臨床藥理學(xué)-臨床藥理ssi

首先改變觀念……..沒有可以接受的事件，所有的感染都是可能被預(yù)防的，除非能夠證明預(yù)防措施是無效的Question1、如何使用是合理使用抗菌藥物？2、強調(diào)合理應(yīng)用抗菌藥物的意義何在？安全有效使用抗菌藥物即：在安全的前提下確保有效治療？（是 性疾病嗎）藥物？（是細菌、真菌或其他病原體）會復(fù)發(fā)嗎？（用藥療程問題）嗎？（對正常菌群的影響）是否進行抗用哪一類抗用哪一種抗菌藥物？（是什么細菌引起的

）細菌對所選藥物敏感嗎？（近期當(dāng)?shù)啬退幮员O(jiān)測結(jié)果如何）用藥劑量足夠嗎？每天一次還是分次給藥？（藥物PK/PD）靜脈用藥還是口服治療？（藥物的生物利用度）藥物能達到

部位嗎？（盆腔、宮頸粘液藥物的組織濃度）的身體狀況能承受這種藥物嗎？（肝腎功能等副作用）沒有更便宜但效果仍良好的藥物？（藥物經(jīng)濟學(xué)分析）用1周就停藥會引起二重會出現(xiàn)耐藥菌嗎？（防細菌耐藥突變濃度）…………臨

最

的用藥決策—

抗

治療選擇細菌患者毒性藥代動力學(xué)防御功能藥效動力學(xué)耐藥抗菌治療三角抗菌藥物我國每年由于藥品使用不當(dāng)藥品不良反應(yīng)造成的人數(shù)在20-50萬人，而其中抗菌藥物占40%

。耐藥菌株的增加，這也是造成我國抗菌藥物使用劑量越來越大、一些炎癥疾病治療的重要原因之一。而與耐藥菌株增加迅速相對應(yīng)的事實是研究一種新的抗菌藥所需的時間的漫長，醫(yī)學(xué)科研工作者在最好的研究條件下開發(fā)一種新的抗菌藥需要10年的時間。主要細菌病原菌的發(fā)現(xiàn)年代疾病細菌名稱發(fā)現(xiàn)人1873麻風(fēng)病麻風(fēng)分枝桿菌漢森（Hansen,G.A.）1877炭疽病炭疽芽孢桿菌科赫（Koch,R.）1880傷寒傷寒沙門氏菌艾博斯（Eberth,C.J.）1882結(jié)核病結(jié)核分枝桿菌科赫（Koch,R.）1883霍亂霍亂弧菌科赫（Koch,R.）1884破傷風(fēng)破傷風(fēng)梭菌尼可奈爾（Nicolaier,A.）1886鏈球菌佛蘭克爾（Franenkel,A.）1887腦膜炎腦膜炎奈瑟氏菌威克塞保（Weichselbaum）1888食物腸炎沙門氏菌格爾特內(nèi)（Gaertner）1894氏菌北里（Kitasato,S.）（Yersin）1898痢疾痢疾志賀氏菌志賀(Shiga,K)Penicillin

1941Methicillin

1959ycin

1958linezolid

2000PCase

producing

SA

1944MRSA

1961VRE

1986VRSA

2002LRE1999提

綱手術(shù)部位定義及(surgical

site

infection，SSI)標(biāo)準手術(shù)切口分類手術(shù)部位

的細菌學(xué)預(yù)防性應(yīng)用抗菌藥物的適應(yīng)癥預(yù)防性藥物的選擇及使用方法Impact

of

SSIs

on

healthcare

resourcesa

case

control

study

involving

215

matched

pairs

of

patientswith

and

without

SSIsRelative

Risk:Death 2.2

(95%

CI:1.1-4.5)Readmission

5.5(95%

CI:

4.0-7.7)ICU

treatment

1.6

(95%

CI:1.3-2.0)The

median

duration

of

hospitalisation:11

days

VS

6days.the

median

extra

duration

attributable

to

SSIswas

6.5

days

(95%

CI:

5-8).Infect

Control

Hosp

Epidemiol

1999;20:725

730.19世紀中葉，手術(shù)切口 率報告為70-80%目前，世界衛(wèi)生組織全球來看很不平衡，從0.5%-15%不等，清潔傷口 率大概在2.1%，清潔污染傷口占3.3%，污染傷口

率在7.1%左右的第CDC報告醫(yī)院 中，SSI占30-50%對我國的193所醫(yī)院

，SSI居醫(yī)院三位醫(yī)院拯40-60%的SSI是可以預(yù)防的，救十萬生命運動六種干預(yù)措施：縮短術(shù)前住院時間，維持手術(shù)患者的正常體溫，根據(jù)指南使用預(yù)防性的抗菌藥物，術(shù)前皮膚清潔，強制性的

報告，向公眾報告NI率，血糖控制提

綱手術(shù)部位定義及(surgical

site

infection，SSI)標(biāo)準手術(shù)切口分類手術(shù)部位

的細菌學(xué)預(yù)防性應(yīng)用抗菌藥物的適應(yīng)癥預(yù)防性藥物的選擇及使用方法Surgical

Site

Infections

(SSIs)are

defined

as

infections

occurring

upto

30

days

after

surgery

(or

up

to

oneyear

after

surgery

in

patients

receivingimplants)

and

affecting

either

the

incisionor

deep

tissue

at

the

operation

site.definitionTypes

of

SSISSI

標(biāo)準切口淺部:具有下列癥狀之一：疼痛或壓痛，局部紅、腫、熱；切口淺層有膿性

物；切口淺層

物培養(yǎng)出致病菌；SSI

標(biāo)準切口深部---累及切口深部筋膜及肌層的從切口深部流出膿液；切口深部自行裂開或由醫(yī)師主動打開，細菌培養(yǎng)陽性且具備下列癥狀體征之一：體溫>38℃，局部疼痛或壓痛；臨床或經(jīng)手術(shù)或病理組織學(xué)或影像學(xué)

發(fā)現(xiàn)切口深部有膿腫：SSI

標(biāo)準／腔隙:放置于

／腔隙的

管有膿性

物；／腔隙的液體或組織培養(yǎng)有致病菌；經(jīng)手術(shù)或病理組織學(xué)或影像學(xué)

／腔隙有膿腫；提

綱手術(shù)部位定義及(surgical

site

infection，SSI)標(biāo)準手術(shù)切口分類手術(shù)部位

的細菌學(xué)預(yù)防性應(yīng)用抗菌藥物的適應(yīng)癥預(yù)防性藥物的選擇及使用方法手術(shù)切口的分類I類清潔切口II類可能污染的切口IV

類污染切口既往將手術(shù)切口分為三類：II類III類手術(shù)切口的分類分類I類（清潔）切口II類（清潔－污染）切口

III類（污染）切口IV類（嚴重污染- ）切口標(biāo)準手術(shù)未進入炎癥區(qū)，未進入呼吸道、及泌尿生殖道，以及閉合性 手術(shù)符合上述條件者手術(shù)進入呼吸道、及泌尿生殖道但無明顯污染，例如無

且順利完成的膽道、胃腸道、 、口咽部手術(shù)新鮮開放性手術(shù)：手術(shù)進入急性炎癥但未化膿區(qū)域；胃腸道內(nèi)容物有明顯溢出污染；無菌技術(shù)有明顯缺陷（如緊急開胸心臟按壓）者有失活組織的陳舊手術(shù)；已有臨床感染或臟器穿孔術(shù)疝修補術(shù)甲狀腺腺瘤切除術(shù)乳腺纖維腺瘤切除術(shù)無人工植入物的經(jīng) 切除術(shù)扁桃體切除術(shù)按上述方法分類，不同切口率有顯著不同清潔切口

發(fā)生率為1％，清潔～污染切口為7％，污染切口為20％，嚴重污染－

切口為40％確切分類一般在手術(shù)后作出，但外科醫(yī)生在術(shù)前應(yīng)進行，作為決定是否須要預(yù)防性使用抗生素的重要依據(jù)。提

綱手術(shù)部位定義及(surgical

site

infection，SSI)標(biāo)準手術(shù)切口分類手術(shù)部位

的細菌學(xué)預(yù)防性應(yīng)用抗菌藥物的適應(yīng)癥預(yù)防性藥物的選擇及使用方法各類手術(shù)最易引起SSI的病原菌手術(shù)最可能的病原菌心臟手術(shù)神經(jīng)外科手術(shù)血管外科手術(shù)手術(shù)頭頸外科手術(shù)腹外疝外科胃十二指腸手術(shù)膽道手術(shù)闌尾手術(shù)結(jié)、直腸手術(shù)泌尿外科手術(shù)婦產(chǎn)科手術(shù)金黃色葡萄球菌、凝固酶金黃色葡萄球菌、凝固酶金黃色葡萄球菌、凝固酶金黃色葡萄球菌、凝固酶金黃色葡萄球菌、凝固酶金黃色葡萄球菌、凝固酶葡萄球菌葡萄球菌葡萄球菌葡萄球菌葡萄球菌葡萄球菌革蘭革蘭革蘭革蘭革蘭革蘭桿菌，鏈球菌、口咽部厭氧菌(如消化鏈球菌)桿菌，厭氧菌(如脆弱類桿菌）桿菌，厭氧菌(如脆弱類桿菌）桿菌，厭氧菌(如脆弱類桿菌）桿菌桿菌，腸球菌、B族鏈球菌，厭氧菌手術(shù)

最可能的病原菌經(jīng)口咽部粘膜切口的大手術(shù)金黃色葡萄球菌，鏈球菌、口咽部厭氧菌（如消化鏈球菌）胸外科手術(shù)（食管、肺）革金黃色葡萄球菌、凝固酶葡萄球菌、鏈球菌，葡萄蘭 桿菌矯形外科手術(shù)(包括用螺釘、鋼板、金屬關(guān)節(jié)置換)金黃色葡萄球菌、凝固酶球菌

、革蘭 桿菌各類手術(shù)最易引起SSI的病原菌手術(shù)部位

的細菌學(xué)最常見的病原菌：葡萄球菌(金黃色葡萄球菌和凝固酶葡萄球菌)，其次：腸道桿菌科細菌(大腸桿菌、腸桿菌屬、克雷伯菌屬等)。SSI的病原菌可以是內(nèi)源性或外源性的，大多數(shù)是內(nèi)源性的。即來自 本身的皮膚、粘膜及空腔臟器內(nèi)的細菌。皮膚攜帶的致病菌多數(shù)是革蘭陽性球菌，但在

及區(qū)，皮膚常被糞便污染而帶有革蘭 桿菌及厭氧菌。手術(shù)切開胃腸道、膽道、泌

、女性生殖道時，典型的SSI致病菌是革蘭 腸道桿菌，在結(jié)直腸和 還有厭氧菌(主要是脆弱類桿菌)，它們是這些部位

／腔隙

的主要病原菌。在任何部位，手術(shù)切口

大多由葡萄球菌引起。提

綱手術(shù)部位定義及(surgical

site

infection，SSI)標(biāo)準手術(shù)切口分類手術(shù)部位

的細菌學(xué)預(yù)防性應(yīng)用抗菌藥物的適應(yīng)癥預(yù)防性藥物的選擇及使用方法如何可以減少圍手術(shù)期的？Patient-related

and

procedure-related

factors

that

may

influence

the

risk

ofsurgical

site

infectionsPatient-related Procedure-relatedageNutritional

statusdiabetesDuration

of

surgical

scrubSkin

antisepsisPreoperative

shavingsmokingobesityPreoperative

skin

preparationDuration

of

operationCoexistent

infection

at

a

remote

body

siteColonisation

with

micro-organisms(staphylococcus

aureus)Antimicrobial

prophylaxisOperatingroom

ventilationInadequate

sterilisation

of

surgical

instrumentsForeign

material

in

the

surgicalsiteSurgical

drainsSurgical

techniquepoor

haemostasisAltered

immune

responsefailure

to

obliteratedead

spaceLength

of

preoperative

hospital

stayTissue

trauma容易導(dǎo)致手術(shù)部位

的（1）因素高齡、營養(yǎng)不良、、肥胖、吸煙、免疫低下、其他部位有

灶、已有不正常的細菌（如鼻孔葡萄球菌定植）、低氧血癥術(shù)前處理術(shù)前住院時間過長、用剃刀剃毛、剃毛過早、手術(shù)野衛(wèi)生狀況差（術(shù)前未很好沐?。?、對有指征者未用抗生素預(yù)防容易導(dǎo)致手術(shù)部位

的

（2）手術(shù)情況手術(shù)時間長(>3h)、術(shù)中發(fā)生明顯污染、置入人工材料、組織

大、止血不徹底、局部積血積液、存在死腔和/或失活組織、留置、術(shù)中低血壓、大量輸血、刷手不徹底、液使用不良、器械敷料滅菌不徹底容易導(dǎo)致手術(shù)部位

的

（3）nelhave

potentially

transmissiblePreoperativePreparation

of

thepatient(1)

Where

possible,

identify

and

treat

remote

infections,

and

postpone

surgery

until

such

infections

have

resolved

(1A)(2)

Do

not

remove

hair

around

the

operation

site,

unless

it

will

interfere

with

the

operation

(1A)(3)

If

hair

is

removed,

this

shouldbe

done

immedia y

before

the

operation,

preferably

with

clippers

(1A)(4)

Adequa y

control

blood

glucose betic

patients,

and

avoid

perioperative

hyperglycaemia

(1B)(5)Encourage

tobacco

cessation

(1B)(6)

Do

notwithhold

necessary

blood

products

as

a

means

of

preventing

SSIs

(1B)(7)

Require

patients

to

shower

or

bathe

withan

antiseptic

agent

on

atleast

the

night

before

the

operation(1B)(8)

Thoroughly

wash

and

clean

around

the

incision

site

to

remove

gross

contamination

before

performing

antiseptic

skinpreparation

(1B)(9)

Use

anappropriate

antiseptic

for

skin

preparation

(1B)Hand/forearm

antisepsis

for

surgical

teammembers(1)

Keepnails

short

anddo

not

wear

artificial

nails

(1B)(2)

Perform

preoperative

surgical

scrub

for

at

least

2

5

min

using

an

appropriate

antiseptic.

Scrub

hands

and

forearmsup

to

theelbows

(1B)(3)

After

performing

the

surgical

scrub,

keep

hands

up

and

away

from

the

body

(elbows

flexed).

Dry

hands

with

asteriletowel

and

don

sterile

gown

and

gloves

(1B)Management

ofinfected

orcolonised

surgical

nel(1)Educate

and

encourage

surgical nel

who

have

signs

and

symptoms

of

transmissible

infectious

illness

to

reportconditions

promptly

to

their

supervisors

andoccupation

health

service

(1B)(2)

Develop

well-defined

policies

concerning

patient

care

responsibilities

wheninfectious

conditions

(1B)(3)

Obtain

appropriate

culturesfrom,

and

exclude

from

duty,

surgical nel

with

draining

skinlesions

until

infectionhas

been

ruled

out

or

resolved

(1B)(4)

Do

notroutinely

exclude nel

who

are

colonised

with

organisms

such

as

S.

aureus

or

Group

A

streptococci

unless

such

nel

have

beenlinked

epidemiologically

to

dissemination

of

the

organism

in

the

healthcare

setting

(1B)Antimicrobial

prophylaxis(1)

Administer

antimicrobial

prophylaxis

only

when

indicated

and

select

agent

according

to

efficacy

against

mostcommonpathogens

associated

with

a

specific

procedure

(1A)(2)

Administer

initial

dose

intravenously,

timed

so

that

bactericidal

concentrations

are

established

in

serum

and

tissueswhen

incision

is

made.

Maintain

therapeutic

concentrations

in

serum

and

tissue

throughout

the

procedure

until

atmost

afew

hours

after

wound

closure

in

the

operating

theatre

(1A)(3)

Before

elective

colorectal

operations,mechanically

prepare

the

colon

by

use

of

enemas

and

cathartic

agents.Administer

non-absorbable

oral

antimicrobial

agents

in

divided

doses

on

the

day

beforethe

operation

(1A)(4)

For

high-risk

caesarean

section,

administer

prophylaxis

immedia y

after

the

umbilical

cord

is

clamped

(1A)(5)

Do

notroutinely

use ycin

for

antimicrobial

prophylaxis

(1B)1.手術(shù)前。（1）盡量縮短患者術(shù)前住院時間。擇期手術(shù)患者應(yīng)當(dāng)盡可能待手術(shù)部位以外治愈后再行手術(shù)。（2）有效控制

患者的血糖水平。（3）正確準備手術(shù)部位皮膚，徹底清除手術(shù)切口部位和周圍皮膚的污染。術(shù)前備皮應(yīng)當(dāng)在手術(shù)當(dāng)日進行，確需去除手術(shù)部位毛發(fā)時，應(yīng)當(dāng)使用不損傷皮膚的方法，避免使（4）片刮除毛發(fā)。前要徹底清除手術(shù)切口和周圍皮膚的污染，采用衛(wèi)生行政部門批準的合適的 劑以適當(dāng)?shù)姆绞?/p>

手術(shù)部位皮膚，皮膚如需延長切口、做新切口或放置

時，應(yīng)當(dāng)擴大范圍應(yīng)當(dāng)符合手術(shù)要求，范圍。（5）如需預(yù)防用抗菌藥物時，手術(shù)患者皮膚切開前30分鐘—2小時內(nèi)或麻醉誘導(dǎo)期給予合理種類和合理劑量的抗菌藥物。需要做腸道準備的患者，還需術(shù)前一天分次、足劑量給予非吸收性口服抗菌藥物。（6）有明顯皮膚

或者患感冒、流感等呼吸道疾病，以及攜帶或多重耐藥菌的醫(yī)務(wù) ，在未治愈前不應(yīng)當(dāng)參加手術(shù)。（7）手術(shù) 要嚴格按照《醫(yī)務(wù) 手衛(wèi)生規(guī)范》進行外科手

。（8）重視術(shù)前患者的抵抗力，糾正水電解質(zhì)的不平衡、貧血、低蛋白血癥等。IntraoperativeVentilation(1)

Maintain

positive

pressure

in

the

operating

theatre

withrespect

to

corridors

andadjacent

areas

(1B)(2)

Maintain

at

least

15

air

changes

per

hour,

of

which

three

should

be

fresh

air

(1B)(3)

Filter

all

air,recirculated

and

fresh,

through

appropriate

filters

(1B)(4)

Introduce

all

air

at

the

ceiling,

and

exhaust

near

the

floor

(1B)(5)

Do

not

use

UV

radiation

in

the

operating

theatre

to

prevent

SSI

(1B)(6)

Keep

operating

theatre

doors

closed

except

as

needed

forpassage

of

equipment, nel,

and

the

patient

(1B)Cleaning

and

disinfection

of

environmental

surfaces(1)

When

visible

soiling

or

contamination

with

blood

or

other

body

fluids

of

surfaces

or

equipment

occurs

during

an

operation,cleanaffected

areas

with

disinfectant

before

the

next

operation

(1B)(2)

Do

not

perform

special

cleaning

or

closing

of

operating

theatres

after

contaminated

or

dirtyoperations

(1B)(3)

Do

notuse

tacky

mats

atthe

entrance

to

the

operating

suite

or

theatre

for

infection

control

(1B)Microbiological

sampling(1)

Do

not

perform

routine

environmental

sampling

of

the

operating

theatre.

Perform

microbiological

sampling

of

operating

theatreenvironmental

surfaces

or

air

only

as

part

of

an

epidemiological

investigation

(1B)Sterilisation

of

surgical

instruments(1)

Sterilise

all

surgical

instruments

according

to

published

guidelines

(1B)(2)

Perform

flash

sterilisation

onlyfor

patientcare

instruments

that

will

be

used

immedia y

(e.g.

to

reprocess

a

dropped

instrument).

Donot

use

flash

sterilisation

for

reasons

of

convenience,

as ternative

to

purchasing

additional

instrument

sets,

or

to

save

time

(1B)Surgical

attire

and

drapes(1)

Wear

a

surgical

mask

that

fully

covers

the

mouth

andnose

when

entering

the

operating

theatre

if

an

operation

is

about

to

begin

oralready

underway,

or

if

sterile

instruments

are

exposed.

Wearthe

mask

throughout

the

operation

(1B)(2)

Wear

a

cap

or

hood

to

cover

fully

the

hair

on

the

head

and

face

when

entering

the

operating

theatre

(1B)(3)

Do

not

wear

shoe

covers

for

the

prevention

of

SSI

(1B)(4)

Wearsterile

gloves

ifa

surgical

team

member.

Put

on

gloves

afterdonning

surgical

gown

(1B)(5)

Use

surgicalgowns

and

drapes

that

are

effective

barriers

when

wet

(i.e.

materials

that

resistliquid

penetration)

(1B)(6)

Change

scrub

suits

that

are

visibly

soiled,

contaminated

and/or

penetrated

byblood

or

other

potentially

infectious

materials

(1B)Asepsis

and

surgical

technique(1)

Adhereto

principles

of

asepsis

when

placing

intravascular

devices

or

when

administering

intravenous

drugs

(1A)(2)

Handle

tissue

gently,

maintain

effective

haemostasis,

minimise

devitalised

tissue

and

foreign

bodies

(e.g.

sutures,

charred

tissue,necrotic

debris),

and

eradicate

dead

space

at

the

surgical

site

(1B)(3)

Use

delayed

primary

skin

closure

or

leave

incision

open

to

heal

by

second

intention

if

the

surgical

site

is

considered

to

be

heavilycontaminated

(1B)(4)

If

drainage

is

necessary,

use

a

closed

suction

drain.

Place

drain

through

a

separate

incision

distant

from

the

operative

incision.Remove

drain

as

soon

as

possible

(1B)手術(shù)中。（1）保證手術(shù)室門關(guān)閉，盡量保持手術(shù)室正壓通氣，環(huán)境表面清潔，最數(shù)量和流動。術(shù)器械、器具及物品等達到滅菌水平。大限度減少（2）保證使用（3）手術(shù)中醫(yī)務(wù)

要嚴格遵循無菌技術(shù)原則和手衛(wèi)生規(guī)范。（4）若手術(shù)時間超過3小時，或者手術(shù)時間長于所用抗菌藥物半衰期的，或者失血量大于1500毫升 術(shù)中應(yīng)當(dāng)對患者追加合理劑量的抗菌藥物。（5）手術(shù) 盡量輕柔地接觸組織，保持有效地止血，最大限度地減少組織損傷，徹底去除手術(shù)部位的壞死組織，避免形成死腔。（6）術(shù)中保持患者體溫正常，防止低體溫。需要局部降溫的特殊手術(shù)執(zhí)行具體專業(yè)要求。（7）沖洗手術(shù)部位時，應(yīng)當(dāng)使用溫度為37℃的無菌生理鹽水等液體。（8）對于需要 術(shù)切口，術(shù)中應(yīng)當(dāng)首選密閉負壓擇遠離手術(shù)切口、位置合適的部位進行置管 ，確保，并盡量選充分。Postoperative

incision

care(1)

Protect

an

incision

that

has

been

closed

primarily

with

a

sterile

dressing

for

24

48

h

postoperatively

(1B)(2)

Wash

hands

before

and

afterchanging

dressings

and

any

contact

with

the

surgical

site

(1B)Surveillance(1)

Use

CDC

definitions

of

SSI

without

modification

for

identifying

SSI

among

surgical

inpatients

and

outpatients

(1B)(2)

For

inpatient

case-finding

(including

readmissions),

use

direct

prospective

observation,

indirect

prospectivedetection,

or

a

combination

of

direct

andindirect

methods

for

the

duration

of

hospitalisation

(1B)(3)

For

outpatient

case-finding,

use

a

method

that modates

available

resources

and

data

needs

(1B)(4)

For

each

patient

undergoing

an

operation

chosenforsurveillance,

record

those

variables

shown

to

beassociatedwith

increased

SSI

risk

(e.g.

surgical

wound

class,

duration

of

operation,

etc.)

(1B)(5)

Periodically

calculate

operation-specific

SSI

rates

stratified

by

variables

shown

to

be

associated

with

increased

SSI

risk

(e.g.

NNISrisk

index)

(1B)(6)

Reportappropria y

stratified,

operation-specific,

SSI

rates

to

surgical

team

members.

The

optimum

frequencyand

format

forcomparisons

of

SSI

r

es

will

bedetermined

by

stratified

case-load

rates

and

the

objectives

of

localcontinuous

quality

improvement

initiatives

(1B)手術(shù)后（1）醫(yī)務(wù) 接觸患者手術(shù)部位或者更換手術(shù)切口敷料前后應(yīng)當(dāng)進行手衛(wèi)生。（2）為患者更換切口敷料時，要嚴格遵守?zé)o菌技術(shù)操作原則及換藥流程。（3）術(shù)后保持 通暢，根據(jù)病情盡早為患者拔除引流管。（4）外科醫(yī)師、護士要定時觀察患者手術(shù)部位切口情況，出現(xiàn)

物時應(yīng)當(dāng)進行微生物培養(yǎng)，結(jié)合微生物報告及患者手術(shù)情況，對外科手術(shù)部位

及時

、治療和監(jiān)測。?導(dǎo)管相關(guān)血流預(yù)防與控制技術(shù)指南留置血管內(nèi)導(dǎo)管是救治危重患者、實施特殊用藥和治療的醫(yī)療操作技術(shù)。置管后的患者存在發(fā)生的。血管內(nèi)導(dǎo)管相關(guān)血流的主要包括：導(dǎo)管留置的時間、置管部位及其細菌定植情況、無菌操作技術(shù)、置管技術(shù)、患者免疫功能和健康狀態(tài)等因素。一、導(dǎo)管相關(guān)血流

的定義導(dǎo)管相關(guān)血流

（Catheter

Related

Blood

Stream

Infection,簡稱CRBSI）是指帶有血管內(nèi)導(dǎo)管或者拔除血管內(nèi)導(dǎo)管48小時內(nèi)的患者出現(xiàn)菌血癥或真菌血癥，并伴有發(fā)熱（>38℃）、寒顫或低血壓等

表現(xiàn)，除血管導(dǎo)管外沒有其他明確的 源。

微生物學(xué)檢查顯示：外周靜脈血培養(yǎng)細菌或真菌陽性；或者從導(dǎo)管段和外周血培養(yǎng)出相同種類、相同藥敏結(jié)果的致病菌。預(yù)防與控制導(dǎo)管相關(guān)血流的工作規(guī)范和操作規(guī)二、導(dǎo)管相關(guān)血流

預(yù)防要點（一）管理要求。1.醫(yī)療機構(gòu)應(yīng)當(dāng)健全規(guī)章制度，制定并程，明確相關(guān)部門和

職責(zé)。2.醫(yī)務(wù)

應(yīng)當(dāng)接受關(guān)于血管內(nèi)導(dǎo)管的正確置管、

和導(dǎo)管相關(guān)血流

預(yù)防與控制措施的培訓(xùn)和教育，熟練掌握相關(guān)操作規(guī)程。3.有條件的醫(yī)療機構(gòu)應(yīng)當(dāng)建立靜脈置管專業(yè)護士隊伍，提高對靜脈置管患者的專業(yè)護理質(zhì)量。4.醫(yī)務(wù)

應(yīng)當(dāng)評估患者發(fā)生導(dǎo)管相關(guān)血流

的 ，實施預(yù)防和控制導(dǎo)管相關(guān)血流感染的工作措施。5.醫(yī)療機構(gòu)應(yīng)當(dāng)逐步開展導(dǎo)管相關(guān)血流

的目標(biāo)性監(jiān)測，持續(xù)改進，有效降低

率。預(yù)防要點置管時。（1）嚴格執(zhí)行無菌技術(shù)操作規(guī)程。置管時應(yīng)當(dāng)遵守最大限度的無菌屏障要求。置管部位應(yīng)當(dāng)鋪大無菌單（巾）；置管 應(yīng)當(dāng)戴帽子、

、無菌手套，穿無菌手術(shù)衣。（2）嚴格按照《醫(yī)務(wù) 手衛(wèi)生規(guī)范》，認真洗手并戴無菌手套后，盡量避免接觸穿刺點皮膚。置管過程中手套污染或破損應(yīng)當(dāng)立即更換。（3）置管使用的醫(yī)療器械、器具等醫(yī)療用品和各種敷料必須達到滅菌水平。（4）選擇合適的靜脈置管穿刺點，成人中心靜脈置管時，應(yīng)當(dāng)首選鎖骨下靜脈，盡量避免使用頸靜脈和股靜脈。（5）采用衛(wèi)生行政部門批準的皮膚

劑穿刺部位皮膚，自穿刺點由內(nèi)向外以同心圓方式

， 范圍應(yīng)當(dāng)符合置管要求。 后皮膚穿刺點應(yīng)當(dāng)避免再次接觸。皮膚

待干后，再進行置管操作。（6）患癤腫、濕疹等皮膚病或患感冒、流感等呼吸道疾病，以及攜帶或多重耐藥菌的醫(yī)務(wù) ，在未治愈前不應(yīng)當(dāng)進行置管操作。.置管后（1）應(yīng)當(dāng)盡量使用無菌透明、透氣性好的敷料覆蓋穿刺點，對于高熱、出汗、穿刺點

、滲出的患者應(yīng)當(dāng)使用無菌紗布覆蓋。（2）應(yīng)當(dāng)定期更換置管穿刺點覆蓋的敷料。更換間隔時間為：無菌紗布為1次/2天，無菌透明敷料為1-2次/周，如果紗布或敷料出現(xiàn)潮濕、松動、可見污染時應(yīng)當(dāng)立即更換。（3）醫(yī)務(wù)

接觸置管穿刺點或更換敷料時，應(yīng)當(dāng)嚴格執(zhí)行手衛(wèi)生規(guī)范。（4）保持導(dǎo)管連接端口的清潔，注射藥物前，應(yīng)當(dāng)用75%

或含碘 劑進行

，待干后方可注射藥物。

血跡等污染時，應(yīng)當(dāng)立即更換。（5）告知置管患者在沐浴或擦身時，應(yīng)當(dāng)注意保護導(dǎo)管，

導(dǎo)管淋濕或浸入水中。（6）在輸血、輸入血制品、脂肪乳劑后的24小時內(nèi)或者停止輸液后，應(yīng)當(dāng)及時更換輸液管路。外周及中心靜脈置管后，應(yīng)當(dāng)用生理鹽水或肝素鹽水進行常規(guī)沖管，預(yù)防導(dǎo)管內(nèi)血栓形成。（7）嚴格保證輸注液體的無菌。（8）緊急狀態(tài)下的置管，若不能保證有效的無菌原則，應(yīng)當(dāng)在48小時內(nèi)盡快拔除導(dǎo)管，更換穿刺部位后重新進行置管，并作相應(yīng)處理。（9）懷疑患者發(fā)生導(dǎo)管相關(guān) ，或者患者出現(xiàn)靜脈炎、導(dǎo)管故障時，應(yīng)當(dāng)及時拔除導(dǎo)管。必要時應(yīng)當(dāng)進行導(dǎo)管尖端的微生物培養(yǎng)。（10）醫(yī)務(wù)

應(yīng)當(dāng)每天對保留導(dǎo)管的必要性進行評估，不需要時應(yīng)當(dāng)盡早拔除導(dǎo)管。（11）導(dǎo)管不宜常規(guī)更換，特別是不應(yīng)當(dāng)為預(yù)防

而定期更換中心靜脈導(dǎo)管和動脈導(dǎo)管。應(yīng)用抗菌藥物預(yù)防外科手術(shù)部位作用是肯定的。但并非所有手術(shù)都需要。適應(yīng)癥嚴重者（如開顱、Ⅰ類切口手術(shù)Ⅰ類清潔手術(shù)，時間長、

大、一旦心臟和大血管、骨關(guān)節(jié)、門脈高壓癥手術(shù)）Ⅰ類清潔手術(shù)

有

高危因素（

，營養(yǎng)不良、免疫低下，高齡）Ⅰ類清潔手術(shù)使用人工材料或人工裝置

術(shù)。Ⅰ類清潔手術(shù)時間較短者盡量不用抗菌藥物Ⅱ類（清潔-污染）切口及部分Ⅲ類（污染）切口手術(shù)，主要是進入胃腸道、呼吸道、女性生殖道術(shù)。嚴重污染的Ⅲ類切口及Ⅳ類切口，應(yīng)治療性使用抗菌藥物，不屬于預(yù)防適應(yīng)癥提

綱手術(shù)部位定義及(surgical

site

infection，SSI)標(biāo)準手術(shù)切口分類手術(shù)部位

的細菌學(xué)預(yù)防性應(yīng)用抗菌藥物的適應(yīng)癥預(yù)防性藥物的選擇及使用方法引起SSI的病原微生物正常、內(nèi)源性微生物，50%來源于完整的皮膚，定植外源性微生物what選擇抗生素時要根據(jù)手術(shù)種類的常見病原菌、切口類別和

有無易感因素等綜合考慮原則上應(yīng)選擇相對廣譜，效果肯定，(殺菌劑而非抑菌劑)、安全及價格相對低廉的抗菌藥物。頭孢菌素是最符合上述條件的★心血管、頭頸、胸腹壁、四肢手術(shù)—首選一代頭孢★進入消化道、呼吸道、女性生殖道

術(shù)—多用二代頭孢，少數(shù)較復(fù)雜的大手術(shù)用三代頭孢★氨基糖苷類有耳腎毒性，不是理想的預(yù)防用藥★一般不用喹諾酮類藥物（可用于經(jīng)直腸的前列腺活檢手術(shù)）頭孢1代是最基本的預(yù)防用藥★對青霉素和頭孢菌素類抗生素過敏者，針對G+球菌可用克林霉素，針對G-桿菌可用氨曲南，大多二者聯(lián)合使用★有特殊適應(yīng)證時，可以選用萬古霉素，如證實有MRSA所致的SSI流行、風(fēng)濕性心臟病合并心內(nèi)膜炎需行開心手術(shù)、已知 定植了MRSA等★移植，需使用覆蓋面更廣的抗生素，如添加β-內(nèi)酰胺酶抑制劑的β-內(nèi)酰胺類