（战略管理）降低感染率的围手术期策略

（战略管理）降低感染率的围手术期策略TheJournalofBoneandJointSurgery(American).2010;92:232-239.PerioperativeStrategiesforDecreasingInfectionAComprehensiveEvidence-BasedApproach降低感染率的围手术期策略：综合性循证医学路径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.对于骨科手术而言，手术部位的感染是一种毁灭性的并发症，往往会导致致残率、致死率以及医疗费用的增加，并且与没有发生感染的病例相比，最终的治疗结果通常也会更差【1】。减少手术部位的感染率，不仅对患者和医生都很有意义，也是利益相关的各方非常关注的问题。如出资方，包括医疗保险与医疗辅助服务中心（CMS，Baltimore,Maryland）；以外科医疗改良项目（SCIP）为代表的相关机构；介于大众公共机构与私人医疗保健机构之间的多机构合作组织，包括医疗机构评审联合委员会（JCAHO，OakbrookTerrace,Illinois）等。减少手术部位的感染率现在是，将来也仍会是，医学领域关注的焦点问题。Toeffectivelypreventsurgicalsiteinfections,theclinicianmustconsiderpreoperative,intraoperative,andpostoperativefactorsandinterventions.Preoperativestrategiesforreductionofinfectionratesincludeidentificationofhigh-riskpatients,screeninganddecolonizationofpatientswithmethicillin-sensitiveStaphylococcusaureusandmethicillin-resistantStaphylococcusaureuscolonization,preoperativepreparationofthepatientwithchlorhexidinegluconate,utilizationofproperhair-removaltechniques,andaddressingpreexistingdentalandnutritionalissuespriortosurgery.为了有效地防止手术部位的感染，临床医生必须审慎地考虑到手术前、手术中以及手术后的相关因素和干预措施。降低感染的术前策略包括识别高风险的患者，对甲氧西林敏感的金黄色葡萄球菌和耐甲氧西林的金黄色葡萄球菌定植的患者进行筛查，并清除定植菌，术前应用洗必泰葡萄糖酸盐进行清洗，应用合适的方法去除毛发，术前妥善处理先前存在的牙齿及营养相关的问题。Thereareavarietyofperioperativestrategiesthatcanandshouldbeemployedtodecreasetheriskofsurgicalsiteinfections.Intraoperativeinterventionsthathavebeenshowntodecreasesurgicalsiteinfectionratesincludetheproperselection,timing,anddosesofprophylacticantibioticsandutilizationofbestpracticesforhandhygieneandsurgicalsitepreparation.Maintainingasterileoperating-roomenvironmentbydecreasingoperating-roomtraffic,monitoringforbreaksinsteriletechnique,anddecreasingtheuseofflashsterilizationisvital.Finally,postoperativestrategiesforthereductionofsurgicalsiteinfectionratesincludetheproperuseanddurationinsituofurinarycathetersandsurgicaldrains;standardizationofwoundcare;useofantibiotic-impregnatedbandages;and,perhapsmostimportantly,maintenanceofproperhandhygiene,isolationprecautions,androomcleaning.有多种围手术期的策略可以并且必须应用以减少手术部位的感染。术中的一些干预因素已经证实可以降低手术部位的感染率，包括选择合适的种类、时机和剂量预防性应用抗生素，手卫生及术区消毒均采用最优化的方案。通过减少手术室的穿行、监视有无违反无菌技术的操作、减少快速消毒的应用对于维持手术的无菌环境是至关重要的。最后，降低手术部位感染率的术后策略包括合理地应用和维持原有的导尿管和术区引流管，对创口进行标准化护理；应用抗生素浸润的绷带，以及，可能最为重要的是，保持正确的手卫生、隔离预防和室内清洁。PreoperativeConsiderations术前注意事项Althougheveryprecautionshouldbetakentopreventinfectionforallorthopaedicpatients,theidentificationofhigh-riskpatientsenablesclinicianstoprovidemaximalpreventionstrategiesforthem.Furthermore,theidentificationofpatientsathighriskforinfectionallowsappropriatepreoperativecounselingforshareddecision-makingandestablishesappropriatepatientexpectationsregardingsurgicalrisks.虽然对于所有骨科患者，都应该采用各种预防措施以防止感染，但临床医生识别出高风险的患者后，便可针对其制定最大限度的防范策略。此外，识别出感染的高风险患者后可进行适当的术前告知谈话，这样可与患者共同制定治疗决策，并使患者对于手术风险树立合理的期望值。Numeroushigh-riskpatientpopulationsandriskfactorsthatplacepatientsathighriskforinfectionaftertotaljointreplacementorspinesurgeryhavebeendescribedintheliterature.Someofthesefactorscanbemodified,whileotherscannot.Anexplanationoftheriskfactorsthatcannotbemodifiedshouldbeincludedwhenpatientsarecounseledabouttheirincreasedriskofinfectionwiththeproposedsurgicalprocedure.Inthisway,patientswillmorecompletelyunderstandtherisksandbenefitswhendecidingonsurgery.Twocommonfactorsthatcannotbemodifiedandthatincreasetheriskofinfectionwithjointreplacementareahistoryofinfectioninthejoint2andahistoryofsteroidinjectionintothejoint3.Factorsthatcannotbemodifiedthatincreasetheriskofinfectioninpatientsundergoingspinesurgeryincludetrauma-relatedsurgery4,useofinstrumentation5,andlumbar6andposterior4surgery.对于关节置换术和脊柱手术的感染，有很多高风险患者人群以及相关的危险因素使患者具有较高感染风险的情况，在以往的文献中都有论述。在这些因素中，有些事可以改善的，而有些则无法改变。对于无法控制的危险因素，在对患者进行术前告知谈话时，应向其说明这样会增加感染的风险。这样，患者在决定做手术时便可更全面地认识到相关的风险和益处。有两个无法控制的因素，既往关节感染病史【2】和既往关节内类固醇注射史【3】，通常会增加关节置换手术的感染风险。而对于进行脊柱手术的患者而言，会增加感染的风险并且无法控制的因素包括创伤相关的手术【4】，需要应用内置物【5】，以及腰椎【6】和后路【4】手术。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风险的因素通常都是可以控制的，因此，对于骨科的择期手术而言，术前通常可以使相关的因素达到最优化的状态。例如，患者合并有炎症性的关节炎【7】，镰状细胞性贫血症【8】，糖尿病【9】，肾功能衰竭【10】和人免疫缺陷症病毒（HIV）感染【11】会增加关节置换的感染率，虽然这些风险因素无法消除，但相关的风险则可以降至最低。比如，患者炎症性关节炎的患者，可以在术前请风湿科医生进行诊治，在围手术期尽量减少或停用免疫抑制类药物。如患者合并有镰状细胞性贫血症，则应仔细筛查皮肤溃疡或骨髓炎的潜在病源，否则容易导致播散至关节假体处引起感染。糖尿病患者应检查其血红蛋白A1C水平，在术前调至正常（<6.9%，可反映长期的血糖控制情况），必要时请内分泌科医生会诊。肾功能衰竭的患者当然也应在术前将肾功能调整至最佳水平，而感染HIV的患者，在关节置换之前，如果可能的话应通过药物治疗使其病毒载量达到检测不到的程度。营养不良也会增加感染的风险，因此，必要时在营养师的帮助下，在术前进行优化也是很有好处的【12】。Smokingandobesityincreasetheriskofinfectionwithspinesurgery13.Althoughthesefactorsareoftendifficulttomodify,patientsshouldbecounseledthatabenefitofsmokingcessationandweightreductionisadecreasedriskofinfectionwithspinesurgery.Patientsconsideringorplanningsurgicalweight-losstreatments,suchasgastricbypasssurgery,probablyshouldbeadvisedtopursuetheseproceduresfirsttoreducetheriskofinfectionatthesitesofhardwareorprosthesesasabenefitfromweightloss.Workingwithpatientsandtheappropriateconsultantstooptimizethesefactorspriortosurgerymayimprovepatientoutcomesbyloweringtheriskofinfectionwithhigh-riskjoint-replacementandspineprocedures.吸烟和肥胖会增加脊柱手术感染的风险【13】。虽然这些因素通常难以控制，但仍然应该告知患者，戒烟以及减轻体重对于降低脊柱手术感染的风险具有重要意义。如果患者正在考虑或计划通过手术来减轻体重，如胃旁路手术，那么应该建议患者先做减肥手术，因为这样对于置入内固定物或假体的部位可以减少感染的风险。与患者充分沟通，提出合理化的建议，在手术前尽量优化这些因素，对这些关节置换和脊柱手术的高风险人群而言，可以改善临床结果，降低感染的风险。Anotherimportantpreoperativeconsiderationispreoperativebathing.Preoperativebathinghasbeenusedtoreducethebacterialloadoftheskinpriortosurgerybecauseskinpreparationimmediatelybeforesurgerydoesnotcompletelysterilizetheskin.Inaddition,directcontaminationcanoccuratthetimeofsurgery.ArecentCochranereviewwasperformedtoassesstheinformationintheliteratureregardingpreoperativebathingwithantisepticsforthepreventionofsurgicalsiteinfection14.Chlorhexidinegluconateisthemostcommonlyusedantisepticforpreoperativebathing.TheCochranereviewrevealedevidencethatthebacterialloadofresidentskinfloraisreducedbyuseofchlorhexidinegluconatepreparationsforpreoperativebathing.Repeated,consecutivetreatmentsreducethisloadprogressivelyovertime.However,concernsaboutthedevelopmentofresistantorganismsandhypersensitivityremain.Therefore,theauthorsofthereviewconcludedthatthereisnoclearevidencethatpreoperativebathingwithchlorhexidinegluconateissuperiortopreoperativebathingwithotherproducts,suchasbarsoap,forreducingtheincidenceofsurgicalsiteinfection.手术前另一个重要的注意事项便是术前洗澡。由于术前即刻的皮肤消毒并不能完全杀灭所有细菌，因而通常都通过术前洗澡以减少皮肤的细菌接种量。此外，如果术前不洗澡，手术时也可能发生直接的污染。最近的一项Cochrane综述对术前应用消毒剂洗澡预防手术部位感染的相关信息进行了评价【14】。洗必泰葡萄糖酸盐是术前洗澡时应用最多的消毒剂。Cochrane综述的相关证据显示术前洗澡时应用洗必泰葡萄糖酸盐进行消毒可使体表常居菌的细菌接种量明显减少。随着时间的延长，反复、持续地洗浴可使该接种量进行性地下降。然而，这样做也有产生耐药菌及出现过敏反应的风险。因此，上文作者的结论认为，为了减少手术部位感染的发生率，在术前洗澡时，并没有明确的证据证实应用洗必泰葡萄糖酸盐优于其他的产品，如肥皂等。Hairremovalhasbeenusedtraditionallytokeephairfromcontaminatingthewound.Morerecently,hairremovalhasallowedsurgeonstoapplyocclusivedressingstotheskinperioperativelytokeepskinflorafromdirectlycontaminatingthewound.Threemethodsusedforhairremovalincludetraditionalrazors,clippers,andhair-removalcreamsordepilatories.Hairlesssurgicalsitescanmakethesurgeryandapplicationofdressingsandprotectivedrapingeasier,buttheuseofrazorstoshavethesurgicalsiteincreasestheriskofintroducingprimaryinfectionsthroughmicroscopicinjuriestotheskin.TheCentersforDiseaseControlandPrevention(CDC)recommendthathairremovalbeminimizedandthat,whenitisnecessary,electricclippersordepilatoriesbeusedratherthanrazors15.ACochranereviewoftheliteratureonhairremovalpriortosurgerysupportedtheCDCrecommendationsandaddedthathairremovalcanbedoneonthedayofthesurgery16.以往术前通常都要求去除毛发以避免污染创口，而最近则倾向于让外科医生在术前应用密闭的敷料覆盖皮肤，从而防止皮肤菌群直接污染创口。传统的去毛方式主要有三种：剃毛、剪毛和脱毛膏或脱毛药物。手术部位去毛后通常可使手术操作更为方便，并使贴膜和防护膜的应用也更为简便，但应用剃刀刮除手术部位的毛发会对皮肤产生微小的损伤，通过这些损伤局部原发感染的风险会明显增加。疾病预防和控制中心（CDC）建议，应尽量避免去毛，如果实在必要，也应该应用电动剪毛刀或脱毛剂，而应避免应用剃毛刀【15】。有学者对术前去毛相关的文献进行了Cochrane综述，其结论与CDC所推荐的方案一致，此外，去毛应该手术当天进行【16】。Dentalcareisanotherpreoperativeissuetobediscussedwithhigh-riskorthopaedicpatients.Allpatients,butparticularlythoseathighriskforinfection,shouldbeencouragedtomaintaingooddentalhealthbeforeandaftersurgery.Bacteremiafromadentalinfectioncancauseacutehematogenousinfectionatthesiteofatotaljointreplacement.Evidenceshowsthatthemostcriticalperiodisthefirsttwoyearsaftersurgery17.TheAmericanAcademyofOrthopaedicSurgeons(AAOS)inconjunctionwiththeAmericanDentalAssociation(ADA)developedguidelinesforantibioticprophylaxisforpatientswithatotaljointreplacementwhorequiredentalprocedures18.Patientsareidentifiedasbeingathighorlowriskdependingontheirmedicalcomorbidities.Dentalproceduresarecategorizedashighorlowriskdependingontheriskofbacteremia.Allpatientsshouldreceiveantibioticprophylaxisforhigh-riskdentalproceduresfortwoyearsafterthejointreplacement,andhigh-riskpatientsshouldreceiveprophylaxisforhigh-riskdentalproceduresforlife.Antibioticregimensareincludedintherecommendations(TableI).术前处理牙科的疾病对于高风险的骨科患者而言也是一个值得探讨的问题。对于所有患者，而感染风险较高的患者尤其，应鼓励其在手术前后保持良好的口腔卫生。源自牙齿感染的菌血症可导致全关节置换部位的急性血源性感染。有证据表明，临界期通常为手术后的头两年【17】。美国骨科医师学会（AAOS）联合美国牙科协会（ADA）对全关节置换的患者进行牙科手术时预防性应用抗生素制定了指南【18】。按照内科合并症的情况将患者分为高或低风险人群；按照菌血症的风险将牙科手术分为高风险或低风险手术。关节置换术后2年内的所有患者在进行高风险的牙科手术时，都应该预防性地应该抗生素，而对于高风险的患者而言，关节置换术后的任何时间行高风险牙科手术时都应该预防性应用抗生素。其推荐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.对高风险的骨科患者而言，围手术期预防性应用抗生素可有效地降低手术部位的感染率。在2002年一项关于脊柱融合手术的meta分析中，Barker【19】指出，在这样的手术中应用抗生素是有益的，即使在不用抗生素时感染率也较低的情况下依然如此。其他类似的研究也证实，在普通的骨科手术和全关节置换手术之前应用抗生素都有着良好的效果【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.对于耐甲氧西林金黄色葡萄球菌定植风险较低的患者选择抗生素时，头孢唑啉（1-2g静脉内给药）或头孢呋辛（1.5g静脉内给药）都是可以考虑的，应用于儿童时剂量应作相应的调整。如果患者对β-内酰胺类药物过敏，可用克林霉素（600mg静脉内给药）或万古霉素（1.0g静脉内给药）代替头孢菌素。如患者居住在耐甲氧西林金黄色葡萄球菌较多的环境中，发生菌群定植的风险往往较高（如敬老院的住户），而曾经感染上述耐甲氧西林金黄色葡萄球菌的患者则发生耐甲氧西林金黄色葡萄球菌感染的风险会明显增加【22,23】，对这些患者应用考虑预防性应用万古霉素（1.0g静脉内给药）【24】。Thepropertiminganddurationofantibioticprophylaxisareimperativeforsafetyandeffectiveness.Ingeneral,antibiotictherapyshouldbestartedwithinonehourpriortothesurgicalincision,andthedrugsshouldbecompletelyinfusedpriortotourniquetinflation.Theexceptiontothisrecommendationisvancomycin,theadministrationofwhichmaybestarteduptotwohourspriortothesurgicalincision.Thisallowsaslowerinfusionanddecreasesthelikelihoodofredmansyndrome.Redmansyndromeoccurswhenhypersensitivitytovancomycincausesdegranulationofmastcellsandareleaseofhistamine.Thehistamineleadstohypotensionandfacialflushing.Redmansyndromeispreventedbytheslowadministrationofvancomycinoveraperiodofonetotwohours.预防性应用抗生素注意合适的时机和持续时间对于其安全性和有效性都是非常关键的。通常应在做手术切口之前的一个小时内应用抗生素，并且止血带充气之前药物必须输注完毕。对这一建议而言，万古霉素是个例外，其开始给药的时间应提前至做手术切口之前两个小时，这样可以缓慢输注，减少红人综合征的发生率。万古霉素过敏时可导致肥大细胞脱颗粒并释放组胺从而出现红人综合征，组胺可导致低血压和颜面部发红。应用万古霉素时缓慢输注，输注时间达1-2小时可防止发生红人综合征。Antibiotictreatmentshouldbestoppedwithintwenty-fourhoursafterwoundclosure.Administrationofprophylacticantibioticsforlongerthantwenty-fourhourshasnotbeendemonstratedtobeeffectiveandmayactuallyleadtosuperinfectionwithdrug-resistantorganisms25.Repeatdosingwithantibioticsisrecommendedduringsurgicalproceduresthatlastforlongerthanfourhoursorwhenthereis>1500mLofbloodloss26.抗生素应在创口闭合后的24小时之内停药。没有证据表明预防性应用抗生素超过24小时是有效的，并且事实上还有可能导致耐药菌的二重感染【25】。而如果手术持续时间较长，超过4小时或术中出血量大于1500ml，则推荐在术中重复给药一次【26】。Werecommendthat,inordertoensuretheproperselectionandtimingofantibioticprophylaxis,thechoiceofantibioticsanddurationofadministrationbeincorporatedintothesurgical"time-out."Rosenbergetal.reportedthatcompliancewiththepropertimingandselectionofantibioticsincreasedfrom65%to99%whentheprotocolwasincorporatedintothetime-out27.在预防性应用抗生素时为了确保合理选择抗生素并确定适当的给药时机，我们推荐，将选择抗生素和确定给药持续时间都归入到手术的“time-out”（手术划刀前暂停核对各项信息）方案中。Rosenberg等曾报道，将相关的内容并入到“time-out”方案中之后，选择抗生素以及用药时间的符合率由65%增加到99%【27】。SurgicalHandAntisepsis术者手部消毒Theobjectiveofapreoperativehandscrubistoremoveorkillasmanybacteriaaspossiblefromthehandsofthesurgicalteam.Aqueousscrubsolutionsconsistingofwater-basedsolutionsofeitherchlorhexidinegluconateorpovidone-iodinehavebeentraditionallyused.术前洗手的目的是为了尽可能多地去除或杀死手术人员手部的细菌。通常应用的液态洗涤剂大多为洗必泰葡萄糖酸盐或聚维酮碘的水溶液。TheauthorsofarecentCochranereview28foundalcohol-basedrubscontainingethanol,isopropanol,orn-propanoltobeaseffectiveasaqueoussolutionsforpreventingsurgicalsiteinfectionsinpatients29.Hajipouretal.30reportedthatalcoholrubsweremoreeffectivethaneitherchlorhexidinegluconateoriodine-basedscrubsforreducingbacterialcolony-formingunits(CFUs)onthehandsofsurgeons.Otherinvestigatorsreportedthattheuseofscrubbrusheshadnopositiveeffectonasepsisandmayactuallyincreasetheriskofinfectionasaresultofskindamage31.Onthebasisofthisevidence,therecommendedprocedureforpreoperativesurgicalhandantisepsisisthat,precedingthefirstscrubofthedayorwhenthehandsaregrosslycontaminated,thesurgicalteamshouldwashwithsoapandwater,useanailpicktocleanunderthenails,anddrywithpapertowels.Theyshouldthenuseanalcohol-basedrubforthreeminutes32.Analcohol-basedrubshouldbeusedforeachsubsequentcase.Theuseofscrubbrushesisnotrecommended.有学者最近的一项Cochrane综述【28】发现，含有乙醇、异丙醇或正丙醇的酒精擦剂与水溶液相比，对于预防患者手术部位的感染具有类似的效果【29】。Hajipour等【30】报道酒精擦剂比洗必泰葡萄糖酸盐或含碘洗涤剂都更为有效，因为前者可减少术者手上的细菌菌落形成单位（CFU）。另外还有学者报道应用毛刷对于手部消毒并没有明显的效果，并且事实上由于会损伤皮肤反而会增加感染的风险【31】。根据这些证据，术者术前手部消毒推荐的方式为，在当天初次刷洗之前或手部严重污染时，手术人员应该用肥皂和水洗手，并用指甲签将指甲下方的污物清理干净，然后用纸巾擦干。然后，术者再用含酒精的擦剂涂抹3分钟【32】。后续的手术每次都应该用含酒精的擦剂进行涂抹，但不推荐应用毛刷进行刷洗。SurgicalSitePreparation手术部位的消毒Chlorhexidinegluconate-basedsolutionshavesupplantedalcoholandiodine-basedsolutionsforsurgicalsitepreparation.Ostranderetal.33examinedtheresidualamountsofbacteriaonfeetpreparedwithachlorhexidinegluconate,iodine/isopropylalcohol,orchloroxylenolscrub.Theyfoundthatchlorhexidinegluconatewassuperiortotheothertwopreparationsolutionsinreducingoreliminatingbacteriafromthefeetpriortosurgery.Chlorhexidinegluconateskinpreparationwassuperiortoeither70%alcoholoriodineindecreasinginfectionassociatedwiththeplacementofcentralvenouscathetersandthedrawingofbloodforculture34,35.Thus,thecurrentevidence-basedrecommendationsandbest-practiceguidelinescallfortheuseofchlorhexidinegluconate-basedsolutionsforsurgicalsitepreparationandplacementofcentralvenouscatheters.手术部位的消毒液，洗必泰葡萄糖酸盐溶液已经替代酒精和含碘的溶液。Ostrander等【33】对洗必泰葡萄糖酸盐、碘/异丙醇或氯二甲苯酚的擦剂消毒足部后，检测残余的细菌数量，结果发现在术后减少或消除足部细菌的功效上洗必泰葡萄糖酸盐优于其他两种消毒剂。而在置入中央静脉导管和抽血样做培养等操作时，应用洗必泰葡萄糖酸盐进行皮肤消毒，相比70%的酒精或碘剂，均可减少感染的发生率【34,35】。因此，在术区消毒以及置入中央静脉导管时，基于现有证据的建议和最佳操作指南都提倡应用洗必泰葡萄糖酸盐溶液。DecreasingtheRiskofSurgicalSiteInfectionRelatedtotheOperating-RoomEnvironment降低手术部位感染相关的手术室环境Althoughthearcanedetailsoftechniquesusedtosterilizesurgicalinstrumentsarebeyondtheexpectedknowledgeofmostorthopaedicsurgeons,manyofasurgeon'sactionscanadverselyaffectsterilizationandincreasetheriskofsurgicalsiteinfections.Flashsterilizationisaprocedureusedbyoperating-roomstafftosterilizeinstrumentsorimplantswithsteam,onanas-neededbasis.Flashsterilizationisnotequivalenttosterilizationincentralprocessing36,37.Incentralsterileprocessing,instrumentsareproperlycleanedandalllumensareinspected;theinstrumentsarethensterilizedandallowedtodrycompletely,afterwhichtheyaredeliveredinclosedcontainersthatensuremaintenanceofsterility.Mostimportantly,theprocessisperformedbytrained,focusedprofessionals.Theentireprocesstakesthreetofourhours.Flashsterilizationshouldbeusedonlyfordroppedinstrumentsorinanemergencysituation.Preventablereasonsforflashsterilizationincludeaninsufficientquantityofinstruments,loanerinstrumentsand/orinstrumentsnotdeliveredintimeforproperprocessing,andinaccurateorincompletesurgicalbookingrequiringtheemergency,unplanneduseofinstrumentsand/orimplants.虽然手术器械灭菌方法中很多不为人知的操作细节并不是大多数骨科医生都期望掌握的知识，但外科医生的很多做法却可对灭菌过程产生负面的影响，并会增加手术部位感染的风险。快速灭菌是手术室工作人员常用的一种对手术器械或内置物的灭菌方式，在一些必要的基座之上，应用蒸汽。快速灭菌并不能等同于中央灭菌过程【36,37】。在中央灭菌处理中，手术器械先用适当的方法清理干净，对所有内腔都进行彻底的检查，然后在对器械进行灭菌，并可使其完全干燥，最后手术器械在运送过程中必须保持密闭的包装，以确保维持其无菌的状态。最为重要的是，这些操作都由经过专业训练的人员完成，整个过程需要3-4小时。快速灭菌只有在术中器械掉落或紧急状况下方可应用。有些因素是可以避免进行快速灭菌的，包括手术器械数量不足，应用替代性器械和/或器械没有按照合适的操作规程按时送达，手术预约错误或不完善需要紧急处理，非计划性地应用手术器械和/或内置物等。Toreducetheincidenceofflashsterilization,werecommendanincreaseinphysicianawarenessabouttheinadequacyofthetechnique;improvementintheaccuracyofsurgicalbooking;mandatingcooperationfromvendorstoensuretimelydeliveryofequipment,includingfinancialpenaltiesforlatedelivery;purchaseofmorefrequentlyflash-sterilizeditems;surgicalschedulingtoaccommodateandmitigateequipmentshortages;and,finally,generationofincidentreportswhenaflash-sterilizedimplantisusedinapatient.Adoptingthesepoliciesandproceduresleadstoadecreaseintheincidenceofflashsterilization38.为了减少快速灭菌，我们建议增强对临床医师的宣传和培训，使其充分认识到这一方法的不足；提高手术预约单的准确性；要求供货商密切配合，确保相关设备及时交付到位，对于延迟送达的应考虑适当给予经济惩罚；对于以往经常进行快速灭菌的器械适当增加购买数量；通过调整手术安排以适应和缓解设备上的不足，最后，快速灭菌的内置物应用于患者后应写出相关的事件报告。采用这些策略和规程可有效降低快速灭菌的使用率【38】。PowderlessGlovesTraditionally,surgicalglovescontainedpowdertoaidinthemanufacturingprocessandtomakedonningeasier.Thepowderwaseithertalcorlycopodiumspores.Becauseofconcernsaboutgranulomaformationandadhesionsassociatedwiththeuseofthesesubstances,cornstarchisnowthepowderofchoice39.However,cornstarchisnotbenign.Itcausesforeign-bodygranulomaformationanddelayedwound-healingandcandecreasetheamountofbacteriarequiredtocauseaclinicallyapparentinfection40.Cornstarchalsoleadstoincreasedlatexsensitivityinhealth-careworkers.Type-Iandtype-IVhypersensitivityreactionstolatexproteininhospitalstaffleadtoincreasesinsicktimeanddecreasedjobsatisfaction41.Powderlessglovesdecreasestaffabsenteeismandeliminatethepotentialforforeign-bodygranulomaformation.Theseglovescost25%morethanpowderedgloves,buttheaddedexpenseismitigatedbyincreasedproductivityoftheoperating-roomstaff41.无粉手套以往外科手套都是有粉的，这样在制造过程中便于操作，同时也可使穿戴更为方便，粉末的成分为滑石粉或石松子。由于考虑到应用这些粉末可能会形成肉芽肿以及粘连，因此目前一般都选用玉米淀粉【39】。然而，玉米淀粉也不是没有任何危险的，其可导致创口延迟愈合或形成异物性肉芽肿，并且它可使通常出现感染相关临床表现所需的细菌数量减少【40】。玉米淀粉还会使医务人员对橡胶的敏感度增加。医院的工作人员对乳胶蛋白的I型和IV型过敏反应会使不适时间延长，并使工作的满意度下降【41】。无粉手套可减少工作人员的缺勤状况，且可避免向体外形成肉芽肿的潜在可能。这些手套比有粉手套贵25%，但由此增加的费用会随着手术室工作人员工作效率的提高而减少【41】。Antiseptic-CoatedSuturesTheuseofantiseptic-coatedsutureshasgeneratedincreasedinterest.Thesesuturesaretypicallycoatedwiththeantiseptictriclosan.Edmistonetal.demonstratedtheeffectivenessofcoatedsuturesininhibitingbacterialgrowthandcontaminationinaninvitromodel42.Inarandomizedcontrolledtrial,Rozzelleetal.reportedasignificantreductioninsurgicalsiteinfectionratesfollowingcerebralspinal-fluid-shuntsurgerywiththeuseofantiseptic-coatedsuturesascomparedwiththeratefollowingthesameprocedurewithouttheuseofsuchsutures43.Thesesuturescost7%to10%morethantheiruncoatedcounterparts.Toourknowledge,nocost-effectivenessanalysishasbeenpublished;however,theuseofthesesuturesinhigh-riskpatientsmaybejustified.具有抗菌表层的缝线应用具有抗菌表层的缝线越来越被人们所重视，这种缝线通常涂有一层抗菌的三氯生。Edmiston等曾报道，在体外实验中，这种有涂层的缝线可有效抑制细菌的繁殖和污染【42】。在另一项随机对照试验中，Rozzelle等报道在脑脊液分流术后应用具有抗菌表层的缝线与没有应用这种缝线的病例相比，手术部位的感染率明显下降【43】。这种缝线相比没有涂层的类似缝线要贵7%至10%。据我们所知，目前尚未发表相关的效价分析，但是在高风险的患者中应用这样的缝线还是合理的。Operating-RoomTrafficMaintainingadisciplinedoperating-roomculturecanreducetheriskofsurgicalsiteinfections.Unnecessaryoperating-roomtrafficincreasestherateofinfections44.Inastudyofspinesurgery,Olsenetal.reportedthattwoormoreresidentsparticipatingintheoperativeprocedurewasanindependentriskfactorforsurgicalsiteinfections,withanoddsratioof2.245.Babkinetal.foundthattherateofsurgicalsiteinfectionsassociatedwithleftkneereplacementswas6.7timeshigherthanthatassociatedwithrightkneereplacementsperformedduringthesametimeperiodandinthesameoperatingrooms46.Whenthedoorontheleftsideoftheoperatingroomwaslocked,preventingingressoregress,thesurgicalsiteinfectionrateassociatedwiththeleftkneereplacementsrapidlydecreasedtothatassociatedwiththerightkneereplacements,afindingthatsupportstheimportanceoflimitingoperating-roomtraffic.手术室的交通在手术室保持遵守职业规范的习惯可减少手术部位感染的风险，在手术室内不必要的穿行会使感染率增加【44】。在一项有关脊柱手术的研究中，Olsen等报道在手术过程中2个或更多的人员加入进去是手术部位感染的一个独立的风险因素，优势比2.245。Babkin等发现，在相同时期内在同一手术间进行手术，左膝关节置换手术部位感染的发生率为由膝关节置换的6.7倍【46】，而当手术室左侧的门锁上以后，避免进出，左膝关节置换的术区感染率便很快下降到与右膝关节置换相当的水平，这一发现也证实了限制手术室交通的重要性。DrainsandBloodTransfusionsWhethertousedrainsattheendoforthopaedicsurgicalproceduresisadecisionthatsurgeonsmakeonthebasisoftheirtraining,opinions,andpersonalexperience,inadditiontoresearchfindings.ArecentCochranereviewonthistopicthatincludedfindingsfromthirty-sixstudies(5464patients)revealedthattheuseofcloseddrainsreducedbruisingandtheneedforreinforcementofdressings47.However,theuseofcloseddrainswasalsoassociatedwithanincreasedneedfortransfusion,ariskfactorthatisdiscussedbelow.Therewasnodifferenceinsurgicalsiteinfectionratesbetweendrainedandundrainedwounds.Theauthorsconcludedthatclosedsuctiondrainswereofdoubtfulbenefit.创口引流与输血在骨科手术临结束时是否放置引流管除了参考相关的研究结果以外，还需要术者根据他们所接受的训练、观点以及个人的经验来决定。最近有一项针对这一问题的Cochrane综述，共纳入了36项研究（5464例患者），结果显示应用封闭式引流可减少瘀伤，同时还可减少加包辅料的需要【47】。不过，应用封闭式引流会相应地增加输血的需求，风险因子如下文所述。是否放置创口引流对于手术部位的感染率并没有明显的差异。作者的结论认为闭合负压引流的有效性仍不确定。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.在骨科手术中放置引流除了其好处仍不确定以外，往往输血的需求相应地也会更多一些。输血会带来感染血液传播的相关病原体的风险，例如HIV、肝炎，以及其他细菌或寄生虫。这种风险虽然仍然存在，但非常小，在美国及其他发达国家，对于捐献的血液都有一个严格的检测程序【48】。与输血相关的更为直接的风险辨识手术部位的感染和住院时间的延长【49】。输血会引起免疫调节，进而导致术区感染的风险增加【50】。Talbot等报道，胸骨切开术后的感染率，输过血的患者比未曾输血的患者要高3.2倍【51】。在一项有关心脏手术的研究中，Bower等报道输血的患者其感染率几乎是没有输血的患者的两倍【52】。Weber等发现，尽管术者控制了术区的感染，但髋关节置换术后输血的患者住院时间会明显延长【49】。减少输血相关需求的策略包括术前评估血红蛋白的水平及红细胞压积，如果符合指征可给予适当的药物治疗以改善这些参数，不能仅仅只根据血红蛋白和红细胞压积的结果，而应该参照继发性贫血的相关策略来决定是否有必要输血。PostoperativeWoundManagementTheCDCrecommendsmaintainingsurgicaldressingsfortwenty-fourtoforty-eighthourspostoperatively53.Somesurgeonsuseathree-dayrule,keepingtheoriginalsurgicaldressinginplaceforseventy-twohours.Thereislittleevidencethatkeepingdressingsonforanextradayortwodecreasestheinfectionrisk;however,ifthedressingisnotcleananddry,itmaybecomeasourceofmicrobesclosetotheincision.Perhapsasimportantasthedurationthatthedressingisinplaceisensuringtheproperprocessforpostoperativewoundmanagement.Thesurgeonshouldreviewpoliciesandprocedurestodeterminewhochangesdressings(e.g.,nurses,orphysiciansonly),underwhatcircumstancestheyarechanged,andiftheyareeverreinforcedratherthanchanged.Thebasicconceptofinfectionpreventionistokeepthewoundcleananddry.Soiledorblood-soakeddressingsshouldberemovedimmediatelyratherthanreinforced.Ifdressingsdonotstayintact,useofadifferentproductmaybewarranted.术后创口的处理CDC推荐术后24至48小时内维持手术的敷料【53】。有些外科医生采用三天原则，72小时内将最初的手术敷料保持在原位。很少有证据认为维持原来的敷料多一或两天会增加感染的风险，然而，如果敷料并不干燥、清洁，则可能成为紧邻切口的微生物来源。术后采用合理的操作规程来处理创口，可能同敷料保持在原位的时间同等重要。术者应对相关的方法和操作程序进行检查，以确定由谁来更换敷料（例如护士，或者只安排医生），在什么情况下他们应该进行更换，或者他们只是增加敷料而不是更换。预防感染的基本概念辨识保持创口干燥和清洁。污染或血液浸透的敷料必须立即更换，而不能加包。如果敷料不能保持其整体性，那么应用不同种类的敷料也是允许的。Amultidisciplinarygroupshouldevaluatecurrentpracticesanddiscusswaystooptimizepostoperativewoundcare.Somebasicissuesareensuringthatanaseptictec