开放性骨折术后伤口感染的危险因素分析

Risk analysis of surgical site infection in open fractures

目的探讨引起开放性骨折术后伤口感染的危险因素及感染病原菌分布情况。方法回顾性分析2011年1月至2013年12月行开放骨折清创术且符合纳入标准的感染组(n=247)及非感染组(n=247)患者共494例,记录并比较两组患者的年龄、性别、住院天数、骨折部位、骨折分型、创伤原因、手术次数、清创次数、首次清创时间、清创手术时长,采用多因素Logistic回归分析开放骨折术后感染的危险因素,同时对伤口感染病原菌种类及药敏结果进行剖析。结果单因素分析示组间住院天数(t=6.397,P<0.01)、骨折部位(x^2=12.589,P<0.05)、骨折分型(x^2=19.384,P<0.01)、手术次数(t=7.459,P<0.01)、清创次数(t=3.416,P<0.01)、首次清创时间(t=3.888,P<0.01)、清创手术时长(t=5.743,P<0.01)差异有统计学意义。多因素Logistic回归分析中与非感染组相比,感染组患者的住院天数长(OR,1.011;95%CI:1.001~1.021)、手术次数多(OR,2.313;95%CI:1.647~3.247)、清创次数多(OR,0.511;95%CI:0.342~0.765)、首次清创时间晚(OR,1.120;95%CI:1.045~1.202)、清创手术时间长(OR,1.390;95%CI:1.174~1.647)。术后感染主要为革兰阴性菌(76.6%),其中以鲍曼不动杆菌(25.5%)和铜绿假单胞菌(22.3%)多见;革兰阳性菌主要为金黄色葡萄球菌(17.3%)。金黄色葡萄球菌的多重耐药菌株占20.3%,鲍曼不动杆菌多重耐药菌株占56.8%、铜绿假单胞菌多重耐药菌株占18.6%。结论手术次数、清创手术时间、首次清创时间、住院天数、清创次数为开放性骨折术后伤口感染相关的危险因素;开放骨折术后感染以革兰阴性菌为主,鲍曼不动杆菌、铜绿假单胞菌和金黄色葡萄球菌耐药菌占比较高。

Objective To study the risk factors and distribution of pathogens for surgical site infection in open fractures. Methods Four hundred ninety- four patients with open fractures treated from January 2011 to December 2013 were included, all patients underwent debridement and were divided into infection group (n=247) and non- infection group (n=247). Age, gender, hospitalization stay, fracture site,fracture classification, cause of injuries, times of operation, times of debridement, latency of primary debridement, debridement duration were compared between two groups. Multi- factor Logistic regression analysis was applied to investigate risk factors of surgical site infection, meanwhile analyzed the pathogenic bacteria and drug sensitivity in all infected wounds. Results The inter- groups analysis showed no significant differences on hospitalization days (t=6.397, P<0.01), fracture site (c2=12.589, P<0.05), fracture classification (c2=19.384, P<0.01), times of operation (t=7.459, P<0.01), times of debridement (t=3.416,P<0.01), times of primary debridement (t=3.888, P<0.01), debridement duration (t=5.743, P<0.01) by single factor analysis. The infection group presented longer hospitalization stays (OR, 1.011; 95% CI: 1.001- 1.021),more operations (OR, 2.313; 95% CI: 1.647- 3.247) and debridements (OR, 0.511; 95% CI: 0.342- 0.765),longer latency of primary debridement (OR, 1.120; 95% CI: 1.045- 1.202) and debridement duration (OR,1.390; 95% CI: 1.174- 1.647) compared to the non- infection group. The dominant postoperative infection bacteria were gram- negative bacteria (76.6%), and common types were Acinetobacter baumannii (25.5%) and Pseudomonas aeruginosa (22.3%). Staphylococcus aureus (17.3%) was the most common gram-positive bacteria. Proportion of methicillin resistant staphylococcus aureus, multiple- drug resistant acinetobacter baumannii and pseudomonas aeruginosa were 20.3% , 56.8% , and 18.6% , respectively. Conclusions Times of operation, duration of debridement, latency of primary debridement, hospitalization stay and times of debridement are risk factors of SSI in patients with open fractures. Gram- negative bacteria are the dominant infection bacteria, and the most common drug resistant bacteria in postoperative open fractures were Acinetobacter baumannii, Pseudomonas aeruginosa and Staphylococcus aureus.