2018—2020年中国结直肠术后手术部位感染现状研究

Surgical site infection after colorectal surgery in China from 2018 to 2020

目的调查中国结直肠术后手术部位感染(SSI)的发生情况, 探讨其风险因素, 为我国结直肠术后SSI的防控提供参考依据。方法采用观察性研究方法, 基于国家手术部位感染监测网2018—2020年开展的多中心研究, 提取3年中所有接受结直肠手术患者的临床资料。共纳入全国50家医院收治的2 122例结直肠手术患者, 其中男性1 252例, 女性870例;中位年龄为63(16)岁;中位体质指数为23(4.58)kg/m2。收集患者的一般资料和围手术期相关临床数据, 排除未成年、孕妇或接受妇产科手术、接受泌尿系统手术、行腹膜后位手术和体表包块切除以及有补片等植入物的手术者。主要结局指标为结直肠术后30 d内SSI发生率, 次要结局指标为术后30 d内病死率、术后重症监护室(ICU)住院时间、术后总住院时间以及住院费用。依据是否发生感染, 将患者分为SSI组和非SSI组, 分析结直肠术后发生SSI的危险因素, 并针对开腹手术和腹腔镜(或机器人)手术后发生SSI的危险因素进行亚组分析。非正态分布的连续性变量以M(IQR)表示, 组间比较采用Mann-WhitneyU秩和检验;单因素分析采用χ2检验, 多因素分析采用Logistic回归模型。结果结直肠术后SSI发生率为5.6%(119/2 122);其中浅部切口感染占39.5%(47/119)、深部切口感染占20.2%(24/119)、器官(间隙)感染占40.3%(48/119)。与非SSI组比较, SSI组患者病死率更高[2.5%(3/119)比0.1%(3/2 003), χ2=22.400, P=0.003], ICU住院时间更长[0(1)d比0(0)d, U=131 339, P<0.001]、术后总住院时间更长[18.5(12.8)d比9.0(6.0)d, U=167 902, P<0.001]、住院费用更多[7.5(4.9)万元比6.0(3.1)万元, U=126 189, P<0.001], 差异均具有统计学意义(均P<0.05)。多因素分析结果显示:合并高血压(OR=1.782, 95%CI:1.173~2.709, P=0.007)、术前白蛋白<35 g/L(OR=1.680, 95%CI:1.089~2.592, P=0.019)、污染或感染切口(OR=1.993, 95%CI:1.076~3.689, P=0.028)、行急诊手术(OR=2.067, 95%CI:1.076~3.972, P=0.029)、行开腹手术(OR=2.132, 95%CI:1.396~3.255, P<0.001)以及手术时间≥3 h(OR=1.804, 95%CI:1.188~2.740, P=0.006)为结直肠术后发生SSI的独立危险因素, 而进行备皮(OR=0.478, 95%CI:0.310~0.737, P=0.001)为SSI发生的独立保护因素。开腹手术组SSI发生率为10.2%(69/675), 显著高于腹腔镜(或机器人)组(3.5%, 50/1 397)(χ2=39.816, P<0.001), 对接受开腹手术患者和接受腹腔镜(或机器人)手术患者分别进行亚组分析。多因素分析结果显示:污染或感染切口(OR=2.168, 95%CI:1.042~4.510, P=0.038)、手术时间≥3 h(OR=2.072, 95%CI:1.171~3.664, P=0.012)为接受开腹结直肠手术患者SSI发生的独立危险因素;而进行术前机械性肠道准备(OR=0.428, 95%CI:0.227~0.807, P=0.009)、备皮(OR=0.356, 95%CI:0.199~0.634, P<0.001)是避免该类患者发生SSI的独立保护因素。对接受腹腔镜(或机器人)手术患者的多因素分析显示, 合并糖尿病(OR=2.292, 95%CI:1.138~4.617, P=0.020)和合并高血压(OR=2.265, 95%CI:1.234~4.159, P=0.008)是结直肠术后SSI发生的独立危险因素。结论 2018—2020年结直肠手术后SSI整体发生率为5.6%, 为减少结直肠术后SSI的发生, 应尽量选择微创手术;术前备皮和机械性肠道准备是预防开腹手术后SSI的有效手段;围手术期应对合并高血压、糖尿病, 以及切口污染严重的患者予以关注、加强护理。

Objective This study aims to survey the incidence of surgical site infection(SSI)in China and to analyze its risk factors,so as to prevent and control SSI after colorectal surgery.Methods An observative study was conducted.Based on a program of Chinese SSI Surveillance from 2018 to 2020,the clinical data of all adult patients undergoing colorectal surgery during this time period were extracted.These included demographic characteristics and perioperative clinical parameters.Minors,pregnant women,obstetric or gynecological surgery,urological system surgery,retroperitoneal surgery,resection of superficial soft tissue masses,and mesh or other implants were excluded.A total of 2122 patients undergoing colorectal surgery from 50 hospitals were included,including 1252 males and 870 females.The median age was 63(16)years and the median BMI was 23(4.58)kg/m2.The primary outcome was the incidence of SSI within 30 days after colorectal surgery.The secondary outcomes were mortality within 30 days postoperatively,length of ICU stays and postoperative hospital stays,and cost of hospitalization.Patients were divided into the SSI group and non-SSI group based on the occurrence of SSI.Multivariable logistic regression was performed to analyze risk factors of SSI after colorectal surgery,and subgroup analysis was conducted for open and laparoscopic surgery.Results The incidence of SSI after colorectal surgery was 5.6%(119/2122),including 47 cases(47/119,39.5%)with superficial incisional infections,24 cases(24/119,20.2%)with deep incisional infections,and 48 cases(48/119,40.3%)with organ/space infections.The occurrence of SSI significantly increased mortality[2.5%(3/119)vs.0.1%(3/2003),χ2=22.400,P=0.003],the length of ICU stay[0(1)day vs.0(0)day,U=131339,P<0.001],postoperative hospital stay[18.5(12.8)days vs.9.0(6.0)days,U=167902,P<0.001],and medical expenses[75000(49000)yuan vs.60000(31000)yuan,U=126189,P<0.001](P<0.05).Multivariate analysis revealed that hypertension(OR=1.782,95%CI:1.173-2.709,P=0.007),preoperative albumin level(OR=1.680,95%CI:1.089-2.592,P=0.019),a contaminated or infected incision(OR=1.993,95%CI:1.076-3.689,P=0.028),emergency surgery(OR=2.067,95%CI:1.076-3.972,P=0.029),open surgery(OR=2.132,95%CI:1.396-3.255,P<0.001),and surgical duration(OR=1.804,95%CI:1.188-2.740,P=0.006)were risk factors for SSI,while preoperative skin preparation(OR=0.478,95%CI:0.310-0.737,P=0.001)was a protective factor for SSI.Subgroup analysis was performed on patients undergoing open or laparoscopic surgery.The incidence of SSI in the open surgery group was 10.2%,which was significantly higher than that in the laparoscopic or robotic group(3.5%,χ2=39.816,P<0.001).Subgroup analysis identified that a contaminated or infected incision(OR=2.168,95%CI:1.042-4.510,P=0.038)and surgical duration(OR=2.072,95%CI:1.171-3.664,P=0.012)were risk factors for SSI after open surgery,while mechanical bowel preparation(OR=0.428,95%CI:0.227-0.807,P=0.009)and preoperative skin preparation(OR=0.356,95%CI:0.199-0.634,P<0.001)were protective factors for SSI after open surgery.In laparoscopic surgery,diabetes mellitus(OR=2.292,95%CI:1.138-4.617,P=0.020)and hypertension(OR=2.265,95%CI:1.234-4.159,P=0.008)were risk factors for SSI.Conclusions The incidence of SSI after colorectal surgery is 5.6%.Minimally invasive surgery should be selected to reduce the occurrence of postoperative SSI.To prevent the occurrence of SSI after open surgery,skin preparation and mechanical bowel preparation should be performed before the operation,and the duration of the operation should be shortened as much as possible.In the perioperative period,care of patients with hypertension,diabetes,and contaminated or infected incisions should be given particular attention.