神经外科术后中枢神经系统感染的临床研究
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摘要
〔目的〕探讨神经外科手术后颅内感染的相关因素及细菌谱变迁。
〔材料方法〕本试验以1996年1月～2003年12月天津医科大学总医院神经外科5405例手术患者(其中并发颅内感染172例)为研究对象。回顾分析了可能与颅内感染相关的各项因素，包括性别、年龄、手术时间、手术季节、术前疾病种类、颅脑损伤是否为开放性、术前合并糖尿病、术前应用激素及抗生素、手术入路、是否行脑室外引流、是否伴发脑脊液漏、术后放置外引流管(脑室外引流不计入此项)、术后应用抗生素等临床资料进行了全面总结，用EXCEL建立数据库，应用成组资料的非条件概率Logistic回归模型对影响感染率的因素进行统计分析。
〔结果〕本组病例5405例，男性3099例，女性2306例，平均年龄48.23±7.38岁，经Logistic回归分析得出感染率与手术时间、脑脊液漏、脑室外引流、放置外引流管、后颅凹入路、合并糖尿病、开放性颅脑损伤有关。而与性别、年龄、手术季节、术前应用激素及小同疾病病种、术前(≥1天)、术后长期使用抗生素无关。
〔结论〕神经外科术后颅内感染是一个多因素参与的复杂问题，在临床实践中应尽量减少手术暴露时间，后颅凹手术应严密缝合防止脑脊液漏，严格掌握脑室外引流时间，尽可能减少各种引流管的放置等方法，以减少颅内感染的发生率。此外，由于目前预防用药多采用第三代头孢菌素和喹诺酮类，G~-菌感染的发病率逐年下降，但G~+菌(多为MRSA／MRCNS)感染的比例又呈上升趋势。
Objective: To study the risk factors and spectrum of neurosurgical postoperative intracranial infection.
Materials and Methods: Totally 5405 patients who had a neurosurgical operation from Jan. 1996 to Dec. 2003 in General Hospitai, Tianjin Medical University were chosen (172 cases with intracranial infection). Many risk factors were studied retrospectively, including sex, age, the operation duration, the season, the preoperative diseases, open or closed craniocerebral injuries, having diabetes mellitus before the operation, preoperative application of hormones and antibiotics, the approach, having CSF fistulae, the insertion of drainage tube ( with the exception of ventricle drainage), postoperative application of antibiotics. A date-base was set up with EXCEL, and Logistic regression was selected to analysis the factors with may cause infection.
Results: the analysis of 5405 cases ( male 3099, female 2306, mean age 48.23 ?7.38) revealed that infection rate was closely related to the operation durations, CSF fistulae, ventricle drainage, the insertion of tubes, the approach of the post fossa, the complication from DM, open craniocerebral injuries. While had little effect on sex, age, the season, longer application of hormones before the operation, preoperative diseases, and longer application of antibiotics before( 1 day ) or after the operation.
Conclusions: Neurosurgical postoperative intracranial infection was related to many factors. To decrease its incidence, in clinical experiences, the operation should be finished as soon as possible, the suture should be done completely to prevent CSF fistulae, and the duration of the ventricle drainage should be controlled strictly. Moreover, because of the preoperative application of the third generation Cephalosporin and Quinolone agents to prevent infection, the infection rate of G" bacteria was decreasing gradually, and that of G+ bacteria (MRSA/MRSE mostly)was increasing.
〔材料方法〕本试验以1996年1月～2003年12月天津医科大学总医院神经外科5405例手术患者(其中并发颅内感染172例)为研究对象。回顾分析了可能与颅内感染相关的各项因素，包括性别、年龄、手术时间、手术季节、术前疾病种类、颅脑损伤是否为开放性、术前合并糖尿病、术前应用激素及抗生素、手术入路、是否行脑室外引流、是否伴发脑脊液漏、术后放置外引流管(脑室外引流不计入此项)、术后应用抗生素等临床资料进行了全面总结，用EXCEL建立数据库，应用成组资料的非条件概率Logistic回归模型对影响感染率的因素进行统计分析。
〔结果〕本组病例5405例，男性3099例，女性2306例，平均年龄48.23±7.38岁，经Logistic回归分析得出感染率与手术时间、脑脊液漏、脑室外引流、放置外引流管、后颅凹入路、合并糖尿病、开放性颅脑损伤有关。而与性别、年龄、手术季节、术前应用激素及小同疾病病种、术前(≥1天)、术后长期使用抗生素无关。
〔结论〕神经外科术后颅内感染是一个多因素参与的复杂问题，在临床实践中应尽量减少手术暴露时间，后颅凹手术应严密缝合防止脑脊液漏，严格掌握脑室外引流时间，尽可能减少各种引流管的放置等方法，以减少颅内感染的发生率。此外，由于目前预防用药多采用第三代头孢菌素和喹诺酮类，G~-菌感染的发病率逐年下降，但G~+菌(多为MRSA／MRCNS)感染的比例又呈上升趋势。
Objective: To study the risk factors and spectrum of neurosurgical postoperative intracranial infection.
Materials and Methods: Totally 5405 patients who had a neurosurgical operation from Jan. 1996 to Dec. 2003 in General Hospitai, Tianjin Medical University were chosen (172 cases with intracranial infection). Many risk factors were studied retrospectively, including sex, age, the operation duration, the season, the preoperative diseases, open or closed craniocerebral injuries, having diabetes mellitus before the operation, preoperative application of hormones and antibiotics, the approach, having CSF fistulae, the insertion of drainage tube ( with the exception of ventricle drainage), postoperative application of antibiotics. A date-base was set up with EXCEL, and Logistic regression was selected to analysis the factors with may cause infection.
Results: the analysis of 5405 cases ( male 3099, female 2306, mean age 48.23 ?7.38) revealed that infection rate was closely related to the operation durations, CSF fistulae, ventricle drainage, the insertion of tubes, the approach of the post fossa, the complication from DM, open craniocerebral injuries. While had little effect on sex, age, the season, longer application of hormones before the operation, preoperative diseases, and longer application of antibiotics before( 1 day ) or after the operation.
Conclusions: Neurosurgical postoperative intracranial infection was related to many factors. To decrease its incidence, in clinical experiences, the operation should be finished as soon as possible, the suture should be done completely to prevent CSF fistulae, and the duration of the ventricle drainage should be controlled strictly. Moreover, because of the preoperative application of the third generation Cephalosporin and Quinolone agents to prevent infection, the infection rate of G" bacteria was decreasing gradually, and that of G+ bacteria (MRSA/MRSE mostly)was increasing.
引文
1．朱士广，杨树源，张建宁．神经外科术后颅内感染及治疗．中华神经精神疾病杂志，1998，24(4)：215—217．
2. von Eiselsberg AF, Ranzi E:Uber die chirurgische Behandlung der Hirn und Rückenmarkstumoren. Arch Klin Chit 102:309-468,1913.
3. Tooth HH: The treatment of tumours of the brain, and the indications for operations. Trans 1st Cong Med London 8:203-299,1913.
4. Olivecrona H: Die Parasagittalen Meningeome. Leipzig: Georg Thieme, 1934, pp141-143.
5. Cushing H, Eisenhart L: Meningiomas, Their Classification, Regional Behaviour, Life History and Surgical end Results. Springfield, IL: Charle C Thomas, 1938, 733-734.
6. Cairns H:Bacterial infections during intracranial operations. Lancet 1:1193-1198,1939.
7. Woodhall B, Neill RG, Dratz HM:Ultravioet radiation as an adjunct in the control of post-operative neurosurgical infection. Ann Surg 129:820-825,1949
8. Wright RL:Postoperative Craniotomy Infections. Spingfield, IL: Charles C Thomas, 1966.
9. Skultety Fm, Nishioka H:Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage: Section Ⅷ, part 2. The results of intracranial surgery in the treatment of aneurysms. J Neruosurg 25:683-704, 1966.
10. Balch RE: Wound infection complicating neurosurgical procedures. J Neurosurg 26:41-45,1967.
11. Green JR Kanshepolsky J, Turkian B: Incidence and singnificance of central nervous system infection in neurosurgical patients. Adv Neurol 6:223-228,1974.
12. thou SN, Erickson DL: Craniotomy infections. Clin Neurosurg 23:357-362,1976.
13. Cruse PJE: Infetion surveillance. South Med J 70:48,1977.
14. Quadery LA, Medlery AV, Miles J: Vactors affecting the incidence of wound infection in neurosurgery. Acta Neurochir 39:133-141,1977.
15. Lhan Re, Thompson GB: Morbidity, mortality, andquality of life following surgery for intraeranial meningioma. J Neurosurg 60:52-60,1984.
16. Jomin M, Lesoin F, Lozes G: 500uptured and operated intracranial arterial aneurysm. Surg Neurol 21:13-18,1984.
17. Vlahov D, Montgomery E, Tenney JN, et al: Neurosurgical wound infections: Methodological and clinical factors affecting calculations of infection rates. J Neurosurg Nuts 16:128-133, 1984.
18. Blomstd GC. Infections in neurosurgery: a retrospective study of 1143 patients and 1517 operations. Acte Neurochir. 1985,78: 81-90.
19. Tenney JH, Vlahov D, Salcman M, et al: Wide variation in risk of wound infection following clean neurosurgery:implications for perioperative antibiotic prophylaxis. J Neurosurg 62:243-247, 1985.
20. van EK B, Bakker FP, van Dulken H, Dijlmans BA:Infections after craniotomy: A retrospective study. J Infect12:105-109,1986.
21. Rasmussen S, Ohrstrom JK, Westergaard L, Kosteljanetz M: Postoperative infections of osteoplastic compared with free bene flaps. Br J Neurosurg 4:49:3-495, 1990.
22. Gaillard T, Gilsbach JM:Intra-operative antibiotic prophylaxis in neuresurgery:A prospective randomized, controlled study on cefotiam. Acta Neurochir 113:103-109, 1991.
23. Mindermann T, Zimmerli W, Gratzl O: Randomized placebo-contrelled trial of single-dose antibiotic prophylaxis with fusidic acid in neurosurgery. Acta Neurochir 121:9-11,1993.
24. Korinek AM. Risk factors for neurosurgiealsite infections after craniotomy: a prospective multicenter study of 2944 patients. Neurosurgery, 1997, 41 (5): 1079-1081.
25．柳国良，罗世棋，王涛．开颅术后颅内感染死亡原因及教训．中华神经外科杂志，1995，11(5)：291—299．
26．高建国，张玉荣，上冠军发．开颅木后颅內感染原因分析．宁夏医学杂志，1999，2(9)：546—547．
27．刘窗溪，万登济，李健龙，等．颅脑手术后颅内感染临床分析．中华医院感染学杂志，2000，10(1)：4—6．
28．袁源，刘远林，付鹏，等．开颅术后颅内感染临床分析．中华医院感染学杂志，2001，11(5)：363—365．
29. James HE, Walsh JW, Wilson HD. Et al; The management ef cerebrospinal fluid shunt infections- a clinical experience. Acre Neurochir. 1981,59:157.
30. Mollman HD, Haines SJ:Risk factors for postoperative neurosurgical wound infection: A case control study. J neurosurg 64: 902-906,1986.
31．程得钧，张建生，丁永忠．后颅窝开颅术后局部引流的临床研究．中华实用医学，2003，5(16)：25-27．
32．连正华，有志才摘．脑室外引流术后感染：584例监护时间和置换导管的结果．国外医学神经病学神经外科学分册，1997，24(5)：265．
33．吴维民，罗云平．侧脑室前角穿刺外引流治疗急性梗阻性脑室内出血．广西医科大学学报，2000，17(1)．40-41．
34．王秉玉，陈若干，侍行文，等．脑室外引流方法与感染．上海第二医科大学学报，2003，23(6)：524-525，532．
35．俞月琴，周小平，周丽霞，等．神经外科择期手术病人颅内感染的追踪调查．中华医院管理杂志，1995，11(12)：739-740．
36．陈建良摘．神经外科感染：1143例与1517次手术回顾性研究．国外医学，神经外科神经病学分册，1986，13(5)：281．
37．叶应湖，蔡赣桥，王以诚．后颅凹开颅术后颅內感染的诊断和治疗．湖北医学院学报，10(2)1989．
38．陈荣月．糖尿病患者医院感染危险因素分析[J]．中国医院感染杂志，2002，12(12)：885-887．
39．人见重美．糖尿病和感染性疾病．日本医学介绍，2003，24(9)：416—417
40. Krause p j, et al. Depressed neutrophil chemotaxis in children suffering blunt trauma. Pediatrics, 1994,93:807.
41. Wolach B, et, al. Some aspects of humoral and neutrophil functions in post-comatose unawareness patients. Brain Inj, 1993,7(5):401.
42．张新忠，史耀亭．脑外伤继发感染与体液免疫抑制．中国急救医学，1997，17(6)：12—14．
43．刘窗溪，万登济，李健龙，等．颅脑手术后颅内感染临床分析．中华医院感染学杂志，2000，10(1)：4—6．
44．赵继宗，王硕，李宗生，等．术前应用菌必治预防神经外科手术感染．中华神经外科杂志，1995，5(1)：53—54．
45．王岷，冯世理．后颅凹术后颅内感染的防治．中华医院感染杂志，1997，7(2)：97．
2. von Eiselsberg AF, Ranzi E:Uber die chirurgische Behandlung der Hirn und Rückenmarkstumoren. Arch Klin Chit 102:309-468,1913.
3. Tooth HH: The treatment of tumours of the brain, and the indications for operations. Trans 1st Cong Med London 8:203-299,1913.
4. Olivecrona H: Die Parasagittalen Meningeome. Leipzig: Georg Thieme, 1934, pp141-143.
5. Cushing H, Eisenhart L: Meningiomas, Their Classification, Regional Behaviour, Life History and Surgical end Results. Springfield, IL: Charle C Thomas, 1938, 733-734.
6. Cairns H:Bacterial infections during intracranial operations. Lancet 1:1193-1198,1939.
7. Woodhall B, Neill RG, Dratz HM:Ultravioet radiation as an adjunct in the control of post-operative neurosurgical infection. Ann Surg 129:820-825,1949
8. Wright RL:Postoperative Craniotomy Infections. Spingfield, IL: Charles C Thomas, 1966.
9. Skultety Fm, Nishioka H:Report on the cooperative study of intracranial aneurysms and subarachnoid hemorrhage: Section Ⅷ, part 2. The results of intracranial surgery in the treatment of aneurysms. J Neruosurg 25:683-704, 1966.
10. Balch RE: Wound infection complicating neurosurgical procedures. J Neurosurg 26:41-45,1967.
11. Green JR Kanshepolsky J, Turkian B: Incidence and singnificance of central nervous system infection in neurosurgical patients. Adv Neurol 6:223-228,1974.
12. thou SN, Erickson DL: Craniotomy infections. Clin Neurosurg 23:357-362,1976.
13. Cruse PJE: Infetion surveillance. South Med J 70:48,1977.
14. Quadery LA, Medlery AV, Miles J: Vactors affecting the incidence of wound infection in neurosurgery. Acta Neurochir 39:133-141,1977.
15. Lhan Re, Thompson GB: Morbidity, mortality, andquality of life following surgery for intraeranial meningioma. J Neurosurg 60:52-60,1984.
16. Jomin M, Lesoin F, Lozes G: 500uptured and operated intracranial arterial aneurysm. Surg Neurol 21:13-18,1984.
17. Vlahov D, Montgomery E, Tenney JN, et al: Neurosurgical wound infections: Methodological and clinical factors affecting calculations of infection rates. J Neurosurg Nuts 16:128-133, 1984.
18. Blomstd GC. Infections in neurosurgery: a retrospective study of 1143 patients and 1517 operations. Acte Neurochir. 1985,78: 81-90.
19. Tenney JH, Vlahov D, Salcman M, et al: Wide variation in risk of wound infection following clean neurosurgery:implications for perioperative antibiotic prophylaxis. J Neurosurg 62:243-247, 1985.
20. van EK B, Bakker FP, van Dulken H, Dijlmans BA:Infections after craniotomy: A retrospective study. J Infect12:105-109,1986.
21. Rasmussen S, Ohrstrom JK, Westergaard L, Kosteljanetz M: Postoperative infections of osteoplastic compared with free bene flaps. Br J Neurosurg 4:49:3-495, 1990.
22. Gaillard T, Gilsbach JM:Intra-operative antibiotic prophylaxis in neuresurgery:A prospective randomized, controlled study on cefotiam. Acta Neurochir 113:103-109, 1991.
23. Mindermann T, Zimmerli W, Gratzl O: Randomized placebo-contrelled trial of single-dose antibiotic prophylaxis with fusidic acid in neurosurgery. Acta Neurochir 121:9-11,1993.
24. Korinek AM. Risk factors for neurosurgiealsite infections after craniotomy: a prospective multicenter study of 2944 patients. Neurosurgery, 1997, 41 (5): 1079-1081.
25．柳国良，罗世棋，王涛．开颅术后颅内感染死亡原因及教训．中华神经外科杂志，1995，11(5)：291—299．
26．高建国，张玉荣，上冠军发．开颅木后颅內感染原因分析．宁夏医学杂志，1999，2(9)：546—547．
27．刘窗溪，万登济，李健龙，等．颅脑手术后颅内感染临床分析．中华医院感染学杂志，2000，10(1)：4—6．
28．袁源，刘远林，付鹏，等．开颅术后颅内感染临床分析．中华医院感染学杂志，2001，11(5)：363—365．
29. James HE, Walsh JW, Wilson HD. Et al; The management ef cerebrospinal fluid shunt infections- a clinical experience. Acre Neurochir. 1981,59:157.
30. Mollman HD, Haines SJ:Risk factors for postoperative neurosurgical wound infection: A case control study. J neurosurg 64: 902-906,1986.
31．程得钧，张建生，丁永忠．后颅窝开颅术后局部引流的临床研究．中华实用医学，2003，5(16)：25-27．
32．连正华，有志才摘．脑室外引流术后感染：584例监护时间和置换导管的结果．国外医学神经病学神经外科学分册，1997，24(5)：265．
33．吴维民，罗云平．侧脑室前角穿刺外引流治疗急性梗阻性脑室内出血．广西医科大学学报，2000，17(1)．40-41．
34．王秉玉，陈若干，侍行文，等．脑室外引流方法与感染．上海第二医科大学学报，2003，23(6)：524-525，532．
35．俞月琴，周小平，周丽霞，等．神经外科择期手术病人颅内感染的追踪调查．中华医院管理杂志，1995，11(12)：739-740．
36．陈建良摘．神经外科感染：1143例与1517次手术回顾性研究．国外医学，神经外科神经病学分册，1986，13(5)：281．
37．叶应湖，蔡赣桥，王以诚．后颅凹开颅术后颅內感染的诊断和治疗．湖北医学院学报，10(2)1989．
38．陈荣月．糖尿病患者医院感染危险因素分析[J]．中国医院感染杂志，2002，12(12)：885-887．
39．人见重美．糖尿病和感染性疾病．日本医学介绍，2003，24(9)：416—417
40. Krause p j, et al. Depressed neutrophil chemotaxis in children suffering blunt trauma. Pediatrics, 1994,93:807.
41. Wolach B, et, al. Some aspects of humoral and neutrophil functions in post-comatose unawareness patients. Brain Inj, 1993,7(5):401.
42．张新忠，史耀亭．脑外伤继发感染与体液免疫抑制．中国急救医学，1997，17(6)：12—14．
43．刘窗溪，万登济，李健龙，等．颅脑手术后颅内感染临床分析．中华医院感染学杂志，2000，10(1)：4—6．
44．赵继宗，王硕，李宗生，等．术前应用菌必治预防神经外科手术感染．中华神经外科杂志，1995，5(1)：53—54．
45．王岷，冯世理．后颅凹术后颅内感染的防治．中华医院感染杂志，1997，7(2)：97．