骨科植入术后医院感染病原菌特点及危险因素分析

Characteristics of pathogens causing nosocomial infections after implantation in department of orthopedics and risk factors

目的探讨骨科植入术后医院感染病原菌特点及危险因素分析。方法选择医院于2014年12月-2016年12月收治的行骨科植入术患者1437例。采集患者痰液、尿液、血液标本,分离培养细菌,其中革兰阳性菌药敏试验采用GN201法,革兰阴性菌药敏试验采用GP法,以纸片扩散法进行药敏试验。回顾性分析患者临床资料,内容包括性别、年龄、手术类型、气压止血时间、术中应用大功率电刀、术后PVP碘纱布贴伤口。结果骨科植入术患者1437例,术后发生医院感染患者66例,感染率为4.59%;66例术后医院感染患者中,30例发生切口感染占45.45%;呼吸道感染16例占24.24%,泌尿道感染12例占18.18%,其他8例占12.12%;术后医院感染66例患者共分离培养病原菌80株,其中革兰阴性菌48株占60.00%,革兰阳性菌30株占37.50%,真菌2株占2.50%;主要革兰阴性菌铜绿假单胞菌对阿莫西林和头孢曲松耐药率较高,分别为90.48%和80.95%;鲍氏不动杆菌对阿莫西林、美罗培南、头孢他啶、阿米卡星等耐药率较高,分别为91.67%、8.33%、83.33%、75.00%;主要革兰阳性菌金黄色葡萄球菌对青霉素、红霉素、环丙沙星耐药率较高,分别为100.00%、85.71%、78.57%;表皮葡萄球菌对红霉素和青霉素耐药率较高,分别为100.00%和90.91%;单因素分析表明,性别、年龄、手术类型比较差异无统计学意义(P>0.05);气压止血时间≥90min、术中应用大功率电刀及术后PVP碘纱布贴伤口具有统计学差异(P<0.05);将单因素分析中具有统计学差异的纳入多因素分析表明,气压止血时间≥90min、术中应用大功率电刀及术后PVP碘纱布贴伤口为术后发生医院感染的独立危险因素。结论骨科植入术后医院感染患者以手术切口感染为主,病原菌以革兰阴性菌为主,气压止血时间≥90min、术中应用大功率电刀及术后PVP碘纱布贴伤口为术后发生医院感染的危险因素,应合理应用抗菌药物及针对危险因素采取相应预防措施。

OBJECTIVE To explore the characteristics of pathogens causing nosocomial infections after implantation in department of orthopedics and analyze the risk factors.METHODS A total of 1437 patients who underwent the orthopedic implants surgery in the hospital from Dec 2014 to Dec 2016 were enrolled in the study.The sputum,urine and blood specimens were collected from the patients,the bacterial culture was carried out,the drug susceptibility testing for gram-positive bacteria was conducted by using GN201 method,the drug susceptibility testing for gram-negative bacteria was carried out by using GP method,and the drug susceptibility testing was performed with the use of disk diffusion method.The clinical data of the patients,including the gender,age,types of surgery,air pressure,time of hemostasis,intraoperative use of high-power electric knife and postoperative pasting wounds with PVP iodine gauze.RESULTS Of the 1437 patients who underwent the orthopedic implants surgery,66 had postoperative nosocomial infections,with the infection rate 4.59% .Among the 66 patients with postoperative nosocomial infections,30（45.45% ）had incision infections,16（24.24% ）had respiratory tract infections,12（18.18% ）had urinary tract infections,and 8（12.12% ）had other sites of infections.Totally 80 strains of pathogens were isolated from the 66 patients with the postoperative nosocomial infections,of which 48（60.00% ）were gram-negative bacteria,30（37.50% ）were gram-positive bacteria,and 2（2.50% ）were fungi.Among the main gram-negative bacteria,the drug resistance rates of Pseudomonas aeruginosa to amoxicillin and ceftriaxone were90.48% and 80.95% ,respectively;the drug resistance rates of Acinetobacter baumannii to amoxicillin,meropenem,ceftazidime and amikacin were 91.67% ,8.33% ,83.33% and 75.00% ,respectively.Among the main grampositive bacteria,the drug resistance rates of Staphylococcus aureus to penicillin,erythromycin and ciprofloxacin were 100.00% ,85.71% and 78.57% ,respectively;the drug resistance rates of Staphylococcus epidermidis to erythromycin and penicillin were 100.00% and 90.91% ,respectively.The univariate analysis indicated that there was no significant difference in the gender,age,or type of surgery（P〈0.05）,and there was significant difference in the air pressure hemostasis time no less than 90 min,intraoperative use of high-power electric knife or postoperative pasting wounds with PVP iodine gauze（P〈0.05）.The multivariate analysis of the factors with statistical significance in the univariate analysis showed that the air pressure hemostasis time no less than 90 min,intraoperative use of high-power electric knife and postoperative pasting wounds with PVP iodine gauze were the independent risk factors for the postoperative nosocomial infections.CONCLUSION The patients with surgical incision infections are dominant among the patients with nosocomial infections after orthopedic implants surgery,and the gram-negative bacteria are the predominant pathogens.The air pressure hemostasis time no less than 90 min,intraoperative use of high-power electric knife and postoperative pasting wounds with PVP iodine gauze are the risk factors for the postoperative nosocomial infections.It is necessary to reasonably use antibiotics and take targeted prevention measures aiming at the risk factors.