1、S. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangRisk Factors Affecting Postoperative SSIlProcedure Classification of woundType of procedureOperation timelHost-related factorsAmerican Society of

2、Anesthesiologists scoreUnderlying diseaseAgeS. C. ChangCDC Guideline for the Prevention of Surgical Site Infection, 1999l Preoperativea. Preparation of the patientb. Hand/forearm antisepsis for surgical team membersc. Management of infected or colonized surgical personneld. Antimicrobial prophylaxis

3、l Intraoperativel Postoperative Incision CareS. C. ChangCDC Guideline for the Prevention of Surgical Site Infection, 1999lAntimicrobial prophylaxis(1) Administer a prophylactic antimicrobial agent only when indicated, and select it based on its efficacy against the most common pathogens causing SSI

4、for a specific operation and published recommendations. (Category IA)S. C. ChangCDC Guideline for the Prevention of Surgical Site Infection, 1999lAntimicrobial prophylaxis(2) Administer by the intravenous route of initial dose of prophylactic antimicrobial agent, timed such that a bactericidal conce

5、ntration of the drug is established in serum and tissues when the incision is made. Maintain therapeutic levels of the agent in serum and tissues throughout the operation and until, at most, a few hours after the incision is closed in the operating room. (Category IA)S. C. ChangCDC Guideline for the

6、 Prevention of Surgical Site Infection, 1999lAntimicrobial prophylaxis(3) Before elective colorectal operations in addition to d2 above, mechanically prepare the colon by use of enemas and cathartic agents. Administer non-absorbable oral antimicrobial agents in divided doses on the day before the op

7、eration. (Category IA)S. C. ChangCDC Guideline for the Prevention of Surgical Site Infection, 1999lAntimicrobial prophylaxis(4) For high-risk cesarean section, administer the prophylactic antimicrobial agent immediately after the umbilical cord is clamped.(Category IA)(5) Do not routinely use vancom

8、ycin for antimicrobial prophylaxis. (Category IB)S. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangS. C. ChangDuration of Antibiotic ProphylaxislSurgical Infection Society Guidelinev The shortest effective course of prophylactic antibiotics should be used. v “si

9、ngle shot”vCoverage limited to the intraoperative period is one of the most significant recent changes in antibiotic prophylaxis and is dramatically different from the 24 to 48 hours coverage previously recommended.S. C. ChangDuration of Antibiotic ProphylaxislSurgical Infection Society GuidelinevIt

10、 has been proved effective for operations involving the GI tract, for orthopedic operation, for c/s and gynecologic procedures.vExtending the course of antibiotic prophylaxis to “cover” lines, tubes, and catheters is unwarranted.S. C. ChangDuration of Antibiotic ProphylaxislFrench Society of Anesthe

11、sia GuidelinevMost practitioners recommend that prophylaxis not exceed 24 hours. vA single dose is as effective as longer prophylaxis. (Di Piro et al from 40 clinical studies)vMultiple postoperative injections have been shown to be not useful in many different kinds of operations.S. C. ChangDuration

12、 of Antibiotic ProphylaxislInfectious Diseases Society of America GuidelinevThe optimal duration of perioperative antimicrobial prophylaxis is not known. Many reports document effective prophylaxis with a single dose of drug.vIt is likely that no further benefit is conferred by the administration of

13、 additional doses after the patient has left the operating room. Postoperative administration is not recommended.S. C. ChangDuration of Antibiotic ProphylaxislInfectious Diseases Society of America GuidelinevAntimicrobial prophylaxis should certainly be discontinued within 24 hours of the operative

14、procedure.vThe continuation of prophylaxis until all catheter and drains have been removed is not appropriate.S. C. ChangRecommendations for Prophylactic Antibiotic (I)(Surgical Infection Society)S. C. ChangRecommendations for Prophylactic Antibiotic (II)(Surgical Infection Society)S. C. ChangS. C.

15、Chang全民健康保險藥品給付規(guī)定全民健康保險藥品給付規(guī)定8.8.預防性的使用抗微生物製劑預防性的使用抗微生物製劑(1)(1)清淨的手術：大致可分甲、乙兩類清淨的手術：大致可分甲、乙兩類乙類：乙類：如心臟手術、腦部手術、臟器移植手術及放置人工植入物之手術，原則上使用不可超過三天（口服與針劑併計），以本表之第一線抗微生物製劑為主；如需使用第一線以外之抗微生物製劑，請詳敘理由，俾利審查（90/2/1修訂）。S. C. Chang全民健康保險藥品給付規(guī)定全民健康保險藥品給付規(guī)定8.8.預防性的使用抗微生物製劑預防性的使用抗微生物製劑(1)(1)清淨但易受污染的手術：清淨但易受污染的手術：術野是清淨但

16、術中易受污染，如肝膽胃腸手術、泌尿道手術、肺部手術、婦科手術、耳鼻喉科手術、牙科手術等手術。原則上抗生物製劑使用三天（口服與針劑併計），以本表之第一線抗微生物製劑為主，若有厭氧菌與嗜氧菌混合污染之可能時，得使用Cephamycin (cefoxitin, cefmetazole)或ampicillin類合併-lactamase inhibitor (ampicillin /sulbactam, amoxicillin/ clavulanic acid)之藥物；如需使用第一線以外之抗微生物製劑，請詳敘理由，俾利審查（90/2/1修訂）。S. C. Chang全民健康保險藥品給付規(guī)定全民健康保險藥

17、品給付規(guī)定9.9.污染性傷口之手術及手術後發(fā)生感染污染性傷口之手術及手術後發(fā)生感染併發(fā)癥，依本局規(guī)定之抗微生物製劑併發(fā)癥，依本局規(guī)定之抗微生物製劑使用原則用藥使用原則用藥（90/2/1增訂）。S. C. Chang健保局預防性抗生素使用之監(jiān)測健保局預防性抗生素使用之監(jiān)測l資料期間：資料期間：89年1月至89年6月l手術種類手術種類: :單純性疝氣手術（75606B、75607C）甲狀腺切除術(82004B)人工髖關節(jié)置換術（64162B）人工膝關節(jié)置換術（64164B）l對象醫(yī)院對象醫(yī)院: :醫(yī)學中心及區(qū)域醫(yī)院S. C. Changl主要分析資料主要分析資料使用抗生素案件比例使用抗生素案件比例

18、使用抗生素之種類分佈使用抗生素之種類分佈使用抗生素之平均劑量使用抗生素之平均劑量平均住院天數(shù)平均住院天數(shù)平均藥費、抗生素藥費平均藥費、抗生素藥費平均住院醫(yī)療費用平均住院醫(yī)療費用健保局預防性抗生素使用之監(jiān)測健保局預防性抗生素使用之監(jiān)測S. C. Chang單純性疝氣手術使用抗生素案件比例單純性疝氣手術使用抗生素案件比例S. C. Chang甲狀腺切除術使用抗生素案件比例甲狀腺切除術使用抗生素案件比例0%20%40%60%80%100%ABCDEFGHIJKLMNOP個案百分比OthersIV cephem+AG+oral cephemIV cephem+AGIV+oral cephemIV cephem 手術個案數(shù)抗生素個案比例 238 130 118 70 60 56 54 44 42 41 36 28 27 21 12 10 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100Chang SC, et al: Nosocom infect Control J 2001(in press)