关于感染的判定
<p>各位大虾，各位战友，小弟有病例请大家判定：属于什么感染？判定依据是什么？</p><p>病例如下</p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt;"><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">：患者：某某某<span lang="EN-US"><span style="mso-spacerun: yes;"> </span></span>性别：女<span lang="EN-US"><span style="mso-spacerun: yes;"> </span></span>年龄：<span lang="EN-US">22</span>岁<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt;"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;"><span style="mso-spacerun: yes;"> </span></span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">入院诊断：<span lang="EN-US">G<sub>1</sub>P<sub>0</sub></span><sup>①</sup><span lang="EN-US">39</span><sup>＋<span lang="EN-US">3</span></sup>周孕头位剖宫产<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt;"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;"><span style="mso-spacerun: yes;"> </span></span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">入院日期：<chsdate wst="on" isrocdate="False" islunardate="False" day="19" month="2" year="2007"><span lang="EN-US">2007</span>年<span lang="EN-US">2</span>月<span lang="EN-US">19</span>日</chsdate><span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 45pt; mso-char-indent-count: 3.0;"><chsdate wst="on" isrocdate="False" islunardate="False" day="19" month="2" year="2007"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">2007</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">年<span lang="EN-US">2</span>月<span lang="EN-US">19</span>日</span></chsdate><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">22</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">：<span lang="EN-US">40</span>硬膜外麻醉下行剖宫产，清理宫腔后以<span lang="EN-US">0/2</span>自溶线连续<span lang="EN-US">2</span>次缝合子宫切口，术后失血约<span lang="EN-US">200mL</span>。术后予以丁卡、洁霉素预防感染。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><chsdate wst="on" isrocdate="False" islunardate="False" day="20" month="2" year="2007"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">2</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">月<span lang="EN-US">20</span>日</span></chsdate><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">，查体温度：<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="39.2" unitname="℃"><span lang="EN-US">39.2</span>℃</chmetcnv>；<span lang="EN-US">21</span>日<span lang="EN-US">19</span>：<span lang="EN-US">00</span>主管医师查房：查体<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="38.8" unitname="℃"><span lang="EN-US">38.8</span>℃</chmetcnv>，腹部切口对合好，稍许发红，无渗血渗液，阴道稍许血性恶露，无恶臭，急查血：<span lang="EN-US">WBC:12.9</span>×<span lang="EN-US">10<sup>9</sup></span>，中性<span lang="EN-US">11.6</span>，考虑切口感染。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><chsdate wst="on" isrocdate="False" islunardate="False" day="22" month="2" year="2007"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">2</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">月<span lang="EN-US">22</span>日</span></chsdate><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">10</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">：<span lang="EN-US">00</span>，查体<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="36.3" unitname="℃"><span lang="EN-US">36.3</span>℃</chmetcnv>，伤口稍许发红，无渗血，稍许渗液为淡黄色；<span lang="EN-US">22</span>：<span lang="EN-US">00</span>查体<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="39.4" unitname="℃"><span lang="EN-US">39.4</span>℃</chmetcnv>。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">23</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">日最高体温<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="37.9" unitname="℃"><span lang="EN-US">37.9</span>℃</chmetcnv>；<span lang="EN-US">24</span>日最高体温<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="38.8" unitname="℃"><span lang="EN-US">38.8</span>℃</chmetcnv>；<span lang="EN-US">25</span>日最高体温<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="37.4" unitname="℃"><span lang="EN-US">37.4</span>℃</chmetcnv>；<span lang="EN-US">26</span>日<span lang="EN-US">8</span>：<span lang="EN-US">00</span>查体<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="38.8" unitname="℃"><span lang="EN-US">38.8</span>℃</chmetcnv>；<span lang="EN-US">27</span>日<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="38.5" unitname="℃"><span lang="EN-US">38.5</span>℃</chmetcnv>。<span lang="EN-US"><p></p></span></span></p><p> </p>关于感染的判定
<p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><chsdate wst="on" isrocdate="False" islunardate="False" day="26" month="2" year="2007"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">2</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">月<span lang="EN-US">26</span>日</span></chsdate><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">感染科会诊记录：病况敬悉，患者术后发热<span lang="EN-US">1</span>周，伴精神食欲差，无畏寒、头痛、恶心、呕吐、腹泻、抽搐及咳嗽、神志改变。查体：<span lang="EN-US">T<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="39" unitname="℃">39.0<span lang="EN-US"><span lang="EN-US">℃</span></span></chmetcnv><span lang="EN-US">，神萎，肤目未见黄染、出血点，浅表淋巴结无肿大，球结膜不充血，颈软，心、肺未见异常，腹膨胀，下腹伤口有稍许脓血性分泌物，左腹痛明显<span lang="EN-US">，无反跳痛，肌紧张，双下肢无水肿，严密观察：WBC</span></span></span>和中性升高。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">我科考虑：发热待诊，败血症可能性较大，但不除外伤口感染和盆腔感染。建议作：<span lang="EN-US">1</span>、血常规和伤口分泌物培养；肥达氏反应。<span lang="EN-US">2</span>、可适当调整抗生素为加替沙星<span lang="EN-US">100ml/Q12h</span>，（如不喂奶）加替硝唑注射液。<span lang="EN-US">3</span>、复查电解质。<span lang="EN-US">4</span>、尽量使用物理降温，并测定体温曲线。我科随访。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><chsdate wst="on" isrocdate="False" islunardate="False" day="27" month="2" year="2007"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">2</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">月<span lang="EN-US">27</span>日</span></chsdate><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">11</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">：<span lang="EN-US">00<span style="mso-spacerun: yes;"> </span></span>血常规：<span lang="EN-US">WBC14.3</span>，电解质：<span lang="EN-US">Na127.9</span>，<span lang="EN-US">Kcl2.63</span>，胸片提示：双肺感染。超声检查：子宫附件：双侧附件区显示不满意。盆腔子宫周围可见条状低回声区，其内透声差，较宽处约<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="1.9" unitname="cm"><span lang="EN-US">1.9cm</span></chmetcnv>，肠间可见散在不规则的低回声区，较宽处约<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="1.5" unitname="cm"><span lang="EN-US">1.5cm</span></chmetcnv>，腹壁切口区未见确切团块图像。诊断提示：未复旧子宫，宫壁局灶性回声改变，盆腔及肠间低回声区。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">主任查房：切口可能是脂肪液化，无恶变，不再作培养。抽取盆腔积液培养。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">27</span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">日<span lang="EN-US">14</span>：<span lang="EN-US">30</span>呼吸内科会诊记录<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">T<chmetcnv wst="on" tcsc="0" numbertype="1" negative="False" hasspace="False" sourcevalue="39.4" unitname="℃">39.4<span lang="EN-US"><span lang="EN-US">℃</span></span></chmetcnv><span lang="EN-US">，下午及夜间发热，无畏寒寒战，无咳嗽、咳痰，呼吸困难，左肺后背段可闻见湿罗音，血常规WBC12.9</span></span><span style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;">×<span lang="EN-US">10<sup>9</sup></span>，胸片显示：双下肺炎变。我科会诊：病人由于肺部感染所致发热属发热性发热，盆腔内感染可能性大，建议必要时作血培养，加强抗感染力度，可加头孢Ⅰ代，加替沙星改为分次使用为<span lang="EN-US">0.4</span>一次性使用。其它诊断治疗同贵科。如有情况我科随访。<span lang="EN-US"><p></p></span></span></p><p class="MsoNormal" style="MARGIN: 0cm 0cm 0pt; TEXT-INDENT: 30pt;"><span lang="EN-US" style="FONT-SIZE: 15pt; FONT-FAMILY: 仿宋_GB2312;"><p> </p></span></p> <p>渗液是否进行培养，另外是否进行血液培养！</p> 渗液培养正常，未进行血液培养，仅做了血常规。 <font face="楷体_GB2312" size="6">一枝梅：产后使用丁卡，不利于产妇哺乳。建议使用对新生儿更安全的抗菌药物。</font> 谢谢楚楚的提醒，好意见，我转达。再次谢谢，以后多交流哈！ 回报：以上病例经过抽取盆腔积液培养，病原菌为：大肠埃希菌。据此判定此次感染为：1、医院感染；2、肺部感染；3、盆腔感染。回复一枝梅
<p><font size="4">一枝梅 ：您好！</font></p><p><font size="4"> 这个病例是择其还是急诊剖宫产？是否先已破膜？术后子宫复旧如何？血常规具体怎样？盆腔积液培养，病原菌为：大肠埃希菌，那么肺部感染的依据呢？</font></p><p><font size="4"> <font size="5">另还有一个问题：洁霉素预防感染，洁霉素是大环内酯类（是抑菌剂），不应该作为预防用药吧！尽量选择杀菌剂，你说呢？</font></font></p> 如果仅有血常规和体温，术后三天可能也会出现吸收热啊？大肠杆菌会不会是污染菌？ 这个病人应综合考虑是否合并羊水污染，术前的血象，和术前是否有其他合并症，应做血培养，是否有败血症的发生，单从伤口上看，不能说明有伤口感染。应在22日做分泌物涂片，是白细胞还是脂肪球，是白细胞应在做细菌培养，是脂肪球考虑是脂肪液化。应不属于医院感染。 如伤口愈合好，应是盆腔感染。回复 #8 hty 的帖子
同意楼主意见！手术后１天血常规的血象高是很正常的（生理反应机制）！要一周后持续增高，临床出现发热等症状才考虑感染！！回复 #2 zzt1442 的帖子
梅竹近期告假，暂时不能与你探讨！欢迎你继续参与讨论！:victory:
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