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脊柱术后伤口感染原因及治疗策略北京大学第三医院骨科田耘SurgicalSiteInfection(SSI)SSI意味着医生的痛苦、患者的眼泪高病残率，成倍增加的花费Becausethemedical,economicandsocialcostsofSSIareenormous，anysignificantreductioninriskswillpaydividends内容摘要定义流行病学影响因素病原学预防治疗措施需要关注的问题SurgicalSiteInfection(SSI)SSIwasdefinedas:anypostoperativewoundthatrequiredtreatmentwithoralorintravenousantibioticsorsurgicaldebridement任何术后伤口需要进行口服或静脉使用抗生素，或者需要外科手术清理者AlbertF.PullterGunne•C.J.H.M.vanLaarhoven•DavidB.CohenIncidenceofsurgicalsiteinfectionfollowingadultspinaldeformitysurgery:ananalysisofpatientriskEurSpineJ(2010)19:982–988SSI的定义手术区出现渗出，可培养出一种或多种致病菌AwoundinfectionwasdefinedaspresenceofpurulenceattheoperativesiteandamicrobiologicculturepositiveforoneormoreorganismsJENNIFERB.MASSIEB,SPostoperativePosteriorSpinalWoundInfections。ClinicalOrthopaedicsandRelatedResearch1992；284：99-108Surgicalsiteinfections(SSI)CDCcriteria(CentresforDiseaseControlandprevention)手术区域的感染发生于术后30天内，或有内固定的患者术后1年内出现的感染。Aninfectionwasconsideredtobeasurgicalsiteinfectionwhenitoccuredatthesiteofthesurgerywithin30daysaftertheoperationorwithin1yeariftheoperationincludedplacementofaforeignbody,e.g.animplant.J.J.P.Schimmel•P.P.Horsting•M.deKleuver•G.Wonders•J.vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ(2010)19:1711–1719流行病学无内固定0.41%(25/6108),有内固定者感染发生率为1.0%(11/1112),总体感染发生率为0.5%(36/7220)田耘陈仲强周方刘忠军脊柱术后伤口深部感染的处理中华外科杂志2005；43：229-2311.61%（15/924）仉建国李书纲杨新宇田野邱贵兴脊柱侧凸后路矫形融合术术后感染的治疗中华骨科杂志2001；21：453-456流行病学手术切口区感染是脊柱手术经常出现的并发症发生率，文献报道0.7～12%。46/830(5.0%),AlbertF.PullterGunne•C.J.H.M.vanLaarhoven•DavidB.CohenIncidenceofsurgicalsiteinfectionfollowingadultspinaldeformitysurgery:ananalysisofpatientriskEurSpineJ(2010)19:982–98836/1,568（2.2%）J.J.P.Schimmel•P.P.Horsting•M.deKleuver•G.Wonders•J.vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ(2010)19:1711–1719SSI的危险因素高龄肥胖糖尿病其他伴随疾病吸烟身体状况差完全的神经功能损伤SSI的高危因素-手术因素翻修手术肿瘤手术出血多手术时间长多节段危险因素Obesity(P=0.035)andhistoryofpriorSSI(P=0.045)significantlyincreasedtheriskofSSIAlbertF.PullterGunne•C.J.H.M.vanLaarhoven•DavidB.CohenIncidenceofsurgicalsiteinfectionfollowingadultspinaldeformitysurgery:ananalysisofpatientriskEurSpineJ(2010)19:982–988危险因素吸烟史smokingshowedasignificantdifferencebetweenthegroups肥胖AnearlysignificantdifferencewasfoundinthecategorizedBMI多节段固定intheinfectedgroupalargerportionofsurgeriesinvolvedfourormorelevels(42%),J.J.P.Schimmel•P.P.Horsting•M.deKleuver•G.Wonders•J.vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ(2010)19:1711–1719危险因素糖尿病InthefinalmodeldiabeteshadthestrongestassociationwithSSI既往手术史apositivehistoryofpreviousspinalsurgeryhadastrongassociationwiththeoccurrenceofaninfection,withanoddsratioof3.70J.J.P.Schimmel•P.P.Horsting•M.deKleuver•G.Wonders•J.vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ(2010)19:1711–1719危险因素-手术时间anincreasedoperatingtimewillresultinsignificantincreasedriskforSSIPullterGunneAF,CohenDB(2009)Incidence,prevalenceandanalysisofriskfactorsforsurgicalsiteinfectionfollowingadultspinalsurgery.Spine(inpress）危险因素-手术时间Surgicalliteraturedocumentsthatoperationslastinglongerthan5hourshaveincreasedwound-infectionratesJohnston,D.H.,Fairclough,J.A,,andBrown.E.M.:Microbialsurveillanceinthesurgicalintensivecareunit.Surg.Gynecol.Obstet.I39:321,1974SSI的症状presentwithatleastoneoftheclassicalsignsofinflammation(pain,swelling,redness,increasedlocaltemperature)drainageofpurulentfluidfromtheoperatingincision,spontaneouswounddehiscentionoranabcesorothersignsofinfectionatobservation,re-operation,histo-pathologicalorradiologicalinvestigation感染的诊断表浅伤口：红肿，压痛，积液渗出GRAM染色和培养ESR增快Keller,R.B.,andPappas,A.M.:Infectionsafterspinalfusionusinginternalfixationinstrumentation.Orthop.Clin.NorthAm.3:99,1972深部感染诊断文献报道术后平均11天的发现期局部早期可能无症状，患者有全身不适的症状，继而伤口痛，发热，寒战等，体检伤口叩痛局部穿刺和细菌GRAM染色确诊，亦有可能阴性WBC及ESR上升Keller,R.B.,andPappas,A.M.:Infectionsafterspinalfusionusinginternalfixationinstrumentation.Orthop.Clin.NorthAm.3:99,1972影像学的帮助临床症状体征很重要：严重的伤口疼痛，头痛，精神状态改变，新出现的神经病损感染诊断时间36/1,568（2.2%）早期13.5天（10-21天），迟发4例J.J.P.Schimmel•P.P.Horsting•M.deKleuver•G.Wonders•J.vanLimbeekRiskfactorsfordeepsurgicalsiteinfectionsafterspinalfusionEurSpineJ(2010)19:1711–1719致病菌ThemostcommonorganismculturedwasStaphylococcusaureus金黄色葡萄球菌High-riskpatientsshouldbeinformedabouttheincreasedriskofcomplications细菌学46patientshadsingleorganismsisolatedand28patientshadpolymicrobialinfections.丙酸杆菌34金葡32表皮葡萄球菌18IonaCollinsThediagnosisandmanagementofinfectionfollowinginstrumentedspinalfusion.EurSpineJ(2008)17:445–450Micro-organism(s)Numberofcases金葡27E.colib1Proteusmirabilis1CNSAc2Streptococcus1Enterococcus1CNSAc?S.aureusa1Enterobacter?S.aureusa1Enterococcus?S.aureusa1GramPositive金黄色葡萄球菌12表皮葡萄球菌8Enierococcirs.faecalis2Strepiococciisviridans1DiphtheroidsIPropionihacteriiitnucnes1Peptococcusspecies(anaerobe)3species(anaerohe)IGramNegative阴沟场杆菌4SerratismurcescensIPseudomonasaeriiginosa1Pseiidotnonasmaltophilia1Acinetobacleran