如何降低感染率——美国骨科医师学会教程

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The Journal of Bone and Joint Surgery (American).2010;92:232-239.

Perioperative Strategiesfor Decreasing Infection
A Comprehensive Evidence-Based Approach
降低感染率的围手术期策略：综合性循证医学路径

Joseph A. Bosco, III,MD1, James D. Slover, MD, MS1 and Janet P. Haas, RN, PhD2
1 Department ofOrthopaedic Surgery, NYU Hospital for Joint Diseases, New York UniversityLangone Medical Center, 301 East 17th Street, New York, NY 10003. E-mailaddress for J.A. Bosco III: joseph.bosco@nyumc.org. E-mail address for J.D.Slover: james.slover@nyumc.org
2 InfectionPrevention and Control, Westchester Medical Center, 100 Woods Road, MacyPavilion SW246, Valhalla, NY 10595. E-mail address: Haasj@wcmc.com
An InstructionalCourse Lecture, American Academy of Orthopaedic Surgeons
Introduction
引言

Surgical siteinfections associated with orthopaedic surgical procedures are devastatingcomplications. They increase morbidity, mortality, and cost and result in outcomesthat are worse than those in uninfected cases1. Decreasing the incidence ofsurgical site infections is not only of interest to patients and surgeons, itis also a major focus of several groups of interested parties. These range frompayers, including the Centers for Medicare and Medicaid Services (CMS,Baltimore, Maryland), to institutions represented by the Surgical CareImprovement Project (SCIP), a multiple-institution partnership between majorpublic and private health-care organizations, including the Joint Commission onAccreditation of Healthcare Organizations (Oakbrook Terrace, Illinois).Decreasing the incidence of surgical site infections is, and will continue tobe, a major focus in medicine.
对于骨科手术而言，手术部位的感染是一种毁灭性的并发症，往往会导致致残率、致死率以及医疗费用的增加，并且与没有发生感染的病例相比，最终的治疗结果通常也会更差【1】。减少手术部位的感染率，不仅对患者和医生都很有意义，也是利益相关的各方非常关注的问题。如出资方，包括医疗保险与医疗辅助服务中心（CMS，Baltimore, Maryland）；以外科医疗改良项目（SCIP）为代表的相关机构；介于大众公共机构与私人医疗保健机构之间的多机构合作组织，包括医疗机构评审联合委员会（JCAHO，Oakbrook Terrace, Illinois）等。减少手术部位的感染率现在是，将来也仍会是，医学领域关注的焦点问题。
To effectivelyprevent surgical site infections, the clinician must consider preoperative,intraoperative, and postoperative factors and interventions. Preoperativestrategies for reduction of infection rates include identification of high-riskpatients, screening and decolonization of patients with methicillin-sensitiveStaphylococcus aureus and methicillin-resistant Staphylococcus aureuscolonization, preoperative preparation of the patient with chlorhexidinegluconate, utilization of proper hair-removal techniques, and addressingpreexisting dental and nutritional issues prior to surgery.
为了有效地防止手术部位的感染，临床医生必须审慎地考虑到手术前、手术中以及手术后的相关因素和干预措施。降低感染的术前策略包括识别高风险的患者，对甲氧西林敏感的金黄色葡萄球菌和耐甲氧西林的金黄色葡萄球菌定植的患者进行筛查，并清除定植菌，术前应用洗必泰葡萄糖酸盐进行清洗，应用合适的方法去除毛发，术前妥善处理先前存在的牙齿及营养相关的问题。
There are a varietyof perioperative strategies that can and should be employed to decrease therisk of surgical site infections. Intraoperative interventions that have beenshown to decrease surgical site infection rates include the proper selection, timing,and doses of prophylactic antibiotics and utilization of best practices forhand hygiene and surgical site preparation. Maintaining a sterileoperating-room environment by decreasing operating-room traffic, monitoring forbreaks in sterile technique, and decreasing the use of flash sterilization isvital. Finally, postoperative strategies for the reduction of surgical siteinfection rates include the proper use and duration in situ of urinarycatheters and surgical drains; standardization of wound care; use ofantibiotic-impregnated bandages; and, perhaps most importantly, maintenance ofproper hand hygiene, isolation precautions, and room cleaning.
有多种围手术期的策略可以并且必须应用以减少手术部位的感染。术中的一些干预因素已经证实可以降低手术部位的感染率，包括选择合适的种类、时机和剂量预防性应用抗生素，手卫生及术区消毒均采用最优化的方案。通过减少手术室的穿行、密切监视无菌术的训练、减少快速消毒的应用对于维持手术的无菌环境是至关重要的。最后，降低手术部位感染率的术后策略包括合理地应用和维持原有的导尿管和术区引流管，对创口进行标准化护理；应用抗生素浸润的绷带，以及，可能最为重要的是，保持正确的手卫生、隔离预防和室内清洁。

转自丁香园http://www.dxy.cn/bbs/topic/19377109?ticket=ST-795618-tegGRSVlpWCeqrsdZurnGKF4Jf1kXU1WmvB-20

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PreoperativeConsiderations
术前注意事项
Although everyprecaution should be taken to prevent infection for all orthopaedic patients,the identification of high-risk patients enables clinicians to provide maximalprevention strategies for them. Furthermore, the identification of patients athigh risk for infection allows appropriate preoperative counseling for shareddecision-making and establishes appropriate patient expectations regardingsurgical risks.
虽然对于所有骨科患者，都应该采用各种预防措施以防止感染，但临床医生识别出高风险的患者后，便可针对其制定最大限度的防范策略。此外，识别出感染的高风险患者后可进行适当的术前告知谈话，这样可与患者共同制定治疗决策，并使患者对于手术风险树立合理的期望值。
Numerous high-riskpatient populations and risk factors that place patients at high risk forinfection after total joint replacement or spine surgery have been described inthe literature. Some of these factors can be modified, while others cannot. Anexplanation of the risk factors that cannot be modified should be included whenpatients are counseled about their increased risk of infection with theproposed surgical procedure. In this way, patients will more completely understandthe risks and benefits when deciding on surgery. Two common factors that cannotbe modified and that increase the risk of infection with joint replacement area history of infection in the joint2 and a history of steroid injection intothe joint3. Factors that cannot be modified that increase the risk of infectionin patients undergoing spine surgery include trauma-related surgery4, use ofinstrumentation5, and lumbar6 and posterior4 surgery.
对于关节置换术和脊柱手术的感染，有很多高风险患者人群以及相关的危险因素使患者具有较高感染风险的情况，在以往的文献中都有论述。在这些因素中，有些事可以改善的，而有些则无法改变。对于无法控制的危险因素，在对患者进行术前告知谈话时，应向其说明这样会增加感染的风险。这样，患者在决定做手术时便可更全面地认识到相关的风险和益处。有两个无法控制的因素，既往关节感染病史【2】和既往关节内类固醇注射史【3】，通常会增加关节置换手术的感染风险。而对于进行脊柱手术的患者而言，会增加感染的风险并且无法控制的因素包括创伤相关的手术【4】，需要应用内置物【5】，以及腰椎【6】和后路【4】手术。
Other factors that increasethe risk of infection are potentially modifiable and, therefore, provide theopportunity for patient optimization prior to elective orthopaedic procedures.For example, patients with inflammatory arthritis7, sickle-cell disease8,diabetes9, renal failure10, and human immunodeficiency virus (HIV)11 haveincreased infection rates with joint replacement. Although these risk factorscannot be eliminated, the risks can be minimized. For example, patients withinflammatory arthritis should have a preoperative consultation with theirrheumatologist about reducing or discontinuing immunosuppressive medicationsperioperatively. Patients with sickle-cell disease should be screened for skinulcerations or potential sources of osteomyelitis, which can cause seeding ofthe site of a prosthetic joint. Diabetic patients should have their hemoglobinA1C levels checked andnormalized (to <6.9%, which reflects long-term glucose control) prior tosurgery; consultation with an endocrinologist may be necessary. Patients withrenal failure certainly should have their renal function optimized prior tosurgery, and patients with HIV should be placed on regimens that achieve anundetectable viral load, if possible, prior to joint replacement. Malnutritionis associated with an increased risk of infection; therefore, preoperativeoptimization, with the assistance of a nutritionist if necessary, isbeneficial12.
其他的一些可能增加感染风险的因素通常都是可以控制的，因此，对于骨科的择期手术而言，术前通常可以使相关的因素达到最优化的状态。例如，患者合并有炎症性的关节炎【7】，镰状细胞性贫血症【8】，糖尿病【9】，肾功能衰竭【10】和人免疫缺陷症病毒（HIV）感染【11】会增加关节置换的感染率，虽然这些风险因素无法消除，但相关的风险则可以降至最低。比如，患者炎症性关节炎的患者，可以在术前请风湿科医生进行诊治，在围手术期尽量减少或停用免疫抑制类药物。如患者合并有镰状细胞性贫血症，则应仔细筛查皮肤溃疡或骨髓炎的潜在病源，否则容易导致播散至关节假体处引起感染。糖尿病患者应检查其血红蛋白A1C水平，在术前调至正常（<6.9%，可反映长期的血糖控制情况），必要时请内分泌科医生会诊。肾功能衰竭的患者当然也应在术前将肾功能调整至最佳水平，而感染HIV的患者，在关节置换之前，如果可能的话应通过药物治疗使其病毒载量达到检测不到的程度。营养不良也会增加感染的风险，因此，必要时在营养师的帮助下，在术前进行优化也是很有好处的【12】。

Smoking and obesityincrease the risk of infection with spine surgery13. Although these factors areoften difficult to modify, patients should be counseled that a benefit ofsmoking cessation and weight reduction is a decreased risk of infection withspine surgery. Patients considering or planning surgical weight-losstreatments, such as gastric bypass surgery, probably should be advised topursue these procedures first to reduce the risk of infection at the sites ofhardware or prostheses as a benefit from weight loss. Working with patients andthe appropriate consultants to optimize these factors prior to surgery mayimprove patient outcomes by lowering the risk of infection with high-riskjoint-replacement and spine procedures.
吸烟和肥胖会增加脊柱手术感染的风险【13】。虽然这些因素通常难以控制，但仍然应该告知患者，戒烟以及减轻体重对于降低脊柱手术感染的风险具有重要意义。如果患者正在考虑或计划通过手术来减轻体重，如胃旁路手术，那么应该建议患者先做减肥手术，因为这样对于置入内固定物或假体的部位可以减少感染的风险。与患者充分沟通，提出合理化的建议，在手术前尽量优化这些因素，对这些关节置换和脊柱手术的高风险人群而言，可以改善临床结果，降低感染的风险。
Another importantpreoperative consideration is preoperative bathing. Preoperative bathing hasbeen used to reduce the bacterial load of the skin prior to surgery becauseskin preparation immediately before surgery does not completely sterilize theskin. In addition, direct contamination can occur at the time of surgery. Arecent Cochrane review was performed to assess the information in theliterature regarding preoperative bathing with antiseptics for the preventionof surgical site infection14. Chlorhexidine gluconate is the most commonly usedantiseptic for preoperative bathing. The Cochrane review revealed evidence thatthe bacterial load of resident skin flora is reduced by use of chlorhexidinegluconate preparations for preoperative bathing. Repeated, consecutivetreatments reduce this load progressively over time. However, concerns aboutthe development of resistant organisms and hypersensitivity remain. Therefore,the authors of the review concluded that there is no clear evidence thatpreoperative bathing with chlorhexidine gluconate is superior to preoperativebathing with other products, such as bar soap, for reducing the incidence ofsurgical site infection.
手术前另一个重要的注意事项便是术前洗澡。由于术前即刻的皮肤消毒并不能完全杀灭所有细菌，因而通常都通过术前洗澡以减少皮肤的细菌接种量。此外，如果术前不洗澡，手术时也可能发生直接的污染。最近的一项Cochrane综述对术前应用消毒剂洗澡预防手术部位感染的相关信息进行了评价【14】。洗必泰葡萄糖酸盐是术前洗澡时应用最多的消毒剂。Cochrane综述的相关证据显示术前洗澡时应用洗必泰葡萄糖酸盐进行消毒可使体表常居菌的细菌接种量明显减少。随着时间的延长，反复、持续地洗浴可使该接种量进行性地下降。然而，这样做也有产生耐药菌及出现过敏反应的风险。因此，上文作者的结论认为，为了减少手术部位感染的发生率，在术前洗澡时，并没有明确的证据证实应用洗必泰葡萄糖酸盐优于其他的产品，如肥皂等。
Hair removal has beenused traditionally to keep hair from contaminating the wound. More recently,hair removal has allowed surgeons to apply occlusive dressings to the skinperioperatively to keep skin flora from directly contaminating the wound. Threemethods used for hair removal include traditional razors, clippers, andhair-removal creams or depilatories. Hairless surgical sites can make thesurgery and application of dressings and protective draping easier, but the useof razors to shave the surgical site increases the risk of introducing primaryinfections through microscopic injuries to the skin. The Centers for DiseaseControl and Prevention (CDC) recommend that hair removal be minimized and that,when it is necessary, electric clippers or depilatories be used rather thanrazors15. A Cochrane review of the literature on hair removal prior to surgerysupported the CDC recommendations and added that hair removal can be done onthe day of the surgery16.
以往术前通常都要求去除毛发以避免污染创口，而最近则倾向于让外科医生在术前应用密闭的敷料覆盖皮肤，从而防止皮肤菌群直接污染创口。传统的去毛方式主要有三种：剃毛、剪毛和脱毛膏或脱毛药物。手术部位去毛后通常可使手术操作更为方便，并使贴膜和防护膜的应用也更为简便，但应用剃刀刮除手术部位的毛发会对皮肤产生微小的损伤，通过这些损伤局部原发感染的风险会明显增加。疾病预防和控制中心（CDC）建议，应尽量避免去毛，如果实在必要，也应该应用电动剪毛刀或脱毛剂，而应避免应用剃毛刀【15】。有学者对术前去毛相关的文献进行了Cochrane综述，其结论与CDC所推荐的方案一致，此外，去毛应该手术当天进行【16】。
Dental care isanother preoperative issue to be discussed with high-risk orthopaedic patients.All patients, but particularly those at high risk for infection, should beencouraged to maintain good dental health before and after surgery. Bacteremiafrom a dental infection can cause acute hematogenous infection at the site of atotal joint replacement. Evidence shows that the most critical period is thefirst two years after surgery17. The American Academy of OrthopaedicSurgeons (AAOS) in conjunction with the American Dental Association (ADA)developed guidelines for antibiotic prophylaxis for patients with a total jointreplacement who require dental procedures18. Patients are identified as beingat high or low risk depending on their medical comorbidities. Dental proceduresare categorized as high or low risk depending on the risk of bacteremia. Allpatients should receive antibiotic prophylaxis for high-risk dental proceduresfor two years after the joint replacement, and high-risk patients should receiveprophylaxis for high-risk dental procedures for life. Antibiotic regimens areincluded in the recommendations (Table I).
术前处理牙科的疾病对于高风险的骨科患者而言也是一个值得探讨的问题。对于所有患者，而感染风险较高的患者尤其，应鼓励其在手术前后保持良好的口腔卫生。源自牙齿感染的菌血症可导致全关节置换部位的急性血源性感染。有证据表明，临界期通常为手术后的头两年【17】。美国骨科医师学会（AAOS）联合美国牙科协会（ADA）对全关节置换的患者进行牙科手术时预防性应用抗生素制定了指南【18】。按照内科合并症的情况将患者分为高或低风险人群；按照菌血症的风险将牙科手术分为高风险或低风险手术。关节置换术后2年内的所有患者在进行高风险的牙科手术时，都应该预防性地应该抗生素，而对于高风险的患者而言，关节置换术后的任何时间行高风险牙科手术时都应该预防性应用抗生素。其推荐的方案中也包括了抗生素的用法（表1）。

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Antibiotics
抗生素

Perioperative prophylactic antibiotics are effective in reducing the rate of surgical site infections in high-risk orthopaedic cases. In a 2002 meta-analysis of spine fusion surgery, Barker19 reported that use of antibiotic therapy for such procedures is beneficial even when the infection rates without antibiotics are low. Similar studies have demonstrated the efficacy of preoperative antibiotics in general orthopaedic surgery and before total joint replacement20,21.

对高风险的骨科患者而言，围手术期预防性应用抗生素可有效地降低手术部位的感染率。在2002年一项关于脊柱融合手术的meta分析中，Barker【19】指出，在这样的手术中应用抗生素是有益的，即使在不用抗生素时感染率也较低的情况下依然如此。其他类似的研究也证实，在普通的骨科手术和全关节置换手术之前应用抗生素都有着良好的效果【20,21】。

The choice of antibiotic for patients with a low risk of methicillin-resistant Staphylococcus aureus colonization is either cefazolin (1 to 2 g administered intravenously) or cefuroxime (1.5 g administered intravenously). These doses must be adjusted for children. For patients with a beta-lactam allergy, clindamycin (600 mg administered intravenously) or vancomycin (1.0 g administered intravenously) should be used in lieu of cephalosporins. Patients who are colonized with methicillin-resistant Staphylococcus aureus are at high risk for colonization (e.g., nursing home residents), or have had a previous methicillin-resistant Staphylococcus aureus infection have an increased risk for the development of an infection with methicillin-resistant Staphylococcus aureus22,23. Prophylaxis with vancomycin (1.0 g administered intravenously) should be considered for these patients24.

对于耐甲氧西林金黄色葡萄球菌定植风险较低的患者选择抗生素时，头孢唑啉（1-2g静脉内给药）或头孢呋辛（1.5g静脉内给药）都是可以考虑的，应用于儿童时剂量应作相应的调整。如果患者对β-内酰胺类药物过敏，可用克林霉素（600mg静脉内给药）或万古霉素（1.0g静脉内给药）代替头孢菌素。如患者居住在耐甲氧西林金黄色葡萄球菌较多的环境中，发生菌群定植的风险往往较高（如敬老院的住户），而曾经感染上述耐甲氧西林金黄色葡萄球菌的患者则发生耐甲氧西林金黄色葡萄球菌感染的风险会明显增加【22,23】，对这些患者应用考虑预防性应用万古霉素（1.0g静脉内给药）【24】。

The proper timing and duration of antibiotic prophylaxis are imperative for safety and effectiveness. In general, antibiotic therapy should be started within one hour prior to the surgical incision, and the drugs should be completely infused prior to tourniquet inflation. The exception to this recommendation is vancomycin, the administration of which may be started up to two hours prior to the surgical incision. This allows a slower infusion and decreases the likelihood of red man syndrome. Red man syndrome occurs when hypersensitivity to vancomycin causes degranulation of mast cells and a release of histamine. The histamine leads to hypotension and facial flushing. Red man syndrome is prevented by the slow administration of vancomycin over a period of one to two hours.

预防性应用抗生素注意合适的时机和持续时间对于其安全性和有效性都是非常关键的。通常应在做手术切口之前的一个小时内应用抗生素，并且止血带充气之前药物必须输注完毕。对这一建议而言，万古霉素是个例外，其开始给药的时间应提前至做手术切口之前两个小时，这样可以缓慢输注，减少红人综合征的发生率。万古霉素过敏时可导致肥大细胞脱颗粒并释放组胺从而出现红人综合征，组胺可导致低血压和颜面部发红。应用万古霉素时缓慢输注，输注时间达1-2小时可防止发生红人综合征。

Antibiotic treatment should be stopped within twenty-four hours after wound closure. Administration of prophylactic antibiotics for longer than twenty-four hours has not been demonstrated to be effective and may actually lead to superinfection with drug-resistant organisms25. Repeat dosing with antibiotics is recommended during surgical procedures that last for longer than four hours or when there is >1500 mL of blood loss26.

抗生素应在创口闭合后的24小时之内停药。没有证据表明预防性应用抗生素超过24小时是有效的，并且事实上还有可能导致耐药菌的二重感染【25】。而如果手术持续时间较长，超过4小时或术中出血量大于1500ml，则推荐在术中重复给药一次【26】。

We recommend that, in order to ensure the proper selection and timing of antibiotic prophylaxis, the choice of antibiotics and duration of administration be incorporated into the surgical "time-out." Rosenberg et al. reported that compliance with the proper timing and selection of antibiotics increased from 65% to 99% when the protocol was incorporated into the time-out27.

在预防性应用抗生素时为了确保合理选择抗生素并确定适当的给药时机，我们推荐，将选择抗生素和确定给药持续时间都归入到手术的“time-out”（手术划刀前暂停核对各项信息）方案中。Rosenberg等曾报道，将相关的内容并入到“time-out”方案中之后，选择抗生素以及用药时间的符合率由65%增加到99%【27】。

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Surgical HandAntisepsis
术者手部消毒
The objective of apreoperative hand scrub is to remove or kill as many bacteria as possible fromthe hands of the surgical team. Aqueous scrub solutions consisting ofwater-based solutions of either chlorhexidine gluconate or povidone-iodine havebeen traditionally used.
术前洗手的目的是为了尽可能多地去除或杀死手术人员手部的细菌。通常应用的液态洗涤剂大多为洗必泰葡萄糖酸盐或聚维酮碘的水溶液。
The authors of arecent Cochrane review28 found alcohol-based rubs containing ethanol,isopropanol, or n-propanol to be as effective as aqueous solutions forpreventing surgical site infections in patients29. Hajipour et al.30 reportedthat alcohol rubs were more effective than either chlorhexidine gluconate oriodine-based scrubs for reducing bacterial colony-forming units (CFUs) on thehands of surgeons. Other investigators reported that the use of scrub brusheshad no positive effect on asepsis and may actually increase the risk ofinfection as a result of skin damage31. On the basis of this evidence, therecommended procedure for preoperative surgical hand antisepsis is that,preceding the first scrub of the day or when the hands are grosslycontaminated, the surgical team should wash with soap and water, use a nailpick to clean under the nails, and dry with paper towels. They should then usean alcohol-based rub for three minutes32. An alcohol-based rub should be usedfor each subsequent case. The use of scrub brushes is not recommended.
有学者最近的一项Cochrane综述【28】发现，含有乙醇、异丙醇或正丙醇的酒精擦剂与水溶液相比，对于预防患者手术部位的感染具有类似的效果【29】。Hajipour等【30】报道酒精擦剂比洗必泰葡萄糖酸盐或含碘洗涤剂都更为有效，因为前者可减少术者手上的细菌菌落形成单位（CFU）。另外还有学者报道应用毛刷对于手部消毒并没有明显的效果，并且事实上由于会损伤皮肤反而会增加感染的风险【31】。根据这些证据，术者术前手部消毒推荐的方式为，在当天初次刷洗之前或手部严重污染时，手术人员应该用肥皂和水洗手，并用指甲签将指甲下方的污物清理干净，然后用纸巾擦干。然后，术者再用含酒精的擦剂涂抹3分钟【32】。后续的手术每次都应该用含酒精的擦剂进行涂抹，但不推荐应用毛刷进行刷洗。

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Surgical SitePreparation
手术部位的消毒
Chlorhexidinegluconate-based solutions have supplanted alcohol and iodine-based solutionsfor surgical site preparation. Ostrander et al.33 examined the residual amountsof bacteria on feet prepared with a chlorhexidine gluconate, iodine/isopropylalcohol, or chloroxylenol scrub. They found that chlorhexidine gluconate wassuperior to the other two preparation solutions in reducing or eliminatingbacteria from the feet prior to surgery. Chlorhexidine gluconate skinpreparation was superior to either 70% alcohol or iodine in decreasinginfection associated with the placement of central venous catheters and thedrawing of blood for culture34,35. Thus, the current evidence-basedrecommendations and best-practice guidelines call for the use of chlorhexidinegluconate-based solutions for surgical site preparation and placement ofcentral venous catheters.
手术部位的消毒液，洗必泰葡萄糖酸盐溶液已经替代酒精和含碘的溶液。Ostrander等【33】对洗必泰葡萄糖酸盐、碘/异丙醇或氯二甲苯酚的擦剂消毒足部后，检测残余的细菌数量，结果发现在术后减少或消除足部细菌的功效上洗必泰葡萄糖酸盐优于其他两种消毒剂。而在置入中央静脉导管和抽血样做培养等操作时，应用洗必泰葡萄糖酸盐进行皮肤消毒，相比70%的酒精或碘剂，均可减少感染的发生率【34,35】。因此，在术区消毒以及置入中央静脉导管时，基于现有证据的建议和最佳操作指南都提倡应用洗必泰葡萄糖酸盐溶液。

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Decreasing the Risk of Surgical Site Infection Related to the Operating-Room Environment
降低手术部位感染相关的手术室环境


Although the arcane details of techniques used to sterilize surgical instruments are beyond the expected knowledge of most orthopaedic surgeons, many of a surgeon's actions can adversely affect sterilization and increase the risk of surgical site infections. Flash sterilization is a procedure used by operating-room staff to sterilize instruments or implants with steam, on an as-needed basis. Flash sterilization is not equivalent to sterilization in central processing36,37. In central sterile processing, instruments are properly cleaned and all lumens are inspected; the instruments are then sterilized and allowed to dry completely, after which they are delivered in closed containers that ensure maintenance of sterility. Most importantly, the process is performed by trained, focused professionals. The entire process takes three to four hours. Flash sterilization should be used only for dropped instruments or in an emergency situation. Preventable reasons for flash sterilization include an insufficient quantity of instruments, loaner instruments and/or instruments not delivered in time for proper processing, and inaccurate or incomplete surgical booking requiring the emergency, unplanned use of instruments and/or implants.

虽然手术器械灭菌方法中很多不为人知的操作细节并不是大多数骨科医生都期望掌握的知识，但外科医生的很多做法却可对灭菌过程产生负面的影响，并会增加手术部位感染的风险。快速灭菌是手术室工作人员常用的一种对手术器械或内置物的灭菌方式，在一些必要的基座之上，应用蒸汽。快速灭菌并不能等同于中央灭菌过程【36,37】。在中央灭菌处理中，手术器械先用适当的方法清理干净，对所有内腔都进行彻底的检查，然后在对器械进行灭菌，并可使其完全干燥，最后手术器械在运送过程中必须保持密闭的包装，以确保维持其无菌的状态。最为重要的是，这些操作都由经过专业训练的人员完成，整个过程需要3-4小时。快速灭菌只有在术中器械掉落或紧急状况下方可应用。有些因素是可以避免进行快速灭菌的，包括手术器械数量不足，应用替代性器械和/或器械没有按照合适的操作规程按时送达，手术预约错误或不完善需要紧急处理，非计划性地应用手术器械和/或内置物等。

To reduce the incidence of flash sterilization, we recommend an increase in physician awareness about the inadequacy of the technique; improvement in the accuracy of surgical booking; mandating cooperation from vendors to ensure timely delivery of equipment, including financial penalties for late delivery; purchase of more frequently flash-sterilized items; surgical scheduling to accommodate and mitigate equipment shortages; and, finally, generation of incident reports when a flash-sterilized implant is used in a patient. Adopting these policies and procedures leads to a decrease in the incidence of flash sterilization38.

为了减少快速灭菌，我们建议增强对临床医师的宣传和培训，使其充分认识到这一方法的不足；提高手术预约单的准确性；要求供货商密切配合，确保相关设备及时交付到位，对于延迟送达的应考虑适当给予经济惩罚；对于以往经常进行快速灭菌的器械适当增加购买数量；通过调整手术安排以适应和缓解设备上的不足，最后，快速灭菌的内置物应用于患者后应写出相关的事件报告。采用这些策略和规程可有效降低快速灭菌的使用率【38】。

Powderless Gloves
Traditionally, surgical gloves contained powder to aid in the manufacturing process and to make donning easier. The powder was either talc or lycopodium spores. Because of concerns about granuloma formation and adhesions associated with the use of these substances, cornstarch is now the powder of choice39. However, cornstarch is not benign. It causes foreign-body granuloma formation and delayed wound-healing and can decrease the amount of bacteria required to cause a clinically apparent infection40. Cornstarch also leads to increased latex sensitivity in health-care workers. Type-I and type-IV hypersensitivity reactions to latex protein in hospital staff lead to increases in sick time and decreased job satisfaction41. Powderless gloves decrease staff absenteeism and eliminate the potential for foreign-body granuloma formation. These gloves cost 25% more than powdered gloves, but the added expense is mitigated by increased productivity of the operating-room staff41.

无粉手套

以往外科手套都是有粉的，这样在制造过程中便于操作，同时也可使穿戴更为方便，粉末的成分为滑石粉或石松子。由于考虑到应用这些粉末可能会形成肉芽肿以及粘连，因此目前一般都选用玉米淀粉【39】。然而，玉米淀粉也不是没有任何危险的，其可导致创口延迟愈合或向体外形成肉芽中，并且它可使通常出现感染相关临床表现所需的细菌数量减少【40】。玉米淀粉还会使医务人员对橡胶的敏感度增加。医院的工作人员对乳胶蛋白的I型和IV型过敏反应会使不适时间延长，并使工作的满意度下降【41】。无粉手套可减少工作人员的缺勤状况，且可避免向体外形成肉芽肿的潜在可能。这些手套比有粉手套贵25%，但由此增加的费用会随着手术室工作人员工作效率的提高而减少【41】。

Antiseptic-Coated Sutures
The use of antiseptic-coated sutures has generated increased interest. These sutures are typically coated with the antiseptic triclosan. Edmiston et al. demonstrated the effectiveness of coated sutures in inhibiting bacterial growth and contamination in an in vitro model42. In a randomized controlled trial, Rozzelle et al. reported a significant reduction in surgical site infection rates following cerebral spinal-fluid-shunt surgery with the use of antiseptic-coated sutures as compared with the rate following the same procedure without the use of such sutures43. These sutures cost 7% to 10% more than their uncoated counterparts. To our knowledge, no cost-effectiveness analysis has been published; however, the use of these sutures in high-risk patients may be justified.

具有抗菌表层的缝线

应用具有抗菌表层的缝线越来越被人们所重视，这种缝线通常涂有一层抗菌的三氯生。Edmiston等曾报道，在体外实验中，这种有涂层的缝线可有效抑制细菌的繁殖和污染【42】。在另一项随机对照试验中，Rozzelle等报道在脑脊液分流术后应用具有抗菌表层的缝线与没有应用这种缝线的病例相比，手术部位的感染率明显下降【43】。这种缝线相比没有涂层的类似缝线要贵7%至10%。据我们所知，目前尚未发表相关的效价分析，但是在高风险的患者中应用这样的缝线还是合理的。

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Operating-RoomTraffic
Maintaining adisciplined operating-room culture can reduce the risk of surgical siteinfections. Unnecessary operating-room traffic increases the rate ofinfections44. In a study of spine surgery, Olsen et al. reported that two ormore residents participating in the operative procedure was an independent riskfactor for surgical site infections, with an odds ratio of 2.245. Babkin et al.found that the rate of surgical site infections associated with left kneereplacements was 6.7 times higher than that associated with right kneereplacements performed during the same time period and in the same operatingrooms46. When the door on the left side of the operating room was locked,preventing ingress or egress, the surgical site infection rate associated withthe left knee replacements rapidly decreased to that associated with the rightknee replacements, a finding that supports the importance of limitingoperating-room traffic.
手术室的交通
在手术室保持遵守职业规范的习惯可减少手术部位感染的风险，在手术室内不必要的穿行会使感染率增加【44】。在一项有关脊柱手术的研究中，Olsen等报道在手术过程中2个或更多的人员加入进去是手术部位感染的一个独立的风险因素，优势比2.245。Babkin等发现，在相同时期内在同一手术间进行手术，左膝关节置换手术部位感染的发生率为由膝关节置换的6.7倍【46】，而当手术室左侧的门锁上以后，避免进出，左膝关节置换的术区感染率便很快下降到与右膝关节置换相当的水平，这一发现也证实了限制手术室交通的重要性。
Drains and BloodTransfusions
Whether to use drainsat the end of orthopaedic surgical procedures is a decision that surgeons makeon the basis of their training, opinions, and personal experience, in additionto research findings. A recent Cochrane review on this topic that includedfindings from thirty-six studies (5464 patients) revealed that the use ofclosed drains reduced bruising and the need for reinforcement of dressings47.However, the use of closed drains was also associated with an increased needfor transfusion, a risk factor that is discussed below. There was no differencein surgical site infection rates between drained and undrained wounds. Theauthors concluded that closed suction drains were of doubtful benefit.
创口引流与输血
在骨科手术临结束时是否放置引流管除了参考相关的研究结果以外，还需要术者根据他们所接受的训练、观点以及个人的经验来决定。最近有一项针对这一问题的Cochrane综述，共纳入了36项研究（5464例患者），结果显示应用封闭式引流可减少瘀伤，同时还可减少加包辅料的需要【47】。不过，应用封闭式引流会相应地增加输血的需求，风险因子如下文所述。是否放置创口引流对于手术部位的感染率并没有明显的差异。作者的结论认为闭合负压引流的有效性仍不确定。
In addition to thedoubtful benefit of surgical drains in orthopaedic procedures, they areassociated with a more frequent need for blood transfusion. Blood transfusioncarries the general risk of infection with blood-borne pathogens, such as HIVor hepatitis, and with other bacteria or parasites. This risk is very small,although still present, in the United  States and other developed countries thathave rigorous testing procedures for donated blood48. The more immediate riskassociated with transfusion is surgical site infection and an increased lengthof hospital stay49. Transfusion of blood induces immunomodulation that can leadto an increased risk of infection at the surgical site50. Talbot et al.reported a 3.2-fold increase in the post-sternotomy infection rate amongpatients who had had a transfusion compared with the rate among those who hadnot51. In a study of cardiac surgery, Bower et al. reported that the rate ofinfection in patients who had had a transfusion was almost twice as high asthat in patients who had not52. Weber et al. found that patients who had had atransfusion after hip arthroplasty had an increased length of hospital stay,even when the authors controlled for surgical site infection49. Strategies todecrease the need for transfusion include preoperative assessment of hemoglobinlevels and the hematocrit and prescription of drugs to improve theseparameters, if indicated, as well as the use of an algorithm that depends onsymptomatic anemia, rather than hemoglobin and hematocrit results alone, todetermine transfusion need.
在骨科手术中放置引流除了其好处仍不确定以外，往往输血的需求相应地也会更多一些。输血会带来感染血液传播的相关病原体的风险，例如HIV、肝炎，以及其他细菌或寄生虫。这种风险虽然仍然存在，但非常小，在美国及其他发达国家，对于捐献的血液都有一个严格的检测程序【48】。与输血相关的更为直接的风险辨识手术部位的感染和住院时间的延长【49】。输血会引起免疫调节，进而导致术区感染的风险增加【50】。Talbot等报道，胸骨切开术后的感染率，输过血的患者比未曾输血的患者要高3.2倍【51】。在一项有关心脏手术的研究中，Bower等报道输血的患者其感染率几乎是没有输血的患者的两倍【52】。Weber等发现，尽管术者控制了术区的感染，但髋关节置换术后输血的患者住院时间会明显延长【49】。减少输血相关需求的策略包括术前评估血红蛋白的水平及红细胞压积，如果符合指征可给予适当的药物治疗以改善这些参数，不能仅仅只根据血红蛋白和红细胞压积的结果，而应该参照继发性贫血的相关策略来决定是否有必要输血。

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Postoperative WoundManagement
The CDC recommendsmaintaining surgical dressings for twenty-four to forty-eight hourspostoperatively53. Some surgeons use a three-day rule, keeping the originalsurgical dressing in place for seventy-two hours. There is little evidence thatkeeping dressings on for an extra day or two decreases the infection risk;however, if the dressing is not clean and dry, it may become a source ofmicrobes close to the incision. Perhaps as important as the duration that thedressing is in place is ensuring the proper process for postoperative woundmanagement. The surgeon should review policies and procedures to determine whochanges dressings (e.g., nurses, or physicians only), under what circumstancesthey are changed, and if they are ever reinforced rather than changed. Thebasic concept of infection prevention is to keep the wound clean and dry.Soiled or blood-soaked dressings should be removed immediately rather thanreinforced. If dressings do not stay intact, use of a different product may bewarranted.
术后创口的处理
CDC推荐术后24至48小时内维持手术的敷料【53】。有些外科医生采用三天原则，72小时内将最初的手术敷料保持在原位。很少有证据认为维持原来的敷料多一或两天会增加感染的风险，然而，如果敷料并不干燥、清洁，则可能成为紧邻切口的微生物来源。术后采用合理的操作规程来处理创口，可能同敷料保持在原位的时间同等重要。术者应对相关的方法和操作程序进行检查，以确定由谁来更换敷料（例如护士，或者只安排医生），在什么情况下他们应该进行更换，或者他们只是增加敷料而不是更换。预防感染的基本概念辨识保持创口干燥和清洁。污染或血液浸透的敷料必须立即更换，而不能加包。如果敷料不能保持其整体性，那么应用不同种类的敷料也是允许的。
A multidisciplinarygroup should evaluate current practices and discuss ways to optimizepostoperative wound care. Some basic issues are ensuring that an aseptictechnique is used for dressing changes and having accurate descriptions of theamount and character of the wound drainage and of the wound itself in anaccessible place. We have found that restrictions on the use of products due tocost may hinder good wound care. For example, restricting the use ofsemipermeable occlusive dressings to the operating room leaves staff on thenursing units without an appropriate product with which to keep surgicaldressings intact. When viewed with respect to the cost of surgical siteinfections, the cost of the occlusive dressing is very reasonable. Staffeducation is needed if long-standing policies and procedures are to be changed.
多学科的团队应对现行的做法进行评价，并探讨术后创口的处理最优化的途径。有些基本的问题必须确保，如换药时注意无菌操作，按照某个合适的次序，确切地描述创口引流管的数量和具体特征，以及创口本身的状况。我们发现由于产品的费用问题而限制其使用的做法会阻碍对创口进行良好的处理。例如，限制手术室以外其他护理人员使用半透性的封闭敷料，而往往又没有合适的产品可以保持手术敷料的完整性。而如果从手术部位感染的角度来考量其经济价值，那么封闭敷料的费用还是非常合理的。如果改变了长期性的方法和规程，则有必要对相关的工作人员就行培训和宣教。
Antimicrobialdressings are available, and research indicates that they may be helpful inreducing infection risk. Silver-based dressings have been available for a longtime, and they are effective in decreasing the risk of mediastinitis followingcardiac surgery54 and following lumbar laminectomy and fusion55. They are notroutinely used for surgical care, most likely because they are expensive andnot always covered by insurance. Other compounds, such as polyhexamethylenebiguanide (PHMfile:///C:/DOCUME~1/ADMINI~1/LOCALS~1/Temp/msohtml1/01/clip_image001.gif, have shown promise in small studies56,57. PHMBdressings look and feel similar to traditional gauze dressings and are muchless expensive than silver-containing dressings. The cost of a PHMB-containing4 x 4-inch sponge is roughly twice the cost of regular 4 x 4-inch gauze (theleast expensive antimicrobial dressing). Gentian violet and methylene blue arecombined for bacteriostatic effect in some dressings, but there is littleevidence to support their use for clean surgical incisions.
有些抗菌敷料也可应用，有研究指出，这些敷料可能有助于降低感染的风险。长期以来含银的敷料在临床都有应用，其对于减少心脏手术后纵隔炎的风险有一定的效果【55】。该敷料在外科手术后并不被常规采用，可能主要是因为其价格昂贵，并且通常也并不在保险的范围之内。其他一些化合物，如聚六亚甲基双胍（PHMB），有一些小样本的研究显示相关的前景较为乐观【56,57】。PHMB敷料的外观和手感与传统的纱布敷料类似，且比含银的敷料要便宜得多。4×4英寸含PHMB的海绵状敷料价格约为4×4英寸常规纱布（最便宜的抗菌敷料）的两倍。有些敷料将龙胆紫和亚甲蓝相结合以达到抑菌作用，但对于清洁的手术切口，很少有证据证实这一作用。

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Other IssuesConcerning Infection Prevention
预防感染的其他问题

Hand Hygiene
Proper hand hygieneis the most important way to prevent infections in health-care settings, yetcompliance with hand-hygiene procedures is suboptimal. The authors of the 2002CDC Guideline for Hand Hygiene in Health-Care Settings reported an average compliancerate of 40%58. Since that time, the Joint Commission on Accreditation ofHealthcare Organizations has made decreasing rates of health-care-associatedinfections one of its national patient-safety goals, and hospitals that areaccredited by the Joint Commission are required to have a hand-hygienemonitoring and improvement program59. Studies have linked improved compliancewith hand-hygiene protocols with decreased rates of marker organisms, such asmethicillin-resistant Staphylococcus aureus60. Many studies have demonstratedthat multi-pronged interventions that include strong administrative support aremore successful over time than are traditional single interventions, such aseducation or feedback of hand-hygiene-compliance data61. Another strategy thathas helped increase hand-hygiene compliance is the use of alcohol-based handsanitizers. These are recommended preferentially by the CDC for routine handhygiene58. The rationale is that alcohol-based sanitizers can be moreconveniently located than sinks and take less time to use than traditional handwashing. In addition, a counterintuitive finding is that alcohol handsanitizers are less irritating to skin than hand washing with soap andwater62,63.
手卫生
注意手的卫生是预防院内感染的重要途径，然而手卫生相关规程的依从性却并不理想。据2002年CDC医疗卫生场所手卫生指南的作者报道平均依从率约为40%[58]。此后，美国医疗机构评审联合委员会将减少医疗卫生场所相关感染率作为国家患者安全目标的重要内容，联合委员会认证的医院必须安装手卫生监视器，切实改善相关的规程[59]。有研究发现改善手卫生方案的顺应性与某些标志性微生物的减少存在相关性，如耐甲氧西林金黄色葡萄球菌等[60]。多项研究显示，随着时间的延长，包括强大的后勤支撑在内的多方面干预往往会比诸如教育或手卫生依从性数据反馈等传统的单一干预模式更成功，[61]。另一个有助于增加手卫生依从性的策略是应用含酒精的手消毒剂，这是CDC常规手卫生优先推荐的方法[58]。因为含酒精的消毒剂相对于洗手池往往更为顺手，并且也比传统的洗手更节省时间。此外，认为意外地发现，含酒精的手消毒剂比肥皂和水洗手对皮肤的刺激更小[62,63]。
Isolation Precautions
Contact isolationprecautions are recommended by the CDC for patients with drug-resistantorganisms, and this is now part of the national patient safety goals of theJoint Commission. Patients with drug-resistant organisms are placed in privaterooms, if possible, or with other patients who harbor the same organism. Gownsand gloves are required for care of these patients and should be donned onentry into the room. The decision about when to don gowns and gloves is nolonger at the discretion of clinicians, since that leads to substantialvariability in adherence. The Joint Commission requires hospitals to monitoradherence to contact precautions and to have a program to improve compliance.Some issues regarding contact precautions are unclear. These include decisionsabout how to handle patients who have been decolonized formethicillin-resistant Staphylococcus aureus, a standardized definition ofresistant gram-negative organisms, and how long to continue contact precautionsfor various organisms. More research is needed in these areas. Contactprecautions are not without consequences. Recent study results indicate that patientssubjected to contact isolation precautions are seen less frequently byattending physicians, are more likely to have skin breakdown or falls, and aremore likely to complain about their care. Hospitals should include strategiesto ameliorate these consequences when isolation precautions are indicated64.
隔离预防
CDC推荐对携带耐药菌的患者实施接触隔离预防，目前这也是联合委员会国家患者安全目标的组成部分。如果可能的话，应该将携带耐药菌的患者安排在单独的病室，或者与其他携带有相同病菌的患者安排在一起。处理这些患者时必须穿防护服戴手套，并且应该在进入房间的入口处穿戴。合适穿防护服戴手套不能任由临床医生来决定，因为这对于病菌的粘附有着很大的差异。联合委员会要求医院对接触预防进行监视，并且有改善依从性的相关计划。关于接触预防有些问题仍有争议，如耐甲氧西林金黄色葡萄球菌已经定植的患者应该怎样接触，革兰氏阴性耐药菌标准的定义，以及对各种病菌分别应该进行多长时间的接触预防等，这一领域内还有很多研究有待深入。当然，接触预防也不有一些不良的影响，最近的研究结果显示，接受接触隔离预防的患者见到主治医师的次数往往更少，出现皮肤破损或摔倒的可能性也更大，同时他们更有可能对医疗护理心存不满。因此，当必须进行隔离预防时，医院应该注意采取相应的策略，改善这些不良影响[64]。

樵夫

Health-Care-AssociatedInfections
医疗保健相关的感染

The CMS is changinggovernment payments for infections that arise as a result of hospital care.Successful interventions, such as the Institute for Healthcare Improvement's"100,000 Lives" campaign (currently, the "5 Million Lives"campaign; http://www.ihi.org/IHI/Programs/Campaign) and theKeystone (Michigan Health and Hospital Association Keystone Center) initiative(http://www.mibcn.com/newsroom/2008/pr_03-12-2008_47388.shtml)have shown that infections are not simply an unavoidable complication of healthcare and that, with attention to infection-prevention practices, manyinfections may be prevented. As a payer, the CMS has decided to rewardinstitutions that use best practices and not pay extra for certain preventablecomplications that are referred to as "never events." As of October2008, the CMS is not paying extra for infectious complications includingcatheter-associated urinary tract infections; central venouscatheter-associated bloodstream infections; surgical site infections followingspine, neck, shoulder, or elbow procedures; or mediastinitis following cardiacsurgery(http://www.cms.hhs.gov/HospitalA ... tions.asp#TopOfPage).
CMS正在改变政府对住院治疗相关感染的拨款，成功的干预，如美国医疗保健促进会的“100000生命”运动（目前的“5000000生命”运动；http://www.ihi.org/IHI/Programs/Campaign）和Keystone（密歇根医疗与医院协会Keystone 中心）所发起的（http://www.mibcn.com/newsroom/2008/pr_03-12-2008_47388.shtml）显示感染并不是医疗活动中单纯的不可避免的并发症，相反，如果对预防感染的工作认真实行，很多感染都是可以预防的。作为一个出资方，CMS决定对应用最佳方案的机构进行奖励，但对于某些可预防的并发症，则将其视为“绝不应发生的事件”，而不会支付额外的费用。从2008年10月开始，CMS便不再对以下感染性并发症支付额外的费用，包括导尿管相关的尿路感染，中心静脉导管相关的血流感染，脊柱、颈、肩或肘部手术后的术区感染，或心脏手术后的纵隔炎等（http://www.cms.hhs.gov/HospitalAcqCond/06_Hospital-Acquired_Conditions.asp#TopOfPage）。
Of thesehealth-care-associated events, urinary tract infections are the most numerous,so efforts at decreasing their occurrence are now a focus of hospitals aroundthe country. Recent studies have shed light on the fact that many clinicians donot know which of their patients have urinary catheters and that there is agreat opportunity to decrease the use of urinary catheterization. There are newguidelines and recommendations for appropriate use of urinary catheters(http://www.journals.uchicago.edu/doi/full/10.1086/591066). A daily assessmentof the necessity for the device is among these recommendations and is probablythe most straightforward approach to decreasing the use of urinary cathetersand the associated infection risk.
在这些医疗相关的不良事件中，尿路感染最为多见，因此尽力减少尿路感染的发生时美国各医院关注的焦点。最近的研究明确了这样一个事实，很多临床医生并不知道他们的哪个患者插了导尿管，并且插导尿管的几率也可大大降低。关于如何合理应用导尿管已有新的指南和建议（http://www.journals.uchicago.edu/doi/full/10.1086/591066）。在这些建议中有一条是每天对尿管的必要性进行评价，这对于减少导尿管的应用及其相关的感染风险，大概是最为直接的方法。
Public Reporting ofHealth-Care-Associated Infections
As a result ofconsumer and payer demands for more transparency about health-care quality,many states now require some level of public reporting ofhealth-care-associated infections. The elements of required reporting and themethodology for reporting vary from state to state, but many are using the CDCNational Healthcare Safety Network (NHSN) as the required system. The NHSN is aweb-based version of the CDC's hospital infection reporting system that hasbeen in place since the 1970s. The standardized definitions of infection havebeen used for many years and have become the gold standard for surveillancedefinitions. In addition to its long track record, advantages of the NHSNsystem include the fact that it is a secure database and that it allows groups(such as states) to sign up together, allows a conferral of rights to seeinstitutional data, provides some data analysis and data display capabilities,produces the national benchmarks for infection rates, and is free to use. NHSNmodules can be accessed online (http://www.cdc.gov/nhsn/psc_da.html).
医疗保健相关感染的公开报告
由于消费者和出资方对医疗质量透明度的要求，目前很多情况下都要求对医疗保健相关感染的状况提供一定程度的公开报告。各州对报告所要求的要件以及报告的方式都各不相同，但大多都采用CDC国家医疗安全网络（NHSN）作为系统性要求。NHSN是CDC医院感染报告系统的网络版，该系统始于1970年代。其感染的标准定义很多年一直被采用，并已成为监督界限的金标准。除了作为一种长期档案外，NHSN体系的优势还包括它是一个非常安全的数据库，允许各团体（例如州）之间相互共享，在获得授权的情况下允许查阅这些公共信息，提供某些数据分析和数据展示的功能，对感染率形成全国性的基点，并且它是免费的。NHSN模块可在线登入（http://www.cdc.gov/nhsn/psc_da.html）。
Infection preventionhas become a focus of attention for patients, payers, and regulators.Physicians and hospitals must now incorporate infection-prevention practicesinto their care or risk losing payment and patients and having negativepublicity when their rates become public. Fortunately, this gives surgeons theopportunity to collaborate with partners throughout the health-care system todeliver the best care possible, paying attention to all processes of care fortheir patients.
感染的预防也已成为患者、出资方以及管理者关注的焦点问题。临床医生和医院现在必须将预防感染的相关举措融入到医疗活动中，否则当感染率的数据公开后，会面临声誉受损、患者和收入下降的风险。幸运的是，这样也使得外科医生有机会与整个医疗系统中的各方紧密合作，尽可能提供最好的医疗服务，并对患者的各个诊疗环节都认真对待。

樵夫

Overview
小结
Reduction of rates ofsurgical site infections promises to be an area of intense interest andactivity in the foreseeable future. Health-care payers and regulatoryorganizations such as CMS and the Joint Commission are demanding accountabilityand reductions in rates of surgical site infection. In the areas in whichevidence-based literature has demonstrated a clear best practice, such asprophylactic use of antibiotics and surgical scrub techniques, physicians andhospitals will be held accountable for compliance with these standards. Thisaccountability will be quantified, and the data will be made available to thepublic. It is also clear that payers will penalize those responsible forfailure to comply with these standards of care. Thus, it is necessary for allto become familiar with the known best practices and standards of care for thereduction of the rates of surgical site infections.
降低手术部位感染的发生率是人们十分关注的领域，并且在可以预见的将来仍会是临床的热点问题。医疗卫生的出资方和管理者如CMS和联合委员会都要求切实降低手术部位感染的发生率。在这一领域，相关的循证医学文献明确证实有些方法是切实可行的，如预防性应用抗生素和手术消毒方法，临床医生和医院都应该认真地依从于这些标准。对此应该明确各自的责任，相关的数据也应该便于公众获取。同时，对于没有参照医疗操作标准的失职行为，出资方也可改为适当的处罚。因此，对于降低手术部位感染率而言，熟悉最佳的做法和医疗操作标准，对相关各方都是很有必要的。

樵夫

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zhang123

已下载收藏了，再学习，慢慢消化，谢谢老师。

snhszyy

回复 12# 樵夫


    已下载学习了谢谢

韦李

谢谢老师。内容很好，已十载，慢慢学习消化。

阿女

老师好有才啊！！！已下载收藏了，再学习，慢慢消化，谢谢老师。

zdhgxc

谢谢老师,已下载收藏了,慢慢消化

论坛好老师

非常值得学习的资料，下载－学习－学习－再学习！

xiyue

已下载收藏了，再学习，慢慢消化，谢谢老师。

larissa

已下载，学习研究中，谢谢老师，您辛苦啦！