【作者】 高斌；

【导师】 宋诗铎；

【作者基本信息】 天津医科大学 ， 内科学， 2009， 博士

【摘要】 第一部分某医院消化内科2007.1-2008.12医院感染监测的研究目的对某医院消化内科的医院感染数据进行描述性研究,以揭示医院感染的分布规律和变化趋势。方法以前瞻性调查方法对2007.1-2008.12该院消化内科的住院病人进行医院感染调查。结果1.共调查住院病人4,198例,医院感染人数394例,医院感染发病率为9.39%,发病密度为3.030例/1000住院日；医院感染发病例次数457例次,例次发病率为10.89%,例次发病密度为3.515例/1000住院日。2.常见医院感染发病部位按构成比依次为：原发性腹膜炎(23%)、血流感染(20%)、上呼吸道感染(20%)和下呼吸道感染(17%),以上占全部医院感染比例4/5。3.医院内上呼吸道感染在第一季度构成排列最高。医院内血流感染呈稳定高水平表现,医院内原发性腹膜炎有稳定下降趋势。4.各类医院感染中,按照以治愈/好转率由高到低依次为胃肠道、上呼吸道、原发性腹膜炎、皮肤软组织、血流感染和下呼吸道感染。自动出院和死亡率最高的两个部位是下呼吸道(18.18%)、血流(17.39%)。各部位医院感染的病死率以腹腔内组织感染为最高(11%),其次是下呼吸道感染(8.70%)和血流感染(7.32%)。5.各病区中,A2病房医院感染发生强度最高,为4.417例次/1000住院日。其中,血流感染发生强度最高的为A2病房(1.646例次/1000住院日),上呼吸道感染发生强度最高的为A5病房(1.459例次/1000住院日),下呼吸道感染发生强度最高的为A2病房(1.084例次/1000住院日)。6.院内腹膜炎感染治疗中每例用于抗菌药物支出的中位数为1,034.40元,四分位区间为693.60-2,579.60。医院内血流感染每例用于抗菌药物支出的中位数为1,030.60元,四分位区间为592.10-2,202.20。院内上呼吸道感染每例用于抗菌药物支出的中位数为442.40元,四分位区间为353.40-632.00。院内下呼吸道感染每例用于抗菌药物支出的中位数为1,635.20元,四分位区间为879.10-2,975.75。院内泌尿系感染每例用于抗菌药物支出的中位数为632.00元,四分位区间为458.92-1,352.60。小结1.本研究采用前瞻性医院感染监测方法,得出较为准确的科学数据,为医院感染发病指标的标准化奠定基础。2.该院消化内科医院感染率有季节变化特点。其医院内上呼吸道感染在第一季度发病密度最高。3.A2病区(重肝科)是医院感染监控的重点科室,血流感染和下呼吸道感染是其最常见的医院感染类型。第二部分抗菌药物预防剖宫产手术部位感染国内文献荟萃分析目的为剖宫产围手术期预防性使用抗生素方案制定提供循证依据。方法检索中国生物医学文献数据库、维普、万方和MEDLINE等数据库,对抗菌药物预防剖宫产手术部位感染的临床随机对照研究进行收集、筛选、评价并提取数据进行荟萃分析。结果1.从国内文献数据库检索1989年-2008年20年间相关文献101篇。有30篇符合要求进入荟萃分析,占29.70%。2.进入荟萃分析的30项研究共对7,346例剖宫产围手术期预防性使用抗生素的效果进行了观察,其中46.67%系2005年以后发表的。3.荟萃分析表明首剂术前半小时到2小时或钳夹脐带后给予短期抗生素较术后长期使用抗生素预防剖宫产手术部位感染(OR=0.34,95%CI0.24-0.48)和产后病率(OR=0.40,95%CI0.32-0.48)的效果显著；对上述两种策略效果差异无论是在预防单纯选择性(OR=0.45,95%CI0.11-1.83)或是在选择/非选择性剖宫产术后子宫内膜炎上均没有统计学意义(OR=0.55,95％CI 0.16-1.96)。4.文献质量偏低。其中4篇Jadad评分为2分,有15篇Jadad评分为1分,其他11篇的Jadad评分为0分。剔除敏感性最低的文献进行敏感性分析后,对术后子宫内膜炎预防荟萃分析显示,上述结果与原荟萃分析结果相近,未出现结果逆转。小结术前半小时到2小时或钳夹脐带短期使用抗生素可作为预防剖宫产手术相关感染的一项策略。第三部分预防剖宫产手术部位感染抗生素使用策略的干预研究目的：评价规范剖宫产围手术期预防性使用抗菌药物的临床效果。方法：采用包括制定循证性很强的医院内剖宫产围手术期抗菌药物预防性使用指南、指南推荐术中钳夹脐带给与单剂一代头孢,同时增加剖宫产手术后手术部位感染监测等干预措施。对某三级医院产科干预后(2008年1月-2009年3月)前瞻性调查手术部位感染、术后子宫内膜炎、产后病率等,与干预前(2006年1月-2007年10月)随机回顾调查进行比较。结果：1.依从干预指南预防性使用抗菌药物的92例,等量随机抽取干预前病例比较,在年龄、孕程胎膜早破、妊高病、过期妊娠、术前住院时间、术前血白细胞计数等方面可比性相当。2.干预前后剖宫产围手术期抗菌药物预防性使用策略的差异明显。表现为抗菌药物品种上干预前采用三代头孢菌素联合甲硝唑,干预后采用一代头孢菌素；预防用药首剂时间上干预前在术前1/2小时-2小时,干预后采用术中钳夹脐带；抗菌药物预防使用疗程上干预前为48小时,干预后仅单剂用药。3.干预前后手术部位感染(浅表)发生情况分别为2.17%(2/92),1.89%(2/106),术后病率发生情况分别为3.26%(3/92),1.89%(2/106),均未见子宫内膜炎。4.干预前后产妇出现外周血白细胞超过13G/L的情形分别为3.26%(3/92)和0.94%(1/106),p<0.25。术后外周血中性粒细胞比例超过80%的情形分别为28.26%(26/92)和28.30%(30/106)。术后体温分别为37.40±0.43摄氏度和37.33±0.49摄氏度,p=0.28。5.干预前后娩出新生儿体重分别为3446±422克和3393±408克,p=0.36。娩出新生儿Apgar评分分别为9.62±0.88和9.79±0.50,p=0.10。Apgar<7的例数分别为2和O。6.两种策略用于抗菌药的支出分别为221.15±67.53元和36.70±25.85元(p=0.00)。小结：本研究对某医院产科2008年1月采用一代头孢菌素单剂钳夹脐带给药作为剖宫产围手术期预防性使用抗菌药物干预,与之前的策略相比在用药品种、预防疗程、首剂时间等方面有所不同。显示干预后的手术相关感染控制效果相当,住院费用(抗菌药物)显著下降。第四部分某医院抗菌药物使用管理的效果评价目的：评价抗菌药物管理策略对医院内抗菌药物使用影响。方法：2006-2008年间在某医院推行包括建立抗菌药物合理使用指导小组、推进感染控制计划、制定针对性的抗生素使用指南、展开教育培训、提高对抗生素使用的监测、对临床使用的支持指导与反馈等一揽子干预策略。收集2005-2008年某医院全部抗菌药物使用频度、费用,2006-2008年该医院金黄色葡萄球菌和大肠杆菌对常用抗菌药物的敏感率。结果：1.抗菌药物占药品比例由3.32%降到2.79%。2.收治患者100人均使用抗菌药物费用从224.20元降至152.04元,效果显著。3.门诊每1000人次使用抗菌药物费用由406.00元降至274.70元。4.咪唑类、抗真菌类、氟喹诺酮类、三代头孢菌素和含酶抑制剂的β-内酰胺类的收治患者人均使用频度降幅排在前列。5.非限制类抗菌药物使用构成比例增加,其中p-内酰胺霉敏感青霉素类、大环内酯类、二代头孢菌素、四环素类、氨基糖苷类、磺胺类排在前列。6.2006-2008年该医院金黄色葡萄球菌对苯唑西林敏感率逐渐上升,分别为71%到82%,p<0.05;对左氧氟沙星的敏感率总体上升,63%到88%,p<0.05。7.2006-2008年该医院大肠杆菌对哌拉西林/舒巴坦的敏感性逐渐上升,38%增至62%,p<0.05；对环丙沙星/左氧氟沙星的敏感性总体上升,18%增至48%,p<0.05。小结：1.系统而有活力的抗生素管理机制是抗生素合理使用的重要保障。2.在干预中,该医院抗菌药物使用整体人均用量呈下降趋势,院抗菌药物使用构成中非限制使用抗菌药物比例呈逐渐上升趋势。3.该院干预后期分离出的金黄色葡萄球菌对苯唑西林、左氧氟沙星的敏感率较干预初期显著上升；该院干预后期检出的大肠杆菌对哌拉西林/舒巴坦、环丙沙星/左氧氟沙星的敏感率较干预初期显著上升。更多还原

【Abstract】 Part I Descriptive Study on Nosocomial Infection in Gestrointesitine Units in an Infectious Disease Hospital from 2007.1 to 2008.12Objective To analyze the data of nosocomial infection (NI) in an infectious teaching hospital for 2 years (from 2007.1 to 2008.12) and reveal the distribution and tendency.Methods To investigate prospectively the incidence of nosocomial infection among in-Patients during 2007.1 and 2008.12.Results1. All 4,198 cases were involved during the surveillance,394 of which were aquired NI. And the incidence of NI was 9.39%, the incidence density of NI was 3.030/1000patient days.457 times attacked, the case-times incidence was 10.89%, the case-times incidence density was 3.515/1000patient days.2. The frequent NI sites are peritonitis (23%), blood stream infection (20%), uper respiratory tract infection (20%) and lower respiratory tract infection (17%), which holds 80% of all.3. The nosocomial uper respiratory tract infections most frequently appeare in the first quarter of year. Nosocomial blood stream infections are stable higher. The incidence of nosocomial peritonitis trends down slowly.4. The best cure of nosocomial infections is gastrointesital tract infection. Then uper resperitory tract infection, peritonitis, skin-soft tissu infection are followed. The lower respiratory tract infection and blood stream infection are on the top in motality and renunciative leaf-off rate.5. The NI incidence in A2 unit is the highest by 4.417/1000patient days, most of which are blood stream infection (1.646/1000patient days) and lower respiratory tract infection (1.459/1000patient days). The incidence of nosocomial uper respiratory tract infection is highest in unit A5, a tradetional Chinese medicine unit,1.084/1000patient days.6. The motality of nosocomial infection is the highest in intraperitoneal tissue infection (11%), followed by lower respiratory tract infection (8.70%) and blood stream infection (7.32%).7. The median value of chemotherapy on single lower respiratory infection aquired in hospital is highest among all NI, by 1,635.20 RMB (592.10-2,202.20). The median value of chemotherapy on single blood streamm infection aquired in hospital is 1,030.60 RMB, (592.10-2,202.20). The median value of chemotherapy on single peritonitis aquired in hospital is 1,034.40 RMB, (693.60-2,579.60). The median value of chemotherapy on single urinary tract infection aquired in hospital is 632.00 RMB, (458.92-1,352.60).The median value of chemotherapy on single uper respiratory infection aquired in hospital is 442.40 RMB, (353.40-632.00).Conclusion1. It is iniatial prospective surveillance on nosocomial infection in China with more credible and scientific incidence, with which could be compared in advanced countries.2. The unit A2 with the highest nosocimial blood stream infection and lower respiratory tract infection is the one that fits to be surveyed as a target object.3. The upper respiratory tract infections aquired in hospital are most frequently in the first quarter of year.Part II The Prophylactic Use of Antibiotics Administration in preventing Surgical Site Infection of Cesarean section:A Meta Analysis of randomized controlled trials in ChinaObjective To evaluate the impact on surgical site infection (SSI), postpartum endometritis and/or puerperal morbidity by prophylactic administration of antibiotics in cesarean section.Methods Comprehensive Chinese randomized controlled trials retrieval about preventing postpartum infection related to cesarean section by antibiotics prophylactic uses was performed via searching electronic database, hand searching bibliographies of books and relevant journals.Results Compared with long term antibiotics prophylaxis started after operation, short term antibiotics prophylaxis started at time during 1/2 to 2 hours before operation or started after umbilical cord clamped showed lower surgical site infection (OR=0.34,95%CI0.24-0.48) and puerperal morbidity(OR=0.40,95%CI0.32-0.48) significantly, and lower postpartum endometritis incidence in selective C-section(OR=0.45,95%CI 0.11-1.83) or unselective C-section (OR=0.55,95%CI 0.16-1.96).Conclusion This meta analysis indicated that short term antibiotics prophylaxis started at time during 1/2 to 2 hours before operation or started after umbilical cord clamped is a strategy for improving to prevent SSI and puerperal morbidity.PartⅢThe evaluation of intervention of prophylactic use of first generation of cephalosporins in Cesarean section by single doseObjective The purpose of this history comparison between retrospective and prospective study was to determine the evidence-based hospital-made guideline of prophylactic antibiotics at cesarean delivery influences maternal/neonatal infectious morbidity.Methods The intervention included to provide evidence-based guideline of prophylactic use of antimicrobial for cesarean section, increase in post-discharge surveillance as a strategy to reassure surgeons of the safety of the reduction. Single-dose of first generation cephalosporins at cord clamping was guided as prophylactic use of antimicrobial for sesarean section. In the pre intervention periods, a retrospective collection of antimicrobial consumption and surgical site infections were measured randomly.Results1. Patients evaluated increased from 0 to 100% and the SSI rates in both periods were 2.17% to 1.89%, respectively. The difference of rates of术后病率between pre and post intervention (3.26% vs 1.89%) has not statistical significance. The endometritis before and after the intervention are not observed.2. The count of white cell in peripheral blood more than 13G/L cases are 3 and 1 respectively. The rate of Neutrophil in peripheral blood WBC more than 80% cases are 26 and 30, respectively.3. There was about 5/6 cost reduction in prophylactic antimicrobial use on average per cesarean section (RMB 221.15±67.53 to RMB 36.70±25.85).4. neonatal weight are 3446±422 g and 3393±408, respectively between before and after intervention, p=0.36. The Apgar scores are 9.62±0.88 and 9.79±0.50, p=0.10. The rates of neonatal Apgar score less than 7 cases are 2.17% and 0.Conclusion1. An ample intervention, including administrative and educational measures, led to high compliance with the first generation of cephalosporins within less than 24 hours after the operation. and saved more except bacterial resistence pressure.2. There was no difference in maternal infectious morbidity whether the duration of cefotazidine given before skin incision were at least 48 hours or single dose of the first generation of cephalosporins at cord clamping.Part IV The trend in antibacterial agents consumption by the appropriate use of antibiotics program at a Infectious Disease HospitalObjective To improve capability of antibiotics reasonable use in hospital.Methods People-centred infection control programmes were implemented over a 3-year period (2006-2008) in an infectious disease hospital, which included acting out antibiotics reasonable use management, strengthening nosocomial control and improving their surveillance capabilities. It was taken to provide pertinent education on reasonable use of antibiotics and formulate antibiotics use guideline to relative infection.Results1. The percentage of antimicrobials in medicine cost in the hospital is decreased from 3.32% to 2.79%.2. The cost of antimicrobials per 100 admitted patients is reduced continuously from RMB 224.20 to 152.04.3. The cost of antimicrobials per 1000 admitted out-clinic patient-times shows decreased trend, RMB 406.00 to 274.70.4. The Defined Daily Doses (DDDs) per 100 patients of antibacterial was on a degressive slope during the intervention. The DDDs per 100 patients of Imidazole derivatives, antimycotics, Fluoroquinolones, Third-generation cephalosporins and Beta-lactam antibacterials and enzyme inhibitors showed decrease marked in use.5. At the same time the component consumption of some antibacterial, such as Macrolides, Beta-lactamase sensitive penicillins, Second-generation cephalosporins, Tetracyclines, Sulfonamides and trimethoprim, and other aminoglycosides excluded streptomycins, were increased markedly.6. The sensibility rate of Staphylococcus aureus rises to oxacillin continuously from 71% to 82%; The one to levofloxacin rises from 63% in 2006 to 88% in 2008.7. Among strains of E.coli, the susceptibility to piperacillin/tazobactam increases from 38% to 62%; This trend is also in the susceptibility to ciprofloxacin/levofloxacin, from 18% to 48%.Conclusion Systematic and active strategy of appropriated use of antibiotics improving access and changing behaviour placed a key role but took time. The successful reduction of the third generation of cephalosporins and increases the susceptibility to E. coli and S. aureus. The longer effect of intervention existed.更多还原