泌尿器科領域における周術期感染症阻止薬適正使用に関する多施設共同研究

Abstract

2002年9月から2003年8月までに多施設で行われた開放・体腔鏡下泌尿器科手術1, 353症例を対象として同一プロトコールによる抗菌薬の予防投与を行い, 術式別の周術期感染症発生率と抗菌薬予防投与法の妥当性を検討した.手術部位感染(SSI)発生率は清潔手術0.7～3.5%, 準清潔手術6.0～10.0%, 消化管利用膀胱全摘除術23.3%であり, 遠隔部感染(RI)発生率は清潔手術5%以下, 準清潔手術7.6～16.7%, 消化管利用膀胱全摘除術35.2%であった.SSI起炎菌の85.3%はグラム陽性菌でMRSAが58.8%を占め, RI起因菌はグラム陽性菌が若干多い傾向にあったが, 尿路感染ではグラム陰性菌と陽性菌がほぼ同数であり, 尿路感染, ドレーン感染からは高率にMRSAが分離された.また, 周術期感染症の危険因子には性別, 年齢, BMI, TP, 糖尿病, 手術時間, 出血量, 肺疾患が挙げられ, 感染症発症群の術後体温, 白血球数, CRPは高い傾向にあり, 特にCRPは周術期感染症予知の鋭敏なマーカーであると考えられた

In order to assess the ability of our protocol for antibiotic prophylaxis to prevent perioperative infections in urologic surgery, 1, 353 operations of open and laparoscopic urologic surgery conducted in 21 hospitals between September 2002 and August 2003 were subjected to analyses. We classified surgical procedures into four categories by invasiveness and contamination levels: Category A; clean less invasive surgery, Category B; clean invasive or clean-contaminated surgery, Category C; surgery with urinary tract diversion using the intestine. Prophylactic antibiotics were administrated intravenously according to our protocol, such as Category A; first or second generation cephems or penicillins on the operative day only, Category B; first and second generation cephems or penicillins for 3 days, and Category C; first, second or third generation cephems or penicillins for 4 days. The wound conditions and general conditions were evaluated in terms of the surgical site infection (SSI) as well as remote infection (RI) up to postoperative day (POD) 30. The SSI rate highest (23.3%) for surgery with intestinal urinary diversion, followed by 10.0% for surgery for lower urinary tract, 8.9% for nephroureterctomy, and 6.0% for radical prostatectomy. The SSI rates in clean surgery including open and laparoscopic nephrectomy/adrenalectomy were 0.7 and 1.4%, respectively. In SSIs, gram-positive cocci such as methicillin-resistant Staphylococcus aureus (58.8%) or Enterobacter faecalis (26.5%) were the most common pathogen. Similarly, the RI rate was the highest (35.2%) for surgery using intestinal urinary diversion, followed by 16.7% for surgery for lower urinary tract, 11.4% for nephroureterctomy, and 7.6% for radical prostatectomy, while RI rates for clean surgery were less than 5%. RIs most frequently reported were urinary tract infections (2.6%) where Pseudomonas aeruginosa (20.3%) and Enterobacter faecalis (15.3%) were the major causative microorganisms. Parameters such as age, obesity, nutritional status (low proteinemia), diabetes mellitus, lung disease, duration of operation, and blood loss volume were recognized as risk factors for SSI or RI in several operative procedures. Postoperative body temperatures, peripheral white blood counts, C reactive protein (CRP) levels in POD 3 were much higher than those in POD 2 in cases suffering from perioperative infections, especially suggesting that CRP could be a predictable marker for perioperative infections.