【正文】 The Journal of Bone and Joint Surgery (American). 2010。92:232239.Perioperative Strategies for Decreasing InfectionA Comprehensive EvidenceBased Approach降低感染率的圍手術(shù)期策略：綜合性循證醫(yī)學(xué)路徑 Joseph A. Bosco, III, MD1, James D. Slover, MD, MS1 and Janet P. Haas, RN, PhD2 1 Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York University Langone Medical Center, 301 East 17th Street, New York, NY 10003. Email address for . Bosco III: @. Email address for . Slover: @2 Infection Prevention and Control, Westchester Medical Center, 100 Woods Road, Macy Pavilion SW246, Valhalla, NY 10595. Email address: Haasj@ An Instructional Course Lecture, American Academy of Orthopaedic Surgeons Introduction 引言 Surgical site infections associated with orthopaedic surgical procedures are devastating plications. They increase morbidity, mortality, and cost and result in outes that are worse than those in uninfected cases1. Decreasing the incidence of surgical site infections is not only of interest to patients and surgeons, it is also a major focus of several groups of interested parties. These range from payers, including the Centers for Medicare and Medicaid Services (CMS, Baltimore, Maryland), to institutions represented by the Surgical Care Improvement Project (SCIP), a multipleinstitution partnership between major public and private healthcare organizations, including the Joint Commission on Accreditation of Healthcare Organizations (Oakbrook Terrace, Illinois). Decreasing the incidence of surgical site infections is, and will continue to be, a major focus in medicine. 對(duì)于骨科手術(shù)而言，手術(shù)部位的感染是一種毀滅性的并發(fā)癥，往往會(huì)導(dǎo)致致殘率、致死率以及醫(yī)療費(fèi)用的增加，并且與沒(méi)有發(fā)生感染的病例相比，最終的治療結(jié)果通常也會(huì)更差【1】。減少手術(shù)部位的感染率，不僅對(duì)患者和醫(yī)生都很有意義，也是利益相關(guān)的各方非常關(guān)注的問(wèn)題。如出資方，包括醫(yī)療保險(xiǎn)與醫(yī)療輔助服務(wù)中心（CMS，Baltimore, Maryland）；以外科醫(yī)療改良項(xiàng)目（SCIP）為代表的相關(guān)機(jī)構(gòu)；介于大眾公共機(jī)構(gòu)與私人醫(yī)療保健機(jī)構(gòu)之間的多機(jī)構(gòu)合作組織，包括醫(yī)療機(jī)構(gòu)評(píng)審聯(lián)合委員會(huì)（JCAHO，Oakbrook Terrace, Illinois）等。減少手術(shù)部位的感染率現(xiàn)在是，將來(lái)也仍會(huì)是，醫(yī)學(xué)領(lǐng)域關(guān)注的焦點(diǎn)問(wèn)題。To effectively prevent surgical site infections, the clinician must consider preoperative, intraoperative, and postoperative factors and interventions. Preoperative strategies for reduction of infection rates include identification of highrisk patients, screening and decolonization of patients with methicillinsensitive Staphylococcus aureus and methicillinresistant Staphylococcus aureus colonization, preoperative preparation of the patient with chlorhexidine gluconate, utilization of proper hairremoval techniques, and addressing preexisting dental and nutritional issues prior to surgery. 為了有效地防止手術(shù)部位的感染，臨床醫(yī)生必須審慎地考慮到手術(shù)前、手術(shù)中以及手術(shù)后的相關(guān)因素和干預(yù)措施。降低感染的術(shù)前策略包括識(shí)別高風(fēng)險(xiǎn)的患者，對(duì)甲氧西林敏感的金黃色葡萄球菌和耐甲氧西林的金黃色葡萄球菌定植的患者進(jìn)行篩查，并清除定植菌，術(shù)前應(yīng)用洗必泰葡萄糖酸鹽進(jìn)行清洗，應(yīng)用合適的方法去除毛發(fā)，術(shù)前妥善處理先前存在的牙齒及營(yíng)養(yǎng)相關(guān)的問(wèn)題。There are a variety of perioperative strategies that can and should be employed to decrease the risk of surgical site infections. Intraoperative interventions that have been shown to decrease surgical site infection rates include the proper selection, timing, and doses of prophylactic antibiotics and utilization of best practices for hand hygiene and surgical site preparation. Maintaining a sterile operatingroom environment by decreasing operatingroom traffic, monitoring for breaks in sterile technique, and decreasing the use of flash sterilization is vital. Finally, postoperative strategies for the reduction of surgical site infection rates include the proper use and duration in situ of urinary catheters and surgical drains。 standardization of wound care。 use of antibioticimpregnated bandages。 and, perhaps most importantly, maintenance of proper hand hygiene, isolation precautions, and room cleaning. 有多種圍手術(shù)期的策略可以并且必須應(yīng)用以減少手術(shù)部位的感染。術(shù)中的一些干預(yù)因素已經(jīng)證實(shí)可以降低手術(shù)部位的感染率，包括選擇合適的種類、時(shí)機(jī)和劑量預(yù)防性應(yīng)用抗生素，手衛(wèi)生及術(shù)區(qū)消毒均采用最優(yōu)化的方案。通過(guò)減少手術(shù)室的穿行、監(jiān)視有無(wú)違反無(wú)菌技術(shù)的操作、減少快速消毒的應(yīng)用對(duì)于維持手術(shù)的無(wú)菌環(huán)境是至關(guān)重要的。最后，降低手術(shù)部位感染率的術(shù)后策略包括合理地應(yīng)用和維持原有的導(dǎo)尿管和術(shù)區(qū)引流管，對(duì)創(chuàng)口進(jìn)行標(biāo)準(zhǔn)化護(hù)理；應(yīng)用抗生素浸潤(rùn)的繃帶，以及，可能最為重要的是，保持正確的手衛(wèi)生、隔離預(yù)防和室內(nèi)清潔。Preoperative Considerations 術(shù)前注意事項(xiàng)Although every precaution should be taken to prevent infection for all orthopaedic patients, the identification of highrisk patients enables clinicians to provide maximal prevention strategies for them. Furthermore, the identification of patients at high risk for infection allows appropriate preoperative counseling for shared decisionmaking and establishes appropriate patient expectations regarding surgical risks. 雖然對(duì)于所有骨科患者，都應(yīng)該采用各種預(yù)防措施以防止感染，但臨床醫(yī)生識(shí)別出高風(fēng)險(xiǎn)的患者后，便可針對(duì)其制定最大限度的防范策略。此外，識(shí)別出感染的高風(fēng)險(xiǎn)患者后可進(jìn)行適當(dāng)?shù)男g(shù)前告知談話，這樣可與患者共同制定治療決策，并使患者對(duì)于手術(shù)風(fēng)險(xiǎn)樹(shù)立合理的期望值。Numerous highrisk patient populations and risk factors that place patients at high risk for infection after total joint replacement or spine surgery have been described in the literature. Some of these factors can be modified, while others cannot. An explanation of the risk factors that cannot be modified should be included when patients are counseled about their increased risk of infection with the proposed surgical procedure. In this way, patients will more pletely understand the risks and benefits when deciding on surgery. Two mon factors that cannot be modified and that increase the risk of infection with joint replacement are a history of infection in the joint2 and a history of steroid injection into the joint3. Factors that cannot be modified that increase the risk of infection in patients undergoing spine surgery include traumarelated surgery4, use of instrumentation5, and lumbar6 and posterior4 surgery. 對(duì)于關(guān)節(jié)置換術(shù)和脊柱手術(shù)的感染，有很多高風(fēng)險(xiǎn)患者人群以及相關(guān)的危險(xiǎn)因素使患者具有較高感染風(fēng)險(xiǎn)的情況，在以往的文獻(xiàn)中都有論述。在這些因素中，有些事可以改善的，而有些則無(wú)法改變。對(duì)于無(wú)法控制的危險(xiǎn)因素，在對(duì)患者進(jìn)行術(shù)前告知談話時(shí)，應(yīng)向其說(shuō)明這樣會(huì)增加感染的風(fēng)險(xiǎn)。這樣，患者在決定做手術(shù)時(shí)便可更全面地認(rèn)識(shí)到相關(guān)的風(fēng)險(xiǎn)和益處。有兩個(gè)無(wú)法控制的因素，既往關(guān)節(jié)感染病史【2】和既往關(guān)節(jié)內(nèi)類固醇注射史【3】，通常會(huì)增加關(guān)節(jié)置換手術(shù)的感染風(fēng)險(xiǎn)。而對(duì)于進(jìn)行脊柱手術(shù)的患者而言，會(huì)增加感染的風(fēng)險(xiǎn)并且無(wú)法控制的因素包括創(chuàng)傷相關(guān)的手術(shù)【4】，需要應(yīng)用內(nèi)置物【5】，以及腰椎【6】和后路【4】手術(shù)。Other factors that increase the risk of infection are potentially modifiable and, therefore, provide the opportunity for patient optimization prior to elective orthopaedic procedures. For example, patients with inflammatory arthritis7, sicklecell disease8, diabetes9, renal failure10, and human immunodeficienc