【文章內(nèi)容簡(jiǎn)介】 l procedures18. Patients are identified as being at high or low risk depending on their medical orbidities. Dental procedures are categorized as high or low risk depending on the risk of bacteremia. All patients should receive antibiotic prophylaxis for highrisk dental procedures for two years after the joint replacement, and highrisk patients should receive prophylaxis for highrisk dental procedures for life. Antibiotic regimens are included in the remendations (Table I). 術(shù)前處理牙科的疾病對(duì)于高風(fēng)險(xiǎn)的骨科患者而言也是一個(gè)值得探討的問題。對(duì)于所有患者，而感染風(fēng)險(xiǎn)較高的患者尤其，應(yīng)鼓勵(lì)其在手術(shù)前后保持良好的口腔衛(wèi)生。源自牙齒感染的菌血癥可導(dǎo)致全關(guān)節(jié)置換部位的急性血源性感染。有證據(jù)表明，臨界期通常為手術(shù)后的頭兩年【17】。美國(guó)骨科醫(yī)師學(xué)會(huì)（AAOS）聯(lián)合美國(guó)牙科協(xié)會(huì)（ADA）對(duì)全關(guān)節(jié)置換的患者進(jìn)行牙科手術(shù)時(shí)預(yù)防性應(yīng)用抗生素制定了指南【18】。按照內(nèi)科合并癥的情況將患者分為高或低風(fēng)險(xiǎn)人群；按照菌血癥的風(fēng)險(xiǎn)將牙科手術(shù)分為高風(fēng)險(xiǎn)或低風(fēng)險(xiǎn)手術(shù)。關(guān)節(jié)置換術(shù)后2年內(nèi)的所有患者在進(jìn)行高風(fēng)險(xiǎn)的牙科手術(shù)時(shí)，都應(yīng)該預(yù)防性地應(yīng)該抗生素，而對(duì)于高風(fēng)險(xiǎn)的患者而言，關(guān)節(jié)置換術(shù)后的任何時(shí)間行高風(fēng)險(xiǎn)牙科手術(shù)時(shí)都應(yīng)該預(yù)防性應(yīng)用抗生素。其推薦的方案中也包括了抗生素的用法（表1）。Antibiotics 抗生素 Perioperative prophylactic antibiotics are effective in reducing the rate of surgical site infections in highrisk orthopaedic cases. In a 2002 metaanalysis of spine fusion surgery, Barker19 reported that use of antibiotic therapy for such procedures is beneficial even when the infection rates without antibiotics are low. Similar studies have demonstrated the efficacy of preoperative antibiotics in general orthopaedic surgery and before total joint replacement20,21. 對(duì)高風(fēng)險(xiǎn)的骨科患者而言，圍手術(shù)期預(yù)防性應(yīng)用抗生素可有效地降低手術(shù)部位的感染率。在2002年一項(xiàng)關(guān)于脊柱融合手術(shù)的meta分析中，Barker【19】指出，在這樣的手術(shù)中應(yīng)用抗生素是有益的，即使在不用抗生素時(shí)感染率也較低的情況下依然如此。其他類似的研究也證實(shí)，在普通的骨科手術(shù)和全關(guān)節(jié)置換手術(shù)之前應(yīng)用抗生素都有著良好的效果【20,21】。The choice of antibiotic for patients with a low risk of methicillinresistant Staphylococcus aureus colonization is either cefazolin (1 to 2 g administered intravenously) or cefuroxime ( g administered intravenously). These doses must be adjusted for children. For patients with a betalactam allergy, clindamycin (600 mg administered intravenously) or vanycin ( g administered intravenously) should be used in lieu of cephalosporins. Patients who are colonized with methicillinresistant Staphylococcus aureus are at high risk for colonization (., nursing home residents), or have had a previous methicillinresistant Staphylococcus aureus infection have an increased risk for the development of an infection with methicillinresistant Staphylococcus aureus22,23. Prophylaxis with vanycin ( g administered intravenously) should be considered for these patients24. 對(duì)于耐甲氧西林金黃色葡萄球菌定植風(fēng)險(xiǎn)較低的患者選擇抗生素時(shí)，頭孢唑啉（12g靜脈內(nèi)給藥）或頭孢呋辛（）都是可以考慮的，應(yīng)用于兒童時(shí)劑量應(yīng)作相應(yīng)的調(diào)整。如果患者對(duì)β內(nèi)酰胺類藥物過敏，可用克林霉素（600mg靜脈內(nèi)給藥）或萬古霉素（）代替頭孢菌素。如患者居住在耐甲氧西林金黃色葡萄球菌較多的環(huán)境中，發(fā)生菌群定植的風(fēng)險(xiǎn)往往較高（如敬老院的住戶），而曾經(jīng)感染上述耐甲氧西林金黃色葡萄球菌的患者則發(fā)生耐甲氧西林金黃色葡萄球菌感染的風(fēng)險(xiǎn)會(huì)明顯增加【22,23】，對(duì)這些患者應(yīng)用考慮預(yù)防性應(yīng)用萬古霉素（）【24】。The proper timing and duration of antibiotic prophylaxis are imperative for safety and effectiveness. In general, antibiotic therapy should be started within one hour prior to the surgical incision, and the drugs should be pletely infused prior to tourniquet inflation. The exception to this remendation is vanycin, the administration of which may be started up to two hours prior to the surgical incision. This allows a slower infusion and decreases the likelihood of red man syndrome. Red man syndrome occurs when hypersensitivity to vanycin causes degranulation of mast cells and a release of histamine. The histamine leads to hypotension and facial flushing. Red man syndrome is prevented by the slow administration of vanycin over a period of one to two hours. 預(yù)防性應(yīng)用抗生素注意合適的時(shí)機(jī)和持續(xù)時(shí)間對(duì)于其安全性和有效性都是非常關(guān)鍵的。通常應(yīng)在做手術(shù)切口之前的一個(gè)小時(shí)內(nèi)應(yīng)用抗生素，并且止血帶充氣之前藥物必須輸注完畢。對(duì)這一建議而言，萬古霉素是個(gè)例外，其開始給藥的時(shí)間應(yīng)提前至做手術(shù)切口之前兩個(gè)小時(shí)，這樣可以緩慢輸注，減少紅人綜合征的發(fā)生率。萬古霉素過敏時(shí)可導(dǎo)致肥大細(xì)胞脫顆粒并釋放組胺從而出現(xiàn)紅人綜合征，組胺可導(dǎo)致低血壓和顏面部發(fā)紅。應(yīng)用萬古霉素時(shí)緩慢輸注，輸注時(shí)間達(dá)12小時(shí)可防止發(fā)生紅人綜合征。Antibiotic treatment should be stopped within twentyfour hours after wound closure. Administration of prophylactic antibiotics for longer than twentyfour hours has not been demonstrated to be effective and may actually lead to superinfection with drugresistant organisms25. Repeat dosing with antibiotics is remended during surgical procedures that last for longer than four hours or when there is 1500 mL of blood loss26. 抗生素應(yīng)在創(chuàng)口閉合后的24小時(shí)之內(nèi)停藥。沒有證據(jù)表明預(yù)防性應(yīng)用抗生素超過24小時(shí)是有效的，并且事實(shí)上還有可能導(dǎo)致耐藥菌的二重感染【25】。而如果手術(shù)持續(xù)時(shí)間較長(zhǎng)，超過4小時(shí)或術(shù)中出血量大于1500ml，則推薦在術(shù)中重復(fù)給藥一次【26】。We remend that, in order to ensure the proper selection and timing of antibiotic prophylaxis, the choice of antibiotics and duration of administration be incorporated into the surgical timeout. Rosenberg et al. reported that pliance with the proper timing and selection of antibiotics increased from 65% to 99% when the protocol was incorporated into the timeout27. 在預(yù)防性應(yīng)用抗生素時(shí)為了確保合理選擇抗生素并確定適當(dāng)?shù)慕o藥時(shí)機(jī)，我們推薦，將選擇抗生素和確定給藥持續(xù)時(shí)間都?xì)w入到手術(shù)的“timeout”（手術(shù)劃刀前暫停核對(duì)各項(xiàng)信息）方案中。Rosenberg等曾報(bào)道，將相關(guān)的內(nèi)容并入到“timeout”方案中之后，選擇抗生素以及用藥時(shí)間的符合率由65%增加到99%【27】。Surgical Hand Antisepsis術(shù)者手部消毒The objective of a preoperative hand scrub is to remove or kill as many bacteria as possible from the hands of the surgical team. Aqueous scrub solutions consisting of waterbased solutions of either chlorhexidine gluconate or povidoneiodine have been traditionally used. 術(shù)前洗手的目的是為了盡可能多地去除或殺死手術(shù)人員手部的細(xì)菌。通常應(yīng)用的液態(tài)洗滌劑大多為洗必泰葡萄糖酸鹽或聚維酮碘的水溶液。The authors of a recent Cochrane review28 found alcoholbased rubs containing ethanol, isopropanol, or npropanol to be as effective as aqueous solutions for preventing surgical site infections in patients29. Hajipour et reported that alcohol rubs were more effective than either chlorhexidine gluconate or iodinebased scrubs for reducing bacterial colonyforming units (CFUs) on the hands of surgeons. Other investigators reported that the use of scrub brushes had no positive effect on asepsis and may actually increase the risk of infection as a result of skin damage31. On the basis of this evidence, the remended procedure for preoperative surgical hand antisepsis is that, preceding the first scrub of the day or when the hands are grossly contaminated, the surgical team should wash with soap and water, use a nail pick to clean under the nails, and dry with paper towels. They should then use an al