这种手术切口感染病原体，国人的错误认识常导致恐慌和错误处置！
A 66-year-old white man underwent surgery for coloncarcinoma, and 2 days later he experienced severe pain at the surgicalwound site. Within several hours, local edema and tendernessdeveloped at the wound, as well as a thin, brownish discharge.Prior to surgery and this episode, he had alwaysmaintained good health. His social history was unremarkable.PHYSICALEXAMINATION VS: T 37.6°C, P 136/min, R 26/min, BP 80/52 mmHgPE: The patient appeared very ill. The surgical wound siteexhibited discoloration of skin and hemorrhagic bullae. There wasa serosanguineous discharge from the infected wound. The affectedmuscles showed failure to bleed, and there was extensive gas in thesoft tissues.【google翻译】一位66岁的白人男子结肠癌接受手术，2天后，他经历了剧烈的疼痛，手术伤口部位。在几个小时内，在伤口局部水肿和压痛，以及一个薄的，带褐色的分泌物。手术和这个情节之前，他一直保持着良好的健康。他的社会历史是不值一提。
体检VS：Ť37.6°C，P136/min，R26/min，血压80/52毫米汞柱PE：病人出现病得很重。手术伤口部位表现出变色的皮肤和出血性大疱。从被感染的伤口排出有一个血性的。受影响的肌肉显示不流血，并有广泛的气体在软组织。
LABORATORYSTUDIESBlood
ESR: 36 mm/hHematocrit: 34%WBC: 15,400/μLDifferential: 60% PMNs, 23% bands, 15% lymphsBlood gases: pH 7.23, pCO2 30 mmHg, pO2 90 mmHgSerum chemistries: creatinine 2.3 mg/dL, LDH 310U/L, bilirubin 2.8 μmol/LImagingNo imaging studies were done.DiagnosticWork-UpTable 69-1 lists the likely causes of illness(differential diagnosis). Both needle aspirate of pus and tissue biopsy are appropriatefor anaerobic cultures. Investigational approach may include【Google翻译】实验室研究血
ESR：36毫米/小时红细胞压积：34％WBC：15,400/μL分类：60％的中性粒细胞，23％的杆状，15％lymphs淋巴血气分析：pH值7.23，二氧化碳分压30毫米汞柱，氧分压90毫米汞柱血清生化检查：肌酐2.3毫克/升，乳酸脱氢酶310 U / L，胆红素2.8微摩尔/升成像没有进行影像学检查。诊断工作表1列出的可能原因疾病（鉴别诊断）。两个针抽吸脓液和组织活检适合厌氧文化。调查方法可能包括
Differential Diagnosis andRationale for Inclusion (consideration)
Anaerobic infection (Clostridium perfringens;polymicrobic)Gram-negative bacterial (e.g., Escherichia coli,Klebsiella spp) infectionMixed infectionStaphylococcus aureusStreptococcus pyogenes
鉴别诊断和纳入的理由（考虑）
厌氧菌感染（产气荚膜梭状芽胞杆菌; 多种微生物）
革兰氏阴性菌（如大肠杆菌，克雷伯氏菌）感染
混合感染
金黄色葡萄球菌
化脓性链球菌
Rationale: The medical history and findings on physicalexamination should arouse suspicion of anaerobic infection. Predisposingfactors (e.g., solid tumor), foul odor of lesion or drainage, gas ordiscoloration in tissue, and tissue necrosis, gangrene, or abscess point towarda narrowed differential diagnosis. Gas gangrene is commonly caused byclostridial species (e.g., C. perfringens). However, Gram-negativebacteria, which are much more common with surgical infections, may, rarely,cause gas in mixed infections of soft tissue. Gram-positive organisms (e.g., Strep.pyogenes, Staph. aureus) also commonly cause postsurgical infections, butusually not gas gangrene. • Gram strain. Typical bacterialmorphologies are suggestive of anaerobes.• Cultures of pus or wound aspirate onselective and nonselective media• Aerobic culture. “Sterile pus” (no growth)indicates anaerobes• Selective anaerobic cultures and speciesidentification
【google翻译】理由：病史和体检结果应该引起怀疑厌氧菌感染。诱发因素（例如，固体肿瘤病变或排水），难闻的气味，气体或变色的组织，组织坏死，坏疽，或脓肿指向一个狭窄的鉴别诊断。气性坏疽的常见原因梭菌物种（如产气荚膜梭菌）。然而，革兰阴性菌，更常见的是与外科手术感染，可能很少，导致气体在混合感染的软组织。革兰阳性菌（如链球菌，化脓性链球菌，金黄色葡萄球菌）也通常导致手术后感染，但通常不气性坏疽。
•革兰株。典型的细菌形态提示厌氧菌。•在选择性和非选择性的平板培养脓液或伤口分泌物•需要培养。 “无菌脓”（没有增长）表示厌氧菌•选择性厌氧培养和物种鉴定
COURSEThe patient was taken to a surgical unit, where hiswound was débrided for cleaning. He was treated with intravenous antibiotics(directed at the anaerobic and facultative anaerobic organisms). A Gram stainof the wound aspirate revealed sparse PMN leukocytes and many large,Gram-positive rods together with a mixture of Gram-negative rods andGram-positive cocci. Anaerobic cultures were diagnostic.
课程病人到手术单位，清洗他的伤口清创。他静脉注射抗生素针对厌氧和兼性厌氧生物处理。伤口分泌物革兰氏染色显示散在的中性粒白细胞和许多大，革兰氏阳性杆菌，革兰阴性杆菌和革兰氏阳性球菌的混合物一起。厌氧培养有诊断意义。
ETIOLOGYClostridium perfringens (gas gangrene)MICROBIOLOGICPROPERTIESThe important clostridial species, C.perfringens, C. septicum, C. novyi, and C. ramosum, are large,box-shaped Gram-positive rods (Fig. 69-1A) and are anaerobic,spore-forming bacteria. Spores are rarely seen in clinical specimens.The organisms are catalase negative and are unable to deactivate H2O2 or O2. (superoxide), which are toxicto the bacteria. The organisms grow only in the deep tissues of the body withlow redox pontential. Many clinically significant anaerobes are aerotolerant(2% to 8% oxygen), in part because they produce superoxide dismutase. Anaerobesfail to grow on solid media in 10% CO2 in air (18% oxygen). Clostridia growslowly (48 to 72h) under anaerobic conditions. Blood agar culture of C.perfringens from an anaerobic cellulitis lesion yields round, grayish-whitecolonies, with an opaque center surrounded by a double zone of β-hemolysis(see Fig. 69-1B). Toxigenic strains cause disease; a significant link toclinical disease is the toxigenicity of the C. perfringens isolate.Nagler reaction for positive lecithinase on egg-yolk agar, neutralized byantitoxin, is the positive proof for a toxigenic isolate.
FIGURE 69-1 A, Gram stain of needle aspirate of anaerobiccellulitis lesion revealing Clostridium perfringens. Note absence of PMNexudates. B, Culture of Clostridium perfringens grown onanaerobic blood agar medium. Note a characteristic double-zone β-hemolysis
【google翻译】病因产气荚膜梭菌（气性坏疽）
微生物特性最重要的产气荚膜梭菌， C.坏疽抗毒素， C. novyi ， C. ramosum ，梭菌种，大，盒形（图-1A ）和革兰氏阳性杆菌是厌氧孢子形成细菌。孢子临床标本中很少见到。生物体的过氧化氢酶阴性，无法停用过氧化氢（ H2O2 ）或O2 。 （超），这是有毒的细菌。生物生长只有在人体深部组织，与低氧化还原pontential的。许多临床显着性厌氧菌耐氧（ 2％至8％的氧气） ，部分原因是因为它们产生的超氧化物歧化酶。厌氧菌无法在固体培养基上生长，在10 ％的空气中CO2 （18 ％氧气） 。梭状芽胞杆菌生长缓慢，在厌氧条件下（ 48至72小时） 。血液琼脂培养基的产气荚膜梭菌的厌氧性蜂窝织炎病变产生圆形，灰白色菌落，用不透明的β -溶血一个双区（参见图 - 1B ）所包围的中心。产毒株引起的疾病;临床疾病的一个重要环节是毒力的产气荚膜梭菌分离。积极的卵磷脂，卵黄琼脂NAGLER反应中的抗毒素，是的积极证明分离产毒。
图69-1 A，革兰氏染色，揭示产气荚膜梭菌厌氧蜂窝织炎病变针穿刺。注意中性粒细胞渗出的情况下。 B，培养产气荚膜梭菌厌氧血琼脂培养基上生长。注意特征的双区β -溶血。
EPIDEMIOLOGYClostridium species are part of the normal human or animalflora, and vegetative cells are found in the colon. C. perfringensorganisms cause disease only when they leave their normal niche (colon) andmake their way to a new location (as occurred in this case). Most infectionsare caused by a mixture of bacteria (2 to 10 different species; anaerobes andaerobes or facultative anaerobes of colonic origin). Any host abnormality thatcauses vascular stasis elevates the risk for anaerobic infection.Carcinoma, diabetes mellitus, colonic (fecalith) obstruction,treatment with immunosuppressive agents, and chemotherapy for malignancy arerecognized predisposing factors for endogenous anaerobic infection.Clostridial spores are found in soil. Exogenous infection is caused via soil contamination of a deep wound from trauma.
流行病学梭状芽孢杆菌属的人类或动物的正常菌群的一部分，和营养细胞在结肠中被发现的。产气荚膜梭菌生物体引起疾病，只有当他们离开其正常的利基（结肠），使他们的方式到一个新的位置（在这种情况下发生）。大多数感染是由细菌（2到10个不同的品种;厌氧菌和需氧菌或兼性厌氧菌，结肠起源）的混合物。任何主机异常，导致血管瘀提升厌氧菌感染的风险。癌，糖尿病，结肠阻塞（fecalith），用免疫抑制剂治疗，恶性肿瘤化疗，确认内源性厌氧菌感染的诱发因素。梭菌孢子在土壤中发现的。外源性感染是通过土壤污染的一道深深的伤口创伤引起。 PATHOGENESISThis is a typical case of cellulitis withprogression to gas gangrene, and the usual culprit is C. perfringens.Bowel surgery to remove a solid tumor allows anaerobes and facultativeanaerobes from the colon access to tissues. The facultative anaerobes assistthe primary anaerobes to proliferate outside their normal sites of habitation,creating a growth environment with low oxygen potential. Under the rightconditions, C. perfringens can invade and multiply in essentially anytissue. At the new location, toxigenesis occurs. Clostridial α-toxinis cytolytic owing to activity of phospholipase C activity on cell membranes.Other catabolic enzymes produced by C. perfringens yield gas in tissues,producing crepitance. Systemically, the patient develops fever, sweating, andlow blood pressure. Muscle grows black and gangrenous.Clostridial infection often disseminates and causesblood stream infection (bacteremia). Isolation of Clostridium septicumfrom blood cultures suggests colon cancer or leukemic cecitis. C.perfringens and C. novyi cause soft-tissue inflammation and fatalbacteremia in injecting drug users.
发病机制 这是一个典型的蜂窝织炎，进展到气性坏疽的情况下，通常的罪魁祸首是产气荚膜梭菌。肠手术切除实体瘤使厌氧菌和兼性厌氧菌组织结肠访问。兼性厌氧菌协助的主要厌氧菌增殖外他们正常居住遗址，低氧气潜力创造一个成长的环境。在合适的条件下，产气荚膜梭菌可侵入和繁殖基本上任何组织。在新的位置，产毒素发生。梭菌α毒素是由于细胞膜上的磷脂酶C活性活性细胞杀伤。其他由产气荚膜梭菌产生的代谢酶组织中产生气体，生产crepitance。全身，病人出现发热，大量出汗，血压低。黑色和坏疽性肌肉生长。梭菌感染往往传播并导致血流感染（菌血症）。坏疽抗毒素梭菌血培养分离表明结肠癌或白血病盲肠炎的。产气荚膜梭菌和C. novyi的会导致软组织发炎，注射吸毒者致命的菌血症。 TREATMENTSurgical drainage and débridement are essential to controlthe infection initially. Antibiotic therapy relies on drugs withgenerally good activity against anaerobes, with some variation insusceptibility. Most isolates are susceptible to penicillin, and it isconsidered the drug of choice. However, other antibiotics are also effectiveand have a broader spectrum: metronidazole (anaerobes only), clindamycin,piperacillin/ tazobactam, imipenem/cilastatin, or meropenem. Antibioticsusceptibility testing is difficult and is indicated only for certain isolatesfrom serious infections (from normally sterile sites).
【google翻译】治疗排水和清创手术是必不可少最初以控制感染。抗生素治疗依赖于药物对厌氧菌的活动总体上是好的，有一些变化的敏感性。大多数菌株对青霉素敏感，它被认为是首选药物。然而，其他抗生素也有效，更广泛：甲硝唑（厌氧菌），克林霉素，哌拉西林/他唑巴坦，亚胺培南/西司他丁，美罗培南。药敏试验是困难的，表示只对某些菌株严重感染（通常无菌部位）。
OUTCOMEThe patient received penicillin and clindamycin andgradually recovered over the course of the next 2 weeks. His recovery wasattributed to successful treatment of polymicrobial infection.
观察该患者接受青霉素和克林霉素，在接下来的2周的过程中逐渐恢复。他的恢复是由于多种微生物感染治疗成功。
PREVENTIONThereis no vaccine for C. perfringens. Gas gangrene is best prevented byimmediate and thorough irrigation and débridement of traumatic wounds andappropriate antibiotic prophylaxis before surgery. Antibiotics used shouldtarget anaerobes as well as enteric Gram-negative bacteria.
预防目前尚无疫苗的产气荚膜梭菌。气性坏疽是最好的防止立即和彻底灌溉和创伤性伤口的清创手术前的预防用药和适当的抗生素。使用抗生素应该针对厌氧菌以及肠道革兰阴性菌。
这个病例很有教育意义，谢谢楼主。应该给我们的外科医生学习学 习 这类感染的预防方法，本案例阐述很明白！
但是，我国目前是如何预防的？相关规定是如何要求的？
针对这个病原体的感控要求，手术室的消毒和用后规定，不少是拍脑袋想出来的，多数没有循证证据。 所以腹腔手术的腹腔内生理盐水冲洗十分必要。 我们的引领者总是给我们以引导和深思，我们的患者手术后环境和手术器械的处理，虽然在供应中心管理规范上有讲到器械的处理，但还有术前、术中、术后怎么落实标准预防还是需要思考的。 我们的院长助理分不清坏疽和炭疽呢！呵呵
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