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수술후 창상감염에 대한 임상 세균학적 고찰

Other Titles
 Clinical and bacteriological study of postoperative wound infection 
Issue Date
1977
Description
의학과/석사
Abstract
[한글] 수술후 창상감염은 협의의 병원내감염이라 할수 있다. 수술시 피부절개를 가할때의 창상은 정상피부에 존재하는 세균에 의하여 오염된다. 그러나 이러한 창상이 전부 감염증을 일으키는 것은 아니다. 외과분야에서 흔히 발견되는 세균들은 Satphylococcus, Streptococcus, Clostridia, Bacteroides와 장내세균들이다. 수술후 창상감염으로 말미암아 독혈증이나 패혈증을 일으키거나 염증으로 말미암아 창상치유의 지연, 출혈 또는 창상파열을 초래하게 된다. 수술후 감염증은 창상의 오염도, 해부학적이나 전신적 요인 또는 원인균주에 따라서 연구할 수 있겠다. 창상감염은 연령, 체중, 영양, 당뇨, 스테로이드나 항생제의 사용, 타장소의 염증, 수술기간과 수술전 입원기간등이 요인이 된다 (Postlethewalt, 1972) 최근에 수술후 창상감염이나 병원내감염의 경우 항생제 내성 균주가 대두되고 있다. 이같은 균주의 감염의 빈도가 많아지고 이는 예방적으로 사용하는 항생제의 오용과 남용, 환자의 격리나 수술실에서의 무균적 조작등과 수기등의 문제점으로 병원내에서 내성균주와 독성이 강한 세균이 증가하는 것이라고 말할수 있겠다(Artz, 1975; Davis, 1973 , Maclean, 1975). 이 논문은 1975년 7월부터 만12개월간 연세의료원 외과에 입원하여 수술받은 2,080예를 대상으로 수술후 창상감염을 창상오염 가능성에 따라 분류하고 성별, 년령, 월별과 수술부위별 발생빈도와 세균배양검사와 항생제감수성검사에 대한 관찰을 하여 다음과 같은 결 과를 얻었다. 1. 수술후 창상감염의 발생빈도는 전체 2,080례중 108례로 5.2%이었다. 2. 성별분포는 남자 6.4%(72례)와 여자 3.2%(36례)로 남자에서 약 2배의 높은 발생율을 보였다. 3. 년령분포는 60세이후 고령에서 보다 높은 감염율을 관찰하였다. 4. 월별 발생빈도는 6월이외의 여름철에 낮은 감염율을 보였다. 5. 오염가능성에 따른 창상분류상 발생빈도는 비오염창상 16례(1.4%), 비교적 비오염상창상 57례(6.97%)와 오염창상 35례(26.1%)로 오염가능성이 많을수록 그 발생빈도 또한 증 가하였다. 6. 세균배양검사상 배양양성 77례에서 15균주 총 163례의 균이 배양되었으며 coaulase positive Staphylocoocus 와 Streptocoocus group A가 각 15례 (8.6%), E.coli 55례 (38.7%), Klebsiella 25례 (15.3%), Pseudomonas 13례 (8.0%), Enterobacter 12례 (7.4%)와 P roteus 11례 (6.8%)와 기타세균으로 배양되었으며 그랍양성균 34례 (20.8%)와 그랍음성균 129례 (79.3%)이었다. 7. 오염가능성별 창상에 따른 배양검사에서 배양음성 12례, 단일균주에 의한 창상감염 36례와 혼합감염 51례로 비오염창상에서 배양음성이 8례 (57%)였고, 단일균주는 특히 coagulase positive Staphylocoocus가 주원인균주로 비오염창상에서 많이 나타났다. 오염가능성의 창상에서는 E.coli가 주원인균주로 발견되었다. 8. 혼합감염에서 그랍음성균간의 감염례가 28례 (56.9%)로 E.coli, Klebsiella, Pseudomonas가 주원인균이었다. 특히 Enterocoocus, Clostridium, Enterobacter, Proteus, Citrobacter, Alcaligenes, Bacteroides와 Psendomonas는 혼합감염에서만이 배양된 균주이었 다. 9. coagulase positive Staphylocoocus 는 carbenicillin, lincomycin와 cloxacillin에 감수성이 높았으며 그랍음성균주는 gentamycin, kanamycin, tetracycline과 chiorampheni cel에 감수성이 높았으며, Psendomonas는 carbenicillin, colimycin과 gentamycin에 감수성이 높았으며 Klebsiella는 각종항생제에 대한 내성균이 가장 많이 나타났다. Clinical and Bacteriological study of Postoperative Wound Infection Chang Hwan Cho Department of Medical Science Postgraduate School Yonsei University (Directed by Prof. Choon Kyu Kim, M.D.) A postoperative wound infection is a specific nosocomial infection. Most surgical incisions are contaminated with normal skin flora. The presence of bacteriaa in the wound at the end of the surgical procedure does not usually result in a wound infection. The microorganisms commonly encountered in surgical infections are the Staphylococci, Streptococci, Clostridia, Bacteroides and the enteric bacteria. Postoperative infections present a double hazard : First, the infection itself may result in toxemia or produce extensive tissue damage and perhaps septicemia. Second, the local effects of infection delay healing of the wound and may cause hemorrhage or disruption of the wound. Surgical infections may be analyzed in relation to procedures in clean or contaminated fields, the anatomic site of systemic involved, and the pathophysiologic activities of the causative microorganisms. The incidence of infection may be influenced such factors as age, obesity, malnutrition, diabetes mellitus, use of steroid therapy or antibiotics, infections remote from the operative site, and duration of operation, and preoperative hospitalization. In the resent years, the postoperative wound and other hospitalaquired infections produced by antibiotic resistant bacteria. The number of infections has apparently increased, and this trend has been ascribed to such factors as indiscrimate antibiotic prophylaxis, over-confidence in the effectiveness of these agents, a disregard of important operating room principle and technics, discontinution of the principle of isolation, and a continuing and progressively active reservoir of antibiotic-resistant and virulent bacteria in the hospital environment. This paper is an analysis of postoperative wound infection according to the types of operation and bacteria involved, based on a study of 2,080 operations performed at Department of Surgery, Yonsei University College of Medicine during the period of January to December, 1975. Methods and Materials: The patients included in this survey were all whose operations were underwent incision through health skin. The following procedures were specifically excluded, according to ????? ????? before the study began: procedures in which the skin was not incised thermal burns and donor sites of split thickness skin graft operations, confined to the oral cavity and nasopharynx, procedure, excision of fingernail incision, and drainage of abscess, Wounds were classified as clean, clean-contaminated and contaminated or dirty, as defined by the National Research Council(1964). Group I(Clean) -- This included those wounds in which the gastrointestinal tract or respiratory tract was not entered, in which no apparent inflammation was encountered, and in which no break in aseptic technique occured. Group Ⅱ(Clean-contaminated)-- This included clean operation that entered the gastreointestinal tract or the respiratory tract but in which there was no break in aseptic technique occured. Group Ⅲ(Contaminated or dirty) -- This included operations in which acute inflammation with or without gross spillage from a hollow viscus occured. The infected cases were recorded the state of selected operation wounds, both while the patient was in hospital and after discharge. The wounds were checked after the first dressing had been removed and subsequently if infected. Wounds were considered uninfected if they healed per primam intention without drainage and definitely infected if there was a purulent discharge, whether or not organisms could be curtures from the purulent material. Wounds were considered possibly infected if they were inflammed without discharge or drainage only culture-positive serous fluid. Stitch abscesses were excluded from definite infection. Only patients considered definitely infected or culture positive were included in this report. Most wounds were examinated bacteriologically by the members of the bacteriology section of the Department of clinical pathology and Microbiology. Aerobic and anaerobic cultures were performed as well as direct macroscopy. Cultured organisms were performed sensitivity test with ampicillin, chloramphenicol, lincomycin, tetracyclin, and carbenicillin for gram-positive organisms and ampicillin, kanamycin, chloramphenicol, streptomycin, tetracyclin and gentamycin for gram-negative except Pseudomonas. Results : 1) The overall infection rate among 2,080 cases was 5.2%. 2) The infection rate was higher in male(6.4%) then female (3.2%). 3) Increase in the rate of infection occured in old age. 4) The infection rate was lower during the summer season. 5) The incidence of postoperative wound infection in 1,128 cases of Group Ⅰ (Clean operation) was 1.4% and in 818 cases of Group Ⅱ(Clean-contaminated operation) was 6.95% and 134 cases of Group Ⅲ(Contaminated operation) was 26.12%. There were remarkable high rate of wound infection in the cases those had contaminated operation. 6) 163 organisms of 15 species of bacteria were isolated from 77 cases of positive culture. No organisms were recovered from 12 cases of the wounds. The bacteria strains were consisted of 34(20.3%) of gram-positive bacteria and 129 (79.7%) of gram-negative such as, coagulase positive Staphylococcus 14 cases(8.6%), Group A Streptococcus, 14(8.6%) E, coli 55(33.7%), Klebsiella 25(15.3%), Pseudomonas 13(8.0%), Enterobacter 12(7.4%), Proteus 11(6.8%) and others. 7) Coagulase positive Staphylococcus was the most common pathogen isolated following Group Ⅰ and coliform bacilli were the most common organism in Group Ⅱ and Ⅲ. 8) Pure gram-negative mixed infection was recovered 28 csaes (56.9%) of the mixed infected wounds, and the predominant organisms were E. coli, Klebsiella and Pseudomonas. Enterocoocus, Clostridium, Enterobacter, Proteus, Citrobacter, Alkaligen, Bacteroided and Pseudomonas were only recovered in mixed infection wounds. 9) In antibiotic sensitivity test of gram-positive organism, more effective antibiotics were carbenicillin, cloxacillin, and lincomycin and gram-negative were gentamycin and chloramphenicol. Pseudomonas was responsed for carbenicillin, colimycin and gentamycin in order of efficacy. The most resistant strain was the Klebsiella.
[영문] A postoperative wound infection is a specific nosocomial infection. Most surgical incisions are contaminated with normal skin flora. The presence of bacteriaa in the wound at the end of the surgical procedure does not usually result in a wound infection. The microorganisms commonly encountered in surgical infections are the Staphylococci, Streptococci, Clostridia, Bacteroides and the enteric bacteria. Postoperative infections present a double hazard : First, the infection itself may result in toxemia or produce extensive tissue damage and perhaps septicemia. Second, the local effects of infection delay healing of the wound and may cause hemorrhage or disruption of the wound. Surgical infections may be analyzed in relation to procedures in clean or contaminated fields, the anatomic site of systemic involved, and the pathophysiologic activities of the causative microorganisms. The incidence of infection may be influenced such factors as age, obesity, malnutrition, diabetes mellitus, use of steroid therapy or antibiotics, infections remote from the operative site, and duration of operation, and preoperative hospitalization. In the resent years, the postoperative wound and other hospitalaquired infections produced by antibiotic resistant bacteria. The number of infections has apparently increased, and this trend has been ascribed to such factors as indiscrimate antibiotic prophylaxis, over-confidence in the effectiveness of these agents, a disregard of important operating room principle and technics, discontinution of the principle of isolation, and a continuing and progressively active reservoir of antibiotic-resistant and virulent bacteria in the hospital environment. This paper is an analysis of postoperative wound infection according to the types of operation and bacteria involved, based on a study of 2,080 operations performed at Department of Surgery, Yonsei University College of Medicine during the period of January to December, 1975. Methods and Materials: The patients included in this survey were all whose operations were underwent incision through health skin. The following procedures were specifically excluded, according to ????? ????? before the study began: procedures in which the skin was not incised thermal burns and donor sites of split thickness skin graft operations, confined to the oral cavity and nasopharynx, procedure, excision of fingernail incision, and drainage of abscess, Wounds were classified as clean, clean-contaminated and contaminated or dirty, as defined by the National Research Council(1964). Group I(Clean) -- This included those wounds in which the gastrointestinal tract or respiratory tract was not entered, in which no apparent inflammation was encountered, and in which no break in aseptic technique occured. Group Ⅱ(Clean-contaminated)-- This included clean operation that entered the gastreointestinal tract or the respiratory tract but in which there was no break in aseptic technique occured. Group Ⅲ(Contaminated or dirty) -- This included operations in which acute inflammation with or without gross spillage from a hollow viscus occured. The infected cases were recorded the state of selected operation wounds, both while the patient was in hospital and after discharge. The wounds were checked after the first dressing had been removed and subsequently if infected. Wounds were considered uninfected if they healed per primam intention without drainage and definitely infected if there was a purulent discharge, whether or not organisms could be curtures from the purulent material. Wounds were considered possibly infected if they were inflammed without discharge or drainage only culture-positive serous fluid. Stitch abscesses were excluded from definite infection. Only patients considered definitely infected or culture positive were included in this report. Most wounds were examinated bacteriologically by the members of the bacteriology section of the Department of clinical pathology and Microbiology. Aerobic and anaerobic cultures were performed as well as direct macroscopy. Cultured organisms were performed sensitivity test with ampicillin, chloramphenicol, lincomycin, tetracyclin, and carbenicillin for gram-positive organisms and ampicillin, kanamycin, chloramphenicol, streptomycin, tetracyclin and gentamycin for gram-negative except Pseudomonas. Results : 1) The overall infection rate among 2,080 cases was 5.2%. 2) The infection rate was higher in male(6.4%) then female (3.2%). 3) Increase in the rate of infection occured in old age. 4) The infection rate was lower during the summer season. 5) The incidence of postoperative wound infection in 1,128 cases of Group Ⅰ (Clean operation) was 1.4% and in 818 cases of Group Ⅱ(Clean-contaminated operation) was 6.95% and 134 cases of Group Ⅲ(Contaminated operation) was 26.12%. There were remarkable high rate of wound infection in the cases those had contaminated operation. 6) 163 organisms of 15 species of bacteria were isolated from 77 cases of positive culture. No organisms were recovered from 12 cases of the wounds. The bacteria strains were consisted of 34(20.3%) of gram-positive bacteria and 129 (79.7%) of gram-negative such as, coagulase positive Staphylococcus 14 cases(8.6%), Group A Streptococcus, 14(8.6%) E, coli 55(33.7%), Klebsiella 25(15.3%), Pseudomonas 13(8.0%), Enterobacter 12(7.4%), Proteus 11(6.8%) and others. 7) Coagulase positive Staphylococcus was the most common pathogen isolated following Group Ⅰ and coliform bacilli were the most common organism in Group Ⅱ and Ⅲ. 8) Pure gram-negative mixed infection was recovered 28 csaes (56.9%) of the mixed infected wounds, and the predominant organisms were E. coli, Klebsiella and Pseudomonas. Enterocoocus, Clostridium, Enterobacter, Proteus, Citrobacter, Alkaligen, Bacteroided and Pseudomonas were only recovered in mixed infection wounds. 9) In antibiotic sensitivity test of gram-positive organism, more effective antibiotics were carbenicillin, cloxacillin, and lincomycin and gram-negative were gentamycin and chloramphenicol. Pseudomonas was responsed for carbenicillin, colimycin and gentamycin in order of efficacy. The most resistant strain was the Klebsiella.
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http://ir.ymlib.yonsei.ac.kr/handle/22282913/117058
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2. 학위논문 > 1. College of Medicine (의과대학) > 석사
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