的預(yù)測(cè)指標(biāo)n沒有預(yù)防性抗生素的書面醫(yī)囑n非教學(xué)醫(yī)院n手術(shù)時(shí)間較短Zoutman D, Chau L, Watterson J, Mackenzie T, Djurfeldt M. A Canadia

28、n survey of prophylactic antibiotic use among hip-fracture patients. Infect Control Hosp Epidemiol 1999 Nov;20(11):752-51. 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,

29、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 G

30、roup. 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 prospecti

31、ve 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.不正確的預(yù)防性抗生素不正確的預(yù)防性抗生素0102030405060總計(jì)總計(jì)AAA修補(bǔ)修補(bǔ)髖關(guān)節(jié)置換髖關(guān)節(jié)置換結(jié)腸切除結(jié)腸切除普通外科普通外科普通外科普

32、通外科髖關(guān)節(jié)骨折髖關(guān)節(jié)骨折違反方案比例違反方案比例 (%)改進(jìn)預(yù)防性抗生素應(yīng)用時(shí)機(jī)的方法改進(jìn)預(yù)防性抗生素應(yīng)用時(shí)機(jī)的方法32%88%0%20%40%60%80%100%Year 1992-94Year 1995正確時(shí)機(jī)的比例正確時(shí)機(jī)的比例Louisville退伍軍人醫(yī)療中心由不同人員應(yīng)用手術(shù)前抗生素n病房護(hù)士 1992 至 1994n手術(shù)室麻醉醫(yī)生 1995正確的時(shí)機(jī)n手術(shù)前抗生素在切開皮膚前1小時(shí)內(nèi)應(yīng)用Matuschka PR, Cheadle WG, Burke JD, Garrison RN. A new standard of care: administration of preope

33、rative antibiotics in the operating room. Am Surg 1997 Jun;63(6):500-3改進(jìn)預(yù)防性抗生素應(yīng)用的方法改進(jìn)預(yù)防性抗生素應(yīng)用的方法目的: 評(píng)價(jià)自動(dòng)手術(shù)中報(bào)警對(duì)長(zhǎng)時(shí)間心臟手術(shù)應(yīng)用第二劑預(yù)防性抗生素的影響設(shè)計(jì): 隨機(jī), 對(duì)照, 評(píng)估者設(shè)盲試驗(yàn)患者: 接受超過4小時(shí)心臟外科手術(shù)的患者, 手術(shù)前已經(jīng)預(yù)防性應(yīng)用頭孢唑啉干預(yù):n報(bào)警組 (n = 137): 在術(shù)前預(yù)防性應(yīng)用抗生素后225分鐘, 手術(shù)室計(jì)算機(jī)自動(dòng)發(fā)出聲音和視覺報(bào)警信號(hào). 30分鐘后, 要求巡回護(hù)士提醒是否已經(jīng)應(yīng)用第二劑預(yù)防性抗生素n對(duì)照組 (n = 136)n歷史對(duì)照組 (n =

34、 480): 研究前6個(gè)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.改進(jìn)預(yù)防性抗生素應(yīng)用的方法改進(jìn)預(yù)防性抗生素應(yīng)用的方法報(bào)警組(n = 137)對(duì)照組(n = 136)歷史對(duì)照組(n = 480)手

35、術(shù)中再次應(yīng)用抗生素68% (93)*40% (55)27% (129)*SSI4% (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 p

36、rophylaxis in prolonged cardiac surgery by automated alerts in the operating room. Infect Control Hosp Epidemiol. 2003 Jan; 24 (1): 13-6.預(yù)防性抗生素的現(xiàn)狀預(yù)防性抗生素的現(xiàn)狀 心臟外科心臟外科, 德國(guó)德國(guó)圍手術(shù)期預(yù)防除4家醫(yī)院外, 所有其他醫(yī)院 (94%) 均應(yīng)用 1GC (n = 32, 43%) 或 2GC (n = 38, 51%), 常常應(yīng)用 24 小時(shí) (n = 60, 81%)預(yù)防性抗生素從不超過3天74%的醫(yī)院 (n = 55) 對(duì)所有心臟手術(shù)均

37、使用相同的預(yù)防性抗生素, 而26%的醫(yī)院 (n = 19) 在部分患者改變預(yù)防性抗生素, 多見于心臟移植預(yù)防性抗生素的改變n根據(jù)藥敏結(jié)果 (n = 63, 85%)n根據(jù)固定的時(shí)間表 (n = 7, 10%)n從不改變 (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. 預(yù)防性抗生素的現(xiàn)狀預(yù)防性抗生素的現(xiàn)狀 心臟外科心臟外科, 德國(guó)德國(guó)手術(shù)后的經(jīng)驗(yàn)性治療總計(jì)應(yīng)用29種不同的抗生素, 分屬8個(gè)種類一線, 二線和三線治療間無顯著差異, 以下情況除外n-內(nèi)酰胺類抗生素 (碳青霉烯類除外) 的應(yīng)用逐漸減少, 從一線的 60%