Probst A, Reimers N, Hecht A, Langenhan R
Klinik für Orthopädie, Unfall- und Handchirurgie, Hegau-Bodensee-Klinikum Singen, Gesundheitsverbund Landkreis Konstanz.
Z Orthop Unfall. 2016 Oct;154(5):477-482. doi: 10.1055/s-0042-105767. Epub 2016 Jun 13.
Perioperative infection prophylaxis with cephalosporins is standard in surgical treatment of proximal femoral fractures (PFF). Geriatric patients (pat.) are at risk of chronic infections and the bacteria from these can lead to unknown hygienic problems in an early operation. We therefore characterised the colonisation of the urinary tract in pat. (≥ 65 years) with PFF and observed bacterial development in deep wound infections over a period of 10 years. The aim was to discover gaps in perioperative infection prophylaxis. Between September 2013 and November 2015, colonisation of the urinary tract and microbial resistance were investigated on admission of all pat. (≥ 65 years) with the diagnosis of PFF (n = 351; f/m 263/88; median age [∅] 83.57 [65-100] years). Between 2005 and 2014, 2161 pat. with a PFF were operated in our clinic (f/m 1623/538; ∅ 82.35 [65-101] years). 991 pat. (∅ 81.84 [65-101] years) with femoral neck fracture [FNF] were treated with endoprosthesis/osteosynthesis, 1170 pat. (∅ 82,78 [65-101] years) with per-/subtrochanteric fracture [PTF] were treated with osteosynthesis. In a retrospective data analysis, deep wound infections, microbiological composition and changes in microbial resistances over time were identified. Bacteriuria (BU) was detected in the urine sediment of 35.61 % (n = 125) of our pat. In 47.2 % of these pat., BU was accompanied by laboratory signs of manifest urinary tract infection. In 10.4 % of these pat., colonisation of the urinary tract with multi-resistant pathogens was detected; 26.4 % were resistant to cefuroxime. The rate of deep infections in pat. with endoprosthesis/osteosynthesis in FNF was 2.8 % (n = 28; f/m 19/9; ∅ 81.35 [67-92] years), with osteosynthesis in PTF 1,1 % (n = 14; f/m 10/4; ∅ 81.0 [70-91] years). A comparison of the periods 2005-2009 and 2010-2014 showed a shift in the spectrum of pathogens from cephalosporin-sensitive to cephalosporin-resistant enterococci. Resistance of pathogens against cephalosporins increased from 43 to 81 %. We found an increasing risk in geriatric pat. from multiresistant pathogens in the urinary tract and from an increase in the cephalosporin resistance of pathogens in urinary tract infections and in deep wound infections. This indicates that perioperative infection prophylaxis with a cephalosporin is not effective. Especially in nursing homes, development of resistance to antibiotics is an increasing problem. Thus, concepts of perioperative infection prophylaxis in geriatric patients should be reconsidered.
使用头孢菌素进行围手术期感染预防是股骨近端骨折（PFF）手术治疗的标准做法。老年患者有慢性感染风险，这些感染的细菌可能在早期手术中导致不明的卫生问题。因此，我们对患有PFF的老年患者（≥65岁）的尿道定植情况进行了特征分析，并观察了10年间深部伤口感染中的细菌演变。目的是发现围手术期感染预防中的漏洞。在2013年9月至2015年11月期间，对所有诊断为PFF的老年患者（≥65岁，n = 351；女/男263/88；中位年龄[∅]83.57[65 - 100]岁）入院时的尿道定植情况和微生物耐药性进行了调查。2005年至2014年期间，我们诊所对2161例患有PFF的患者进行了手术（女/男1623/538；∅82.35[65 - 101]岁）。991例（∅81.84[65 - 101]岁）股骨颈骨折（FNF）患者接受了假体植入/骨固定治疗，1170例（∅82.78[65 - 101]岁）转子周围/转子下骨折（PTF）患者接受了骨固定治疗。在一项回顾性数据分析中，确定了深部伤口感染、微生物组成以及微生物耐药性随时间的变化。在我们的患者中，35.61%（n = 125）的尿液沉淀物中检测到菌尿（BU）。在这些患者中，47.2%的菌尿伴有明显尿路感染的实验室指标。在这些患者中，10.4%检测到尿道被多重耐药病原体定植；26.4%对头孢呋辛耐药。FNF患者接受假体植入/骨固定治疗后的深部感染率为2.8%（n = 28；女/男19/9；∅81.35[67 - 92]岁），PTF患者接受骨固定治疗后的深部感染率为1.1%（n = 14；女/男10/4；∅81.0[70 - 91]岁）。对2005 - 2009年和2010 - 2014年这两个时期的比较显示，病原体谱从对头孢菌素敏感的肠球菌转变为对头孢菌素耐药的肠球菌。病原体对头孢菌素的耐药性从43%增加到81%。我们发现老年患者中，来自尿道多重耐药病原体以及尿路感染和深部伤口感染中病原体头孢菌素耐药性增加的风险在上升。这表明使用头孢菌素进行围手术期感染预防无效。尤其是在养老院，抗生素耐药性的发展是一个日益严重的问题。因此，应重新考虑老年患者围手术期感染预防的观念。
