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本帖最后由 jerkran 于 2024-8-16 08:49 编辑
https://mp.weixin.qq.com/s?__biz=MzkzOTI0OTU5Ng==&mid=2247539015&idx=2&sn=298be2ba2b0fd472b6f38bab99d43d5a&chksm=c2f1c394f5864a82d3dbee06e95ec184a823fea404e9bbdbce4343a639b18509415cb7c42bc4&token=1614542203&lang=zh_CN#rd
Strategies to prevent surgical site infections in acute-care hospitals:2022 Update
预防急症护理医院手术部位感染的策略：2022 年更新
Abstract and purpose 摘要和目的[color=rgba(0, 0, 0, 0.9)]The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014.1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.本文件旨在以简洁的格式突出实用建议，旨在帮助急症护理医院实施和优先考虑其手术部位感染 （SSI） 预防工作。本文件更新了 2014 年发布的《预防急症护理医院手术部位感染的策略》。 本专家指导文件由美国卫生保健流行病学学会 （Society for Healthcare Epidemiology of America， SHEA） 赞助。它是由 SHEA、美国传染病学会 （IDSA）、感染控制和流行病学专业人员协会 （APIC）、美国医院协会 （AHA） 和联合委员会（TJC）领导的合作努力的产物，许多具有专业知识的组织和学会的代表做出了重要贡献。 Summary of major changes 主要更新摘要This section lists major changes from the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update,Reference Anderson, Podgorny and Berríos-Torres1 including recommendations that have been added, removed, or altered. Recommendations are categorized as essential practices that should be adopted by all acute-care hospitals (in 2014 these were “basic practices,” renamed to highlight their importance as a foundation for hospitals’ healthcare-associated infection (HAI) prevention programs) or additional approaches that can be considered for use in locations and/or populations within hospitals when SSIs are not controlled after implementation of essential practices (in 2014 these were called “special approaches”). See Table 1 for a complete summary of recommendations contained in this document.
本部分列出了《预防急症护理医院手术部位感染的策略：2014 年更新》的主要更改， Reference Anderson, Podgorny and Berríos-Torres1 包括已添加、删除或更改的建议。建议被归类为所有急症护理医院都应采用的基本实践（在 2014 年，这些是“基本实践”，更名以强调它们作为医院医疗保健相关感染 （HAI） 预防计划基础的重要性），当医疗机构在实施SSI基本实践后可以进一步提高要求时，可以考虑使用进一步实践方法用于医院内的其它科室和/或高危人群，（在 2014 年，这些方法被称为“特殊方法”）。有关本文档中包含的建议的完整摘要，请参见表 1。Table 1. Summary of Recommendations to Prevent Surgical Site Infections (SSIs)表 1.预防手术部位感染 （SSI） 的建议摘要 [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)]表1 翻译如下：
Essential practices 基本实践做法1. Administer antimicrobial prophylaxis according to evidence-based standards and guidelines.73,75 (Quality of evidence: HIGH)1. 根据循证证据和指南实施抗微生物药物预防。 73,75 （证据质量：高）2. Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery to reduce the risk of SSI.115,116 (Quality of evidence: HIGH)2. 在择期结直肠手术前联合使用肠外和口服抗菌药物预防，以降低 SSI 的风险。 115,116 （证据质量：高）3. Decolonize surgical patients with an anti-staphylococcal agent in the preoperative setting for orthopedic and cardiothoracic procedures. (Quality of evidence: HIGH) Decolonize surgical patients in other procedures at high risk of staphylococcal SSI, such as those involving prosthetic material. (Quality of evidence: LOW)3. 在骨科和心胸外科手术的术前环境中使用抗葡萄球菌剂对手术患者进行去定植。（证据质量：高）在葡萄球菌 SSI 高风险的其他手术中对手术患者进行去定植，例如涉及假体材料的手术。（证据质量：低）4. Use antiseptic-containing preoperative vaginal preparation agents for patients undergoing cesarean delivery or hysterectomy. (Quality of evidence: MODERATE)4.对接受剖宫产或子宫切除术的患者使用含消毒剂的术前阴道准备剂。（证据质量：中等）5. Do not remove hair at the operative site unless the presence of hair will interfere with the surgical procedure.4,119 (Quality of evidence: MODERATE)5.不要在手术部位脱毛，除非毛发的存在会干扰手术过程。 4,119 （证据质量：中等）6. Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic. (Quality of evidence: HIGH)6.将含酒精的术前皮肤准备剂与抗菌剂结合使用。（证据质量：高）7. For procedures not requiring hypothermia, maintain normothermia (temperature > 35.5°C) during the perioperative period. (Quality of evidence: HIGH)7.对于不需要体温过低的手术，围手术期保持体温正常（体温>35.5°C）。（证据质量：高）8. Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (Quality of evidence: HIGH)8.使用不透水的塑料伤口保护器进行胃肠道和胆道手术。（证据质量：高）9. Perform intraoperative antiseptic wound lavage.171 (Quality of evidence: MODERATE)9.进行术中抗菌剂伤口灌洗。 171 （证据质量：中等）10. Control blood-glucose level during the immediate postoperative period for all patients.94 (Quality of evidence: HIGH)10.控制所有患者术后即刻的血糖水平。 94 （证据质量：高）11. Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety. (Quality of evidence: HIGH)11. 使用检查清单和/或集束措施包来确保遵守最佳实践，以提高手术患者的安全性。（证据质量：高）12. Perform surveillance for SSI. (Quality of evidence: MODERATE)12. 对 SSI 进行监测。（证据质量：中等）13. Increase the efficiency of surveillance by utilizing automated data. (Quality of evidence: MODERATE)13. 利用自动化数据提高监测效率。（证据质量：中等）14. Provide ongoing SSI rate feedback to surgical and perioperative personnel and leadership. (Quality of evidence: MODERATE).14. 向外科和围手术期人员和领导提供持续的 SSI 率反馈。（证据质量：中等）。15. Measure and provide feedback to HCP regarding rates of compliance with process measures.94 (Quality of evidence: LOW)15. 衡量并向 HCP 提供有关流程措施遵守率的反馈。 94 （证据质量：低）16. Educate surgeons and perioperative personnel about SSI prevention measures. (Quality of evidence: LOW)16. 对外科医生和围手术期人员进行 SSI 预防措施的教育。（证据质量：低）17. Educate patients and their families about SSI prevention as appropriate. (Quality of evidence: LOW)17. 酌情对患者及其家属进行 SSI 预防教育。（证据质量：低）18. Implement policies and practices to reduce the risk of SSI for patients that align with applicable evidence-based standards, rules and regulations, and medical device manufacturer instructions for use.4,94 (Quality of evidence: MODERATE)18. 实施符合适用的循证标准、规则和条例以及医疗器械制造商使用说明的政策和做法，以降低患者患 SSI 的风险。 4,94 （证据质量：中等）19. Observe and review operating room personnel and the environment of care in the operating room and in central sterile reprocessing. (Quality of evidence: LOW)19.观察和审查手术室人员和手术室及消毒供应中心无菌再处理中的护理环境。（证据质量：低）
Additional approaches 进一步实践方法Perform an SSI risk assessment. (Quality of evidence: LOW)1. 执行 SSI 风险评估。（证据质量：低）2. Consider use of negative pressure dressings in patients who may benefit. (Quality of evidence: MODERATE)2. 考虑对可能获益的患者使用负压敷料。（证据质量：中等）3. Observe and review practices in the preoperative clinic, postanesthesia care unit, surgical intensive care unit and/or surgical ward. (Quality of evidence: MODERATE)3. 观察和审查术前门诊、麻醉后监护室、外科重症监护室和/或外科病房的做法。（证据质量：中等）4. Use antiseptic-impregnated sutures as a strategy to prevent SSL (Quality of evidence: MODERATE)4.使用抗菌剂浸渍缝合线作为预防SSL的策略（证据质量：中等）
Approaches that should not be considered a routine part of SSI prevention不应被视为 SSI 预防常规部分的方法1. Do not routinely use vancomycin for antimicrobial prophylaxis.73 (Quality of evidence: MODERATE)1.不要常规使用万古霉素进行抗菌预防。 73 （证据质量：中等）2. Do not routinely delay surgery to provide parenteral nutrition. (Quality of evidence: HIGH)2. 不要常规地延迟手术以提供肠外营养。（证据质量：高）3. Do not routinely use antiseptic drapes as a strategy to prevent SSL (Quality of evidence: HIGH)3.不要常规使用消毒敷料作为预防SSL的策略（证据质量：高）
Unresolved issues 未解决的问题1. Optimize tissue oxygenation at the incision site1. 优化切口部位的组织氧合2. Preoperative intranasal and pharyngeal CHG treatment for patients undergoing cardiothoracic procedures2. 接受心胸外科手术的患者的术前鼻内和咽部CHG治疗3. Use of gentamicin-collagen sponges3.庆大霉素-胶原蛋白海绵的使用4. Use of antimicrobial powder4.抗菌粉的使用5. Use of surgical attire5. 手术服的使用
Essential practices 基本实践做法Modified recommendation to administer prophylaxis according to evidence-based standards and guidelines to emphasize that antimicrobial prophylaxis should be discontinued at the time of surgical closure in the operating room.修订了根据循证标准和指南进行预防的建议，以强调在手术室进行手术闭合时应停止抗微生物药物预防。 The use of parenteral and oral antibiotics prior to elective colorectal surgery is now considered an essential practice. This recommendation was included in the 2014 document but was a sub-bullet recommendation. This recommendation was elevated to its own recommendation for increased emphasis.在择期结直肠手术前使用肠外和口服抗生素现在被认为是一种基本做法。该建议包含在 2014 年的文件中，但只是一个子项目符号建议。这项建议被提升为它自己的建议，以进一步强调。 Reclassified decolonization of surgical patients with an anti-staphylococcal agent for cardiothoracic and orthopedic procedures from an Additional Approach to an Essential Practice.将使用抗葡萄球菌剂进行心胸和骨科手术的手术患者的去定植重新分类，从附加方法到基本实践。 The use of vaginal preparation with an antiseptic solution prior to cesarean delivery and hysterectomy was added as an essential practice.在剖宫产和子宫切除术之前使用消毒液进行阴道准备被添加为一项基本做法。 Reclassified intraoperative antiseptic wound lavage from an Additional Approach to an Essential Practice. However, this approach should only be used when sterility of the antiseptic can be ensured and maintained.将术中消毒伤口灌洗从“进一步实践方法”重新分类为“基本实践”。然而，只有当可以确保和保持消毒剂的无菌性时，才应使用这种方法。 Control of blood-glucose levels during the immediate postoperative period for all patients was modified (1) to emphasize the importance of this intervention regardless of a known diagnosis of diabetes mellitus, (2) to elevate the evidence level to “high” for all procedures, and (3) to lower the target glucose level from <180 mg/dL to 110–150 mg/dL.修改了所有患者术后即刻血糖水平的控制：（1） 强调这种干预的重要性，无论已知的糖尿病诊断如何，（2） 将所有手术的证据水平提高到“高”，以及 （3） 将目标血糖水平从 <180 mg/dL 降低到 110-150 mg/dL。 Reclassified use of bundles to promote adherence with best practices from Unresolved to an Essential Practice. Discussion of the use of checklists and bundles was combined for this recommendation.重新分类了集束措施包的使用，以促进对最佳实践的遵守，从未解决过，也未解决，变成了基本实践。本建议合并了关于使用核查清单和**包的讨论。 Reclassified observe and review operating room personnel and the environment of care in the operating room and central sterile reprocessing from an Additional Approach to an Essential Practice.重新分类、观察和审查手术室人员和手术室的护理环境，以及消毒供应中心无菌再处理，分类到基本实践方法。
- Additional approaches 进一步实践方法
Reclassified the recommendation to perform an SSI risk assessment from an Essential Practice to an Additional Approach.将执行 SSI 风险评估的建议从“基本实践”重新分类为“附加方法”。 The use of negative pressure dressings was added as an Additional Practice. To date, available evidence suggests that this strategy is most likely effective in specific procedures (eg, abdominal procedures) and/or specific patients (eg, increased body mass index).负压敷料的使用被添加为一项额外的做法。迄今为止，现有证据表明，该策略最有可能在特定手术（如腹部手术）和/或特定患者（如体重指数升高）中有效。 Reclassified the use of antiseptic-impregnated sutures from Not Recommended to Additional Approaches.将消毒剂浸渍缝合线的使用从“不推荐”重新分类为“其他方法”。
Reclassified the use of supplemental oxygen for patients requiring mechanical ventilation from an Essential Practice to Unresolved.将需要机械通气的患者使用补充氧气从“基本实践”重新分类为“未解决”。 Added discussion on the use of antimicrobial powder.增加了关于使用抗菌粉剂的讨论。 Added discussion on the use of surgical attire as a strategy to prevent SSI.增加了关于使用手术服作为预防 SSI 的策略的讨论。
[color=rgba(0, 0, 0, 0.9)]This document was developed following the process outlined in the Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents.2 No guideline or expert guidance document can anticipate all clinical situations, and this document is not meant to be a substitute for individual clinical judgment by qualified professionals.本文件是按照《SHEA 赞助指南手册》和《专家指导文件》中概述的流程制定的。 2 没有任何指南或专家指导文件可以预测所有临床情况，本文件不能替代合格专业人员的个人临床判断。 [color=rgba(0, 0, 0, 0.9)]This document is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, writing-group consensus, and consideration of potential harm, when applicable. A summary list of recommendations is provided along with the relevant rationale in Table 1.本文件基于现有证据、理论依据、当前实践、实际考虑因素、写作小组共识以及对潜在危害的考虑（如适用）的综合。表1提供了建议的简要清单以及相关理由。 Methods 方法SHEA recruited 3 subject-matter experts in the prevention of SSI to lead the panel of members representing the Compendium partnering organizations—SHEA, IDSA, APIC, AHA, and The Joint Commission, as well as representation by the Centers for Disease Control and Prevention (CDC).SHEA 招募了 3 名预防 SSI 的主题专家来领导代表 Compendium 合作组织（SHEA、IDSA、APIC、AHA 和TJC）的成员小组，以及疾病预防与控制中心 （CDC） 的代表。 SHEA utilized a consultant medical librarian, who developed a comprehensive search strategy for PubMed and Embase (January 2012–July 2019, updated to August 2021). Article abstracts were reviewed by panel members. Each abstract was reviewed by at least 2 reviewers using the abstract management software Covidence (Melbourne, Australia), and selected abstracts were reviewed as full text. In July 2021, the Compendium Lead Authors group voted to update the literature findings, and the librarian re-ran the search to update it to August 2021. Panel members reviewed the search yield via Covidence and incorporated relevant references.SHEA 聘请了一名医学图书馆员顾问，他为 PubMed 和 Embase 制定了全面的检索策略（2012 年 1 月至 2019 年 7 月，更新至 2021 年 8 月）。文章摘要由小组成员审查。每篇摘要均由至少2名审稿人使用摘要管理软件Covidence（澳大利亚墨尔本）进行审稿，选定的摘要作为全文进行审稿。2021 年 7 月，Compendium 主要作者小组投票决定更新文献发现，图书馆员重新进行检索，将其更新至 2021 年 8 月。小组成员通过Covidence审查了检索结果，并纳入了相关参考资料。 Recommendations resulting from this literature review process were classified based on the quality of evidence and the balance between desirable and potential for undesirable effects of various interventions (Table 2). Panel members met via video conference to discuss literature findings; recommendations; quality of evidence for these recommendations; and classification as essential practices, additional practices, or unresolved issues. Panel members reviewed and approved the document and its recommendations.根据证据质量以及各种干预措施的期望和潜在不良影响之间的平衡，对这一文献综述过程产生的建议进行了分类（表2）。小组成员通过视频会议举行会议，讨论文献研究成果;这些建议的证据质量;并分类为基本实践、附加实践或未解决的问题。小组成员审查并批准了该文件及其建议。Table 2. Quality of Evidencea表 2.证据 a 质量 [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)]a Based on the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) “Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Recommendations Categorization Scheme for Infection Control and Prevention Guideline Recommendations” (October 2019), the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE),Reference Guyatt, Oxman and Vist339 and the Canadian Task Force on Preventive Health Care.340a 根据 CDC 医疗保健感染控制实践咨询委员会 （HICPAC） 的“疾病控制与预防中心和医疗保健感染控制实践咨询委员会感染控制和预防指南建议分类方案更新”（2019 年 10 月）、推荐、评估、发展和评估 （GRADE） Reference Guyatt, Oxman and Vist339 等级以及加拿大预防性医疗保健工作组。 340 表2 翻译如下： HIGH | Highly confident that the true effect lies close to that of the estimated size and direction of the effect, for example, when there are a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
高度确信真实效应接近于估计效应的大小和方向，例如，当存在范围广泛的研究且没有重大限制时，研究之间的差异很小，并且汇总估计值具有较窄的置信区间。 | | The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different, for example, when there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide.
真实效应可能接近估计的效应大小和方向，但存在着实质性差异的可能性，例如，当只有少数研究并且有些研究有局限性但没有主要缺陷时，研究之间存在一些差异，或者汇总估计的置信区间很宽。 | | The true effect may be substantially different from the estimated size and direction of the effect, for example, when supporting studies have major flaws, there is important variation between studies, the confidence interval of the summary estimate is very wide, or there are no rigorous studies.
真实效应可能与估计的效应大小和方向有很大差异，例如，当支持性研究存在重大缺陷时，研究之间存在重要差异，汇总估计值的置信区间非常宽，或者没有严格的研究。 |
The Compendium Expert Panel, made up of members with broad healthcare epidemiology, surgical, and infection prevention expertise, reviewed the draft manuscript after consensus had been reached by writing-panel members.指南专家小组由具有广泛医疗保健流行病学、外科和感染预防专业知识的成员组成，在写作小组成员达成共识后审查了手稿草案。 Following review and approval by the Expert Panel, the 5 Compendium partners, collaborating professional organizations, and CDC reviewed the document. Prior to dissemination, the guidance document was reviewed and approved by the SHEA Guidelines Committee, the IDSA Practice Standards and Guidelines Committee, AHA, and The Joint Commission, and the Boards of SHEA, IDSA, and APIC.在专家小组审查和批准后，5个纲要合作伙伴、合作专业组织和CDC审查了该文件。在发布之前，该指导文件已由 SHEA 指南委员会、IDSA 实践标准和指南委员会、AHA 和联合委员会以及 SHEA、IDSA 和 APIC 的董事会审查和批准。 All panel members complied with the SHEA and IDSA policies on conflict-of-interest disclosure.所有小组成员都遵守了 SHEA 和 IDSA 关于利益冲突披露的政策。 Section 1: Rationale and statements of concern 第 1 部分：指南制定理由和关注说明Burden of outcomes associated with SSI与 SSI 相关的负担结果[color=rgba(0, 0, 0, 0.9)]1. Surgical site infections (SSIs) are common complications in acute-care facilities.1. 手术部位感染 （SSI） 是急症护理机构中的常见并发症。
a. SSIs occur in ∼1%–3% of patients undergoing inpatient surgery, depending on the type of operative procedure performed.3,Reference Berrios-Torres, Umscheid and Bratzler4 In total, 21,186 SSIs were reported to the CDC National Healthcare Safety Network (NHSN) in 2021 from a total of 2,759,027 operative procedures.3a. 在接受住院手术的患者中，SSI 发生率为 ∼1%-3%，具体取决于所执行的手术类型。 3,Reference Berrios-Torres, Umscheid and Bratzler4 2021 年，总共向 CDC 国家医疗保健安全网络 （NHSN） 报告了 21,186 例 SSI，共计 2,759,027 次手术。 3 b. Additional data on ambulatory and outpatient surgeries are needed. Overall, many of these procedures are lower risk by virtue of procedure type and patient selection, and some may involve minimally invasive techniques that have a lower risk of infection.Reference Baker, Dicks and Durkin5,Reference Dencker, Bonde, Troelsen, Varadarajan and Sillesen6 It is important to mention, however, that both inpatient and ambulatory operating rooms need to adhere to strict infection prevention standards.b.需要关于门诊和门诊手术的更多数据。总体而言，由于手术类型和患者选择，其中许多手术的风险较低，有些可能涉及感染风险较低的微创技术。 Reference Baker, Dicks and Durkin5,Reference Dencker, Bonde, Troelsen, Varadarajan and Sillesen6 然而，值得一提的是，住院手术室和门诊手术室都需要遵守严格的感染预防标准。 c. SSIs now are one of the most common and most costly HAIs.Reference Anderson, Pyatt, Weber and Rutala7–Reference Zimlichman, Henderson and Tamir11c. SSIs现在是最常见和最昂贵的HAI之一。 Reference Anderson, Pyatt, Weber and Rutala7–Reference Zimlichman, Henderson and Tamir11 2. Up to 60% of SSIs are preventable using evidence-based guidelines.Reference Meeks, Lally and Carrick12,Reference Umscheid, Mitchell, Doshi, Agarwal, Williams and Brennan13
2. 高达 60% 的 SSI 可以使用循证指南进行预防。 Reference Meeks, Lally and Carrick12,Reference Umscheid, Mitchell, Doshi, Agarwal, Williams and Brennan13
3. When not prevented, SSIs can result in a significant increase in postoperative hospital days and many also require reoperation, both during the initial surgical admission and during hospital readmission.Reference Zimlichman, Henderson and Tamir11,Reference Cruse14–Reference Anderson, Kaye and Chen163. 如果不加以预防，SSI 会导致术后住院天数显着增加，并且许多 SSI 还需要再次手术，无论是在初次手术入院期间还是在再次入院期间。 Reference Zimlichman, Henderson and Tamir11,Reference Cruse14–Reference Anderson, Kaye and Chen16 4. Patients with an SSI have a 2–11 times higher risk of death compared to operative patients without SSI.Reference Engemann, Carmeli and Cosgrove17,Reference Kirkland, Briggs, Trivette, Wilkinson and Sexton18 Also, 77% of deaths in patients with SSI are directly attributable to SSI.Reference Mangram, Horan, Pearson, Silver and Jarvis194. 与没有 SSI 的手术患者相比，有 SSI 的患者死亡风险高 2-11 倍。 Reference Engemann, Carmeli and Cosgrove17,Reference Kirkland, Briggs, Trivette, Wilkinson and Sexton18 此外，77% 的 SSI 患者死亡直接归因于 SSI。 Reference Mangram, Horan, Pearson, Silver and Jarvis19 5. Attributable costs of SSI vary depending on the type of operative procedure, medical implants, and the type of infecting pathogen.Reference Anderson, Kaye and Chen16,Reference Kirkland, Briggs, Trivette, Wilkinson and Sexton18,Reference Apisarnthanarak, Jones, Waterman, Carroll, Bernardi and Fraser20–Reference Whitehouse, Friedman, Kirkland, Richardson and Sexton27 Overall, it is estimated that the cost of care for patients who develop an SSI is 1.4–3 times higher than for patients who do not develop an SSI.Reference Moolla, Reddy and Fwemba28 Deep-incisional and organ-space SSIs are associated with the highest cost.Reference Moolla, Reddy and Fwemba28 All studies evaluated in a systematic review reported some economic benefit associated with SSI prevention, but there is significant heterogeneity in the literature related to cost accounting.Reference Shaaban, Yassine, Bedwani and Abu-Sheasha29,Reference Hasegawa, Tashiro and Mihara30 In the United States, SSIs are believed to account for $3.5 billion to $10 billion annually in healthcare expenditures.Reference O’Hara, Thom and Preas31,Reference Scott325. SSI 的可归因成本因手术类型、医疗植入物和感染病原体的类型而异。 Reference Anderson, Kaye and Chen16,Reference Kirkland, Briggs, Trivette, Wilkinson and Sexton18,Reference Apisarnthanarak, Jones, Waterman, Carroll, Bernardi and Fraser20–Reference Whitehouse, Friedman, Kirkland, Richardson and Sexton27 总体而言，据估计，发生 SSI 的患者的护理费用比未发生 SSI 的患者高 1.4-3 倍。 Reference Moolla, Reddy and Fwemba28 深切口和器官间隙 SSI 的成本最高。 Reference Moolla, Reddy and Fwemba28 在一项系统评价中评估的所有研究都报告了与预防SSI相关的一些经济效益，但在与成本核算相关的文献中存在显著的异质性。 Reference Shaaban, Yassine, Bedwani and Abu-Sheasha29,Reference Hasegawa, Tashiro and Mihara30 在美国，据信 SSI 每年占 35 亿至 100 亿美元的医疗保健支出。 Reference O’Hara, Thom and Preas31,Reference Scott32 6. Finally, data reported to the CDC NHSN show that SSIs can be caused by antibiotic-resistant bacteria such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococci, and multidrug-resistant gram-negative bacilli. These infections can be more difficult to manage and can be caused by pathogens that are resistant to standard empiric antibiotics.Reference Weiner-Lastinger, Abner and Edwards336. 最后，向CDC NHSN报告的数据显示，SSIs可由耐甲氧西林金黄色葡萄球菌、耐万古霉素肠球菌和多重耐药革兰氏阴性杆菌等抗生素耐药细菌引起。这些感染可能更难管理，并且可能由于标准经验性抗生素治疗引起病原体耐药。 Reference Weiner-Lastinger, Abner and Edwards33
Risk factors for SSISSI 的危险因素[color=rgba(0, 0, 0, 0.9)]1. Numerous risk factors have been described for SSI, including intrinsic factors, patient-specific risk factors, and perioperative factors related to surgical practices (Table 3). Some common patient-specific risk factors include obesity, diabetes, immunosuppressive therapy, malnutrition, and smoking. In pediatrics, premature infants are also at higher risk, especially those undergoing gastrointestinal surgery early in life. Examples of perioperative risk factors include inadequacies in surgical scrub, the antiseptic preparation of the skin, antimicrobial prophylaxis, and duration of surgery.1. 已经描述了许多 SSI 的危险因素，包括内在因素、患者特异性危险因素以及与外科手术相关的围手术期因素（表 3）。一些常见的患者特异性危险因素包括肥胖、糖尿病、免疫抑制治疗、营养不良和吸烟。在儿科，早产儿的风险也更高，尤其是那些在生命早期接受胃肠道手术的早产儿。围手术期危险因素的例子包括手术擦洗、皮肤消毒剂准备、抗菌药物预防和手术持续时间。 [color=rgba(0, 0, 0, 0.9)]Table 3. Selected Risk Factors for and Recommendations to Prevent Surgical Site Infection (SSI)表 3.预防手术部位感染 （SSI） 选定危险因素的建议 [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)]a Vancomycin and fluoroquinolones can be given 2 hours prior to incision.a 万古霉素和氟喹诺酮类药物可在切口前 2 小时给药。 [color=rgba(0, 0, 0, 0.9)]表3翻译如下：
Risk Factor 风险因素 | Recommendation 推荐意见 | Quality of Evidence 证据质量 | Intrinsic, patient-related (preoperative)内在的、患者相关的（术前） | | | No formal recommendation: relationship to increased risk of SSI may be secondary to comorbidities or immunosenescence341-343
无正式推荐：与 SSI 风险增加的关系可能继发于合并症或免疫衰老 341-343 | | | No formal recommendation. Prior irradiation at the surgical site increases the risk of SSI, likely due to tissue damage and wound ischemia.183
没有正式的建议。手术部位的先前放疗会增加 SSI 的风险，可能是由于组织损伤和伤口缺血所致。 183 | | History of skin and soft-tissue infections
皮肤和软组织感染史 | No formal recommendation. History of a prior skin infection may be a marker for inherent differences in host immune function.344
没有正式的建议。既往皮肤感染史可能是宿主免疫功能固有差异的标志。 344 | | | | Control serum blood-glucose levels for all surgical patients including patients without diabetes.345
控制所有手术患者（包括非糖尿病患者）的血糖水平。 345 | | | Increase dosing of prophylactic antimicrobial agent for morbidly obese patients.73,346
增加疾病肥胖患者预防性抗菌药物的剂量。 73,346 | | | Encourage smoking cessation within 30 days of procedure.4,347-351
鼓励在手术后 30 天内戒烟。 4,347-351 | | Immunosuppressive medications
免疫抑制药物 | Avoid immune-suppressive medications in perioperative period if possible
如果可能，在围手术期避免使用免疫抑制药物 | | | No formal recommendation. Though a noted risk factor,352 do not delay surgery for use of total parenteral nutrition.
没有正式的建议。虽然这是一个值得注意的危险因素， 352 但不要因为使用全胃肠外营养而延误手术。 | | S. aureus nasal colonization
金黄色葡萄球菌鼻腔定植 | Decolonize patients with nasal mupirocin or povidine-iodine prior to surgery
在手术前使用鼻用莫匹罗星或聚维定碘对患者进行去定植 | | Preparation of patient病人的准备 | | Do not remove unless hair will interfere with the operation4; if hair removal is necessary, remove outside of the operating room by clipping. Do not use razors.
除非毛发会干扰手术 4 ，否则不要去毛;如果需要去毛，请在手术室外剪下毛发，不要使用剃须刀。 | | Preoperative infections 术前感染 | Identify and treat infections remote to the surgical site (eg, urinary tract infection in the presence of prior to elective surgery.4,353 Do not routinely test or treat for asymptomatic bacteriuria except in urologic procedures.
识别并治疗其它部位感染，使其远离手术部位（例如，在择期手术前存在尿路感染。除泌尿科手术外，不要常规检测或治疗无症状菌尿。 | | Operative characteristics手术操作 | Surgical scrub (surgical team members’ hands and forearms)
外科手消毒（手术团队成员的手和前臂） | Use appropriate antiseptic agent to perform preoperative surgical scrub.4,354 For most products, scrub the hands and forearms for 2–5 minutes.
使用适当的消毒剂进行术前手术擦洗。对于大多数产品，擦洗双手和前臂 2-5 分钟。 | | | Wash and clean skin around incision site. Use a dual agent skin prep containing alcohol unless contraindications exist.4
清洗并清洁切口部位周围的皮肤。除非存在禁忌症，否则使用含有酒精的双重药剂皮肤准备。 | | Antimicrobial prophylaxis
抗菌药物预防 | Administer only when indicated.4 Select appropriate agents based on surgical procedure, most common pathogens causing SSI for a specific procedure, and published recommendations.73 Administer within 1 hour of incision to maximize tissue concentration.73 Discontinue antimicrobial agents after incisional closure in the operating room.a
仅在有指征时给药。 根据外科手术、引起特定手术 SSI 的最常见病原体以及已发表的建议选择合适的药物。 在切口后 1 小时内给药，以最大限度地提高组织浓度。 在手术室切口闭合后停用抗菌药物。 a | | | Blood transfusions increase the risk of SSI by decreasing macrophage function. Reduce blood loss and need for blood transfusion to greatest extent possible.355-357
输血会降低巨噬细胞功能，从而增加 SSI 的风险。最大程度减少失血和输血需求。 | | Surgeon skill/technique 外科医生技能/技术 | Handle tissue carefully and eradicate dead space.4
小心处理组织并消除死腔。 | | Appropriate gloving 适当的手套 | All members of the operative team should double glove and change gloves when perforation is noted.358
手术团队的所有成员都应戴上双层手套，并在发现穿孔时更换手套。 | | | Adhere to standard principles of operating room asepsis.4
遵守手术室无菌操作标准原则 | | | No formal recommendation in most recent guidelines; minimize as much as possible without sacrificing surgical technique and aseptic practice.
最新指南中没有正式建议;在不牺牲手术技术和无菌实践的情况下，尽可能减少。 | | Operating room characteristics手术室特性 | | Follow American Institute of Architects’ recommendations for proper air handling in the operating room.4,359
遵循美国建筑师学会关于手术室适当空气处理的建议 | | | Minimize operating room traffic.4,207,208
最大限度地减少手术室人流量。 | | Environmental surfaces 环境表面 | Use an Environmental Protection Agency (EPA)–approved hospital disinfectant to clean visibly soiled or contaminated surfaces and equipment in accordance with manufacturer’s instructions.4
按照制造商的说明，使用环境保护署 （EPA） 批准的医院消毒剂消毒明显脏污或污染的表面和设备。 | | Sterilization of surgical equipment
手术设备的灭菌 | Sterilize all surgical equipment according the device manufacturer’s validated parameters: cycle type, time, temperature, pressure, and dry time. Minimize the use of immediate use steam sterilization.4,360
根据设备制造商的验证参数对所有手术设备进行灭菌：循环类型、时间、温度、压力和干燥时间。尽量减少使用即用蒸汽灭菌。 | |
[color=rgba(0, 0, 0, 0.9)]2. The CDC NHSN–determined risk factors for different procedure categories are incorporated in the calculation of the standardized infection ratio (SIR).342. CDC NHSN 确定的不同类别手术的风险因素被纳入标准化感染率 （SIR） 的计算中。 34 Section 2: Background on detection of SSI 第 2 部分：SSI监测 的背景Surveillance definitions for SSISSI 的监测定义[color=rgba(0, 0, 0, 0.9)]1. Surveillance definitions must be established and consistently applied over time to make comparisons within and between institutions meaningful.1. 必须建立监测定义，并随着时间的推移始终如一地应用，以使机构内部和机构之间的比较具有意义。
a. NHSN definitions for SSI are widely used for public reporting, interfacility comparison, and pay-for-performance comparisons,35–38 based on selected procedures identified by procedure codes assigned from the International Classification of Diseases, 10 th Revision Clinical Modifications/Procedure Coding System (ICD-10-CM/PCS) and/or current procedural terminology (CPT) codes.35–37a. NHSN 对 SSI 的定义广泛用于公共报告、医疗机构间比较和按绩效付费进行比较， 35–38 基于由国际疾病分类、10 th 修订临床修改/程序编码系统 （ICD-10-CM/PCS） 和/或当前手术术语 （CPT） 代码。 35–37 b. Validation of the application of surveillance definitions between data abstractors may be necessary to ensure consistent application.41,42b.为确保应用的一致性，可能需要对监测数据进行验证。 41,42 2. According to widely used CDC NHSN definitions,43 SSIs are classified as follows (Fig. 1):
2. 根据广泛使用的CDC NHSN定义， 43 SSIs分类如下（图1）： a.Superficial incisional (involving only skin or subcutaneous tissue of the incision)
浅表切口（仅累及切口的皮肤或皮下组织）
Superficial incisional primary (SIP): SSI identified in a primary incision in a patient with 1 or more incisions. 原发性浅切口（SIP）：在有 1 个或 1 个以上切口的患者的主要切口发现 SSI。 Superficial incisional secondary (SIS): SSI identified in the secondary incision in a patient that has had an operation with >1 incision.
继发性浅切口（SIS）：在进行过一次以上切口手术的患者的二次切口中发现的 SSI。
b.Deep incisional (involving fascia and/or muscular layers)
深切口（累及筋膜和/或肌肉层）
Deep-incisional primary (DIP): SSI identified in a primary incision in a patient who has had an operation with 1 or more incisions.
原发性深切口（DIP）：在接受过 1 个或多个切口手术的患者的主要切口上发现的 SSI。
Deep-incisional secondary (DIS): SSI identified in a secondary incision in a patient who has had an operation with > 1 incision.
深切口继发性 （DIS）：在接受过 > 1 切口手术的患者的二次切口中发现的 SSI。
c.Organ-space: Involving any part of the body opened or manipulated during the procedure, excluding skin incision, fascia, or muscle layers.
器官空间：涉及在手术过程中打开或操纵的身体任何部位，不包括皮肤切口、筋膜或肌肉层。
[color=rgba(0, 0, 0, 0.9)]Fig. 1. CDC National Healthcare Safety Network (NHSN) classification for surgical site infection. Modified from Horan TC, et al.Reference Horan, Gaynes, Martone, Jarvis and Emori362 CDC definitions of nosocomial surgical site infections, 1992.图 1.CDC 国家医疗保健安全网络 （NHSN） 手术部位感染分类。修改自 Horan TC 等人， Reference Horan, Gaynes, Martone, Jarvis and Emori362 CDC 对医院手术部位感染的定义，1992 年。 [color=rgba(0, 0, 0, 0.9)]
Surveillance methods for SSI and detection of patientsSSI的监测方法和患者发现
[color=rgba(0, 0, 0, 0.9)]1. The most accurate method of SSI surveillance is the direct method for case finding with daily observation of the surgical site by a physician, advanced practice provider, registered nurse, or infection preventionist starting 24–48 hours postoperatively.Reference Cruse and Foord15,Reference Condon, Schulte, Malangoni and Anderson-Teschendorf44–Reference Mead, Pories, Hall, Vacek, Davis and Gamelli46 Although the direct method of case finding has been used as the “gold standard” for some studies, it is rarely used by infection prevention staff due to its high resource utilization requirements and impracticality.1. 最准确的 SSI 监测方法是直接发现病例的方法，由医生、高级实践提供者、注册护士或感染预防人员在术后 24-48 小时开始每天观察手术部位。 Reference Cruse and Foord15,Reference Condon, Schulte, Malangoni and Anderson-Teschendorf44–Reference Mead, Pories, Hall, Vacek, Davis and Gamelli46 尽管直接发现病例的方法已被用作一些研究的“金标准”，但由于其资源利用率要求不高且不切实际，很少被感染预防人员使用。 [color=rgba(0, 0, 0, 0.9)]2. The indirect method of case finding is less time-consuming than the direct method; it can be performed using criteria or algorithms applied to electronic records; and it can be performed retrospectively.间接病例查找法比直接病例查找法耗时更短；可以标准或算法进行查找电子记录；还可以进行回顾性查找。
a. The indirect method of case finding consists of 1 or a combination of the following as appropriate based on inpatient or outpatient surveillance and the setting:间接病例发现方法包括以下一种或以下方法的组合，视情况而定，具体取决于住院或门诊别人的监测情况： i. Review of microbiology reports and patient medical recordsi. 审查微生物学报告和患者病历 ii. Surgeon and/or patient surveys by mail, telephone, or web-based applicationReference Lober and Evans47ii. 通过邮件、电话或基于网络的应用程序 Reference Lober and Evans47 进行外科医生和/或患者调查 iii. Patient or family interview, particularly when postoperative care is remote and/or follow-up care is being provided by an alternative provideriii. 患者或家属访谈，特别是当术后护理是远程的和/或后续护理由替代提供者提供时 iv. Screening for early or additional postoperative visits, readmission, and/or return to the operating roomiv. 筛查早期或额外的术后就诊、再入院和/或重返手术室的情况 v. Other information such as coded diagnoses, coded procedures, operative reports, or antimicrobials orderedv. 其他信息，例如诊断编码、手术编码、手术报告或订购的抗菌药物
b. Indirect methods of SSI surveillance have been demonstrated to be reliable (sensitivity, 84%–89%) and specific (specificity, 99.8%) compared to the “gold standard” of direct surveillance.Reference Baker, Luce, Chenoweth and Friedman48–Reference Cho, Chung and Choi50 Components of the indirect methods that were associated with highest sensitivities included review of nursing notes, billing codes, and antimicrobials used.b.与直接监测的“金标准”相比，间接 SSI 监测方法已被证明是可靠的（敏感性，84%-89%）和特异性（特异性，99.8%）。 Reference Baker, Luce, Chenoweth and Friedman48–Reference Cho, Chung and Choi50 与最高敏感性相关的间接方法的组成部分包括审查护理记录、计费代码和使用的抗菌剂。 c. Indirect methods for SSI surveillance are less reliable for surveillance of superficial-incisional infections, particularly those occurring after discharge.Reference Ming, Chen, Miller and Anderson51c. 间接的SSI监测方法对于监测浅表切口感染，特别是那些在出院后发生的感染不太可靠。 Reference Ming, Chen, Miller and Anderson51 3. Automated data systems and electronic health records should be used to improve efficiency, improve sensitivity, and broaden SSI surveillance.Reference Cho, Chung and Choi50
3. 应使用自动化数据系统和电子健康记录来提高效率、提高灵敏度并扩大 SSI 监测。 Reference Cho, Chung and Choi50
a. SSI surveillance can be expanded by utilizing hospital databases that include administrative claims data (including diagnosis and procedure codes), antimicrobial days, readmission to the hospital, return to the operating room and/or by implementing a system that imports automated microbiologic culture data, surgical procedure data, and general demographic information into a single surveillance database.Reference Chalfine, Cauet and Lin52–Reference Yokoe, Noskin and Cunnigham54a. 可以通过利用医院数据库来扩大 SSI 监测，这些数据库包括行政索赔数据（包括诊断和手术ICD代码）、抗菌使用天数、再入院、重返手术室和/或实施将自动微生物培养数据、外科手术数据和一般人口统计信息导入单一监测数据库的系统。 Reference Chalfine, Cauet and Lin52–Reference Yokoe, Noskin and Cunnigham54 b. These methods improve the sensitivity of indirect surveillance for detection of SSI and reduce the effort of the infection preventionist.Reference Chalfine, Cauet and Lin52b.这些方法提高了间接监测对SSI检测的敏感性，并减少了感染预防人员的工作量。 Reference Chalfine, Cauet and Lin52 c. Medicare claims data can be used to enhance surveillance methods for SSI and to identify hospitals with unusually high or low rates of SSI.Reference Calderwood, Kleinman and Bratzler55,Reference Huang, Placzek and Livingston56c. Medicare 索赔数据可用于增强 SSI 的监测方法，并确定 SSI 发生率异常高或低的医院。 Reference Calderwood, Kleinman and Bratzler55,Reference Huang, Placzek and Livingston56 d. Administrative data can be used to increase the efficiency of SSI reporting and validation.Reference Haley, Van Antwerpen and Tserenpuntsag57–Reference Noorit, Siribumrungwong and Thakkinstian59d. 行政数据可用于提高 SSI 报告和验证的效率。 Reference Haley, Van Antwerpen and Tserenpuntsag57–Reference Noorit, Siribumrungwong and Thakkinstian59 e. Use of algorithms,Reference van Rooden, Tacconelli and Pujol58 machine learning,Reference Zhu, Simon and Wick60 and predictive models may be helpful in surveillance of SSIs.e.使用算法、 Reference van Rooden, Tacconelli and Pujol58 Reference Zhu, Simon and Wick60 机器学习和预测模型可能有助于监测 SSI。 f. Administrative and automated data used for surveillance purposes should be validated to ensure accuracy.
f.自动化监测数据应经过验证，以确保准确性。 g. Electronic health record (EHR) vendors should increase standardization and automated collection of key metrics. The focus should be to reduce data burden on hospital and health-system staff.
g.电子健康记录 （EHR） 供应商应提高关键指标的标准化和自动化收集。重点应是减轻医院和卫生系统工作人员的数据负担。 4. The proportion of SSIs detected through postdischarge surveillance can vary by surveillance method, operative setting, type of SSI, and surgical procedure.
4. 通过出院后监测到的 SSI 的比例可能因监测方法、手术环境、SSI 类型和外科手术而异。
a. The majority of surgical procedures are now outpatient procedures.Reference Grundmeier, Xiao and Ross61 In addition, length of stay following inpatient procedures has decreased. Surveillance methodologies must take these practice changes into account.
现在大多数外科手术都是门诊手术。 Reference Grundmeier, Xiao and Ross61 此外，住院手术后的住院时间也有所缩短。监测方法必须考虑到这些做法的变化。 b. Superficial incisional SSIs are most commonly detected and managed in the outpatient setting. In contrast, deep-incisional and organ-space infections typically require readmission to the hospital for management.Reference Ming, Chen, Miller and Anderson51
b.浅表切口 SSI 最常在门诊环境中被发现和管理。相比之下，深切口和器官间隙感染通常需要再次入院进行治疗发现。 Reference Ming, Chen, Miller and Anderson51 c. Surveillance for SSIs in the ambulatory care setting is challenging because patients may not return to the same organization for routine postoperative careReference Yokoe, Avery, Platt and Huang62 or for management of complications.63
c. 在门诊护理环境中对 SSI 的监测具有挑战性，因为患者可能不会返回同一医疗机构进行常规术后护理 Reference Yokoe, Avery, Platt and Huang62 或并发症管理。 63 5. CDC is prescriptive about denominator data collection43; however, it is less prescriptive on how possible cases (numerator data) should be identified for evaluation.
5. CDC对分母数据收集 43 有规定;然而，对于如何确定可能的情况（分子数据）进行评估，它的规定较弱。
a. Differences in case finding methodology may lead to variability in surveillance rates.Reference Pop-Vicas, Stern, Osman and Safdar64
病例发现方法的差异可能导致监测率的差异。 Reference Pop-Vicas, Stern, Osman and Safdar64 b. CDC encourages standardization of data sources for more consistent reporting. Both state health departments and the CMS select hospitals for data validation.
b. CDC鼓励对数据源进行标准化，以实现更一致的报告。州卫生部门和CMS都选择医院进行数据验证。 c. By improving completeness of reporting, the overall institutional SSI rate typically increases.Reference Kent, McDonald, Harris, Mason and Spelman65–Reference Sands, Vineyard and Platt67 As more data sources are used, the detection of SSIs is likely to increase.Reference Chalfine, Cauet and Lin52
c. 通过提高报告的完整性，机构总体SSI率通常会增加。 Reference Kent, McDonald, Harris, Mason and Spelman65–Reference Sands, Vineyard and Platt67 随着更多数据源的使用，对 SSI 的发现可能会增加。 Reference Chalfine, Cauet and Lin52
Section 3: Background on prevention of SSI 第三部分 预防SSI的背景Summary of existing guidelines, recommendations, and requirements现有指南、建议和要求的摘要[color=rgba(0, 0, 0, 0.9)]A number of guidelines are available on the prevention of SSIs, and our writing panel compared and contrasted some of the differences in developing our current recommendations.Reference Fields, Pradarelli and Itani68 We list some of these guidelines below, along with current US reporting requirements.有许多关于预防 SSI 的指南，我们的写作小组比较和对比了在制定我们当前推荐建议时的一些差异。 Reference Fields, Pradarelli and Itani68 我们在下面列出了其中的一些指南，以及美国当前的SSIs监测报告要求。 [color=rgba(0, 0, 0, 0.9)]1. CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC) guidelinesReference Berrios-Torres, Umscheid and Bratzler4,Reference Segreti, Parvizi, Berbari, Ricks and Berrios-Torres691. CDC和医疗感染控制实践咨询委员会（HICPAC）指南 Reference Berrios-Torres, Umscheid and Bratzler4,Reference Segreti, Parvizi, Berbari, Ricks and Berrios-Torres69 [color=rgba(0, 0, 0, 0.9)]2. American College of Surgeons and Surgical Infection Society SSI GuidelinesReference Ban, Minei and Laronga702. 美国外科医师学会和外科感染学会 SSI 指南 Reference Ban, Minei and Laronga70 [color=rgba(0, 0, 0, 0.9)]3. World Health Organization 2018713. 世界卫生组织 2018 71 [color=rgba(0, 0, 0, 0.9)]4. National Institute for Health and Clinical Excellence (NICE)—United Kingdom 2008Reference Haley, Van Antwerpen and Tserenpuntsag57,Reference van Rooden, Tacconelli and Pujol584. 英国国家健康与临床卓越研究所 （NICE）——2008 Reference Haley, Van Antwerpen and Tserenpuntsag57,Reference van Rooden, Tacconelli and Pujol58 年 [color=rgba(0, 0, 0, 0.9)]5. SHEA Expert Guidance: Infection Prevention in the Operating Room Anesthesia Work AreaReference Munoz-Price, Bowdle and Johnston725. SHEA专家指导：手术室麻醉工作区 Reference Munoz-Price, Bowdle and Johnston72 的感染预防 [color=rgba(0, 0, 0, 0.9)]6. American Society of Health-System Pharmacists (ASHP) Clinical Practice Guideline for Antimicrobial Prophylaxis in Surgery 2013Reference Bratzler, Dellinger and Olsen736. 美国卫生系统药剂师协会 （ASHP） 2013 Reference Bratzler, Dellinger and Olsen73 年外科抗菌药物预防临床实践指南 [color=rgba(0, 0, 0, 0.9)]7. Institute for Healthcare Improvement (IHI)Reference Calderwood, Yokoe and Murphy747. 医疗保健改善研究所 （IHI） Reference Calderwood, Yokoe and Murphy74
a. The IHI created a nationwide quality improvement project to improve outcomes in hospitalized patients,Reference Griffin75,76 including 6 preventive measures for SSI that are also included in the 100,000 and 5 Million Lives Campaigns.Reference Griffin75,76IHI 创建了一个全国性的质量改进项目，以改善住院患者的预后， Reference Griffin75,76 包括 6 项 SSI 预防措施，这些措施被纳入了 “十万人和 五百万人生命宣传活动”。 8. Federal requirements 8. 联邦要求
a. Centers for Medicare & Medicaid Services (CMS)医疗保险和医疗补助服务中心（CMS） i. In accordance with the Deficit Reduction Act of 2005, US hospitals that are paid by Medicare under the acute-care inpatient prospective payment system receive their full Medicare Annual Payment Update only if they submit required quality measure information to CMS.i. 根据 2005 年《减少赤字法案》，在急症护理住院患者预期支付系统下由 Medicare 支付的美国医院只有在向 CMS 提交所需的质量测量信息时才能收到完整的 Medicare 年度支付更新。 ii. In addition, US acute-care hospitals submit data to the NHSN for complex SSIs following colon surgery and abdominal hysterectomy. These data are publicly reported on the CMS Hospital Care Compare website77,78 and are used to determine pay-for-performance in both the Hospital-Acquired Condition Reduction Program79 and the Hospital-Value Based Purchasing Program.80ii. 此外，美国急症护理医院向 NHSN 提交结肠手术和腹部子宫切除术后复杂 SSI 的数据。这些数据在 CMS Hospital Care Compare 网站上 77,78 公开报告，用于确定医院获得性疾病减少计划 79 和医院基于价值的购买计划中的绩效薪酬。 80 iii. Accrediting organizations with deeming authority granted by the CMS, such as The Joint Commission and Det Norske Veritas Healthcare (DNV), verify that CMS requirements are met as part of the accreditation process.iii. 对具有 CMS 授予的推定权限的认证组织，例如联合委员会和 Det Norske Veritas Healthcare （DNV），在认证过程中验证是否满足 CMS 要求。
Infrastructure requirements基础要求[color=rgba(0, 0, 0, 0.9)]Facilities performing surgery should have the following elements in place:进行手术的机构应具备以下要素： [color=rgba(0, 0, 0, 0.9)]1. Trained infection prevention personnel1.训练有素的感染预防人员
a. Infection preventionists (1) must be specifically trained in methods of SSI surveillance, (2) must have knowledge of and the ability to prospectively apply the CDC/NHSN definitions for SSIs, (3) must possess basic computer and mathematical skills, and (4) must be adept at providing feedback and education to healthcare personnel (HCP) when appropriate.Reference Berrios-Torres, Umscheid and Bratzler4,81感染预防人员 （1） 必须接受过 SSI 监测方法的专门培训，（2） 必须了解并有能力前瞻性地应用 CDC/NHSN SSI定义进行监测，（3） 必须具备基本的计算机和数学技能，以及 （4） 必须善于在适当的时候向医疗保健人员 （HCP） 提供反馈和教育。 Reference Berrios-Torres, Umscheid and Bratzler4,81 b. Having an increased number of infection preventionists, certified infection preventionists, and a hospital epidemiologist are associated with lower rates of SSI. A specific threshold for staffing has not been defined.Reference Clifford, Newhart, Laguio-Vila, Gutowski, Bronstein and Lesho82b.感染预防人员、经过认证的感染预防人员和医院流行病学家的数量增加与 SSI 的发生率较低有关。尚未确定人员配置的具体门槛。 Reference Clifford, Newhart, Laguio-Vila, Gutowski, Bronstein and Lesho82 2. Education for HCP 2. 医护人员教育
a. A surgeon leader or champion can be a critical partner in changing culture and improving adherence to prevention practices.外科医生、领导者或倡导者可以成为改变文化和提高对预防实践的依从性的关键合作伙伴。
b. Regularly provide education to surgeons and perioperative personnel through continuing education activities directed at minimizing perioperative SSI risk through implementation of recommended process measures.b.通过继续教育活动，定期向外科医生和围手术期人员提供教育，旨在通过实施推荐的流程措施来最大限度地降低围手术期 SSI 风险。
i. Combine several educational components into concise, efficient, and effective recommendations that are easily understood and remembered.Reference van Kasteren, Mannien and Kullberg83i. 将几个教育组成部分结合成简洁、高效和有效的建议，这些建议易于理解和记忆。 Reference van Kasteren, Mannien and Kullberg83 ii. Provide education regarding the outcomes associated with SSI, risks for SSI, and methods to reduce risk to all surgeons, anesthesiologists, and perioperative personnel.ii. 提供有关 SSI 相关结果、SSI 风险以及降低所有外科医生、麻醉师和围手术期人员风险的方法的教育。 c. Ensure that education and feedback regarding SSI rates and specific measures that can be used to prevent infection filter down to all frontline multidisciplinary HCPs providing care in the perioperativeReference Ahuja, Peiffer-Smadja and Peven84 and postoperative settings.Reference Johnson, Newman and Green85c. 确保有关 SSI 率和可用于预防感染的具体措施的教育和反馈渗透到所有在围手术期 Reference Ahuja, Peiffer-Smadja and Peven84 和术后环境中提供护理的一线多学科 HCP。 Reference Johnson, Newman and Green85 3. Education of patients and families. Provide education for patients and patients’ families to reduce risk associated with intrinsic patient-related SSI risk factors.Reference Schweon86,Reference Torpy, Burke and Glass87
3.对患者和家属的教育。为患者和患者家属提供教育，以降低与患者相关的内在 SSI 风险因素相关的风险。 Reference Schweon86,Reference Torpy, Burke and Glass87 4. Computer-assisted decision support and automated reminders
4. 计算机辅助决策支持和自动提醒系统
a. Several institutions have successfully employed computer-assisted decision support methodology to improve the rate of appropriate administration of antimicrobial prophylaxis (including re-dosing during prolonged cases).Reference Kanter, Connelly and Fitzgerald88–Reference Webb, Flagg and Fink91一些机构已经成功地采用了计算机辅助决策支持方法，以提高抗微生物药物预防的适当给药率（包括在长期病例中重新给药）。 Reference Kanter, Connelly and Fitzgerald88–Reference Webb, Flagg and Fink91 b. Computer-assisted decision support can be time-consuming to implement,Reference Munoz-Price, Bowdle and Johnston72 and institutions must appropriately validate computer-assisted decision support systems after implementation to ensure that they are functioning appropriately.Reference Cato, Liu, Cohen and Larson92b.计算机辅助决策支持的实施可能非常耗时， Reference Munoz-Price, Bowdle and Johnston72 机构必须在实施后适当验证计算机辅助决策支持系统，以确保它们正常运行。 Reference Cato, Liu, Cohen and Larson92 5. Utilization of automated data
5. 自动化数据的利用
a. Install information technology infrastructure to facilitate data transfer, receipt, and organization to aid with tracking of process and outcome measures.安装信息技术基础设施，以促进数据传输、接收和组织，以帮助跟踪过程和结果措施。 b. Consider use of data mining software to identify potential SSIs which can then be further evaluated.b.考虑使用数据挖掘软件来识别潜在的 SSI，然后可以进一步评估这些 SSI。 c. Consider leveraging existing electronic health record capabilities to provide process measure information that informs improvement approaches.c. 考虑利用现有的电子健康记录功能来提供过程测量信息，为改进方法提供信息。
Section 4: Recommended strategies to prevent SSI 第 4 部分：预防 SSI 的推荐策略Recommendations are categorized as either (1) essential practices that should be adopted by all acute-care hospitals or (2) additional approaches that can be considered when hospitals have successfully implemented essential practices and seek to further improve outcomes in specific locations and/or patient populations. Essential practices include recommendations in which the potential to affect HAI risk clearly outweighs the potential for undesirable effects. Additional approaches include recommendations in which the intervention is likely to reduce HAI risk but there is concern about the risks for undesirable outcomes, recommendations for which the quality of evidence is low, or recommendations where the evidence supports the effect of the intervention in select settings (e.g., during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially implementing infection prevention approaches listed as essential practices. If HAI surveillance or other risk assessments suggest that there are ongoing opportunities for improvement, hospitals should consider adopting some or all of the infection prevention approaches listed as additional approaches. These approaches can be implemented in specific locations or patient populations or can be implemented hospital-wide, depending on outcome data, risk assessment, and/or local requirements. Each infection prevention recommendation is given a quality of evidence grade (Table 2).建议分为 （1） 所有急症护理医院都应采用的基本实践，或 （2） 当医院成功实施基本实践并寻求进一步改善特定地点和/或患者群体的结果时可以考虑的其他方法。基本做法包括一些建议，其中影响 HAI 风险的潜力明显大于产生不良影响的可能性。其他方法包括以下建议：干预措施可能降低HAI风险，但担心不良结局的风险，证据质量低的建议，或证据支持干预在特定环境（例如，在疫情爆发期间）或特定患者群体中的作用的建议。医院可以通过最初实施列为基本实践的感染预防措施来优先考虑他们的工作。如果 HAI 监测或其他风险评估表明存在持续的改进机会，医院应考虑采用部分或全部列出的感染预防方法作为附加方法。这些方法可以在特定科室或患者群体实施，也可以在全院范围内实施，具体取决于结果数据、风险评估和/或当地要求。每项感染预防建议都获得了证据质量等级（表2）。 Essential practices for preventing SSI recommended for all acute-care hospitals建议所有急症护理医院使用预防 SSI 的基本做法Administer antimicrobial prophylaxis according to evidence-based standards and guidelines.75 (Quality of evidence: HIGH)
根据循证标准和指南实施抗微生物药物预防。 （证据质量：高）
For cefazolin, use 30–40 mg/kg for pediatric patients, use 2 grams for patients weighing ≤120 kg, and 3 grams for patients weighing >120 kg.109,110 Although data are conflicting regarding the role of 3 grams of cefazolin dosing in reducing SSI in obese patients, multiple studies have shown a benefit compared to 2-gram dosing in this patient population,110-112 with few adverse events from a single dose of 3 grams versus 2 grams of cefazolin. Although some hospitals use 1 gram for adult patients weighing ≤80 kg, there is no harm associated with giving a 2-gram dose.
对于头孢唑啉，儿科患者使用 30-40 mg/kg，体重 ≤120 kg 的患者使用 2 g，体重 >120 kg 的患者使用 3 g。 109,110 尽管关于 3 克头孢唑林给药在降低肥胖患者 SSI 方面的作用的数据相互矛盾，但多项研究表明，与 2 克给药相比，该患者群体具有益处， 110-112 与 2 克头孢唑林相比，单次给药 3 克相比，不良事件很少。虽然一些医院对体重 ≤80 公斤的成年患者使用 1 克，但给予 2 克剂量没有伤害。 Dose vancomycin at 15 mg/kg.113
万古霉素的剂量为 15 mg/kg。 Dose gentamicin at 5 mg/kg for adult patients and 2.5 mg/kg for pediatric patients. For morbidly obese patients receiving gentamicin, use the ideal weight plus 40% of the excess weight for dose calculation.114
庆大霉素的剂量为成人患者 5 mg/kg，儿童患者剂量为 2.5 mg/kg。对于接受庆大霉素的疾病肥胖患者，使用理想体重加上超重的 40% 进行剂量计算。 114 Although some guidelines suggest stopping the antimicrobial agents within 24 hours of surgery, there is no evidence that antimicrobial agents given after incisional closure contribute to reduced SSIs102 even when drains are inserted during the procedure.103 In contrast, antibiotics given after closure contribute to increased antimicrobial resistance104,105 and increased risk of Clostridioides difficile infection106 and acute kidney injury.107
尽管一些指南建议在手术后 24 小时内停用抗菌药物，但没有证据表明切口闭合后给予的抗菌药物有助于减少 SSI， 即使在手术过程中插入引流管也是如此。 相比之下，封堵后给予抗生素会增加抗微生物药物耐药 性，并增加艰难梭菌感染 和急性肾损伤的风险。 In a single-center, retrospective, cohort study comparing joint arthroplasty, patients who received a single dose of antibiotic prophylaxis (no additional doses after skin closure) versus 24-hour antibiotic administration, there were no differences in the following outcomes between these 2 groups: prosthetic joint infection, superficial infection, 90-day reoperation, and 90-day complications.108
在一项比较关节置换术的单中心、回顾性队列研究中，接受单剂量抗生素预防（皮肤闭合后不增加剂量）与 24 小时抗生素给药的患者，这两组之间的以下结局没有差异：假体关节感染、浅表感染、90 天再次手术和 90 天并发症。 Although it is not recommended to routinely use vancomycin, this agent should be considered in patients who are known to be MRSA colonized (including those identified on preoperative screening), particularly if the surgery involves prosthetic material.
虽然不建议常规使用万古霉素，但对于已知定植了 MRSA 的患者（包括术前筛查发现的患者），尤其是手术涉及假体材料的患者，应考虑使用万古霉素。 Two hours are allowed for the administration of vancomycin and fluoroquinolones due to longer infusion times.
由于输注时间较长，万古霉素和氟喹诺酮类药物的给药时间允许为两小时。 For cesarean delivery, administer antimicrobial prophylaxis prior to skin incision rather than after cord clamping.97
对于剖宫产，应在皮肤切开前进行抗菌药物预防，而不是在脐带钳夹后进行预防性治疗。 In procedures using “bloodless” techniques, many experts believe that antimicrobial agents should be infused prior to tourniquet inflation, though data are lacking to inform this recommendation.98
在使用“不流血”技术的手术中，许多专家认为应在止血带充气之前输注抗菌剂，尽管缺乏数据来为这一建议提供信息。
Begin administration within 1 hour prior to incision to maximize tissue concentration.73,93,94 Administering an antimicrobial agent <1 hour prior to incision is effective; some studies show superior efficacy for administration between 0 and 30 minutes prior to incision compared with administration between 30 and 60 minutes prior to incision.95,96
在切口前 1 小时内开始给药，以最大限度地提高组织浓度。 在切口前 <1 小时给药抗菌剂是有效的;一些研究表明，在切口前 0 到 30 分钟给药比在切口前 30 到 60 分钟给药更有效。 Select appropriate antimicrobial agents based on the surgical procedure, the most common pathogens known to cause SSI for the specific procedure, and published recommendations.73
根据外科手术过程、已知引起特定手术 SSI 的最常见病原体以及已发表的建议，选择适当的抗菌药物。 Obtain a thorough allergy history. Self-reported β-lactam allergy has been linked to a higher risk of SSI due to use of alternative, non–β-lactam and often inferior antibiotics, and many patients with a self-reported β-lactam allergy can safely receive a β-lactam antibiotic as prophylaxis.99-101
获得全面的过敏史。由于使用替代的、非β内酰胺类和通常劣质的抗生素，自我报告的 β-内酰胺类过敏与 SSI 的风险较高有关，许多自我报告的 β-内酰胺类过敏的患者可以安全地接受β内酰胺类抗生素作为预防。 Discontinue antimicrobial agents after incisional closure in the operating room.73
在手术室切口闭合后停用抗菌药物。 Adjust dosing based on patient weight,73 according to the following examples:
根据患者体重调整剂量， 73 根据以下示例： Re-dose prophylactic antimicrobial agents for lengthy procedures and in cases with excessive blood loss during the procedure (ie, >1,500 mL).73 Re-dose prophylactic antimicrobial agents at intervals of 2 half-lives (measured from the time the preoperative dose was administered) in cases that exceed this period. For example, re-dose cefazolin after 4 hours in procedures >4 hours long.73
对于长时间的手术和手术过程中失血过多的情况（即 >1,500 mL），重新给予预防性抗菌药物。 在超过此时期的病例中，以 2 个半衰期的间隔（从术前给药时间开始测量）重新给药预防性抗菌剂。例如，在 4 小时的手术中重新给药头孢唑林>4 小时。
Use a combination of parenteral and oral antimicrobial prophylaxis prior to elective colorectal surgery to reduce the risk of SSI.115,116 (Quality of evidence: HIGH)
在择期结直肠手术前，使用肠外抗菌药和口服抗菌药联合预防，以降低 SSI 风险。（证据质量：高）
A 2019 meta-analysis of 40 studies (28 randomized clinical trials [RCTs] and 12 observational studies) found that the combination of parenteral and oral antimicrobial prophylaxis and mechanical bowel preparation prior to elective colorectal surgery significantly reduces SSI, postoperative ileus, anastomotic leak, and 30-day mortality, without an increase in C. difficile infection.116 In 2021,117 the meta-analysis was updated to include the results from the MOBILE and ORALEV trials, which further demonstrated the decreases shown in 2019,119,120 along with data showing that oral antimicrobial prophylaxis alone without mechanical bowel preparation significantly reduces SSI, anastomotic leak, and 30-day mortality.121,122 We continue to recommend the combination of parenteral and oral antimicrobial prophylaxis and mechanical bowel preparation prior to elective colorectal surgery, unless there is a contraindication to mechanical bowel preparation, in which case, only parenteral and oral antimicrobial prophylaxis should be administered.
2019 年一项针对 40 项研究（28 项随机临床试验 [RCT] 和 12 项观察性研究）的荟萃分析发现，在择期结直肠手术前联合使用胃肠外和口服抗菌药物预防以及机械肠道准备可显著降低 SSI、术后肠梗阻、吻合口瘘和 30 天死亡率，而艰难梭菌感染率不会增加。2021 年，荟萃分析进行了更新，纳入了 MOBILE 和 ORALEV 试验的结果，这些试验进一步证明了 2019 年显示的下降， 同时数据显示，单独口服抗菌药物预防而不进行机械肠道准备可显着降低 SSI、吻合口瘘和 30 天死亡率。 我们仍然推荐在择期结直肠手术前联合使用胃外和口服抗菌药物预防以及机械肠道准备，除非有机械肠道准备的禁忌证，在这种情况下，应仅进行肠外和口服抗菌药物预防。 Use of combination parenteral and oral antimicrobial agents to reduce the risk of SSI should be considered in any surgical procedure where entry into the colon is possible or likely, as in gynecologic oncology surgery.
在可能或可能进入结肠的任何外科手术中，如妇科肿瘤外科手术，都应考虑使用肠外和口服联合抗菌药物来降低 SSI 的风险。 Mechanical bowel preparation without use of oral antimicrobial agents does not decrease the risk of SSI.115 A recent prospective randomized multicenter trial confirmed earlier meta-analysis findings, with significantly higher SSI and anastomotic leakage in patients who received mechanical bowel preparation without oral antimicrobial agents.122
不使用口服抗菌药物的机械肠道准备并不能降低 SSI 的风险。最近的一项前瞻性随机多中心试验证实了早期的荟萃分析结果，在未口服抗菌药物的情况下接受机械肠道准备的患者，SSI 和吻合口瘘明显更高。
Decolonize surgical patients with an antistaphylococcal agent in the preoperative setting for orthopedic and cardiothoracic procedures. (Quality of evidence: HIGH). Decolonize surgical patients for other procedures at high risk of staphylococcal SSI, such as those involving prosthetic material. (Quality of evidence: LOW)
在骨科和心胸外科手术的术前环境中使用抗葡萄球菌药物对手术患者进行去定植。（证据质量：高）。对手术患者进行其他葡萄球菌性 SSI 高风险的手术，例如涉及假体材料的手术。（证据质量：低）
Preoperative bathing with agents such as CHG has been shown to reduce bacterial colonization of the skin.140,141 Several studies have examined the utility of preoperative showers, but none has definitively proven that they decrease SSI risk. A Cochrane review evaluated the evidence for preoperative bathing or showering with antiseptics for SSI prevention.142 Six RCTs evaluating 4% CHG use were included in the analysis, with no clear evidence of benefit noted. Several of these studies had methodologic limitations and were conducted several years ago. Thus, the role of preoperative bathing in SSI prevention remains uncertain.
术前使用 CHG 等药物洗澡已被证明可以减少细菌在皮肤上的定植。几项研究检查了术前淋浴的效用，但没有一项明确证明它们可以降低 SSI 风险。一项 Cochrane 评价评估了术前沐浴或淋浴用抗菌剂预防 SSI 的证据，分析纳入了六项评估 4% CHG 使用率的随机对照试验，没有发现明确的获益证据。其中几项研究在方法学上存在局限性，并且是几年前进行的。因此，术前沐浴在预防SSI中的作用仍不确定。
To achieve the maximum antiseptic effect of CHG, adequate levels of CHG must be achieved and maintained on the skin. Typically, adequate levels are achieved by allowing CHG to dry completely. Additional strategies for preoperative bathing with CHG, such as preimpregnated cloths, have shown promise,143-145 but data are currently insufficient to support this approach.
为了达到CHG的最大抗菌效果，必须在皮肤上达到并维持足够的CHG水平。通常，通过让 CHG 完全干燥来获得足够的水平。使用 CHG 进行术前沐浴的其他策略，例如预浸布，已显示出希望， 但目前数据不足以支持这种方法。 One single-center RCT comparing intranasal povidone-iodine with mupirocin in total joint arthroplasty and spinal surgery patients found that povidone-iodine and mupirocin were similarly effective.137 In that RCT, topical CHG wipes in combination with povidone-iodine was given within 2 hours of surgery versus with mupirocin during the 5 days before surgery.137 There was no significant difference between deep SSI rates when comparing those who received povidone-iodine with those who received mupirocin.
一项单中心 RCT 比较了鼻内聚维酮碘与莫匹罗星在全关节置换术和脊柱手术患者中的疗效，发现聚维酮碘和莫匹罗星的效果相似。在该随机对照试验中，局部 CHG 湿巾联合聚维酮碘在手术后 2 小时内给药，而在手术前 5 天内与莫匹罗星联合使用，与接受聚维酮碘治疗的患者相比，深部SSI感染率之间没有显著差异。 Two quasi-experimental, single-center studies of intranasal povidone-iodine decolonization reported a significant reduction in SSIs when compared with standard care among preintervention groups. One study paired intranasal povidone-iodine decolonization with CHG wipes and oral povidone-iodine rinse for elective orthopedic surgery138; the other study paired it with CHG wipes or baths and povidone-iodine skin antisepsis for urgent lower extremity repairs of fractures that required hardware.139
两项关于鼻内聚维酮碘去菌的准实验性单中心研究报告称，与干预前的标准护理相比，干预组的 SSI 显著减少。其中一项研究将聚维酮碘鼻内去菌与 CHG 湿巾和口服聚维酮碘冲洗配对用于择期骨科手术；另一项研究将其与 CHG 湿巾或浴液和聚维酮碘皮肤防腐配对用于需要硬件的下肢骨折紧急修复。 A prospective, interventional, cohort study with crossover design involving 21,000 patients concluded that universal, rapid screening for MRSA at admission combined with decolonization of carriers did not reduce the SSI rate due to MRSA.131 This study included 8 surgical specialties: abdominal surgery, orthopedics, urology, neurosurgery, cardiovascular surgery, thoracic surgery, plastic surgery, and solid-organ transplantation. Similarly, a prospective interventional cohort study of 10 hospitals did not find a decrease in MRSA clinical cultures when MRSA screening and decolonization were performed among 9 surgical specialties. However, when the analysis was limited to patients undergoing clean surgery, MRSA screening and decolonization was significantly associated with reductions in MRSA SSI rates.132,133 Clean surgery included cardiothoracic, neuro, orthopedic, plastic, and vascular surgery.
一项涉及 21,000 名患者的交叉设计的前瞻性、干预性队列研究得出结论，入院时普遍、快速筛查 MRSA 结合携带者的去定植并未降低 MRSA 引起的 SSI 发生率。 本研究纳入腹部外科、骨科、泌尿科、神经外科、心血管外科、胸外科、整形外科、实体器官移植8个外科专科。同样，一项针对 10 家医院的前瞻性干预队列研究发现，当在 9 个外科专科进行 MRSA 筛查和去定植时，MRSA 临床培养没有减少。然而，当分析仅限于接受清洁手术的患者时，MRSA筛查和去定植与MRSA SSI感染率的降低显着相关。 清洁手术包括心胸外科、神经外科、骨科、整形外科和血管外科。 A double-blinded, randomized-controlled trial involving >4,000 patients undergoing general, gynecologic, neurologic, or cardiothoracic surgery showed that universal intranasal mupirocin application, when not combined with CHG bathing, did not significantly reduce the S. aureus SSI rate.134 In a secondary analysis of this data, the use of intranasal mupirocin was associated with an overall decreased rate of nosocomial S. aureus infections among the S. aureus carriers.
一项涉及 >4,000 名接受普通手术、妇科手术、神经手术或心胸手术的患者的双盲、随机对照试验表明，在不与 CHG 沐浴联合使用的情况下，普遍使用鼻内莫匹罗星并不能显着降低金黄色葡萄球菌 SSI 率。 在对该数据的二次分析中，使用鼻内莫匹罗星与金黄色葡萄球菌携带者医院金黄色葡萄球菌感染率总体降低有关。 For example, a randomized, double-blind, placebo-controlled, multicenter trial showed that rapid identification of S. aureus nasal carriers, followed by decolonization with intranasal mupirocin and CHG bathing was associated with a >2-fold reduction in the risk for postoperative infection due to S. aureus and an almost five-fold reduction in incidence of deep-incisional SSI due to S. aureus.126 Patients undergoing clean procedures (eg, cardiothoracic, orthopedic, vascular) who were randomized to decolonization also had reduced 1-year mortality compared with those patients who were randomized to the placebo.127
例如，一项随机、双盲、安慰剂对照、多中心试验表明，快速识别金黄色葡萄球菌鼻携带者，然后使用鼻内莫匹罗星和 CHG 浴进行去定植，可使金黄色葡萄球菌术后感染风险降低 >2 倍，金黄色葡萄球菌引起的深切口 SSI 发病率降低近 5 倍。 与随机分配至安慰剂组的患者相比，接受清洁手术（如心胸外科、骨科、血管外科）的患者被随机分配到去定植组，其1年死亡率也有所降低。 A 20-hospital, nonrandomized, quasi-experimental study of patients undergoing cardiac surgery or total joint arthroplasty found a significant decrease in deep-incisional or organ-space S. aureus SSI after implementing a bundle of interventions, including S. aureus nasal screening, decolonization of nasal carriers with mupirocin, CHG bathing for all patients, and perioperative antibiotic prophylaxis adjustment based on MRSA carriage status.128
一项针对接受心脏手术或全关节置换术的患者的 20 家医院非随机准实验研究发现，在实施一系列干预措施后，深切口或器官间隙金黄色葡萄球菌 SSI 显着降低，包括金黄色葡萄球菌鼻腔筛查、使用莫匹罗星对鼻腔携带者进行去定植、对所有患者进行 CHG 沐浴以及基于 MRSA 携带状态的围手术期抗生素预防调整。 Notably, universal decolonization for targeted procedures is likely more cost effective than screen-and-treat strategies.129,130 Universal decolonization may also be easier to implement.
值得注意的是，针对目标手术的普遍去定植化可能比筛查和治疗策略更具成本效益。 普遍去定值化也可能更容易实施。 Some hospitals continue to use screen-and-treat strategies because the results from screening for MRSA colonization can guide antibiotic prophylaxis.
一些医院继续使用筛查和治疗策略，因为 MRSA 定植筛查结果可以指导抗生素预防。 Published data are most supportive of using intranasal mupirocin and chlorhexidine bathing. There are some preliminary data on intranasal povidone-iodine administered immediately before surgery. This approach may have practical advantages, but more data are needed.124 Fewer data exist for other alternative strategies such as intranasal alcohol-based antisepsis and phototherapy.
已发表的数据最支持使用莫匹罗星鼻内注射剂和洗必泰沐浴剂。关于手术前立即鼻内注射聚维酮碘也有一些初步数据。这种方法可能具有实际优势，但还需要更多数据。其他替代策略的数据较少，如鼻内酒精消毒和光疗。 The strongest data recommend up to 5 days of intranasal mupirocin (twice daily) and bathing with chlorhexidine gluconate (CHG) (daily).
最强的数据建议长达 5 天的鼻内莫匹罗星（每日两次）和葡萄糖酸氯己定 （CHG）（每天一次）。
Decolonization refers to the practice of treating patients with an antimicrobial and/or antiseptic agent to suppress S. aureus colonization inclusive of both methicillin-susceptible S. aureus (MSSA) and methicillin-resistant S. aureus (MRSA).
去定植是指使用抗菌剂和/或消毒剂治疗患者以抑制金黄色葡萄球菌定植的做法，包括对甲氧西林敏感的金黄色葡萄球菌 （MSSA） 和耐甲氧西林金黄色葡萄球菌 （MRSA）。 A meta-analysis of 17 studies of patients undergoing cardiac or orthopedic procedures concluded that decolonization strategies prevent S. aureus SSIs.125
一项对接受心脏或骨科手术的患者进行的 17 项研究的荟萃分析得出结论，去定植策略可预防金黄色葡萄球菌 SSI。 Some trials demonstrated that preoperative screening for S. aureus, combined with intranasal mupirocin and CHG bathing, was effective in reducing SSI.
一些试验表明，术前筛查金黄色葡萄球菌，结合鼻内莫匹罗星和CHG浴，可有效降低SSI。 In contrast, other trials that assessed a wide range of surgical specialties did not observe a protective effect against SSIs.
相比之下，其他评估了广泛外科专业的试验没有观察到对SSIs的保护作用。 A Cochrane review concluded that mupirocin decolonization of the nares alone may be effective, particularly in certain groups, including patients undergoing orthopedic and cardiothoracic procedures.135 However, routine preoperative decolonization with mupirocin without screening may lead to mupirocin resistance.136
一项 Cochrane 评价得出结论，单独对鼻孔进行莫匹罗星去定植可能有效，尤其是在某些人群中，包括接受骨科和心胸外科手术的患者。 然而，未经筛查使用莫匹罗星进行常规术前去定植可能会导致莫匹罗星耐药。 Routine decolonization with antiseptic agents such as intranasal povidone-iodine without screening can be performed because povidone-iodine resistance has not been observed.
由于尚未观察到聚维酮-碘耐药性，因此可以使用消毒剂（如鼻内聚维酮碘）进行常规去定植，而无需筛查。 Data are mixed on at-home preoperative bathing with CHG-containing products alone for patients not known to be colonized with Staphylococcus aureus.
对于未发现金黄色葡萄球菌定植的患者，术前单独使用含 CHG 产品进行居家沐浴的数据不一。
Use antiseptic-containing preoperative vaginal preparation agents for patients undergoing cesarean delivery or hysterectomy. (Quality of evidence: MODERATE)
对于接受剖宫产或子宫切除术的患者，使用含抗菌剂的术前阴道准备剂。（证据质量：中等）
Use of povidone-iodine or CHG-based vaginal preparation agents immediately before cesarean delivery reduces endometritis by 59%, with possibly even greater benefit among women in labor.146 Products should be chosen and used in accordance with manufacturer’s instructions for use.
在剖宫产前立即使用聚维酮碘或基于 CHG 的阴道准备剂可使子宫内膜炎减少 59%，在分娩妇女中可能获益更大。 应按照制造商的使用说明选择和使用产品。 Vaginal preparation with antiseptic solution is also recommended for elective hysterectomy.147
择期子宫切除术也建议使用消毒液进行阴道准备。 147
Do not remove hair at the operative site unless the presence of hair will interfere with the surgical procedure.4,119 (Quality of evidence: MODERATE)
不要在手术部位脱落毛发，除非毛发的存在会干扰手术过程。 （证据质量：中等）
If hair removal is necessary in elective procedures, remove hair outside the operating room using clippers or a depilatory agent.
如果在择期手术中需要脱毛，请使用剪子或脱毛剂在手术室外脱毛。 Razors may be acceptable for hair removal in a subset of procedures (eg, procedures involving male genitalia). One small, single-center, RCT demonstrated that clipping hair on the scrotum can cause more skin trauma than razors; clipping hair did not decrease the rate of SSI.148
剃须刀在一部分手术（例如，涉及男性生殖器的手术）中可以接受脱毛。一项小型、单中心随机对照试验表明，与剃须刀相比，剪掉阴囊上的毛发可造成更多的皮肤创伤;剪发并没有降低SSI的发生率。
Use alcohol-containing preoperative skin preparatory agents in combination with an antiseptic. (Quality of evidence: HIGH)
将含酒精的术前皮肤准备剂与抗菌剂结合使用。（证据质量：高）
A Cochrane review of 13 studies, published in 2015, was inconclusive regarding the best strategy for preoperative skin antisepsis.150 Only 1 of these studies compared 0.5% CHG–alcohol to povidone-iodine–alcohol.
2015 年发表的一项针对 13 项研究的 Cochrane 评价对术前皮肤抗菌剂的最佳策略尚无定论。 这些研究中只有 1 项比较了 0.5% CHG-酒精与聚维酮-碘-酒精。 Four RCTs (3 single center and 1 multicenter) have compared CHG–alcohol to povidone-iodine–alcohol.
四项随机对照试验（3项单中心和1项多中心）比较了CHG-酒精与聚维酮-碘-酒精。 CHG–alcohol is the antiseptic of choice for patients with S. aureus colonization.128
CHG-酒精是金黄色葡萄球菌定植患者的首选消毒剂。 128 In the absence of alcohol, CHG may have advantages over povidone-iodine, including longer residual activity and activity in the presence of blood or serum.156,157
在没有酒精的情况下，CHG 可能比聚维酮碘具有优势，包括更长的残留活性和在血液或血清存在下的活性。 Antiseptics are not interchangeable. Follow manufacturer’s instructions to ensure correct application. Topical CHG preparations may be contraindicated for use in mouth, eyes and ears, patients with skin disease involving more than the superficial layers of skin, and procedures involving the meninges. Use of topical CHG preparations for preterm infants is controversial due to concerns for skin toxicity, absorption, and resultant toxicity including neurotoxicity.158 However, apart from these specific contraindications, topical CHG for skin antisepsis and SSI prevention has been shown to be safe.158-162
消毒剂是不可互换的。请按照制造商的说明进行操作，以确保正确使用。外用 CHG 制剂可能禁忌用于口腔、眼睛和耳朵、涉及皮肤表层以上的皮肤病患者以及涉及脑膜的手术。由于担心皮肤毒性、吸收和由此产生的毒性（包括神经毒性），对早产儿使用局部 CHG 制剂存在争议。 然而，除了这些特定的禁忌症外，用于皮肤消毒剂和 SSI 预防的局部 CHG 已被证明是安全的。 158-162
Tuuli et al151 conducted a single-center RCT of 1,147 women undergoing cesarean delivery. Women randomized to receive CHG–alcohol had a 45% reduction in SSI compared to women randomized to receive povidone-iodine–alcohol (relative risk, 0.55; 95% confidence interval, 0.34–0.90; P = .02).
Tuuli 等人 对 1,147 名接受剖宫产的妇女进行了单中心 RCT。与随机接受聚维酮碘醇组的女性相比，随机接受CHG-酒精治疗的女性的SSI降低了45%（相对风险，0.55;95%置信区间，0.34-0.90;P = .02）。 Ritter et al152 conducted a single-center RCT of 279 patients undergoing lower-limb procedures. Patients randomized to receive povidone-iodine–alcohol had a 3.5-fold higher rate of wound healing complications, including SSI, compared with patients randomized to receive CHG-alcohol.
Ritter 等人 对 279 名接受下肢手术的患者进行了单中心 RCT。与随机接受 CHG-酒精治疗的患者相比，随机接受聚维酮碘酒精治疗的患者伤口愈合并发症（包括 SSI）的发生率高 3.5 倍。 Broach et al153 conducted a single-center, noninferiority RCT of 802 patients undergoing elective, clean-contaminated colorectal procedures. The SSI rate was higher among patients randomized to receive povidone-iodine–alcohol (18.7% vs 15.9%), which failed to meet criterion for noninferiority compared to CHG–alcohol.
Broach 等人对 802 名接受选择性、清洁污染的结直肠手术的患者进行了单中心、非劣效性 RCT。随机接受聚维酮-碘-酒精组的患者的 SSI 率更高 （18.7% vs 15.9%），与 CHG-酒精组相比，其未能达到非劣效性标准。 Charehbili et al154 conducted a multicenter, cluster-randomized trial with crossover among 3,665 patients undergoing breast, vascular, colorectal, gallbladder, or orthopedic procedures. No difference in SSI rates was observed between the 2 groups, but some concerns were raised about the methods, including cluster sample size, number of clusters, and how the treatment period was analyzed.155
Charehbili 等人 154 进行了一项多中心、整群随机试验，在 3,665 名接受乳腺、血管、结直肠、胆囊或骨科手术的患者中进行了交叉试验。两组之间没有观察到SSI率的差异，但对方法提出了一些担忧，包括聚类样本量、聚类数量以及如何分析治疗期。 Alcohol is highly bactericidal and effective for preoperative skin antisepsis, but it does not have persistent activity when used alone. Rapid, persistent, and cumulative antisepsis can be achieved by combining alcohol with CHG or an iodophor.149 Alcohol is contraindicated for certain procedures due to fire risk, including procedures in which the preparatory agent may pool or not dry (eg, involving hair). Alcohol may also be contraindicated for procedures involving mucosa, cornea, or ear.
酒精具有很强的杀菌作用，对术前皮肤消毒有效，但单独使用时没有持久的活性。通过将酒精与 CHG 或碘伏混合使用，可以实现快速、持久和累积的消毒。 由于存在火灾风险，某些手术禁忌酒精，包括准备剂可能积聚或不干燥的手术（例如，涉及头发）。涉及粘膜、角膜或耳朵的手术也可能禁忌酒精。 The most effective antiseptic to combine with alcohol remains unclear; however, data from recent trials favor the use of CHG–alcohol over povidone-iodine–alcohol.
与酒精结合使用最有效的消毒尚不清楚;然而，最近试验的数据支持使用 CHG-酒精而不是聚维酮-碘-酒精。
For procedures not requiring hypothermia, maintain normothermia (temperature >35.5°C) during the perioperative period. (Quality of evidence: HIGH)
对于不需要低体温的手术，围手术期保持正常体温（体温 >35.5°C）。（证据质量：高）
Even mild hypothermia can increase SSI rates. Hypothermia may directly impair neutrophil function or impair it indirectly by triggering subcutaneous vasoconstriction and subsequent tissue hypoxia. Hypothermia may increase blood loss, leading to wound hematomas or the need for transfusion—both of which can increase SSI rates.163
即使是轻度体温过低也会增加 SSI 率。体温过低可能直接损害中性粒细胞功能，或通过触发皮下血管收缩和随后的组织缺氧间接损害中性粒细胞功能。体温过低可能会增加失血，导致伤口血肿或需要输血，这两者都会增加 SSI 发生率。 RCTs have shown the benefits of both preoperative and intraoperative warming in reducing SSI rates and intraoperative blood loss.164-166
随机对照试验显示，术前和术中加温均能降低SSI发生率和术中失血。 Preoperative normothermia may be most beneficial167; patients who received 30 minutes of preoperative warming had lower intraoperative hypothermia rates.168 One study used 2 hours of preoperative warming, but a meta-analysis suggested that 30 minutes should be sufficient.
术前体温正常可能是最有益 的;接受术前加温 30 分钟的患者术中体温过低率较低。 一项研究使用了术前 2 小时的热身，但一项荟萃分析表明 30 分钟应该就足够了。 Patients who are hypothermic at the end of surgery may remain hypothermic for up to 5 hours. Although there is not a standardized duration of postoperative warming, one study used 2 hours of postoperative warming and showed reduced rates of SSI.
手术结束时体温过低的患者可能会保持体温过低长达 5 小时。虽然没有标准化的术后升温持续时间，但一项研究使用了术后 2 小时升温，并显示 SSI 的发生率降低。
Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery. (Quality of evidence: HIGH)
在胃肠道和胆道手术中使用不透水塑料伤口保护器。（证据质量：高）
There was a significant trend toward greater protective effect using a dual ring protector as compared to a single ring protector: 29% decrease in risk of SSI for dual ring and 16% decrease in risk of SSI for single ring.169
与单环保护器相比，使用双环保护器具有更强的保护效果的显着趋势：双环的 SSI 风险降低 29%，单环的 SSI 风险降低 16%。 Another prospective randomized study of dual ring protectors in pancreatectomy showed a reduction in SSI rate from 44% to 21% (P = .011) with the use of a dual ring protector.170
另一项关于胰腺切除术中使用双环保护器的前瞻性随机研究显示，使用双环保护器可将 SSI 率从 44% 降低到 21% （P = .011）。
A wound protector, a plastic sheath that lines a wound, facilitates retraction of an incision during surgery without the need for additional mechanical retractors.
伤口保护器是衬在伤口上的塑料护套，有助于在手术过程中缩回切口，而无需额外的机械牵开器。 A recent meta-analysis of 14 randomized clinical trials in 2,689 patients reported that the use of a plastic wound protector was associated with a 30% decrease in risk of SSI.169
最近一项针对 2,689 名患者的 14 项随机临床试验的荟萃分析报告称，使用塑料伤口保护器可使 SSI 风险降低 30%。
Perform intraoperative antiseptic wound lavage.171 (Quality of evidence: MODERATE)
进行术中消毒伤口灌洗。 171 （证据质量：中等）
Wound lavage is a common practice, although the solution and volume used for lavage differs among surgeons.
伤口灌洗是一种常见的做法，尽管外科医生用于灌洗的溶液和体积不同。 Evidence does not support saline lavage (nonantiseptic lavage) to reduce SSIs.171,172
证据不支持生理盐水灌洗（非防腐灌洗）可减少SSI。 Several systematic reviews and meta-analyses support the use of prophylactic intraoperative wound irrigation with sterile dilute povidone-iodine lavage to decrease the risk of SSIs. One systematic review and meta-analysis published in 2017 evaluated 21 RCTs and concluded that lavage with sterile dilute povidone-iodine decreased the risk of SSI compared to nonantiseptic lavage (odds ratio [OR], 0.31; 95% confidence interval [Cl], 0.13–0.73).102,173 This study reported no benefit from antibiotic irrigation and discouraged this practice.
几项系统评价和荟萃分析支持使用无菌稀释聚维酮碘灌洗剂进行预防性术中伤口冲洗，以降低 SSI 的风险。2017 年发表的一项系统评价和荟萃分析评估了 21 项随机对照试验，得出的结论是，与非抗菌灌洗相比，无菌稀释聚维酮碘灌洗可降低 SSI 的风险（比值比 [OR]，0.31;95% 置信区间 [Cl]，0.13-0.73）。 102,173 这项研究报告说抗生素冲洗没有益处，因此不鼓励这种做法。 A systematic review and network meta-analysis published in 2021 reported that relative to saline lavage, both antibiotic irrigation (OR, 0.439; 95% CI, 0.282–0.667) and sterile dilute povidone-iodine (OR, 0.573; 95% CI, 0.321–0.953) decreased the risk of SSI. A third systematic review and meta-analysis published in 2015 reported a similar benefit of antibiotic irrigation and sterile dilute povidone-iodine in the subgroup analysis focused on colorectal surgery.174,175 Data were mixed in a different meta-analysis published in 2019,176 potentially due to whether the antibiotic lavage (typically a β-lactam or aminoglycoside agent) was used in clean–clean-contaminated or contaminated–dirty wounds.
2021 年发表的一篇系统综述和网络荟萃分析报告称，相对于生理盐水灌洗，抗生素灌洗（OR，0.439；95% CI，0.282-0.667）和无菌稀释聚维酮碘（OR，0.573；95% CI，0.321-0.953）均可降低 SSI 风险。2015 年发表的第三篇系统综述和荟萃分析报告称，在以结直肠手术为重点的亚组分析中，抗生素灌洗和无菌稀释聚维酮碘具有类似的益处。174,175 2019 年发表的另一篇荟萃分析报告中的数据参差不齐176 ，这可能是由于抗生素灌洗（通常是β-内酰胺类或氨基糖苷类药物）是用于清洁-清洁-污染还是污染-污染-清洁伤口。（国内不推荐抗菌药物冲洗？） We recommend the use of dilute povidone-iodine lavage over saline lavage, making sure that sterility is maintained during preparation and administration to enhance patient safety. We recommend studying antibiotic irrigation versus dilute povidone-iodine irrigation in an RCT focused on intra-abdominal surgery that is contaminated–dirty.
我们建议使用稀聚维酮碘灌洗液而不是生理盐水灌洗液，确保在制备和给药过程中保持无菌状态，以提高患者安全性。我们建议在一项针对污染-肮脏的腹腔内手术的随机对照试验中研究抗生素冲洗与稀释聚维酮-碘冲洗那种更优。 Given the dearth of povidone-iodine solutions formally labeled “sterile,” we advise surgeons to educate themselves as to their options and to carefully weigh the risks and benefits of using povidone-iodine solutions available at their facility.
鉴于缺乏正式标记为“无菌”的聚维酮碘溶液，我们建议外科医生对自己的选择进行自我教育，并仔细权衡使用其医疗机构中可用的聚维酮碘溶液的风险和益处。 Bacitracin is contraindicated. The FDA withdrew injectable bacitracin from the market because safety concerns outweighed the benefits. This was based on case reports of intraoperative anaphylactic shock associated with bacitracin irrigation.177
杆菌肽是禁忌的。美国食品和药物管理局（FDA）从市场上撤回了可注射杆菌肽，因为安全性问题超过了好处。这是基于与杆菌肽冲洗相关的术中过敏性休克的病例报告。 Other agents worth additional study include polyhexanide and rifampicin in certain patient populations.178,179
其他值得进一步研究的药物包括聚己胺和利福平在某些患者群体中的作用。
Control blood-glucose level during the immediate postoperative period for all patients.94 (Quality of evidence: HIGH)
控制所有患者术后即刻的血糖水平。 94 （证据质量：高）
Monitor and maintain postoperative blood-glucose level regardless of diabetes status.
无论糖尿病状况如何，都要监测和维持术后血糖水平。 Maintain postoperative blood-glucose level between 110 and 150 mg/dL. Increased glucose levels during the operational procedure are associated with higher levels in the postoperative setting.180 Studies on postoperative blood glucose have focused on monitoring through postoperative day 1–2; however, heterogeneity between studies makes it impossible to recommend a definitive window for postoperative blood-glucose control other than 24–48 hours.94,180-185
将术后血糖水平维持在 110 至 150 mg/dL 之间。手术过程中血糖水平升高与术后血糖水平升高有关。 180 术后血糖研究的重点是在术后第 1-2 天进行监测;然而，由于研究之间的异质性，因此无法推荐除 24-48 小时之外的术后血糖控制的明确窗口。 The ideal method for maintaining target postoperative blood-glucose level remains unknown. Generally, continuous insulin-infusion protocols lead to better control than subcutaneous insulin (sliding scale) strategies.186 Continuous insulin infusion commonly requires intensive monitoring; thus, its use in the ambulatory surgery is often not feasible.
维持目标术后血糖水平的理想方法仍然未知。通常，连续胰岛素输注方案比皮下注射胰岛素（滑动比例）策略能更好地控制。持续输注胰岛素通常需要密切监测;因此，它在门诊手术中的使用通常是不可行的。 Intensive postoperative blood-glucose control (targeting levels <110 mg/dL) has not consistently shown reduced risk of SSI. Although some studies have demonstrated decreased SSI rates,187 others have demonstrated higher rates of hypoglycemia and adverse outcomes including stroke and death.188
强化术后血糖控制（目标水平 <110 mg/dL）并未始终显示 SSI 风险降低。尽管一些研究表明 SSI 率降低， 但其他研究表明低血糖和不良后果（包括中风和死亡）的发生率更高。
Use a checklist and/or bundle to ensure compliance with best practices to improve surgical patient safety. (Quality of evidence: HIGH)
使用检查清单和/或集束措施来确保遵守最佳实践，以提高手术患者的安全性。（证据质量：高）
A multicenter, quasi-experimental study conducted across 8 countries demonstrated that use of the WHO checklist led to lower surgical complication rates, including SSI and death.190
一项在 8 个国家/地区进行的多中心准实验研究表明，使用 WHO 检查表可降低手术并发症发生率，包括 SSI 和死亡率。 These findings have been confirmed in subsequent single- and multicenter quasi-experimental studies.191,192
这些发现已在随后的单中心和多中心准实验研究中得到证实。
The World Health Organization (WHO) checklist is a 19-item surgical safety checklist to improve adherence with best practices.189
世界卫生组织 （World Health Organization， WHO） 检查表是一份包含 19 项手术安全检查表，旨在提高对最佳实践的依从性。 189 Overall, the use of bundles can reduce SSI, but the exact elements needed in a bundle are unknown.193 This issue is important because some elements have considerable cost and logistical implications, so it is important to understand the impact of individual elements outside a bundle.193
总体而言，使用集束措施束可以减少 SSI，但集束措施中所需的确切要素尚不清楚。 这个问题很重要，因为某些要算具有相当大的成本和物流影响，因此了解集束包之外的各个要素的影响非常重要。
Perform surveillance for SSI. (Quality of evidence: MODERATE)
对 SSI 进行监测。（证据质量：中等）
Develop a database for storing, managing, and accessing data collected on SSIs.
开发一个数据库，用于存储、管理和访问在 SSI 上收集的数据。 Implement a system for collecting data needed to identify and report SSIs. This is discussed in Section 2. Consider collecting data on patient comorbidities (including American Society of Anesthesiology [ASA] score and specific risk factors such as body mass index and diabetes), surgical factors (including wound class, operative duration), process measures (including completion of essential practices discussed in this section), and specifics of SSI (including depth, infecting organism, and antimicrobial susceptibilities).
实施一个系统，收集识别和报告SSI所需的数据。这已在第 2 节中讨论。考虑收集有关患者合并症（包括美国麻醉学会 （American Society of Anesthesiology， ASA） 评分和特定危险因素（如体重指数和糖尿病）、手术因素（包括伤口类别、手术持续时间）、过程措施（包括完成本节讨论的基本实践）和 SSI 具体情况（包括深度、感染病原体和抗菌药物敏感性）的数据。 Develop a system for routine review and interpretation of SSI rates and/or SIRs to detect significant increases or outbreaks and to identify areas where additional resources might be needed to improve SSI rates.34,194 If increased rates are identified, determine the number of infections that were potentially preventable.195
建立一套系统，对 SSI 感染率和/或 SIR 进行常规监测和解释，以发现显著增加或爆发，并确定可能需要提高额外资源来控制SSI 感染率的领域。
Identify high-risk, high-volume operative procedures to be targeted for SSI surveillance based on a risk assessment of patient populations, operative procedures performed, and available SSI surveillance data. Some surveillance is also mandated by federal and state regulations.
根据对患者群体的风险评估、执行的手术程序和可用的 SSI 监测数据，确定针对 SSI 监测的高风险、大容量手术程序。联邦和州法规还强制要求进行的一些监测。 Identify, collect, store, and analyze data needed for the surveillance program.4
识别、收集、存储和分析监控计划所需的数据。 Convene key national agencies, organizations, and societies to evaluate. Where possible, align definitions and reporting requirements.
召集主要国家机构、组织和学会进行评估。在可能的情况下，统一定义和报告要求。
Increase the efficiency of surveillance by utilizing automated data. (Quality of evidence: MODERATE)
通过利用自动化数据提高监控效率。（证据质量：中等）
Implement a method to electronically transmit data to infection prevention and control personnel needed to determine denominator data and calculate SSI rates for various procedures. This might include procedure data, process measure data, readmission and rehospitalization data, postoperative antimicrobial data, microbiology data, and diagnosis and procedure codes.54,196-199
实施一种方法，以电子方式将数据传输给需要的感染预防和控制人员，以确定分母数据并计算各种程序的 SSI 率。这可能包括程序数据、过程测量数据、再入院和再住院数据、术后抗菌数据、微生物学数据以及诊断和手术ICD代码。
Provide ongoing SSI rate feedback to surgical and perioperative personnel and leadership. (Quality of evidence: MODERATE)
向外科和围手术期人员和领导提供持续的 SSI 率反馈。（证据质量：中等）
Provide risk-adjusted SSI SIRs for each type of procedure under surveillance and reported to the NHSN. For procedures not reported to the NHSN, there may be alternative data to review through surveillance programs such as National Surgical Quality Improvement Program (NSQIP).201
为接受监测的每种手术提供风险调整后的 SSI SIR，并向 NHSN 报告。对于未向 NHSN 报告的手术，可能有替代数据可以通过监测计划进行审查，例如国家外科质量改进计划 （NSQIP）。 Anonymously benchmark procedure-specific, risk-adjusted SSI SIRs among peer surgeons.
在同行外科医生中匿名对特定手术、风险调整后的 SSI SIR 进行基准测试。
Routinely audit and provide confidential feedback on SSI rates or SIRs and adherence to process measures to individual surgeons, the surgical division and/or department chiefs, and hospital leadership.4,200
定期审核并向个别外科医生、外科部门和/或部门主管以及医院领导提供有关 SSI 感染率或 SIR标化率以及遵守流程措施的保密反馈。
Measure and provide feedback to HCP regarding rates of compliance with process measures.94 (Quality of evidence: LOW)
衡量并向 HCP 提供有关流程措施遵守率的反馈。 94 （证据质量：低）
Educate surgeons and perioperative personnel about SSI prevention measures. (Quality of evidence: LOW)
对外科医生和围手术期人员进行 SSI 预防措施的教育。（证据质量：低）
Include risk factors, outcomes associated with SSI, local epidemiology (eg, SSI rates by procedure, rate of methicillin-resistant Staphylococcus aureus [MRSA] infection in a facility), and essential prevention measures.
包括危险因素、与SSI相关的结局、当地流行病学（例如，按手术划分的SSI发生率、医疗机构中耐甲氧西林金黄色葡萄球菌[MRSA]感染的发生率）和基本预防措施。
Educate patients and their families about SSI prevention as appropriate. (Quality of evidence: LOW)
对患者及其家属进行适当的 SSI 预防教育。（证据质量：低） a.Provide instructions and information to patients prior to surgery describing strategies for reducing SSI risk. Specifically provide preprinted materials to patients.202
在手术前向患者提供说明和信息，描述降低 SSI 风险的策略。专门为患者提供预印材料。 b.Examples of printed materials for patients are available from the following web pages:
以下网页提供了为患者提供的印刷材料示例：
JAMA patient page: Wound Infections87
美国医学会（JAMA）患者页面：伤口感染 Surgical Care Improvement Project Tips for Safer Surgery203
外科护理改善项目：更安全手术 的提示 CDC Frequently Asked Questions About Surgical-Site Infections204
CDC关于手术部位感染 的常见问题 SHEA Infection Prevention Handout for Patients and Visitors205
为患者和访客提供的 SHEA 感染预防讲义
Implement policies and practices to reduce the risk of SSI for patients that align with applicable evidence-based standards, rules and regulations, and medical device manufacturer instructions for use.4,94 (Quality of evidence: MODERATE)
[color=rgba(0, 0, 0, 0.9)]实施符合适用的循证标准、规则和法规以及医疗器械制造商使用说明的政策和实践，以降低患者患 SSI 的风险。 4,94 （证据质量：中等）
Optimally disinfect the hands of the surgical team members.
对手术团队成员的手进行最佳消毒。 Adhere to hand hygiene practices, including nonsurgeon members of the operating team.206
坚持手部卫生习惯，包括手术团队中的非外科医生。 206 Reduce unnecessary traffic in operating rooms.207,208
减少手术室中不必要的交通流量。 207,208 Avoid use of nonsterile water sources in the operating room.209,210
避免在手术室使用非无菌水源。 209,210 Properly care for and maintain the operating rooms, including appropriate air handling, pressure relative to hallway, temperature, humidity, and optimal cleaning and disinfection of equipment and the environment.4
妥善护理和维护手术室，包括适当的空气处理、相对于走廊的压力、温度、湿度以及设备和环境的最佳清洁和消毒。 4 Maintain asepsis from the start of preparation of surgical instruments on the sterile field through wound closure and dressing.
从无菌区域开始准备手术器械开始，到伤口闭合和敷料，保持无菌状态。 Establish a robust infection control risk assessment program focused on mitigating risk during construction projects.
建立健全的感染控制风险评估计划，重点降低建筑项目期间的风险。 Proactively address potential risks from supply-chain shortages and communicate to frontline teams.
积极解决供应链短缺的潜在风险，并与一线团队进行沟通。 Discuss any staffing shortages and potential impact on outcomes as they relate to compliance with SSI prevention measures.
讨论任何人员短缺和对结果的潜在影响，因为它们与遵守 SSI 预防措施有关。
19.Observe and review operating-room personnel and the environment of care in the operating room and in central sterile reprocessing. (Quality of evidence: LOW)
观察和审查手术室人员和手术室以及手术室和消毒供应中心再处理中的护理环境。（证据质量：低） a.Perform direct observation audits of operating-room personnel to assess operating-room processes and practices to identify infection control lapses, including but not limited to adherence to process measures (antimicrobial prophylaxis choice, timing and duration protocols, hair removal, etc), surgical hand antisepsis, patient skin preparation, operative technique, surgical attire (wearing and/or laundering outside the operating room), and level of operating-room traffic.211-215 Perform remediation when breaches of standards are identified.
对手术室人员进行直接观察审核，以评估手术室的流程和做法，以识别感染控制失误，包括但不限于遵守流程措施（抗菌预防选择、时间和持续时间协议、脱毛等）、外科手部防腐、患者皮肤准备、手术技术、手术服装（在手术室外穿着和/或清洗）以及手术室交通水平。 211-215 在发现违反标准的行为时执行补救措施。
ⅰ.Operating-room personnel should include surgeons, surgical technologists, anesthesiologists, circulating nurses, residents, medical students, trainees, and device manufacturer representatives.211
手术室人员应包括外科医生、外科技师、麻醉师、巡回护士、住院医师、医学生、实习生和设备制造商代表。 211 b.Provide feedback and review infection control measures with operating-room and environmental personnel.
与手术室和环境人员一起提供反馈并审查感染控制措施 Review instrument reprocessing and flash sterilization or immediate-use steam sterilization (IUSS) logs.
查看器械再处理和瞬时灭菌或立即使用蒸汽灭菌 （IUSS） 日志。 Review maintenance records for operating room heating, ventilation, and air conditioning (HVAC) system including, results of temperature, relative humidify, and positive air pressure maintenance testing in the operating rooms(s).
审查手术室供暖、通风和空调 （HVAC） 系统的维护记录，包括手术室的温度、相对湿度和正气压维护测试结果。
Additional approaches for preventing SSI预防 SSI 的其他方法[color=rgba(0, 0, 0, 0.9)]These additional approaches can be considered when hospitals have successfully implemented essential practices and seek to further improve outcomes in specific locations and/or patient populations.当医院已成功实施基本实践并寻求进一步改善特定科室和/或患者群体的结果时，可以考虑这些额外的方法。 Perform an SSI risk assessment. (Qualify of Evidence: LOW)
执行 SSI 风险评估。（证据质量：低）
Convene a multidisciplinary team (eg, surgical leadership, hospital administration, qualify management services, and infection control) to identify gaps, improve performance, measure compliance, assess impacts of interventions, and provide feedback.216
召集一个多学科团队（例如，外科领导、医院管理、合格管理服务和感染控制），以确定差距、提高绩效、衡量依从性、评估干预措施的影响并提供反馈。 216
Consider use of negative-pressure dressings in patients who may benefit. (Quality of Evidence: MODERATE)
考虑对可能获益的患者使用负压敷料。（证据质量：中等）
Negative-pressure dressings placed over closed incisions are thought to work by reducing fluid accumulation in the wound. Recent systematic reviews have demonstrated a significant reduction in SSI with their use.217-219
将负压敷料放置在闭合的切口上被认为可以通过减少伤口中的液体积聚而起作用。最近的系统评价表明，使用它们可显着降低 SSI。 217-219 These dressings have been particularly noted to reduce SSIs in patients who have undergone abdominal surgery220,221 and joint arthroplasty,222,223 although not all studies have shown benefit224 and some indicate benefit only in a subset of procedures such as revision arthroplasty.222
特别注意到这些敷料可以减少接受过腹部手术 220,221 和关节置换术的患者的 SSI， 222,223 尽管并非所有研究都显示有益 224 ，有些研究表明仅在部分手术（如翻修关节置换术）中有益。 222 Guidance is lacking regarding which patients most benefit from the use of negative-pressure dressings, with some evidence that the benefit increases with age and body mass index.225
目前还没有关于哪些患者最受益于使用负压敷料的指南，但有证据表明，使用负压敷料的益处会随着年龄和体重指数的增加而增加。 Negative-pressure dressings seem most successful at reducing superficial SSIs,226 but some risk of blistering has been observed.222 These blisters could lead to breaks in the skin that might increase risk of infection.
负压敷料似乎在减少浅表性 SSI 方面最成功， 226 但已观察到一些水疱的风险。 222 这些水疱可能导致皮肤破裂，从而增加感染风险。 It is important to assess the ability of the patient to manage a negative-pressure dressing, particularly if used in the ambulatory setting.
评估患者管理负压敷料的能力非常重要，尤其是在门诊环境中使用负压敷料时。 Cost-effectiveness studies of negative-pressure dressings are needed.
需要对负压敷料进行成本效益研究。
Observe and review practices in the preoperative clinic, postanesthesia care unit, surgical intensive care unit, and/or surgical ward. (Quality of evidence: MODERATE)
观察和审查术前门诊、麻醉后监护室、外科重症监护室和/或外科病房的做法。（证据质量：中等）
Perform direct observation audits of hand-hygiene practices among all HCP with direct patient contact.213
对所有与患者直接接触的医护人员的手部卫生做法进行直接观察审核。 213 Evaluate wound care practices.227
评估伤口护理实践。 227 Perform direct observation audits of environmental cleaning practices.
对环境清洁实践进行直接观察审核。 Provide feedback and review infection control measures with HCP in these perioperative care settings.
在这些围手术期护理环境中，与 HCP 一起提供反馈并审查感染控制措施。
Use antiseptic-impregnated sutures as a strategy to prevent SSI. (Quality of evidence: MODERATE)
使用消毒剂浸渍缝合线作为预防 SSI 的策略。（证据质量：中等）
Human volunteer studies involving foreign bodies have demonstrated that the presence of surgical sutures decreases the inoculum required to cause an SSI from 106 to 102 organisms.228
涉及异物的人体志愿者研究表明，手术缝合线的存在可将导致 SSI 所需的接种体从 106 个减少到 102 228。 Some trials have shown that surgical wound closure with triclosan-coated polyglactin 910 antimicrobial sutures may decrease the risk of SSI compared to standard sutures.229,230 For example, an RCT of 410 colorectal surgeries concluded that the rate of SSI decreased >50% among patients who received antimicrobial sutures (9.3% in control group vs 4.3 among cases; P = .05).231
一些试验表明，与标准缝合线相比，使用三氯生包被的聚乳素 910 抗菌缝合线进行手术伤口缝合可能会降低 SSI 的风险。 例如，一项针对 410 例结直肠手术的随机对照试验得出结论，接受抗菌缝合的患者 SSI 发生率下降了 >50%（对照组为 9.3%，病例为 4.3%;P = .05）。 231 In contrast, a systematic review and meta-analysis evaluated 7 RCTs and concluded that neither SSI rates (OR, 0.77; 95% CI, 0.4–1.51; P = .45) nor wound dehiscence rates (OR, 1.07; 95% CI, 0.21–5.43; P = .93) were statistically different compared to controls.232 In addition, a small study raised concern about higher wound dehiscence rates associated with using these antimicrobial sutures.233
相比之下，一项系统评价和荟萃分析评估了 7 项随机对照试验，并得出结论，两者的 SSI 率未有差异 （OR， 0.77; 95% CI， 0.4–1.51;P = .45）和伤口裂开率（OR，1.07;95% CI，0.21–5.43;P = .93）与对照组相比在统计学上存在差异。 此外，一项小型研究对使用这些抗菌缝合线相关的伤口裂开率较高表示担忧。 233 The impact of routinely using antiseptic-impregnated sutures on the development of antiseptic resistance remains unknown.
常规使用抗菌剂浸渍缝合线对抗菌剂耐药性发展的影响仍然未知。
Approaches that should not be considered a routine part of SSI prevention不应被视为 SSI 预防常规部分的方法Do not routinely use vancomycin for antimicrobial prophylaxis.73 (Quality of evidence: MODERATE)
不要常规使用万古霉素进行抗菌药物预防。 73 （证据质量：中等）
Among cardiac surgery patients, receipt of vancomycin in combination with a β-lactam for perioperative prophylaxis was associated with increased AKI compared with either antibiotic alone107,240
在心脏手术患者中，与单独 107,240 使用任何一种抗生素相比，接受万古霉素联合β内酰胺类药物进行围手术期预防与AKI增加有关 In a cohort study of 70,101 surgical cases, vancomycin plus β-lactam combination prophylaxis was associated with a greater risk of AKI compared with vancomycin alone.241 In that study, vancomycin plus a β-lactam reduced the incidence of SSIs following cardiothoracic procedures compared with either antibiotic alone. However, this antimicrobial combination did not reduce SSIs for orthopedic, vascular, hysterectomy, or colorectal procedures.
在一项纳入 70,101 例手术病例的队列研究中，与单独使用万古霉素相比，万古霉素加β-内酰胺类联合预防与更高的 AKI 风险相关。 241 在该研究中，与单独使用任何一种抗生素相比，万古霉素加β-内酰胺类药物可降低心胸外科手术后 SSI 的发生率。然而，这种抗菌药物组合并未减少骨科、血管、子宫切除术或结直肠手术的 SSI。 Suspected high rates of MRSA SSI should not be used as justification for vancomycin use. In a cohort study of 79,092 surgical procedures, the primary reason for vancomycin perioperative prophylaxis was the perception of high facility rates of MRSA or high-risk procedure for MRSA. Patients who received vancomycin prophylaxis because of the perceived high facility risk of MRSA had no increase in prevalence of MRSA colonization compared with the general surgical population. The incidence of SSIs was the same regardless of vancomycin prophylaxis, but the incidence of acute kidney injury (AKI) was significantly higher among patients who received vancomycin.236
疑似 MRSA SSI 发生率高不应作为使用万古霉素的理由。在一项纳入 79,092 例外科手术的队列研究中，万古霉素围手术期预防的主要原因是认为 MRSA 的改医疗机构发生率高或 MRSA 的高风险手术。与一般手术人群相比，由于认为 医疗机构MRSA 的风险高而接受万古霉素预防的患者，MRSA 定植的患病率没有增加。无论是否预防使用万古霉素，SSI 的发生率都相同，但接受万古霉素治疗的患者急性肾损伤 （AKI） 的发生率显着更高。 236 In a retrospective cohort study of 79,058 surgical procedures, vancomycin perioperative prophylaxis was inde-pendently associated with significantly increased risk of AKI.107
在一项纳入 79,058 例外科手术的回顾性队列研究中，万古霉素围手术期预防与 AKI 风险显着增加密切相关。 107 Two meta-analyses of studies comparing glycopeptides to β-lactam antimicrobial prophylaxis concluded that there was no difference in rates of SSI between the 2 antimicrobial prophylaxis regimens.125,237
两项荟萃分析比较了糖肽类与β-内酰胺类抗菌药物预防的研究，得出的结论是，两种抗菌药物预防方案之间的 SSI 发生率没有差异。 125,237
Vancomycin should not routinely be used for antimicrobial prophylaxis, but it can be an appropriate agent for specific scenarios.128,234 Reserve vancomycin for specific clinical circumstances, as in patients who are known to be MRSA colonized (including those identified on preoperative screening), particularly if the surgery involves prosthetic material. Vancomycin can also be used in the setting of a proven outbreak of SSIs due to MRSA.235
万古霉素不应用于常规用于抗菌药物预防，但它可以是特定情况下的合适药物。 128,234 万古霉素用于特定临床情况，例如已知已定植 MRSA 的患者（包括术前筛查中发现的患者），尤其是在手术涉及假体材料的情况下。万古霉素也可用于经证实的 MRSA 引起的 SSI 暴发的情况。 235 Vancomycin does not have activity against gram-negative pathogens and appears to have less activity against MSSA than β-lactam agents. The addition of vancomycin to standard antimicrobial prophylaxis has been done in specific circumstances, but the benefits should be weighed against the risks.73,237-239
万古霉素对革兰氏阴性病原体没有活性，对 MSSA 的活性似乎低于β-内酰胺类药物。在标准抗菌药物预防中加用万古霉素已在特定情况下进行，但应权衡利弊。 73,237-239
Do not routinely delay surgery to provide parenteral nutrition. (Quality of evidence: HIGH)
不要常规地延迟手术以提供肠外营养。（证据质量：高）
Preoperative administration of total parenteral nutrition (TPN) has not been shown to reduce the risk of SSI in prospective RCTs and may increase the risk of SSI.242,243
在前瞻性随机对照试验中，术前给予全肠外营养 （TPN） 尚未被证明可以降低 SSI 的风险，并且可能增加 SSI 的风险。 242,243 Individual trials comparing enteral and parenteral perioperative nutrition and comparing immunomodulating diets containing arginine and/or glutamine to standard control diets tend to have very small sample sizes and fail to show significant differences in SSI rates. In 2 recent meta-analyses, however, postoperative infectious complications were reduced in patients receiving enteral diets containing glutamine and/or arginine administered either before or after the surgical procedure.244,245
比较肠内和肠外围手术期营养以及比较含有精氨酸和/或谷氨酰胺的免疫调节饮食与标准对照饮食的个体试验往往样本量非常小，并且未能显示SSI率的显着差异。然而，在最近的 2 项荟萃分析中，在手术前或手术后接受含有谷氨酰胺和/或精氨酸的肠内饮食的患者术后感染并发症有所减少。 244,245
Do not routinely use antiseptic drapes as a strategy to prevent SSI. (Quality of evidence: HIGH)
不要常规使用消毒敷料作为预防 SSI 的策略。（证据质量：高）
A 2007 Cochrane review of 5 trials concluded, nonantiseptic incise drapes were associated with a higher risk of SSIs compared to no incise drapes (RR, 1.23; 95% CI, 1.02–1.48)246 although this association may have been heavily weighted by one specific study.247
2007 年一项针对 5 项试验的 Cochrane 评价得出结论，与无切口覆盖相比，非消毒切口敷料与更高的 SSI 风险相关 （RR， 1.23;95% CI， 1.02–1.48）， 246 尽管这种关联可能被一项特定研究严重重视。 247 Two trials (abdominal and cardiac surgical patients) compared iodophor-impregnated drapes to no drapes.247,248 Although wound contamination was decreased in one trial,247 neither trial demonstrated that iodophor-impregnated drapes decreased the rate of SSI.
两项试验（腹部和心脏手术患者）比较了碘伏浸渍的薄片与无薄片。 247,248 尽管一项试验减少了伤口污染，但 247 两项试验均未证明碘伏浸渍的敷料降低了SSI的发生率。 A nonrandomized retrospective study similarly concluded that impregnated drapes do not prevent SSI after hernia repair.249
一项非随机回顾性研究同样得出结论，浸渍消毒敷料并不能预防疝修补术后的 SSI。 249
Unresolved issues 未解决的问题Optimize tissue oxygenation at the incision site.
优化切口部位的组织氧合。
In a meta-analysis of 5 studies, perioperative supplemental oxygen administration led to a relative SSI risk reduction of 25%. In contrast, a more recent meta-analysis of 15 studies was inconclusive.250 Additional studies published since the 2014 SHEA Compendium have similarly not shown a reduction in SSI in patients who received supplemental oxygen at a fraction of inspired oxygen (FiO2) of 80%.251-253
在一项纳入 5 项研究的荟萃分析中，围手术期补充供氧可使相对 SSI 风险降低 25%。相比之下，最近对 15 项研究的荟萃分析尚无定论。 250 自 2014 年 SHEA 纲要以来发表的其他研究同样没有显示接受吸入氧 （FiO 2 ） 分数为 80% 的补充氧气的患者的 SSI 降低。 251-253 Most trials compared 80% FiO2 to 20%–35% FiO2. The benefit of other oxygen concentrations remains unknown.
大多数试验比较了80%的FiO 2 和20%-35%的FiO 2 。其他氧浓度的益处仍然未知。 The best available evidence for the use of supplemental oxygen is in patients undergoing high-risk surgery with general anesthesia using mechanical ventilation.254-256
使用辅助氧气的最佳可用证据是在接受使用机械通气进行全身麻醉的高风险手术的患者中。 254-256 Supplemental oxygen is most effective when combined with additional strategies to improve tissue oxygenation including maintenance of normothermia and appropriate volume replacement. Tissue oxygenation at the incision site depends on vasoconstriction, temperature, blood supply, and cardiac output.
当辅助供氧与改善组织氧合的其他策略（包括维持体温正常和适当的容量替代）相结合时，效果最为有效。切口部位的组织氧合取决于血管收缩、温度、血液供应和心输出量。
Preoperative intranasal and pharyngeal CHG treatment for patients undergoing cardiothoracic procedures
接受心胸外科手术的患者的术前鼻内和咽部 CHG 治疗
Use of gentamicin-collagen sponges
使用庆大霉素-胶原海绵
Colorectal surgical patients. Several single-center randomized trials demonstrated that gentamicin-collagen sponges decrease the risk of SSI following colorectal procedures.258-260 However, the rate of SSI was higher with the sponge in 2 recent, large, multicenter RCTs.261,262
结直肠手术患者。几项单中心随机试验表明，庆大霉素-胶原海绵可降低结直肠手术后发生 SSI 的风险。 258-260 然而，在最近的 2 项大型多中心随机对照试验中，海绵的 SSI 发生率更高。 261,262 Cardiothoracic surgical patients. Four RCTs have evaluated the use of gentamicin-collagen sponges in cardiothoracic surgery. Three of these trials demonstrated a decrease in SSIs and one demonstrated no difference.263-266 A recent meta-analysis combining these trials and 10 observational studies concluded that the risk of deep sternal wound infection was significantly lower in patients who received a gentamicin-collagen sponge than patients who did not (RR, 0.61; 95% CI, 0.39–0.98) despite significant heterogeneity among the trials.267
心胸外科患者。四项随机对照试验评估了庆大霉素-胶原海绵在心胸外科中的应用。其中三项试验显示SSIs减少，一项试验显示没有差异。 263-266 最近一项结合这些试验和 10 项观察性研究的荟萃分析得出结论，尽管试验之间存在显著异质性，但接受庆大霉素-胶原海绵治疗的患者发生胸骨深部伤口感染的风险明显低于未接受庆大霉素-胶原海绵治疗的患者（RR，0.61;95% CI，0.39-0.98）。 267
Gentamicin-collagen sponges have been evaluated as an intervention to decrease SSI among colorectal and cardiac surgical patients.
庆大霉素-胶原海绵已被评估为降低结直肠和心脏手术患者 SSI 的干预措施。 Gentamicin-collagen sponges are not currently FDA approved for use in the United States.
庆大霉素胶原蛋白海绵目前尚未获得 FDA 批准在美国使用。
Use of antimicrobial powder
使用抗菌粉
Multiple publications have examined the use of vancomycin powder in surgical incisions, especially for spinal and cranial procedures for which S. aureus is a primary pathogen.268,269 Although a few reviews report a lower rate of SSI in spinal surgery with the use of vancomycin powder,270 other references report a significant increase in the proportion of SSI with polymicrobial and gram-negative pathogens when they occur.271-273 In addition, a prospective randomized trial comparing the use of vancomycin powder in combination with intravenous vancomycin to the use of intravenous vancomycin alone found no benefit with the addition of vancomycin powder.274
多篇出版物研究了万古霉素粉在手术切口中的使用，特别是对于金黄色葡萄球菌是主要病原体的脊柱和颅脑手术。 268,269 尽管一些综述报告称，使用万古霉素粉在脊柱手术中 SSI 的发生率较低， 270 但其他参考文献报告称，当多种微生物和革兰氏阴性病原体发生时，SSI 的比例显着增加。 271-273 此外，一项前瞻性随机试验比较了万古霉素粉剂联合静脉注射万古霉素与单独静脉注射万古霉素，发现加用万古霉素粉剂没有益处。 274
Use of surgical attire
手术服的使用
Although there are longstanding traditions and opinions regarding surgical attire in the operating room, no strong evidence exists for many of them. It has not been demonstrated that surgical attire affects SSI rates.275 One approach to managing issues pertaining to surgical attire is to form a multidisciplinary body including infection control, surgery, nursing, and anesthesia to discuss and agree to some sensible, not overly aggressive or cumbersome attire standards, and to establish policies and procedures that are compliant with state and CMS requirements.275
尽管关于手术室中的手术装有悠久的传统和观点，但其中许多都没有强有力的证据。尚未证明手术服会影响 SSI 率。 275 管理与手术服装有关的问题的一种方法是组建一个多学科机构，包括感染控制、手术、护理和麻醉，以讨论并同意一些明智的、不过分激进或繁琐的服装标准，并制定符合州和 CMS 要求的政策和程序。 275
Section 5: Performance measures 第 5部分：评价指标Internal reporting 内部报告[color=rgba(0, 0, 0, 0.9)]These performance measures are intended to support internal hospital quality improvement efforts and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for SSI (Table 4).这些绩效指标旨在支持医院内部质量改进工作，并不一定满足外部报告需求。本文建议的过程和结果测量来自已发表的指南、其他相关文献和作者的意见。向医院高级领导、护理领导和照顾有 SSI 风险患者的临床医生报告过程和结果措施（表 4）。 [color=rgba(0, 0, 0, 0.9)] Table 4. SSI Prevention Internal Reporting Process and Outcome Measures表 4.SSI 预防内部报告流程和结果措施[color=rgba(0, 0, 0, 0.9)]表4翻译如下： [color=rgba(0, 0, 0, 0.9)]Internal Reporting Process Measure Example: Compliance with
Antimicrobial Prophylaxis Guidelines内部报告流程措施示例：遵守抗菌药物预防指南Percentage of procedures in which antimicrobial prophylaxis was provided appropriately = (No. of patients who appropriately received antimicrobial prophylaxis/Total number of selected operations performed) ×100适当提供抗菌药物预防的程序百分比 =（适当接受抗菌药物预防的患者人数/进行的选定手术总数）×100
1. Correct antibiotic for specific surgery1. 针对特定手术选择正确的抗生素
2. Correct antibiotic dose2. 正确的抗生素剂量
3. Administrative start time within 1 hour of incision (2 hours allowed for vancomycin and fluroquinolones)3.切口后1小时内开始给药时间（万古霉素和氟喹诺酮类药物允许2小时）
4. Discontinuation of agent after skin closure4.皮肤闭合后停药Internal Reporting Outcome Measure Example: Surgical Site Infection Standardized Infection Ratio (SIR)内部报告结果测量示例：手术部位感染标准化感染率 （SIR）SIR = Ratio of observed number of SSIs (O)/Predicted number of SSIs (P) for a specific type of procedure278SIR = 观察到的 SSI 数量 （O） 与特定类型手术的预测 SSI 数量 （P） 的比率 Process measures 指标计算[color=rgba(0, 0, 0, 0.9)]EXAMPLE: Compliance with antimicrobial prophylaxis guidelines示例：遵守抗微生物药物预防指南 [color=rgba(0, 0, 0, 0.9)]Measure the percentage of procedures in which antimicrobial prophylaxis was provided appropriately. Appropriateness includes (1) correct antibiotic for specific surgery, (2) correct antibiotic dose, (3) administration start time within 1 hour of incision (2 hours allowed for vancomycin and fluoroquinolones), and (4) discontinuation of the agent after skin closure.衡量适当提供抗微生物药物预防的程序的百分比。适当性包括 （1） 针对特定手术的正确抗生素，（2） 正确的抗生素剂量，（3） 切口后 1 小时内给药开始时间（万古霉素和氟喹诺酮类药物允许 2 小时），以及 （4） 皮肤闭合后停药。
Numerator: Number of patients who appropriately received antimicrobial prophylaxis.
分子：适当接受抗菌药物预防的患者人数。 Denominator: Total number of selected operations performed.
分母：已执行的选定操作的总数。 Multiply by 100 so that measure is expressed as a percentage.
乘以 100，使该度量值表示为百分比。
Outcome measures 内部报告结局指标[color=rgba(0, 0, 0, 0.9)]EXAMPLE: Surgical site infection SIR示例：手术部位感染 SIR External reporting 外部报告[color=rgba(0, 0, 0, 0.9)]There are many challenges in providing useful information to consumers and other working partners while preventing unintended consequences of public reporting of HAIs.283-285 Recommendations and requirements for public reporting of HAIs have been provided by HICPAC,286,287 the National Quality Forum,288 and the CMS289 (Table 5).
在向利益者和其他工作伙伴提供有用信息的同时，还存在许多挑战，同时防止公开报告HAIs的意外后果。 283-285 HICPAC、 286,287 国家质量论坛 288 和CMS 289 提供了公开报告HAIs的建议和要求（表5）。 [color=rgba(0, 0, 0, 0.9)]Table 5. SSI Prevention External Reporting Outcome Measures表 5.SSI 预防外部报告结果措施 [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)]Note. CDC, Centers for Disease Control and Prevention; NHSN, National Health Safety Network. CMS, Centers for Medicare & Medicaid Services; HICPAC, Healthcare Infection Control Practices Advisory Committee.
注意。CDC、疾病控制与预防中心;NHSN，国家健康安全网络。CMS，医疗保险和医疗补助服务中心;HICPAC，医疗感染控制实践咨询委员会。 [color=rgba(0, 0, 0, 0.9)]aRecommendations and requirements for public reporting provided by HICPAC,286,287 the National Quality Forum,288 and the CMS.289
a HICPAC、 国家质量论坛 和CMS提供的公开报告建议和要求。 [color=rgba(0, 0, 0, 0.9)]表5翻译如下： Federal requirementsa
联邦要求a | 1. Reported via CDC NHSN in the CMS Hospital Inpatient Quality Reporting program.289
1. 通过 CDC NHSN 在 CMS 医院住院患者质量报告计划中报告。 289
2. Since 2012, SSI data reporting for inpatient abdominal hysterectomy and inpatient colon procedures has been required.290,291
2. 自 2012 年以来，住院患者腹部子宫切除术和住院结肠手术的 SSI 数据报告已被要求。 290,291
3. Hospitals in states with a SSI reporting mandate must abide by their state’s requirements, even if they are more extensive than federal requirements.
3. 具有 SSI 报告任务的州的医院必须遵守其所在州的要求，即使这些要求比联邦要求更广泛。 | State requirements and collaboratives国家要求和合作 | 1. In states with mandatory SSI reporting requirements, hospitals must collect and report the data required by the state.
1. 在有强制性 SSI 报告要求的州，医院必须收集和报告州要求的数据。
2. Hospitals should check with the state or local health department for requirements.
2.医院应向国家或地方卫生部门查询要求。 |
Outcome measures 外部报告结局指标External reporting measures now focus mostly on outcomes.
现在，外部报告措施主要侧重于结果。 Since 2012, the CMS has imposed a reporting requirement for SSI data for inpatient abdominal hysterectomy and inpatient colon procedures.290,291
自 2012 年以来，CMS 对住院患者腹部子宫切除术和住院结肠手术的 SSI 数据实施了报告要求。 290,291 Federal and state requirements
联邦和州要求
CMS published a final rule in the Federal Register on August 18, 2011 that includes surgical site infection (SSI) reporting via the NHSN in the CMS Hospital Inpatient Quality Reporting (IQR) Program requirements for 2012.289 More specifically, the rule announced a reporting requirement for SSI data for inpatient abdominal hysterectomy and inpatient colon procedures.291
CMS 于 2011 年 8 月 18 日在《联邦公报》上发布了一项最终规则，其中包括在 2012 年 CMS 医院住院患者质量报告 （IQR） 计划要求中通过 NHSN 报告手术部位感染 （SSI） 报告。 289 更具体地说，该规则宣布了住院患者腹部子宫切除术和住院结肠手术的 SSI 数据报告要求。 291 The requirements for SSI reporting to the NHSN for the hospital IQR program do not preempt or supersede state mandates for SSI reporting to NHSN (ie, hospitals in states with a SSI reporting mandate must abide by their state’s requirements, even if they are more extensive than the requirements for this CMS program). NHSN users reporting SSI data to the system must adhere to the definitions and reporting requirements for SSIs as specified in the NHSN Patient Safety Component Protocol Manual.43,291
对于医院 IQR 计划，向 NHSN 报告 SSI 的要求不会优先或取代州政府要求向 NHSN 报告 SSI（即，具有 SSI 报告任务的州的医院必须遵守其州的要求，即使它们比此 CMS 计划的要求更广泛）。向系统报告 SSI 数据的 NHSN 用户必须遵守 NHSN 患者安全组件协议手册中规定的 SSI 定义和报告要求。 43,291
Federal requirements 联邦要求 State requirements. Hospitals in states that have mandatory SSI reporting requirements must collect and report the data required by the state. For information on state requirements, check with your state or local health department.
国家要求。有强制性 SSI 报告要求的州的医院必须收集和报告州要求的数据。有关州要求的信息，请咨询您所在州或地方卫生部门。
External quality initiatives 外部报告质量控制举措[color=rgba(0, 0, 0, 0.9)]Several external quality initiatives focused on SSI prevention are ongoing. The benefits from participation in these external quality initiatives are unknown but may include improvement in the culture of safety and patient outcomes, including decreased rates of SSI.292几项以预防 SSI 为重点的外部质量举措正在进行中。参与这些外部质量计划的好处尚不清楚，但可能包括安全文化和患者预后方面的改善，包括 SSI 率的降低。 292 Section 6: Implementation of SSI prevention strategies 第 6 节：SSI 预防策略的实施SSI prevention science and education must be partnered with purposeful implementation of interventions to achieve desired outcomes. Beyond protocol development and educational efforts, this includes measurement of adherence to agreed-upon practices, understanding and addressing potential barriers to adherence, and frequent feedback to all partners.SSI 预防、科学和教育必须与有目的地实施干预措施相结合，以达到预期的结果。除了协议制定和教育工作外，这还包括衡量对商定做法的遵守情况，理解和解决遵守的潜在障碍，以及经常向所有合作伙伴提供反馈。 Reliability is the frequency at which an intervention is completed when indicated. Implementation of any practice requires monitoring for reliability, commonly known as a process measure. In SSIs, process measurement is especially important to successful implementation due to the complexity of systems involved and of the outcome itself. Connecting a reduction or increase in SSI rates to utilization of a bundle is difficult without reliability measurement, and protocol adherence has been directly correlated to improved outcomes.Reference Harris, Sammarco and Swenson293 Successful implementation efforts described in the literature have frequently failed to identify a single effective intervention, instead emphasizing the effect of process reliability.Reference Young, Knepper, Vigil, Miller, Carey and Price294–Reference Gorgun, Rencuzogullari and Ozben296可靠性是指在有指征时完成干预的频率。任何实践的实施都需要对可靠性进行监控，通常称为过程度量。在 SSI 中，由于所涉及的系统和结果本身的复杂性，过程测量对于成功实施尤为重要。如果没有可靠性测量，就很难将 SSI 率的降低或增加与束的利用率联系起来，并且协议依从性与改善的结果直接相关。 Reference Harris, Sammarco and Swenson293 文献中描述的成功实施工作往往未能确定单一的有效干预措施，而是强调过程可靠性的影响。 Reference Young, Knepper, Vigil, Miller, Carey and Price294–Reference Gorgun, Rencuzogullari and Ozben296 High reliability can be achieved through different methods and conceptual frameworks. The following outline summarizes ways in which facilities have achieved reliability. Choice of a method for a given group depends on system context,Reference Kaplan, Brady and Dritz297,Reference Tomoaia-Cotisel, Scammon and Waitzman298 local knowledge of improvement and implementation science, and resources available to support the effort.高可靠性可以通过不同的方法和概念框架来实现。以下概述总结了设施实现可靠性的方法。为特定组选择一种方法取决于系统环境、 Reference Kaplan, Brady and Dritz297,Reference Tomoaia-Cotisel, Scammon and Waitzman298 当地改进和实施科学的知识以及可用于支持这项工作的资源。 [color=rgba(0, 0, 0, 0.9)]Table 6. Fundamental Elements of Accountability and Engagement for SSI Prevention表 6.预防 SSI 的问责制和参与的基本要素 [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] 表6 翻译如下： [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)] [color=rgba(0, 0, 0, 0.9)]3.Human factors engineering人因工程学
Interventions that automate reminders (eg, alarms to prevent excessive door opening or electronic alerts to re-dose antibiotics)325,326 or processes themselves may be effective at preventing SSIs.325,327 Existing information systems, such as electronic health records, can be leveraged for this purpose as well as for standardizing evidence-based order sets.
自动提醒的干预措施（例如，防止过度开门的警报或重新给药抗生素的电子警报） 325,326 或过程本身可能有效预防SSI。 325,327 现有的信息系统，如电子健康记录，可以用于这一目的，也可以用于标准化基于证据的医嘱集。 Operating-room door openings are a surrogate marker for poor operating-room discipline.208,327,329 Agreeing on a limit for how many door openings during surgery are acceptable and staying below that limit have been associated with decreased incidence of SSIs.328 Communication between the surgeon and operating-room staff on the equipment needed prior to surgery can lead to fewer door openings.328 Operating-room personnel turnover during procedures has been associated with an increased risk of SSI, even after statistically adjusting for length of surgery.330 When possible, shift changes and breaks should wait until the procedure has ended.
手术室门开度是手术室纪律不良的替代标志。 208,327,329 就手术期间可接受的门开次数达成一致，并保持在该限制以下与 SSI 的发生率降低有关。 328 外科医生和手术室工作人员在手术前就所需设备进行沟通可以减少开门次数。 328 手术过程中手术室人员流动与 SSI 风险增加有关，即使在统计上调整了手术时间后也是如此。 330 如果可能，换班和休息应等到程序结束。 Standardizing practices through the use of dedicated teams, checklists, and surgeon preference cards, and ensuring adequate staffing have all been effective strategies to implement interventions.31,208,331-333
通过使用专门的团队、检查表和外科医生偏好卡来标准化实践，并确保有足够的人员配备，这些都是实施干预措施的有效策略。 31,208,331-333 Interventions to prevent SSIs can be optimized by identifying the people (eg, preoperative nurse, operating room nurse, surgeon, patient, or family) needed to successfully implement the intervention and provide them with directed tools to support adherence with the intervention. The perspectives of each of these partners need to be considered to identify barriers and facilitators to intervention adherence.334
预防SSI的干预措施可以通过确定成功实施干预措施所需的人群（例如，术前护士、手术室护士、外科医生、患者或家属）来优化，并为他们提供有针对性的工具以支持对干预措施的依从性。需要考虑这些合作伙伴中的每一个的观点，以确定坚持干预措施的障碍和促进因素。 334 4.Accountability 问 责 Accountability is an essential principle for preventing HAIs by ensuring evidence-based implementation strategies are used consistently, maximizing their effectiveness in preventing HAIs.
问责制是预防 HAI 的一项基本原则，通过确保始终如一地使用基于证据的实施策略，最大限度地提高其预防 HAI 的有效性。 Engagement and commitment of executive and senior leadership are essential to setting goals, removing barriers, and justifying the effort to build and sustain improvements.319,335-337 Engaged local leaders (eg, a senior surgeon) also give the effort and expectations legitimacy.
行政和高级领导层的参与和承诺对于设定目标、消除障碍以及证明建立和维持改进的努力的合理性至关重要。 319,335-337 敬业的地方领导人（例如，高级外科医生）也赋予了努力和期望的合法性。 Interventions, bundle components, and practices should be evidence-based as much as possible338 and should be deemed appropriate for the surgical population (eg, evidence from the adult population may not be appropriate to apply in a pediatric population).
干预措施、联合治疗和实践应尽可能以证据为基础， 338 并应被认为适合于手术人群（例如，来自成人人群的证据可能不适合应用于儿科人群）。 5.Safety culture and practices
安全文化和实践 SSI prevention efforts align well with, and may be contextualized within, patient and employee safety campaigns. However, culture change is a prolonged and ongoing process. SSI prevention should not be delayed until safety culture is improved, but rather used as a concrete example of the benefits of safe behaviors.
SSI 预防工作与患者和员工安全活动非常一致，并可能在患者和员工安全活动中进行背景化。然而，文化变革是一个漫长而持续的过程。在安全文化得到改善之前，不应拖延预防SSI，而应将其作为安全行为益处的具体例子。
Acknowledgments. 声明[color=rgba(0, 0, 0, 0.9)]The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).
本报告中的调查结果和结论只代表作者的观点，并不代表美国疾病预防与控制中心（CDC）的官方立场。 References 参考文献（略，见以下网址）[color=rgba(0, 0, 0, 0.9)]https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/strategies-to-prevent-surgical-site-infections-in-acutecare-hospitals-2022-update/2F824B9ADD6066B29F89C8A2A127A9DC
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发表于 2024-8-16 08:39