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中国实体器官移植手术部位感染管理专家共识(2022版)

中国医师协会器官移植医师分会, 中华医学会器官移植学分会. 中国实体器官移植手术部位感染管理专家共识(2022版)[J]. 器官移植, 2023, 14(1): 11-23. doi: 10.3969/j.issn.1674-7445.2023.01.002
引用本文: 中国医师协会器官移植医师分会, 中华医学会器官移植学分会. 中国实体器官移植手术部位感染管理专家共识(2022版)[J]. 器官移植, 2023, 14(1): 11-23. doi: 10.3969/j.issn.1674-7445.2023.01.002
Branch of Organ Transplant Physicians of Chinese Medical Doctor Association, Branch of Organ Transplantation of Chinese Medical Association. Chinese experts consensus on the management of surgical site infection in solid organ transplantation (2022 edition)[J]. ORGAN TRANSPLANTATION, 2023, 14(1): 11-23. doi: 10.3969/j.issn.1674-7445.2023.01.002
Citation: Branch of Organ Transplant Physicians of Chinese Medical Doctor Association, Branch of Organ Transplantation of Chinese Medical Association. Chinese experts consensus on the management of surgical site infection in solid organ transplantation (2022 edition)[J]. ORGAN TRANSPLANTATION, 2023, 14(1): 11-23. doi: 10.3969/j.issn.1674-7445.2023.01.002

中国实体器官移植手术部位感染管理专家共识(2022版)

doi: 10.3969/j.issn.1674-7445.2023.01.002
基金项目: 

国家自然科学基金重点项目 81930016

国家自然科学基金重大研究计划 92159202

国家重点研发计划"干细胞研究与器官修复"重点专项 2021YFA1100500

浙江省重点研发计划 2019C03050

浙江省重点研发计划 2022C03108

详细信息
  • 中图分类号: R617, R619+.3

Chinese experts consensus on the management of surgical site infection in solid organ transplantation (2022 edition)

  • 摘要: 近年来,我国实体器官移植事业蓬勃发展,移植数量和疗效均显著提升。手术部位感染(SSI)仍是影响实体器官移植受者生存的重要因素。本共识聚焦SSI管理基本原则、流行病学与危险因素、特殊病原体感染管理和诊断技术等方面内容,汇聚全国器官移植学、感染病学、重症医学、检验医学和临床药学等多学科专家意见,系统阐述我国器官移植SSI管理相关经验,旨在规范各移植中心SSI的防控措施,降低我国实体器官移植术后SSI的发生率和病死率。

     

  • 表  1  实体器官移植手术部位感染常见病原体

    Table  1.   Common pathogens of surgical site infection in solid organ transplantation

    手术部位 感染发生率(%) 常见病原体
    肝脏 10.0~37.0 大肠埃希菌、肺炎克雷伯菌、鲍曼不动杆菌、铜绿假单胞菌、嗜麦芽窄食单胞菌、肠球菌、金黄色葡萄球菌、凝固酶阴性葡萄球菌、假丝酵母菌
    肾脏 3.0~11.0 金黄色葡萄球菌、凝固酶阴性葡萄球菌、肠球菌、阴沟肠杆菌、铜绿假单胞菌、假丝酵母菌
    5.0~19.0 大肠埃希菌、肺炎克雷伯菌、铜绿假单胞菌、伯克霍尔德菌、嗜麦芽窄食单胞菌、肠球菌、金黄色葡萄球菌、凝固酶阴性葡萄球菌、假丝酵母菌、曲霉
    心脏 4.0~19.0 凝固酶阴性葡萄球菌、金黄色葡萄球菌、肠球菌、假丝酵母菌
    小肠/多器官 14.0~53.0 肠杆菌、假单胞菌、肠球菌、金黄色葡萄球菌、假丝酵母菌
    下载: 导出CSV

    表  2  实体器官移植手术部位感染的危险因素

    Table  2.   Risk factors for surgical site infection in solid organ transplantation

    移植类型 受者因素 手术因素 供者/移植物因素
    所有移植 糖尿病、高龄、营养不良、肥胖、移植部位手术史、再次移植、住院时间长、受者术前感染史、免疫抑制剂高暴露 输血、手术时间长、术区污染、切口愈合不良、吻合口漏 供者感染史、移植物缺血再灌注损伤
    肝移植 腹水、肾脏替代治疗、高终末期肝病模型评分、术前重症监护病房(ICU)治疗史、术前抗菌药物使用史 消化道穿孔、行Roux-en-Y胆总管空肠吻合术、胆漏、胆道感染、肝动脉血栓、再次手术 移植物抗宿主病、急性排斥反应、边缘性供肝、供者ICU治疗时间长、移植肝功能恢复不良
    肾移植 贫血、长期低蛋白饮食、慢性肾小球肾炎 血肿、手术创伤大、输尿管漏 移植肾功能延迟恢复、供肾灌注污染、急性排斥反应
    肺移植 肾功能不全、胸骨切开史 缺血时间长、因出血导致的再开胸探查 供者ICU治疗时间长
    心脏移植 机械通气时间长 缺血时间长、使用双侧乳内动脉、术中失血量大 供者病原体定植(尤其是革兰阴性菌)
    小肠/多器官移植 依赖肠外营养、移植前多次住院史、腹腔脏器解剖异常、肾脏替代治疗 使用人工植入材料、再次腹部手术、胃肠漏、皮瓣 排斥反应、移植肠道菌群紊乱
    下载: 导出CSV

    表  3  常见多重耐药菌感染药物治疗方案

    Table  3.   Drug therapy for common multidrug-resistant bacterial infections

    病原体 首选治疗方案 备选治疗方案
    产超广谱β-内酰胺酶肠杆菌 高危患者:碳青霉烯类;低危患者:β-内酰胺类/β-内酰胺酶抑制剂合剂(如头孢哌酮-舒巴坦和哌拉西林-他唑巴坦等) 低危患者:头霉素类(头孢美唑、头孢西丁或头孢米诺)
    耐碳青霉烯类肠杆菌 头孢他啶-阿维巴坦(产金属酶时联合氨曲南),或替加环素单药/联合,或以多黏菌素为基础的联合治疗 联合使用以下两种或以上药物:大剂量、延长输注碳青霉烯类(最低抑菌浓度≤ 8 mg/L)、磷霉素、氨基糖苷类、喹诺酮类,或头孢地尔*、依拉环素*、美罗培南-法硼巴坦*、亚胺培南+ 西司他丁/雷利巴坦*
    耐碳青霉烯类铜绿假单胞菌 头孢他啶-阿维巴坦(产金属酶时联合氨曲南)、以多黏菌素为基础的联合治疗、以抗铜绿假单胞菌β-内酰胺酶类为基础的联合治疗 以环丙沙星为基础的联合治疗、头孢地尔*、头孢洛扎-他唑巴坦*、亚胺培南-西司他丁/雷利巴坦*
    耐碳青霉烯类鲍曼不动杆菌 以多黏菌素为基础的联合治疗、以替加环素为基础的联合治疗、以舒巴坦及其合剂为基础的联合治疗 三药联合:头孢哌酮-舒巴坦+替加环素+碳青霉烯类(不包括厄他培南);头孢哌酮-舒巴坦+多西环素+碳青霉烯类(不包括厄他培南);亚胺培南+利福平+多黏菌素或妥布霉素,或头孢地尔*
    耐甲氧西林金黄色葡萄球菌 万古霉素、利奈唑胺、达托霉素、替考拉宁 替加环素、头孢洛林*、特拉万星*
    耐万古霉素肠球菌 利奈唑胺、达托霉素 对青霉素类敏感:青霉素类复合制剂(如大剂量氨苄西林-他唑巴坦、氨苄西林-舒巴坦等),替考拉宁(限VanB基因型),替加环素
    注:表中用药方案需基于药敏试验结果;高危患者指由病原体引起脓毒症的患者;低危患者指病原体引起局部感染的患者;*.该药在中国大陆尚未上市。
    下载: 导出CSV

    表  4  临床常见即时检验技术

    Table  4.   Common clinical instant test techniques

    适用范围 检测项目 检测靶标 主要检测平台 技术原理 标本类型 补充注释
    有明确的感染部位/病灶且有病原学倾向 碳青霉烯耐药基因 blaKPC,blaIMP,blaNDM,blaOXA和blaVIM基因 GeneXpert 荧光PCR技术 肛拭子等 检测范围可覆盖不动杆菌属、肠杆菌属、大肠埃希菌、肺炎克雷伯菌和铜绿假单胞菌等
    Verigene BC GN 探针杂交技术 血液
    金黄色葡萄球菌 mecA基因 GeneXpert 荧光PCR技术 组织、脓液等  
    革兰阳性菌 mecA,vanA/B基因 Verigene BC-GP 探针杂交技术 血液 检测范围可覆盖金黄色葡萄球菌、粪肠球菌及屎肠球菌等
    艰难梭菌 谷氨酸脱氢酶及毒素A/B抗原 Alere 酶联免疫层析 粪便  
    tcdB基因 GeneXpert 荧光PCR技术 粪便、肛拭子 可检测高毒力株027型
    隐球菌 荚膜多糖抗原 IMMY/FungiXpert 胶体金免疫层析 血清、脑脊液 检测范围可覆盖7种隐球菌
    结核分枝杆菌 IS6110基因 Ustar 恒等温扩增技术 痰液等  
    rpoB基因 GeneXpert 荧光PCR技术 痰液等 检测利福平药物敏感性
    有明确的感染部位/病灶但没有病原学倾向 血流感染 22种血流感染病原体 ddPCR系统 数字PCR技术 血液 检测范围可覆盖15种病原体和7种耐药基因
    呼吸道感染 33种呼吸道感染病原体 FilmArray 巢式PCR技术 痰、肺泡灌洗液等 检测范围可覆盖7种耐药相关基因和26种常见病原体
    胃肠道感染 22种胃肠道感染病原体 FilmArray 巢式PCR技术 粪便 检测范围可覆盖5种病毒和4种寄生虫
    未知病原体感染   Illumina/华大基因 高通量测序技术 各类样本  
    注:KPC.肺炎克雷伯菌碳青霉烯酶;IMP.亚胺培南酶;NDM.新德里金属-β-内酰胺酶;OXA.苯唑西林酶;VIM.维罗纳整合素金属-β-内酰胺酶;mecA.甲氧西林耐药决定因子A;Van.耐万古霉素肠球菌基因;tcdB.艰难梭菌毒素B;IS6110.特异性插入序列6110;rpoB. RNA聚合酶β亚基;Gene-Xpert.全自动医用PCR分析系统;PCR.聚合酶链式反应;ddPCR. 微滴式数字PCR。
    下载: 导出CSV
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  • 收稿日期:  2022-11-22
  • 网络出版日期:  2023-01-17
  • 刊出日期:  2023-01-15

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