Staphylococcus aureus bacteremia in the surgical patient:: A prospective analysis of 73 postoperative patients who developed Staphylococcus aureus bacteremia at a tertiary care facility
Staphylococcus aureus bacteremia in the surgical patient:: A prospective analysis of 73 postoperative patients who developed Staphylococcus aureus bacteremia at a tertiary care facility
复制标题
DOI：
10.1016/s1072-7515(99)00211-2
复制
发表时间：
2000-01-01
影响因子：
5.2
通讯作者：
Corey, GR
中科院分区：
文献类型：
--
作者：
Gottlieb, GS;Fowler, VG;Corey, GR
背景：金黄色葡萄球菌是术后患者感染和菌血症的常见原因。不幸的是，目前还没有评估这些患者的前瞻性研究，因此并发症的发生率、后续治疗方案和预后仍不清楚。这项术后金黄色葡萄球菌菌血症 (SAB) 前瞻性研究的目的是确定菌血症的主要来源并确定术后 SAB 的常见并发症。方法：建立了一个登记册，前瞻性地在 1994 年 9 月至 1996 年 12 月期间纳入了 309 名连续成年 SAB 患者。其中 73 名患者 (23.6%) 在术后出现 SAB。 结果：分析这些患者的临床特征73 名术后患者揭示了三个重要结果。首先，感染性心内膜炎在 SAB 术后患者中非常常见，并且心内膜炎的典型特征通常不存在。 73 名患者中的 31 名进行了经食管超声心动图检查；其中 10 例（32.3%）患者符合杜克明确心内膜炎标准，但其中只有 3 例患者经胸超声心动图检测到赘生物，只有 2 例患者出现感染性心内膜炎外周斑痕。其次，心胸外科手术后 SAB 的发生与潜在的金黄色葡萄球菌纵隔炎密切相关。胸骨正中切开术后发生 SAB 的 23 名患者中有 21 名患有纵隔炎（阳性预测值 91.3%）。在许多情况下，当检测到SAB时，纵隔炎的诊断并不明显。第三，术后SAB患者的并发症、复发和死亡率较高。 73 名患者中有 14 名 (19.2%) 出现多种非心脏转移并发症，包括转移性脓肿 (5)、化脓性栓子 (3)、肺炎或脓胸 (2)、化脓性关节炎 (I)、硬膜外脓肿 (1) 和其他转移灶 (7)。 73 例患者中，有 12 例 (16.4%) 在首次 SAB 发作治疗后出现复发性葡萄球菌感染，其中 8 例 (11.0%) 出现复发性菌血症。在幸存的患者中，复发性葡萄球菌感染的患者比感染治愈的患者更有可能出现手术伤口感染的情况 (p = 0.05)。最后，SAB 导致的死亡率 (11.0%) 和全因死亡率 (21.9%) 很高。 结论：术后 SAB 通常是一种发病率和死亡率较高的严重疾病。对于患有金黄色葡萄球菌菌血症的手术患者，需要进行彻底的诊断评估，以确保及早发现转移性感染，如感染性心内膜炎，并确定需要手术干预的病灶，如纵隔炎。 （J Am Coll Surg 2000；190:50-57。(C) 2000 年美国外科医生学会）。
Background: Staphylococcus aureus is a frequent cause of infection and bacteremia in the postoperative patient. Unfortunately there have been no prospective studies evaluating these patients, so the incidence of complications, subsequent treatment algorithms, and prognosis remain undefined. The objectives of this prospective study of postoperative Staphylococcus aureus bacteremia (SAB) were to define the primary sources of bacteremia and to identify the common complications of SAB in the postoperative setting.Methods: A registry was developed into which 309 consecutive adult patients with SAB were prospectively enrolled between September 1994 and December 1996. Seventy-three of these patients (23.6%) developed SAB in the postoperative setting.Results: Analysis of the clinical features of these 73 postoperative patients revealed three important results. First, infective endocarditis is surprisingly common in postoperative patients with SAB and the classical stigmata of endocarditis are often absent. Transesophageal echocardiography was performed in 31 of 73 patients; 10 of these patients (32.3%) met Duke Criteria for definite endocarditis, but only 3 of these patients had vegetations detected by transthoracic echocardiography, and only 2 patients had peripheral stigmata of infective endocarditis.Second, the development of SAB after cardiothoracic surgery was strongly associated with underlying S. aureus mediastinitis. Twenty-one of the 23 patients who developed SAB after median sternotomy had mediastinitis (positive predictive value 91.3%). In many cases, the diagnosis of mediastinitis was not apparent when SAB was detected.Third, complications, relapses, and mortality were high in postoperative patients with SAB. Fourteen of 73 patients (19.2%) developed multiple noncardiac metastatic complications, including metastatic abscesses (5), septic emboli (3), pneumonia or empyema (2), septic arthritis (I), epidural abscess (1), and other metastatic foci (7). Twelve of 73 patients (16.4%) had recurrent staphylococcal infection after treatment of their first episode of SAB, including 8 patients (11.0%) with recurrent bacteremia. Of patients who survived, those with recurrent staphylococcal infection were more likely to have an infected surgical wound than were patients who were cured of infection (p = 0.05). Finally, mortality attributable to SAB (11.0%), and all-cause mortality (21.9%), was high.Conclusions: SAB in the postoperative setting is often a severe disease with high morbidity and mortality A thorough diagnostic evaluation is indicated in surgical patients with S. aureus bacteremia to ensure the early detection of metastatic infections such as infective endocarditis and to define foci such as mediastinitis requiring surgical intervention. (J Am Coll Surg 2000;190:50-57. (C) 2000 by the American College of Surgeons).