脊柱手术后深部切口感染患者多次清创的危险因素

doi:10.19723/j.issn.1671-167X.2021.02.009

摘要/Abstract

摘要：

目的: 探讨可能导致脊柱手术患者切口感染接受多次清创术的危险因素,以引起医务人员的警惕和重视,并探讨预防措施。方法: 回顾性分析2012年1月至2017年12月就诊于北京大学第三医院骨科,行脊柱手术后发生切口感染并进行清创术的84例患者资料,所有患者切口感染均发生于术后30 d内,诊断符合美国疾病预防控制中心(Centers for Disease Control,CDC)制定的深部手术切口感染的诊断标准。治疗采用早期清创术、一期关闭切口、置管对口冲洗引流,并根据细菌培养结果合理应用抗生素。清创术后密切关注患者生命体征、临床表现、抽血化验结果及引流液性状、细菌培养结果,如果不能控制感染或好转后再次出现原手术切口感染则行二次清创术。60例患者行单次清创术,包括男性36例、女性24例,年龄36~77岁,平均57.2岁;24例患者行多次清创术(14例接受2次清创,6例接受3次清创,1例接受4次清创,2例接受5次清创,1例接受6次清创),包括男性17例、女性7例,年龄21~70岁,平均49.5岁。对单次清创组和多次清创组之间变量进行单因素分析,将单因素分析有统计学意义(P<0.05)的变量纳入二元Logistic回归模型进行多因素分析。结果: 本组二次清创率为28.6%。多次清创组累计住院时间(82.4±46.3) d,单次清创组累计住院时间(40.4±31.5) d(P=0.018);多次清创组6例取出内置物,单次清创组4例取出内置物(P=0.049);多次清创组7例行皮瓣移植术修复创面,单次清创组无病例行皮瓣移植(P<0.001)。单因素分析显示,原始手术时间大于3 h、原始手术出血量大于400 mL、合并糖尿病、感染后细菌学检验结果、伴有远隔部位感染等变量在两组间差异有统计学意义(P<0.05)。多因素分析显示,原始手术时间大于3 h(OR=3.60,95%CI:1.12~11.62)、合并糖尿病(OR=3.74,95%CI:1.06~13.22)、细菌学检验结果为耐甲氧西林金黄色葡萄球菌(methicillin-resistant Staphylococcus aureus,MRSA)(OR=16.87,95%CI:0.50~5.45)与脊柱手术后切口感染接受多次清创术显著相关。接受多次清创术的患者住院时间明显延长,面临内置物取出风险增高,部分患者还需皮瓣移植修复创面。结论: 原始手术时间大于3 h、合并糖尿病、细菌培养结果为MRSA是脊柱手术后切口感染接受多次清创术的独立危险因素,这些因素需要引起医务人员的重视并进行积极干预。

关键词: 脊柱, 外科伤口感染, 清创术, 危险因素

Abstract:

Objective: To investigate the risk factors that contribute to multiple debridements in patients suffering from deep incisional surgical site infection after spinal surgery and advise medical personnel to pay special attention to these risk factors. Methods: We retrospectively enrolled 84 patients who got deep incisional surgical site infection after spinal surgery from Jan. 2012 to Dec. 2017. The infections occurred within 30 days after the surgery, and the identification met the criteria of deep incisional surgical site infection of Centers of Disease Control (CDC). Early debridement with first stage closure of the wound and a continuous inflow-outflow irrigation system was used, and reasonable antibiotics were chosen according to the bacterial culture results. During the treatment, the vital signs, clinical manifestations, blood test results, drainage fluid colour and bacterial culture results were acquired. If the infection failed to be controlled or relapsed, a second debridement was performed. Of the 84 cases, 60 undergwent single debridement which included 36 male cases and 24 female cases, and the age ranged from 36 to 77 years, with a mean of 57.2 years. Twenty four had multiple debridements (twice in 14 cases, three times in 6 cases, four times in 1 case, five times in 2 cases, six times in 1 cases) which included 17 male cases and 7 female cases, and the age ranged from 21 to 70 years, with a mean of 49.5 years. Risk factors that predispose patients to multiple debridements were identified using univariate analysis. Risk factors with P values less than 0.05 in univariate analysis were included together in a multivariate Logistic regression model using back-forward method. Results: Multiple debridements were performed in 28.6% of all cases. The hospital stay of multiple debridements group was (82.4±46.3) days compared with (40.4±31.5) days in single debridement group (P=0.018). Instrumentation was removed in 6 cases in multiple debridements group and 4 cases in single debridement group (P=0.049). Flap transplantation was performed in 7 cased in multiple debridements group while none in single debridement group (P<0.001). Diabetes, primary operation duration longer than 3 hours, primary operation blood loss more than 400 mL, bacteriology examination results, distant site infection were significantly different between the two groups in univariate analysis. In multivariate analysis, primary operation duration longer than 3 hours (OR=3.60, 95%CI: 1.12-11.62), diabetes (OR=3.74, 95%CI: 1.06-13.22), methicillin-resistant Staphylococcus aureus (MRSA) infected (OR=16.87, 95%CI: 2.59-109.73) were the most important risk factors related to multiple debridements in the patients with deep incisional surgical site infection after spinal surgery. Conclusion: Diabetes, primary operation duration more than 3 hours, MRSA infected are independent risk factors for multiple debridements in patients suffering from deep incisional surgical site infection after spinal surgery. Special caution and prophylaxis interventions are suggested for these factors.

Key words: Spine, Surgical wound infection, Debridement, Risk factors

中图分类号:

R619.3

周柏林,李危石,孙垂国,齐强,陈仲强,曾岩. 脊柱手术后深部切口感染患者多次清创的危险因素[J]. 北京大学学报（医学版）, 2021, 53(2): 286-292.

ZHOU Bo-lin,LI Wei-shi,SUN Chui-guo,QI Qiang,CHEN Zhong-qiang,ZENG Yan. Risk factors for multiple debridements of the patients with deep incisional surgical site infection after spinal surgery[J]. Journal of Peking University (Health Sciences), 2021, 53(2): 286-292.

图/表 2

表1

表2

参考文献 28

[1]	Pull ter Gunne AF, Mohamed AS, Skolasky RL, et al. The presentation, incidence, etiology, and treatment of surgical site infections after spinal surgery[J]. Spine (Phila Pa 1976), 2010,35(13):1323-1328.
[2]	Gerometta A, Rodriguez OJC, Bitan F. Infections in spinal instrumentation[J]. Int Orthop, 2012,36(2):457-464. pmid: 22218913
[3]	Fang XT, Wood KB. Management of postoperative instrumented spinal wound infection[J]. Chin Med J (Engl), 2013,126(20):3817-3821.
[4]	Chen SH, Lee CH, Huang KC, et al. Postoperative wound infection after posterior spinal instrumentation: Analysis of long-term treatment outcomes[J]. Eur Spine J, 2015,24(3):561-570. pmid: 25351841
[5]	Pull ter Gunne AF, Hosman AJ, Cohen DB, et al. A methodolo-gical systematic review on surgical site infections following spinal surgery: Part 1: risk factors[J]. Spine (Phila Pa 1976), 2012,37(24):2017-2033.
[6]	Cahill PJ, Warnick DE, Lee MJ, et al. Infection after spinal fusion for pediatric spinal deformity: Thirty years of experience at a single institution[J]. Spine (Phila Pa 1976), 2010,35(12):1211-1217.
[7]	Kim JI, Suh KT, Kim SJ, et al. Implant removal for the management of infection after instrumented spinal fusion[J]. J Spinal Disord Tech, 2010,23(4):258-265. pmid: 20084022
[8]	仉建国, 李书纲, 杨新宇, 等. 脊柱侧凸后路矫形融合术术后感染的治疗[J]. 中华骨科杂志, 2001,21(8):453-456.
[9]	Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee[J]. Am J Infect Control, 1999,27(2):97-132; Quiz 133-134; Discussion 96. pmid: 10196487
[10]	Blackmur JP, Tang EY, Dave J, et al. Use of broth cultures peri-operatively to optimise the microbiological diagnosis of musculoskeletal implant infections[J]. Bone Joint J, 2014, 96-B(11):1566-1570. doi: 10.1302/0301-620X.96B11.33852 pmid: 25371476
[11]	Tomov M, Mitsunaga L, Durbin-Johnson B, et al. Reducing surgical site infection in spinal surgery with betadine irrigation and intrawound vancomycin powder[J]. Spine (Phila Pa 1976), 2015,40(7):491-499.
[12]	郑召民, 王冰, 齐强, 等. 脊柱术后切口深部感染内置物的归宿[J]. 中国脊柱脊髓杂志, 2015(11):965-970.
[13]	Lonjon G, Dauzac C, Fourniols E, et al. Early surgical site infections in adult spinal trauma: A prospective, multicentre study of infection rates and risk factors[J]. Orthop Traumatol Surg Res, 2012,98(7):788-794.
[14]	Dubory A, Giorgi H, Walter A, et al. Surgical-site infection in spinal injury: Incidence and risk factors in a prospective cohort of 518 patients[J]. Eur Spine J, 2015,24(3):543-554. doi: 10.1007/s00586-014-3523-4 pmid: 25148864
[15]	Martin ET, Kaye KS, Knott C, et al. Diabetes and risk of surgical site infection: A systematic review and meta-analysis[J]. Infect Control Hosp Epidemiol, 2016,37(1):88-99. pmid: 26503187
[16]	Saeedinia S, Nouri M, Azarhomayoun A, et al. The incidence and risk factors for surgical site infection after clean spinal operations: A prospective cohort study and review of the literature[J]. Surg Neurol Int, 2015,6:154. pmid: 26500800
[17]	Huysman E, Mathieu C. Diabetes and peripheral vascular disease[J]. Acta Chir Belg, 2009,109(5):587-594. doi: 10.1080/00015458.2009.11680493 pmid: 19994800
[18]	Gallacher SJ, Thomson G, Fraser WD, et al. Neutrophil bactericidal function in diabetes mellitus: Evidence for association with blood glucose control[J]. Diabet Med, 1995,12(10):916-920. pmid: 8846684
[19]	Rajagopalan S. Serious infections in elderly patients with diabetes mellitus[J]. Clin Infect Dis, 2005,40(7):990-996. pmid: 15824991
[20]	Kim DH, Spencer M, Davidson SM, et al. Institutional prescreening for detection and eradication of methicillin-resistant Staphylococcus aureus in patients undergoing elective orthopaedic surgery[J]. J Bone Joint Surg Am, 2010,92(9):1820-1826. pmid: 20610773
[21]	Takahashi Y, Takesue Y, Uchino M, et al. Value of pre- and postoperative meticillin-resistant Staphylococcus aureus screening in patients undergoing gastroenterological surgery[J]. J Hosp Infect, 2014,87(2):92-97. pmid: 24836292
[22]	Kalra L, Camacho F, Whitener CJ, et al. Risk of methicillin-resistant Staphylococcus aureus surgical site infection in patients with nasal MRSA colonization[J]. Am J Infect Control, 2013,41(12):1253-1257. pmid: 23973424
[23]	Levy PY, Ollivier M, Drancourt M, et al. Relation between nasal carriage of Staphylococcus aureus and surgical site infection in orthopedic surgery: The role of nasal contamination. A systematic literature review and meta-analysis[J]. Orthop Traumatol Surg Res, 2013,99(6):645-651. pmid: 23992764
[24]	Yano K, Minoda Y, Sakawa A, et al. Positive nasal culture of methicillin-resistant Staphylococcus aureus (MRSA) is a risk factor for surgical site infection in orthopedics[J]. Acta Orthop, 2009,80(4):486-490.
[25]	Yano M, Doki Y, Inoue M, et al. Preoperative intranasal mupirocin ointment significantly reduces postoperative infection with Staphylococcus aureus in patients undergoing upper gastrointestinal surgery[J]. Surg Today, 2000,30(1):16-21. pmid: 10648077
[26]	De Lucas-Villarrubia JC, Lopez-Franco M, Granizo JJ, et al. Strategy to control methicillin-resistant Staphylococcus aureus post-operative infection in orthopaedic surgery[J]. Int Orthop, 2004,28(1):16-20. pmid: 12750847
[27]	Veeravagu A, Patil CG, Lad SP, et al. Risk factors for postoperative spinal wound infections after spinal decompression and fusion surgeries[J]. Spine (Phila Pa 1976), 2009,34(17):1869-1872.
[28]	Boston KM, Baraniuk S, O’Heron S, et al. Risk factors for spinal surgical site infection, Houston, Texas[J]. Infect Control Hosp Epidemiol, 2009,30(9):884-889. pmid: 19642902

Metrics

Viewed

Full text

Abstract

Cited

Shared

Discussed

Items	Single debridement	Multiple debridement	χ²	P
Gender			0.864	0.353
Male	36	17
Female	24	7
Age >60 years old	26	10	0.019	0.889
BMI≥28	22	10	0.182	0.670
Primary operation duration >3 h	16	13	5.735	0.017
Blood loss >400 mL	24	17	6.523	0.011
Segments number			0.120	0.942
2-3	29	12
4-5	27	10
>5	4	2
Systemic inflammatory response	22	13	2.160	0.142
Diabetes	10	9	4.251	0.039
Bacterial culture results			13.581	0.002
MRSA	2	7
Methicillin-sensitive Gram-positive bacteria	20	9
Others	18	8
Distal infection	10	10	6.906	0.015
Diagnosis			3.635	0.162
Tumor	1	1
Trauma	3	4
Degenerative	56	19
Implement used	44	21	1.966	0.161
Surgical approach			0.000	1.000
Posterior	59	23
Anterior and posterior	1	1
Surgical location			5.597	0.061
Cervical	16	2
Thoracic	3	4
Lumbar	41	18