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[摘要] 目的 通過目标性监测探讨脊柱手术部位病原菌分布和耐药性以及手术部位感染的危险因素，为临床合理用药及防治提供依据。方法 回顾性分析随机抽取的2015年5月～2016年12月间816例首次在我院脊柱科就诊的各类疾病患者的病历资料，统计分析手术部位感染患者的病原菌以及耐药性，通过病历资料分析相关的危险因素。将手术部位感染患者中出现诊断时的临床表现和相关实验室炎性指标输入EXCEL软件中，统计阳性率。结果 816例患者脊柱手术部位切口分泌物培养阳性38例，目标性监测术后手术部位中的感染率为4.66%；38例患者分离得到55株病原菌，其中64.82%为革兰阳性菌；革兰阳性菌前三位分别是金黄色葡萄球菌、表皮葡萄球菌、粪肠球菌；35.18%为革兰阴性菌，其中以大肠埃希菌为主，8株占14.55%；未检测出对万古霉素耐药的金黄色葡萄球菌，耐甲氧西林的表皮葡萄球菌的检出率高于金黄色葡萄球菌，革兰阴性菌的耐药性严重；单因素分析显示，年龄、糖尿病、手术时间等6项因素与脊柱手术切口感染的发生有关。进一步多因素回归分析显示糖尿病、手术持续时间≥180 min、住院天数≥15 d与脊柱手术切口感染有关。 结论 脊柱手术切口感染病原菌主要以金黄色葡萄球菌为主，耐药性高，糖尿病、手术持续时间≥180 min、住院天数≥15 d均是感染的独立危险因素。
[关键词] 手术部位；目标性监测；病原菌；危险因素
[中图分类号] R446.5；R619 [文献标识码] A [文章编号] 1673-9701（2018）08-0023-05
Pathogen distribution and risk factors in spine surgical site
SUN Jingxi SUN Yongning WANG Fubin CHEN Jianming
Department of Critical Care Medicine， Ningbo Sixth Hospital， Ningbo 315040，China
[Abstract] Objective To investigate the distribution and drug resistance of pathogen and the risk factors of infection in spine surgical site through targeted surveillance， so as to provide basis for rational drug use and prevention in clinical work. Methods Retrospective analysis were conducted on medical records of 816 patients. They were randomly selected from patients with spine diseases who were admitted in our hospital for the first time from May 2015 to December 2016. Pathogen and drug resistance in patients with surgical site infection， and related risk factors from medical records were statistically analyzed. The clinical manifestations at diagnosis and related laboratory inflammatory markers in patients with surgical site infection were imported into the EXCEL software and the positive rates were calculated. Results Among 816 cases， 38 cases were positive of incisional secretions in spine surgery. The infection rate in the surgical site was 4.66% after surgery according to targeted surveillance. 55 strains of pathogens were isolated from the 38 positive cases， of which 64.82% were Gram-positive bacteria with Staphylococcus aureus， Staphylococcus epidermidis and Enterococcus faecalis being the first three strains. 35.18% were Gram-negative bacteria， of which Escherichia coli was the main species with 8 strains accounting for 14.55%. No vancomycin-resistant Staphylococcus aureus was detected. The detection rate of methicillin-resistant Staphylococcus epidermidis was higher than that of Staphylococcus aureus. The drug resistance of Gram-negative bacteria was serious. Univariate analysis showed that six factors including age， diabetes， operation time and others were associated with the incidence of incisional infection. Further multivariate regression analysis showed that diabetes， surgical duration≥180 min， hospital stay≥15 d were associated with surgical incision infection. Conclusion Staphylococcus aureus is the main pathogen in spine incisional infection. The high drug resistance， diabetes mellitus， duration of operation≥180 min and hospital stay≥15 d are the independent risk factors of infection. 当患者手术部位有红肿热痛的症状出现时，其感染的可能性大。临床上可以根据患者的特点而选用药物。患者翻修手术是手术部位感染的危险因素，但本研究中不是独立危险因素，可能的原因是病历数不够多。住院时间长不是医院内感染的危险因素，可能是病历数量不够，而手术时间是手术部位感染的危险因素，因此尽量缩短手术时间，减少院内感染发生的概率。故针对脊柱手术部位感染患者，可以采取下列预防措施：（1）及早发现控制血糖；（2）尽量选用封闭的导尿引流系统及早期去除导尿管[17]，选用合适的导尿管；（3）多科室协作，多学科会诊，尽量减少患者的住院时间，减少感染的风险；（4）缩短手术时间；（5）对于有脓尿的患者经验性用药的同时做病原学检查，根据病原学结果及时更换抗菌药物，合理选用抗生素，减少耐药菌的发生；（6）严格把握近ICU的指征。
脊柱手术部位感染以革兰阳性菌为主，其中又以金黄色葡萄球菌占多数，耐药严重，万古霉素和利奈唑胺可以作为经验性用药用于诊断明确但细菌学结果未出的患者。糖尿病、手术持续时间>180 min、住院天数≥15 d均是感染的独立危险因素。我们计划采用术前控制血糖、缩短手术时间和缩短住院天数来减少手术部位感染的发生。
临床上预防脊柱手术部位感染[18-20]，必须进行规范管理，多部门齐抓共管，实行目标监测与管理相结合，全面控制多重耐药菌的感染。不断提高医护人员的消毒隔离意识，同时提供充足、实用的防护用品和配备充足的人力资源对确保消毒隔离措施的有效落实具有重要意义
[参考文献]
[1] 吴彬彬，王华锋，梁皀清，等. 脊柱手术部位感染的防治现状及进展[J].中国医师杂志，2016，18（s1）：248-251.
[2] Smith JS，Shaffrey CI，Sansur CA， et al. Rates of infection after spine surgery based on 108，419 procedures：925[J]. Neurosurgery，2009，65（2）：409.
[3] Watanabe M，Sakai D， Matsuyama D， et al. Risk factors for surgical site infection following spine surgery： Efficacy of intraoperative saline irrigation[J]. Journal of Neurosurgery Spine， 2010，12（5）：540.
[4] Shiono Y，Watanabe K，Hosogane N，et al. Sterility of posterior elements of the spine in posterior correction surgery[J]. Spine，2012，37（6）：523-526.
[5] 中华人民共和国卫生部.医院感染诊断标准（试行）[J]. 中华医学杂志，2001，81（5）：314-320.
[6] 刘健，廖镇江，张勤. 外用重组人粒细胞巨噬细胞集落刺激因子凝胶制剂 治疗深Ⅱ度烧伤创面Ⅳ期临床研究[J]. 中华烧伤杂志，2016，32（9）：542-548.
[7] 刘少强，齐强，陈仲强，等. 脊柱术后手术部位感染67例临床分析[J].中华外科杂志，2016，54（7）：523-527.
[8] Abduljabbar A，Berven SH，Hu SS，et al. Surgical site infections in spine surgery： Identification of microbiologic and surgical characteristics in 239 cases.[J]. Spine， 2013， 38（22）：E1425.
[9] 朱正明，朱培谦，邵江华，等. 外科手术切口感染的病原学检测及耐药谱分析[J]. 中华医院感染学杂志，2008， 18（8）：1186-1188.
[10] Meeks DW， Lally KP， Carrick MM， et al. Compliance with guidelines to prevent surgical site infections： As simple as 1-2-3？[J]. American Journal of Surgery，2011， 201（1）：76-83.
[11] 刘欣，王忠，先疆燕，等. 手术部位感染文献计量学分析[J].中国感染控制杂志， 2017， 16（2）：151-155.
[12] 胡光宇，李新锋，黄平，等. 保留内置物清创联合真空负压封闭引流治疗早发性腰椎融合术后感染[J]. 脊柱外科杂志，2010，8（5）：278-282.
[13] 周源，齐强.脊柱术后手术部位感染诊断现状及进展[J]. 中国脊柱脊髓杂志，2015，25（11）：1026-1029.
[14] Pile JC. Evaluating postoperative fever： A focused approach[J].Cleveland Clinic Journal of Medicine，2006，73 （Suppl 1）：S62.
[15] Lazennec JY，Fourniols E，Lenoir T，et al. Infections in the operated spine： Update on risk management and therapeutic strategies[J]. Orthopaedics
[关键词] 手术部位；目标性监测；病原菌；危险因素
[中图分类号] R446.5；R619 [文献标识码] A [文章编号] 1673-9701（2018）08-0023-05
Pathogen distribution and risk factors in spine surgical site
SUN Jingxi SUN Yongning WANG Fubin CHEN Jianming
Department of Critical Care Medicine， Ningbo Sixth Hospital， Ningbo 315040，China
[Abstract] Objective To investigate the distribution and drug resistance of pathogen and the risk factors of infection in spine surgical site through targeted surveillance， so as to provide basis for rational drug use and prevention in clinical work. Methods Retrospective analysis were conducted on medical records of 816 patients. They were randomly selected from patients with spine diseases who were admitted in our hospital for the first time from May 2015 to December 2016. Pathogen and drug resistance in patients with surgical site infection， and related risk factors from medical records were statistically analyzed. The clinical manifestations at diagnosis and related laboratory inflammatory markers in patients with surgical site infection were imported into the EXCEL software and the positive rates were calculated. Results Among 816 cases， 38 cases were positive of incisional secretions in spine surgery. The infection rate in the surgical site was 4.66% after surgery according to targeted surveillance. 55 strains of pathogens were isolated from the 38 positive cases， of which 64.82% were Gram-positive bacteria with Staphylococcus aureus， Staphylococcus epidermidis and Enterococcus faecalis being the first three strains. 35.18% were Gram-negative bacteria， of which Escherichia coli was the main species with 8 strains accounting for 14.55%. No vancomycin-resistant Staphylococcus aureus was detected. The detection rate of methicillin-resistant Staphylococcus epidermidis was higher than that of Staphylococcus aureus. The drug resistance of Gram-negative bacteria was serious. Univariate analysis showed that six factors including age， diabetes， operation time and others were associated with the incidence of incisional infection. Further multivariate regression analysis showed that diabetes， surgical duration≥180 min， hospital stay≥15 d were associated with surgical incision infection. Conclusion Staphylococcus aureus is the main pathogen in spine incisional infection. The high drug resistance， diabetes mellitus， duration of operation≥180 min and hospital stay≥15 d are the independent risk factors of infection. 当患者手术部位有红肿热痛的症状出现时，其感染的可能性大。临床上可以根据患者的特点而选用药物。患者翻修手术是手术部位感染的危险因素，但本研究中不是独立危险因素，可能的原因是病历数不够多。住院时间长不是医院内感染的危险因素，可能是病历数量不够，而手术时间是手术部位感染的危险因素，因此尽量缩短手术时间，减少院内感染发生的概率。故针对脊柱手术部位感染患者，可以采取下列预防措施：（1）及早发现控制血糖；（2）尽量选用封闭的导尿引流系统及早期去除导尿管[17]，选用合适的导尿管；（3）多科室协作，多学科会诊，尽量减少患者的住院时间，减少感染的风险；（4）缩短手术时间；（5）对于有脓尿的患者经验性用药的同时做病原学检查，根据病原学结果及时更换抗菌药物，合理选用抗生素，减少耐药菌的发生；（6）严格把握近ICU的指征。
脊柱手术部位感染以革兰阳性菌为主，其中又以金黄色葡萄球菌占多数，耐药严重，万古霉素和利奈唑胺可以作为经验性用药用于诊断明确但细菌学结果未出的患者。糖尿病、手术持续时间>180 min、住院天数≥15 d均是感染的独立危险因素。我们计划采用术前控制血糖、缩短手术时间和缩短住院天数来减少手术部位感染的发生。
临床上预防脊柱手术部位感染[18-20]，必须进行规范管理，多部门齐抓共管，实行目标监测与管理相结合，全面控制多重耐药菌的感染。不断提高医护人员的消毒隔离意识，同时提供充足、实用的防护用品和配备充足的人力资源对确保消毒隔离措施的有效落实具有重要意义
[参考文献]
[1] 吴彬彬，王华锋，梁皀清，等. 脊柱手术部位感染的防治现状及进展[J].中国医师杂志，2016，18（s1）：248-251.
[2] Smith JS，Shaffrey CI，Sansur CA， et al. Rates of infection after spine surgery based on 108，419 procedures：925[J]. Neurosurgery，2009，65（2）：409.
[3] Watanabe M，Sakai D， Matsuyama D， et al. Risk factors for surgical site infection following spine surgery： Efficacy of intraoperative saline irrigation[J]. Journal of Neurosurgery Spine， 2010，12（5）：540.
[4] Shiono Y，Watanabe K，Hosogane N，et al. Sterility of posterior elements of the spine in posterior correction surgery[J]. Spine，2012，37（6）：523-526.
[5] 中华人民共和国卫生部.医院感染诊断标准（试行）[J]. 中华医学杂志，2001，81（5）：314-320.
[6] 刘健，廖镇江，张勤. 外用重组人粒细胞巨噬细胞集落刺激因子凝胶制剂 治疗深Ⅱ度烧伤创面Ⅳ期临床研究[J]. 中华烧伤杂志，2016，32（9）：542-548.
[7] 刘少强，齐强，陈仲强，等. 脊柱术后手术部位感染67例临床分析[J].中华外科杂志，2016，54（7）：523-527.
[8] Abduljabbar A，Berven SH，Hu SS，et al. Surgical site infections in spine surgery： Identification of microbiologic and surgical characteristics in 239 cases.[J]. Spine， 2013， 38（22）：E1425.
[9] 朱正明，朱培谦，邵江华，等. 外科手术切口感染的病原学检测及耐药谱分析[J]. 中华医院感染学杂志，2008， 18（8）：1186-1188.
[10] Meeks DW， Lally KP， Carrick MM， et al. Compliance with guidelines to prevent surgical site infections： As simple as 1-2-3？[J]. American Journal of Surgery，2011， 201（1）：76-83.
[11] 刘欣，王忠，先疆燕，等. 手术部位感染文献计量学分析[J].中国感染控制杂志， 2017， 16（2）：151-155.
[12] 胡光宇，李新锋，黄平，等. 保留内置物清创联合真空负压封闭引流治疗早发性腰椎融合术后感染[J]. 脊柱外科杂志，2010，8（5）：278-282.
[13] 周源，齐强.脊柱术后手术部位感染诊断现状及进展[J]. 中国脊柱脊髓杂志，2015，25（11）：1026-1029.
[14] Pile JC. Evaluating postoperative fever： A focused approach[J].Cleveland Clinic Journal of Medicine，2006，73 （Suppl 1）：S62.
[15] Lazennec JY，Fourniols E，Lenoir T，et al. Infections in the operated spine： Update on risk management and therapeutic strategies[J]. Orthopaedics