四肢开放性骨折术后伤口感染情况与影响因素分析

Analysis of wound infection and influencing factors following open fracture of extremities

目的观察四肢开放性骨折患者术后伤口感染的病原学特征与耐药情况,分析导致感染的影响因素。方法纳入自2015-01—2016-12行内固定手术治疗的554例四肢开放性骨折,对术后伤口分泌物进行细菌培养与鉴定,记录病原菌特征、多重耐药菌分布及药敏情况,并分析导致术后感染的影响因素。结果128例有细菌生长,感染发生率为23.1%。一共检出144株病原菌,76株革兰阳性球菌(36株金黄色葡萄球菌,20株表皮葡萄球菌,11株溶血葡萄球菌,6株肠球菌属,2株链球菌)、65株革兰阴性杆菌(30株铜绿假单胞菌,22株大肠埃希菌,8株肺炎克雷伯菌和4株鲍曼不动杆菌)和3株真菌。革兰氏阳性球菌对氨苄西林的耐药率最高,耐药率最低的是万古霉素;革兰氏阴性菌对氨苄西林、苯唑西林及青霉素的呈现不同的耐药率,敏感性较好抗菌药物是碳青霉烯类药物。合并基础疾病、择期手术、围手术期未使用抗生素、住院时间≥20 d、Gustilo分型越高的四肢开放性骨折患者术后感染发生风险越高。结论四肢开放性骨折患者术后伤口感染的主要病原菌是革兰阳性球菌,临床医师应加强监测病原菌变化及耐药趋势,合理使用抗生素。同时术前需要预防合并基础疾病、择期手术、围手术期未使用抗生素、住院时间长、Gustilo分型越高的患者发生术后感染。

Objective To observe the pathogenic characteristics and drug resistance of postoperative wound infection in patients with open fracture of extremities and analyze the influencing factors of infection. Methods A total of 554 cases of open fracture of extremities treated by internal fixation from January 2015 to December 2016 were included in the study. The bacterial culture and identification of incision secretion were carried out, the characteristics of pathogenic bacteria, the distribution of multidrug-resistant bacteria and drug sensitivity were recorded, and the influencing factors of postoperative infection were analyzed. Results One hundred and twenty-eight cases had bacterial growth, the incidence of infection was23.1%. A total of 144 pathogenic bacteria were detected, including 76 gram-positive cocci(36 Staphylococcus aureus, 20 Staphylococcus epidermidis, 11 Staphylococcus haemolyticus, 6 Enterococci, 2 Streptococcus), 65 gram-negative bacteria(30 Pseudomonas aeruginosa, 22 Escherichia coli, 8 Klebsiella pneumoniae and 4 Acinetobacter baumannii) and 3 fungi. Grampositive bacteria had the highest resistance rate to ampicillin, and vancomycin had the lowest resistance rate;Gram-negative bacteria had different resistance rates to ampicillin, oxacillin and penicillin. Carbapenems were more sensitive antibiotics. The open fracture patients with basic diseases, selective operation, without antibiotics in perioperative period, with hospitalization time ≥20 days, and with higher Gustilo classification had higher risks of postoperative infection. Conclusion Gram-positive cocci are the main pathogens of postoperative wound infection in patients with open fracture of extremities. Clinicians should monitor the change of pathogenic bacteria and the trend of drug resistance, and use antibiotics reasonably. At the same time, it is necessary to prevent postoperative infection in patients with underlying diseases, selective surgery, without antibiotics in perioperative period, with long hospital stay and higher Gustilo classification.