November 21, 2006（荷兰阿姆斯特丹讯）－荷兰的一群医师以一种便宜、简单且有效的方法来降低心脏
手术后院内感染机率，他们使用一种容易获得的消毒剂，chlorhexidine gluconate。
主要研究者Patrique Segers（荷兰阿姆斯特丹大学
学术医学中心）向Heartwire表示，这项消毒方式应该应用到所有重大手术；Segers与同事于2006年11月22日的美国内科学会期刊中报告这项发现。
他表示，该研究结果强调了院内感染应该受到重视；心脏手术是一项重大手术，但是每天都在进行，其并发症的机率不高，但手术后仍有可能发生感染的机会，且我们必须记住的是，预防永远是最重要的。
【Chlorhexidine的杀菌及抑菌效果长达12个小时】
Segers与其同事解释心脏手术后的感染率大约是20%，这样的感染是造成死亡与发病的重要原因，且会延长住院时间及需要抗生素治疗。
他表示，虽然潜在可能致病的
微生物可以透过照护者的手以及受污染的器具传播，但最主要的病原菌来源是病患本身的菌丛。
目前，部分医院使用局部消毒剂，例如mupirocin来清除微生物，例如金黄色葡萄球菌，这是手术部位感染最重要的微生物；Segers向Heartwire表示，然而，不是每个人都对于这个方法具有信心，且对于使用这样的抗生素会使细菌产生抗药性感到担忧。
他附带表示，另外一项方法牵涉到选择性地清除病患消化道中的细菌，但是这项措施是昂贵的，每位病患约需要200欧元的花费，且目前为止的研究结果并不一致。
他的团队决定要以一项前瞻性随机分派、双盲、安慰剂控制试验来研究chlorhexidine gluconate，他们针对荷兰某机构于2003年至2005年进行选择性心脏手术的954位病患进行研究；他们发现该消毒剂具有高度抗微生物活性，它会与细菌表面结合，杀菌与抑菌的效果长达12个小时；除此之外，该消毒剂几乎没有副作用。
0.12% chlorhexidine gluconate溶液或安慰剂在手术前后被用来漱口或是以凝胶方式涂抹在鼻腔一天四次，所有病患都于手术前后使用cefuroxime预防感染。
【使用chlorhexidine减少一天住院时间】
使用chlorhexidine相较于安慰剂，受试者发生院内感染的机率为19.8%比26.2%（绝对风险下降6.4%；p＝0.002）；特别的是，使用chlorhexidine受试者，发生与呼吸道相关感染及深部手术伤口感染的比率较低（呼吸道相关感染绝对风险下降6.5%；p＝0.002，深部手术伤口感染绝对风险下降3.2%；p＝0.002）。
Segers表示，为了预防一次院内感染的发生，必须有16位病患接受chlorhexidine治疗，这是个不昂贵的预防措施；Chlorhexidine治疗每天仅需花费6块欧元（7.20元美金），换算成预防一次院内感染约需192欧元（230元美金）。
接受chlorhexidine治疗受试者总住院时间为9.5天，相较于安慰剂组则是10.3天（p＝0.04）；在荷兰，每多住院一天，约需花费1000欧元，Segers向Heartwire表示，这样的数字使得用chlorhexidine来预防院内感染是十分值得的。
Simple, Cheap Disinfectant Prevents Infection After Cardiac Surgery
By Lisa Nainggolan
Medscape Medical News
November 21, 2006 (Amsterdam, the Netherlands) – A team of Dutch doctors has come up with a cheap, simple, and effective way to reduce nosocomial infection after cardiac surgery using a commonly available disinfectant, chlorhexidine gluconate [1].
The procedure should be applicable to all forms of major surgery, the lead investigator, Dr Patrique Segers (Academic Medical Center, University of Amsterdam, the Netherlands), told heartwire. Segers and colleagues report their findings in the November 22, 2006 issue of the Journal of the American Medical Association.
He said the results emphasize that hospital-acquired infections should not be overlooked. "Cardiac surgery is major surgery, but it is done every day. The rate of complications is not high, but there is still a significant rate of infection occurring afterward, and we need to remember that prevention is of the utmost importance."
Chlorhexidine is bactericidal and bacteriostatic for up to 12 hours
Segers and colleagues explain that the rate of nosocomial infection after cardiac surgery is around 20% and that such infections are an important cause of morbidity and mortality, prolonging hospital stay and requiring antibiotic treatment. Although potentially pathogenic microorganisms can be transmitted to patients from the hands of healthcare workers and from contaminated equipment, the primary source of infections is the patient's own flora, they explain.
Currently, some hospitals use topical antibiotics such as mupirocin to try to eradicate organisms such as Staphylococcus aureus–-the most important pathogen responsible for surgical site infections. However, not everyone is convinced of the effectiveness of this approach, Segers told heartwire, and there is concern that overuse of such antibiotics will lead to the emergence of resistant strains of the bacteria.
Another approach used in some places involves selective decontamination of the digestive tract of the patient, he added, but this is expensive--it costs approximately €200 per patient--and has shown inconclusive results in trials so far.
His team decided to investigate the use of chlorhexidine gluconate in a prospective, randomized, double-blind, placebo-controlled trial in 954 patients undergoing elective cardiothoracic surgery at one institute in the Netherlands from 2003 to 2005. They note that the disinfectant has a high level of antibiotic activity; it binds electrostatically to surfaces, where it exerts bactericidal and bacteriostatic effects for up to 12 hours. In addition, it is virtually devoid of adverse effects.
A 0.12% chlorhexidine gluconate solution or placebo was used as an oral rinse and a gel for nasal application four times daily, before and after surgery. All patients also received cefuroxime perioperatively as well.
Use of chlorhexidine reduces hospitalization by one day
The incidence of nosocomial infection in the chlorhexidine and placebo groups was 19.8% and 26.2%, respectively (absolute risk reduction 6.4%; p=0.002). In particular, lower respiratory-tract infections and deep surgical site infections were less common in the chlorhexidine group (ARR 6.5%; p=0.002 and ARR 3.2%; p=0.002, respectively).
For the prevention of one nosocomial infection, 16 patients need to be treated with chlorhexidine gluconate, which makes it an inexpensive preventive measure, Segers said. The cost of the chlorhexidine treatment is only €6 (US $7.20) per day, which means that the cost to prevent one nosocomial infection is around €192 (US $230).
Total hospital stay was 9.5 days for those treated with chlorhexidine, compared with 10.3 days in the placebo group (p=0.04). In the Netherlands, each extra day in hospital costs around €1000, Segers told heartwire, making the chlorhexidine strategy extremely cost-effective.
Segers P, Speekenbrink RGH, Ubbink DT, et al. Prevention of nosocomial infection in cardiac surgery by decontamination of the nasopharynx and oropharynx with chlorhexidine gluconate. A randomized controlled trial. JAMA 2006; 296: 2460-2466.
The complete contents of Heartwire, a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.
作者：
Lisa Nainggolan 2007-6-20