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ÈEMATA ANAIÓÈÇÓÉÏËÏÃÉÁÓ KAI ENTATIKHÓ IATPIKHÓ 99

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Ïé ëïéìþîåéò ÷åéñïõñãéêïý ðåäßïõ (×Ë) óôçí Êáñäéï÷åéñïõñãéêÞ ðåñéëáìâÜíïõí ôï óôÝñíï, ôï õðïêåßìåíï ìåóï-èùñÜêéï êáé ôéò âáëâßäåò (óôåñíßôéäá, ìåóïèùñáêßôéäá, åíäïêáñäßôéäá, áíôßóôïé÷á) êáé óõìâáßíïõí óôï 0.4-4% ôùí÷åéñïõñãéêþí åðåìâÜóåùí, åíþ ðÜíù áðü ôï 50% áõôþí ïöåßëïíôáé óå ÷ñõóßæïíôá óôáöõëüêïêêï (Staplylococcusaureus) Þ áñíçôéêïýò óôçí ðçêôÜóç óôáöõëüêïêêïõò (Coagulase Negative Staplylococci, CNS). Ç åìöÜíéóç ÷åé-ñïõñãéêÞò ëïßìùîçò (óôåñíßôéäáò, ìåóïèùñáêßôéäáò Þ åíäïêáñäßôéäáò) óõíïäåýåôáé áðü áõîçìÝíç íïóçñüôçôá êáéèíçôüôçôá. Ç åðéëïãÞ ôùí êáôÜëëçëùí áíôéâéïôéêþí ãéá ÷çìåéïðñïöýëáîç (×ÐÖ) Ýãéíå éäéáßôåñá äýóêïëç óôçíðïñåßá ôïõ ÷ñüíïõ ìå ôçí åìöÜíéóç ôïõ áíèåêôéêïý óôç ìåèéêéëëßíç ÷ñõóßæïíôá óôáöõëüêïêêïõ (MRSA) êáé ôùíáíèåêôéêþí óôç ìåèéêéëëßíç CNS (MR-CNS). Ç åðéëïãÞ ôùí áíôéâéïôéêþí ãéá ×ÐÖ ðñÝðåé íá ëáìâÜíåé õðüøç ôçíôïðéêÞ ìéêñïâéïëïãéêÞ ÷ëùñßäá (óå åðßðåäï ÊëéíéêÞò êáé Íïóïêïìåßïõ) êáèþò êáé ôá ðïóïóôÜ áíôï÷Þò ôùí óõ÷íü-ôåñùí ìéêñïâßùí óôá áíôéâéïôéêÜ. Óôåíïý öÜóìáôïò êáé ÷áìçëïý êüóôïõò áíôéâéïôéêÜ èåùñïýíôáé êáôáëëçëüôåñáãéá ×ÐÖ. Ðñïôåéíüìåíá áíôéâéïôéêÜ ãéá ×ÐÖ óôçí ÊÑ× ðáñáìÝíïõí ïé êåöáëïóðïñßíåò (1çò êáé 2çò ãåíéÜò). Ç×ÐÖ ÷ïñçãåßôáé åíôüò (within) 30-60 ëåðôþí ðñéí ôçí Ýíáñîç ôçò åðÝìâáóçò êáé ç Ýã÷õóÞ ôùí áíôéâéïôéêþí ïëï-êëçñþíåôáé ðñéí ôçí ÷åéñïõñãéêÞ ôïìÞ (ãéá áíôéâéïôéêÜ ìå áðáéôïýìåíç áñãÞ Ýã÷õóç, üðùò ç âáíêïìõêßíç, ç ÷ïñÞ-ãçóç îåêéíÜ åíôüò 60-120 ëåðôþí ðñéí ôç ÷åéñïõñãéêÞ ôïìÞ êáé ïëïêëçñþíåôáé ðñéí áðü áõôÞ). Ç ÷ïñÞãçóç ôùíöáñìÜêùí ôçò ãåíéêÞò áíáéóèçóßáò óêüðéìï åßíáé íá áðÝ÷åé ÷ñïíéêÜ (5-10 ëåðôÜ) áðü ôçí ×ÐÖ (âë. êßíäõíïòáëëåñãéêÞò áíôßäñáóçò). Ðñïôåßíåôáé äéÜñêåéá ×ÐÖ <48 þñåò. Ç äéÜñêåéá ôçò ×ÐÖ äåí ðñÝðåé íá ðáñáôåßíåôáéëüãù ðáñáìïíÞò êáèåôÞñùí, öëåâéêþí ãñáììþí êáé ðáñï÷åôåýóåùí êÜèå åßäïõò. Ãéá äéÜñêåéá åîùóùìáôéêÞòêõêëïöïñßáò Üíù ôùí 4 ùñþí ðñïôåßíåôáé êáé äåýôåñç äüóç áíôéâéïôéêïý äéåã÷åéñçôéêÜ (êåöáëïóðïñßíçò). Óåáóèåíåßò õøçëïý êéíäýíïõ ãéá ×Ë ìå MRSA Þ óå Íïóïêïìåßï ìå ×Ë áðü MRSA >15-20% åðß ôïõ óõíüëïõ ôùí×Ë, ðñïôåßíåôáé ÷ïñÞãçóç âáíêïìõêßíçò (1 äüóç ðñïåã÷åéñçôéêÜ, ìå Þ ÷ùñßò 2ç äüóç ìåôåã÷åéñçôéêÜ óå 12 þñåò)óå óõíäõáóìü ìå ôçí êëáóéêÞ ×ÐÖ (1çò Þ 2çò ãåíéÜò êåöáëïóðïñßíç). Óå áëëåñãßá óôá â-ëáêôáìéêÜ áíôéâéïôéêÜ,ðñïôåßíåôáé âáíêïìõêßíç ìå ðñïóèÞêç áíôéâéïôéêïý ìå äñÜóç Ýíáíôé gram-áñíçôéêþí ìéêñïâßùí (ü÷é áìéíïãëõêï-óßäç, ðéèáíÞ åðéëïãÞ êÜðïéá êéíïëüíç). Óå áóèåíåßò ìå ãíùóôü Þ ýðïðôï áðïéêéóìü ìå ðïëõáíèåêôéêÜ ìéêñüâéá êáéóå ðñþéìç åðáíåðÝìâáóç ãéá ìç ëïéìþäåò áßôéï, óõóôÞíåôáé ×ÐÖ ìå ó÷Þìá ðïõ êáëýðôåé êáé ôá ìéêñüâéá áõôÜ, ãéá24-48 þñåò óõíïëéêÜ. Ç åêñßæùóç ñéíéêÞò öïñåßáò MRSA ìå ìïõðõñïóßíç ìðïñåß íá ðñïôáèåß ùò åðéêïõñéêü ìÝôñïãéá ôïí Ýëåã÷ï ôùí íïóïêïìåéáêþí ëïéìþîåùí áðü MRSA, õðü ðñïûðïèÝóåéò, ìå Üãñõðíç åðéôÞñçóç ôçò åõáéóèç-óßáò ôùí óôåëå÷þí óôï áíôéâéïôéêü êáé óå óõíåííüçóç ìå ôéò ÅÍË ôùí Íïóïêïìåßùí. ÔïðéêÞ åöáñìïãÞ Üëëïõåßäïõò áíôéâéïôéêþí êáé ðëýóåéò ìå áíôéâéïôéêÜ/áíôéóçðôéêÜ äåí åßíáé åðáñêþò ôåêìçñéùìÝíåò êáé äå óõóôÞíïíôáéùò ôáêôéêÞ ñïõôßíáò. Ãéá êÜèå Íïóïêïìåßï êñßíåôáé óêüðéìç ç Ýêäïóç ôïðéêþí ïäçãéþí ÷çìåéïðñïöýëáîçò êáé çóõíå÷Þò áíáðñïóáñìïãÞ ôïõò óå ôïðéêÜ, åèíéêÜ êáé äéåèíÞ äåäïìÝíá ðïõ áöïñïýí ôç óõ÷íüôçôá ôùí ×Ë êáé ôùíõðåýèõíùí ìéêñïâßùí, ôá ðïóïóôÜ ìéêñïâéáêÞò áíôï÷Þò êáé ôá åðéêáéñïðïéçìÝíá óõìðåñÜóìáôá åðéóôçìïíéêþí

KWSTOYLA ARBANITH - 2.qxp 20/3/2014 10:39 Page 99

ÅÉÓÁÃÙÃÇÏ üñïò "÷åéñïõñãéêÞ ëïßìùîç" (×Ë, Surgical SiteInfection, SSI) áíáöÝñåôáé óôç ëïßìùîç ôïõ ÷åéñïõñãé-êïý ôñáýìáôïò êáé ôçò êïéëüôçôáò, ôùí ïóôþí, ôùí áñ-èñþóåùí, ôùí ìçíßããùí êáé ôùí Üëëùí éóôþí ðïõ ðåñé-ëáìâÜíïíôáé óôçí ÷åéñïõñãéêÞ åðÝìâáóç (Ðßíáêáò 1).Óå åðåìâÜóåéò ðïõ ðåñéëáìâÜíïõí ôïðïèÝôçóç åìöõ-ôåõìÜôùí (implants) Þ ðñïóèåôéêþí õëéêþí (prostheticdevices), ï üñïò "÷åéñïõñãéêÞ ëïßìùîç" ðåñéëáìâÜíåéêáé ôá õëéêÜ áõôÜ. Óôï ðáñüí êåßìåíï ï üñïò áíáöÝñå-ôáé óå üëá ôá ðáñáðÜíù. Ïé ×Ë áðïôåëïýí ìéá áðü ôéòóõ÷íüôåñåò íïóïêïìåéáêÝò ëïéìþîåéò ìå óõíÝðåéåò óôçíïóçñüôçôá êáé èíçôüôçôá ôùí ÷åéñïõñãéêþí áóèåíþí,ôçí ðáñáôåôáìÝíç ðáñáìïíÞ óôï Íïóïêïìåßï êáé ôçóçìáíôéêÞ áýîçóç ôïõ óõíïëéêïý êüóôïõò íïóçëåßáò.1

Ôáõôü÷ñïíá, ïé ×Ë áðïôåëïýí äåßêôç Ýêâáóçò ôùí ÷åé-ñïõñãéêþí åðåìâÜóåùí, äåßêôç ðïéüôçôáò ðáñå÷üìå-íùí õðçñåóéþí õãåßáò óôïõò ÷åéñïõñãéêïýò áóèåíåßòêáé äçëþíïíôáé õðï÷ñåùôéêÜ, ìåôáîý Üëëùí íïóïêï-ìåéáêþí ëïéìþîåùí, óå áñêåôÝò ÷þñåò êáé çðåßñïõò(NHSN: ÇÐÁ, Eurosurveillance: Åõñþðç, UK-HPASurgical Site Infections: ÌåãÜëç Âñåôáíßá, CNISPNational Mandatory surveillance of SSI: ÊáíáäÜò).

ÐÁÑÁÃÏÍÔÅÓ ÊÉÍÄÕÍÏÕ ÃÉÁ ×ÅÉÑÏÕÑÃÉÊÇËÏÉÌÙÎÇÐáñÜãïíôåò ðïõ ó÷åôßæïíôáé ìå ôïí áóèåíÞ êáé ôï åßäïòôçò åðÝìâáóçò (Ðßíáêáò 2): Ôï Åèíéêü Äßêôõï ÅðéôÞñçóçò Ëïéìþîåùí (NationalNosocomial Infections Surveillance, NNIS-NHSN) ôïõÊÝíôñïõ ÅëÝã÷ïõ ÍïóçìÜôùí (Centers for DiseaseControl, CDC) ôùí ÇÐÁ, ðñïôåßíåé Ýíá äåßêôç (riskindex), o ïðïßïò êáé åðéêñÜôçóå äéåèíþò ùò ìÝèïäïòõðïëïãéóìïý ôïõ êéíäýíïõ ãéá ÷åéñïõñãéêÞ ëïßìùîç(×Ë).2,3 Ï äåßêôçò áõôüò (NNIS score) âáóßæåôáé óåôñåéò ðáñÜãïíôåò: • ôo ASA (American Society of Anesthesiologists)

score, ðïõ áíôéêáôïðôñßæåé ôç ãåíéêÞ êáôÜóôáóçõãåßáò ôïõ áóèåíïýò ðñéí ôçí åðÝìâáóç êáé âáóßæå-ôáé óôéò óõííïóçñüôçôåò (comorbidities) êáôÜ ôç÷ñïíéêÞ óôéãìÞ ôçò åðÝìâáóçò (ASA score >2 óõíï-äåýåôáé áðü áõîçìÝíï êßíäõíï ãéá ×Ë).4 (Ðßíáêáò3)

• ôçí êáôçãïñßá ôïõ ÷åéñïõñãéêÞò åðÝìâáóçò (woundclass), ðïõ áíôéêáôïðôñßæåé ôï âáèìü ìéêñïâéáêÞò å-

ðéìüëõíóçò (contamination) ôïõ ÷åéñïõñãéêïý ðåäß-ïõ2 (Ðßíáêáò 4): üóï áõîÜíåôáé ç ìéêñïâéáêÞ åðéìü-ëõíóç ôüóï áõîÜíåé êáé ï êßíäõíïò ãéá ×Ë

• ôç äéÜñêåéá ôçò åðÝìâáóçò, ðïõ áíôéêáôïðôñßæåé ôáôå÷íéêÜ ÷áñáêôçñéóôéêÜ áõôÞò, üóï ìåãáëýôåñç, ôü-óï ìåãáëýôåñïò êáé ï êßíäõíïò ãéá ×Ë.

Ôï NNIS score åßíáé ìçäÝí, Ýíá, äýï Þ ôñßá, áíÜëïãáìå ôïí áñéèìü ôùí ðáñáãüíôùí êéíäýíïõ ðïõ õößóôá-íôáé ãéá êÜèå áóèåíÞ (ASA score, would class, äéÜñ-êåéá åðÝìâáóçò), åíþ ç ðéèáíüôçôá ãéá ×Ë áõîÜíåé ìåôçí áýîçóç áõôïý (Åéêüíá 1).

Åîùãåíåßò ðáñÜãïíôåò ÔÝôïéïé åßíáé ç ðñïåã÷åéñçôéêÞ ðñïåôïéìáóßá ôïõ äÝñ-ìáôïò ôïõ ÷åéñïõñãéêïý ðåäßïõ, ïé ðåñéåã÷åéñçôéêÝò ôå-÷íéêÝò (ð.÷. ôñüðïé áöáßñåóçò ôñé÷þí, áíôéóçðôéêü äéÜ-ëõìá, äéåã÷åéñçôéêÝò ôå÷íéêÝò) êáé ç ìåôåã÷åéñçôéêÞðåñéðïßçóç ôùí ÷åéñïõñãéêþí ôñáõìÜôùí.

ÃåíéêÜ ãéá ôçí áíôéìéêñïâéáêÞ ÷çìåéïðñïöýëáîçÇ ðñïöõëáêôéêÞ ÷ïñÞãçóç áíôéâéïôéêþí (ÐáñÜñôçìá 1)óå ÷åéñïõñãéêÝò åðåìâÜóåéò (áíôéìéêñïâéáêÞ Þ ðåñéåã-÷åéñçôéêÞ ÷çìåéïðñïöýëáîç-×ÐÖ, surgical antibioticprophylaxis, antibiotic prophylaxis in surgery) áðïôåëåß å-ðéêïõñéêü ìÝóï êáé ü÷é õðïêáôÜóôáôï ôçò êáôÜëëçëçò÷åéñïõñãéêÞò ôå÷íéêÞò. Óõíåðþò, áõôÞ èá ðñÝðåé íá èåù-ñåßôáé ùò áíáðüóðáóôï óõóôáôéêü ìéáò óõíïëéêÞò êáé á-ðïôåëåóìáôéêÞò óôñáôçãéêÞò åëÝã÷ïõ êáé ðñüëçøçò ôùííïóïêïìåéáêþí ëïéìþîåùí óôïõò ÷åéñïõñãéêïýò áóèå-íåßò. Ç ðñïöõëáêôéêÞ ÷ïñÞãçóç áíôéâéïôéêþí áíáóôÝë-ëåé ôçí áíÜðôõîç ôùí ìéêñïâßùí ðïõ åðéìïëýíïõí ôï ÷åé-ñïõñãéêü ðåäßï êáé ôçí ðñïóêüëëçóÞ ôïõò óôá ðñïóèåôé-êÜ õëéêÜ, ìåéþíïíôáò, Ýôóé, ôïí êßíäõíï ëïßìùîçò.5-7 Ôáõ-ôü÷ñïíá, üìùò, ç ÷ïñÞãçóç áíôéâéïôéêþí ðñïÜãåé ôçí åì-öÜíéóç áíèåêôéêþí óå áõôÜ ìéêñïâßùí êáé ðñïäéáèÝôåéãéá ëïßìùîç ìå ìéêñïïñãáíéóìïýò üðùò ôï Clostridiumdifficile (ìéá áðü ôéò áéôßåò ãéá êïëßôéäá óõíäåüìåíç ìå á-íôéâéïôéêÜ, antibiotic-associated colitis).8

Óôü÷ïé ôçò áíôéìéêñïâéáêÞò ÷çìåéïðñïöýëáîçò åßíáé:• Ç ìåßùóç ôçò åðßðôùóçò ôùí ÷åéñïõñãéêþí ëïéìþîåùí • Ç ÷ñÞóç ôùí áíôéâéïôéêþí ìå êáíüíåò ðïõ óôï÷åýïõí

óôçí áðïôåëåóìáôéêüôçôá• Ç ìåßùóç ôçò áñíçôéêÞò åðßäñáóçò ôùí áíôéâéïôéêþí

óôç öõóéïëïãéêÞ ÷ëùñßäá ôïõ áóèåíïýò êáé óôçí åì-

ÈEMATA ANAIÓÈÇÓÉÏËÏÃÉÁÓ KAI ENTATIKHÓ IATPIKHÓ100

áíáêïéíþóåùí. Ðåñéïñéóìüò ôçò óõ÷íüôçôáò êáé äéÜñêåéáò ôçò ×ÐÖ, êõñßùò ôùí êåöáëïóðïñéíþí êáé ôçò êëéíäá-ìõêßíçò, êáèþò êáé åðéëïãÞ áõôþí ìå âÜóç ôá ôïðéêÜ åðéäçìéïëïãéêÜ äåäïìÝíá, áðïôåëïýí óçìáíôéêÝò åíÝñãåéåòðñïò ôçí êáôåýèõíóç ôçò ìåßùóçò ôùí áíåðéèýìçôùí åíåñãåéþí ôùí áíôéâéïôéêþí óôï óýíïëü ôïõò.

ËÝîåéò ÊëåéäéÜ: áíôéìéêñïâéáêÞ ÷çìåéïðñïöýëáîç, êáñäéï÷åéñïõñãéêÞ.


öÜíéóç ðïëõáíèåêôéêþí ìéêñïâßùí • Ç ìåßùóç ôùí áíåðéèýìçôùí åíåñãåéþí áðü ôá áíôé-

âéïôéêÜ• Ç åëá÷éóôïðïßçóç ôçò åðßäñáóçò ôùí áíôéâéïôéêþí

óôïõò öõóéïëïãéêïýò ìç÷áíéóìïýò Üìõíáò ôïõ ïñãáíé-óìïý.

ÁÍÔÉÌÉÊÑÏÂÉÁÊÇ ×ÇÌÅÉÏÐÑÏÖÕËÁÎÇ ÓÔÇÍÊÁÑÄÉÏ×ÅÉÑÏÕÑÃÉÊÇÏé ëïéìþîåéò ÷åéñïõñãéêïý ðåäßïõ (×Ë) óôçí Êáñäéï-÷åéñïõñãéêÞ ðåñéëáìâÜíïõí ôï óôÝñíï, ôï õðïêåßìåíïìåóïèùñÜêéï êáé ôéò âáëâßäåò (óôåñíßôéäá, ìåóïèùñá-


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. /(organ/space)

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êßôéäá, åíäïêáñäßôéäá, áíôßóôïé÷á) êáé óõìâáßíïõí óôï0.4-4% ôùí ÷åéñïõñãéêþí åðåìâÜóåùí, åíþ ðÜíù áðüôï 50% áõôþí ïöåßëïíôáé óå ÷ñõóßæïíôá óôáöõëüêïê-êï (Staplylococcus aureus, S. aureus) Þ áñíçôéêïýò óôçíðçêôÜóç óôáöõëüêïêêïõò (Coagulase NegativeStaplylococci, CNS).9-17 Ç åðéëïãÞ ôùí êáôÜëëçëùíáíôéâéïôéêþí ãéá ÷çìåéïðñïöýëáîç (×ÐÖ) Ýãéíå éäéáß-ôåñá äýóêïëç óôçí ðïñåßá ôïõ ÷ñüíïõ ìå ôçí åìöÜíéóçôïõ áíèåêôéêïý óôç ìåèéêéëëßíç ÷ñõóßæïíôá óôáöõëü-êïêêïõ (Methicillin Resistant Staphylococcus Aureus,MRSA) êáé ôùí áíèåêôéêþí óôç ìåèéêéëëßíç CNS(Methicillin Resistant Coagulase NegativeStaphylococci, MR-CNS). Óýìöùíá ìå ôï NHSN óôéòÇÐÁ, ç äéÜìåóç óõ÷íüôçôá (median rate) ôïõ MRSAåðß ôïõ óõíüëïõ ôùí óôåëå÷þí S. aureus, óôéò ÌïíÜäåò

ÅíôáôéêÞò Èåñáðåßáò (ÌÅÈ) êáé óå åêôüò ÌÅÈ Êëé-íéêÝò, îåðåñíÜ ôï 40%, åíþ ãéá ôïí MR-CNS ôï 65%.18

ÔïõëÜ÷éóôïí ôï Ýíá ôñßôï ôùí áðïéêéóìÝíùí ìå ôá áíôß-óôïé÷á ìéêñüâéá áóèåíþí åìöáíßæåé íïóïêïìåéáêÞëïßìùîç (10ðëÜóéá ðéèáíüôçôá óå óýãêñéóç ìå ôïõò ìçáðïéêéóìÝíïõò áóèåíåßò).19-21 Ç áïñôïóôåöáíéáßá ðá-ñÜêáìøç ðïõ áðïôåëåß óõíçèéóìÝíç ðñáêôéêÞ óôçíÊáñäéï÷åéñïõñãéêÞ, ðåñéëáìâÜíåé ëÞøç ìïó÷åõìÜôùíáðü ôéò óáöçíåßò öëÝâåò. Ìå ôïí ôñüðï áõôü ìåôáöÝ-ñïíôáé ìéêñüâéá áðü ôá êÜôù Üêñá óôï ÷åéñïõñãéêüðåäßï (âë. óôÝñíï, ìåóïèùñÜêéï, êáñäéÜ). Ç åìöÜíéóç÷åéñïõñãéêÞò ëïßìùîçò (óôåñíßôéäáò, ìåóïèùñáêßôéäáòÞ åíäïêáñäßôéäáò) óõíïäåýåôáé áðü áõîçìÝíç íïóçñü-ôçôá êáé èíçôüôçôá. ÅðéðëÝïí, óôçí ÊÑ× åßíáé éäéáßôå-ñá óõ÷íÞ ç ôïðïèÝôçóç ðñïóèåôéêþí õëéêþí, êõñßùò


2.

(> 20% )

( . . / S. aureus) ( )

(ventilation) (sterilisation)

(drains) ( ,

, )


óå ÷åéñïõñãéêÝò åðåìâÜóåéò âáëâßäùí êáé áïñôÞò. Ïéëïéìþîåéò ðñïóèåôéêïý õëéêïý âáëâßäáò Þ ìïó÷åýìá-ôïò óôçí áïñôÞ óõíïäåýïíôáé, åðßóçò, áðü óçìáíôéêÞíïóçñüôçôá êáé èíçôüôçôá. ¢ëëïé ðáñÜãïíôåò ðïõ áõ-îÜíïõí ôïí êßíäõíï ×Ë óôçí ÊÑ× åßíáé: ç åîùóùìáôé-êÞ êõêëïöïñßá êáé ç óõóôçìáôéêÞ øýîç ãéá êáñäéï-ðñïóôáóßá, ç ðáñáìïíÞ êáèåôÞñùí, ðáñï÷åôåýóåùí,åðéêÜñäéùí Þ Üëëïõ ôýðïõ âçìáôïäïôéêþí êáëùäßùíìåôÜ ôï ÷åéñïõñãåßï, ç õøçëÞ ðéèáíüôçôá ãéá áéìïññá-ãßá ìå óõíïäü áíÜãêç ìåôáããßóåùí êáé åðáíåðÝìâá-óçò êáé ç êáèõóôåñçìÝíç áðïäÝóìåõóç áðü ôï ìç÷áíé-êü áåñéóìü êáôÜ ôç ìåôåã÷åéñçôéêÞ ðåñßïäï.Óôï ðáñüí êåßìåíï èá ðáñïõóéáóôïýí, ìåôáîý Üëëùí,ïé óçìáíôéêüôåñåò êáôåõèõíôÞñéåò ïäçãßåò êáé óõóôç-ìáôéêÝò áíáóêïðÞóåéò ôùí ôåëåõôáßùí Ýîé åôþí êáèþòêáé óõìðåñÜóìáôá ðïõ ðñïêýðôïõí áðü áõôÝò.22-26

ÁíôéìéêñïâéáêÞ ÷çìåéïðñïöýëáîç óôçí Êáñäéï÷åé-ñïõñãéêÞÇ åîùóùìáôéêÞ êõêëïöïñßá åßíáé ìéá ôå÷íéêÞ ðïõ ó÷å-äüí áðïêëåéóôéêÜ ÷ñçóéìïðïéåßôáé óôéò åðåìâÜóåéòêáñäéÜò êáé åðéäñÜ óçìáíôéêÜ óôïí üãêï êáôáíïìÞò,ôç öáñìáêïêéíçôéêÞ êáé ôçí êÜèáñóç ôùí áíôéâéïôéêþíðïõ ÷ñçóéìïðïéïýíôáé ãéá ÷çìåéïðñïöýëáîç (×ÐÖ)(êåöáëïóðïñßíåò, âáíêïìõêßíç, áìéíïãëõêïóßäåò).ÊÜðïéá áðü áõôÜ, åðéðñüóèåôá, üðùò ç âáíêïìõêßíç,ðáãéäåýïíôáé (sequestered) óôï äéáìÝñéóìá ôçò "êáñ-äéïðíåõìïíéêÞò" ìç÷áíÞò, ãåãïíüò ðïõ ìåéþíåé ôç âéï-äéáèåóéìüôçôÜ ôïõò, ôüóï êáôÜ ôç äéÜñêåéá üóï êáé êá-ôÜ ôç äéáêïðÞ ôçò åîùóùìáôéêÞò êõêëïöïñßáò.27-30 Êá-ôÜëëçëç ðåñéåã÷åéñçôéêÞ äüóç èåùñåßôáé áõôÞ ðïõ åðé-ôõã÷Üíåé éêáíïðïéçôéêÜ éóôéêÜ åðßðåäá, éäéáßôåñá óåïóôÜ êáé óôÝñíï êáé ü÷é áõôÞ ðïõ åðéôõã÷Üíåé ôéò ðáñá-äïóéáêÜ ìåôñïýìåíåò óõãêåíôñþóåéò óôï áßìá. Êëéíé-êÝò êáé ðåéñáìáôéêÝò ìåëÝôåò ðáñÝ÷ïõí éêáíïðïéçôéêÞôåêìçñßùóç ãéá åðáíáëçðôéêÞ äüóç áíôéâéïôéêïý êáôÜôçí åîùóùìáôéêÞ êõêëïöïñßá åíôüò äýï ÷ñüíùí çìß-

óåéáò æùÞò (t ½) ôïõ öáñìÜêïõ:31,32 ð.÷. ç êåöáæïëßíçðáñïõóéÜæåé t 1/2 1.8 þñåò, ãé áõôü êáé óõóôÞíåôáé çåðáíá÷ïñÞãçóÞ ôçò üôáí ç åðÝìâáóç ðáñáôåßíåôáé ìåáíïé÷ôü ÷åéñïõñãéêü ðåäßï ãéá äéÜóôçìá ìåãáëýôåñïôùí 3-4 ùñþí. Ç êáôáëëçëüôçôá åíüò áíôéâéïôéêïý êñß-íåôáé ìåôáîý Üëëùí êáé áðü ôçí éêáíüôçôá ôïõ íá äéá-ôçñåß åðßðåäá óôïí ïñü ðÜíù áðü ôçí MIC (MinimumInhibitory Concentration) ôïõ Ýíáíôé ôïõ ìéêñïâßïõ ãéáôï ïðïßï ÷ïñçãåßôáé ç ×ÐÖ (ð.÷. Staphylococcus sp.ãéá ôçí Êáñäéï÷åéñïõñãéêÞ). Áõôüò åßíáé êáé ï âáóé-êüò ëüãïò ôçò åðáíáëçðôéêÞò äüóçò êÜèå -2 t ½ ôïõ á-íôéâéïôéêïý ãéá ×ÐÖ.33

Ïé êáôåõèõíôÞñéåò ïäçãßåò22,23 ðïõ åêäüèçêáí áðü ôçíAmerican Society of Thorasic Surgeons ãéá ôç ×ÐÖóôçí Êáñäéï÷åéñïõñãéêÞ (2006 êáé 2007), ðñïôåßíïõíôá ðáñáêÜôù:

• Ãéá ×ÐÖ óå áóèåíåßò ÷ùñßò ðéèáíüôçôá ãéá MRSAðñïôåßíåôáé â-ëáêôáìéêü áíôéâéïôéêü (Level ofEvidence A).

• Ìåôáîý ôùí â-ëáêôáìéêþí áíôéâéïôéêþí ðñïôéìÜôáéç êåöáæïëßíç (cefazolin, 1çò ãåíéÜò êåöáëïóðïñßíç)ëüãù äéáèåóéìüôçôáò êáé ÷áìçëïý êüóôïõò, ðáñÜ ôïãåãïíüò üôé ïé ðåñéóóüôåñåò ôõ÷áéïðïéçìÝíåò ìåëÝ-ôåò ìå ïìÜäá åëÝã÷ïõ (RCTs) äåí êÜíïõí äéÜêñéóçìåôáîý ôùí äéáöüñùí êåöáëïóðïñéíþí (Level ofEvidence B).

• Ç êåöáæïëßíç ðñÝðåé íá ÷ïñçãåßôáé åíôüò (within) 60ëåðôþí ðñéí ôçí ÷åéñïõñãéêÞ ôïìÞ (Level of EvidenceA), óå äüóç 2 gr ãéá ÂÓ > 60 kg (Level of EvidenceB).

• Óå áóèåíåßò ìå öõóéïëïãéêÞ íåöñéêÞ ëåéôïõñãßá êáéðáñáìïíÞ áíïéêôïý ÷åéñïõñãéêïý ðåäßïõ ðñïôåßíå-ôáé 2ç äüóç êåöáæïëßíçò (1 gr) êÜèå 3-4 þñåò. Áí çåîùóùìáôéêÞ êõêëïöïñßá ðñïâëÝðåôáé íá ôåëåéþóåéåíôüò 4 ùñþí, ðñïôåßíåôáé ç 2ç äüóç íá ÷ïñçãåßôáéìåôÜ ôï ôÝëïò áõôÞò, þóôå íá åðéôõã÷Üíïíôáé éêáíï-


3. (ASA score).

ASA score 1 .2 (mild) .3 (severe)

, (incapacitating). 4 ,

.5 (moribund) , 24

, .



ðïéçôéêÜ åðßðåäá óôï áßìá (Level of Evidence B).• Ãéá áóèåíÞ ìå ãíùóôü Þ ýðïðôï áðïéêéóìü ìå

MRSA, ãéá áóèåíåßò ðïõ íïóçëåýïíôáé óå Íïóïêï-ìåßï Þ ÊëéíéêÞ ìå áõîçìÝíç åðßðôùóç MRSA, ãéááóèåíåßò ìå ðñïçãïýìåíç íïóçëåßá ãéá >3 ìÝñåò ÞìåôáöïñÜ áðü Üëëï êÝíôñï, ãéá áóèåíåßò ìå ðñïç-ãïýìåíç ëÞøç áíôéâéïôéêþí êáé áóèåíåßò ìå ðñïóèå-ôéêÞ âáëâßäá Þ åíäáããåéáêÞ ðñüèåóç, ðñïôåßíåôáéóõíäõáóìüò â-ëáêôáìéêïý (cefazolin ãéá 24-48 þñåò)ìå ãëõêïðåðôßäéï (âáíêïìõêßíç) óå 1-2 äüóåéò (Levelof Evidence C). Ëüãù áìéãïýò äñÜóçò Ýíáíôé gram-èåôéêþí ìéêñïâßùí, ç âáíêïìõêßíç äåí ðñÝðåé íá ÷ï-ñçãåßôáé ìüíç ôçò ùò ×ÐÖ (Level of Evidence C).

• ¼ôáí åíäåßêíõôáé ç ÷ïñÞãçóç âáíêïìõêßíçò, ðñï-ôåßíåôáé äüóç 1-1.5 gr Þ äüóç ðñïóáñìïóìÝíç óôïâÜñïò óþìáôïò (ÂÓ, weight-adjusted dose): 15 mg/kgÂÓ óå 1 þñá, ìå ïëïêëÞñùóç ôçò Ýã÷õóçò åíôüò 60ëåðôþí ðñéí ôçí ÷åéñïõñãéêÞ ôïìÞ (Level ofEvidence A)31,34

• Ç ðñïóèÞêç áìéíïãëõêïóßäçò óôç âáíêïìõêßíç ìåóêïðü ôçí êÜëõøç gram-áñíçôéêþí ìéêñïâßùí óåáóèåíåßò ìå áëëåñãßá óôá â-ëáêôáìéêÜ, äåí ðñïôåß-íåôáé ïìüöùíá, êáèþò ïýôå ç áðïôåëåóìáôéêüôçôÜôçò åßíáé åðáñêþò áðïäåäåéãìÝíç, ïýôå èåùñåßôáé

áóöáëÞò (óïâáñüò êßíäõíïò íåöñïôïîéêüôçôáò êáéùôïôïîéêüôçôáò ëüãù êáèõóôåñçìÝíçò áðÝêêñéóçòýóôåñá áðü ôçí åîùóùìáôéêÞ êõêëïöïñßá)37 (Levelof Evidence C). Áí ôåëéêÜ ÷ïñçãçèåß áìéíïãëõêïóß-äç, ðñïôåßíåôáé óõíÞèùò ìßá äüóç åíôüò 60 ëåðôþíðñéí ôç ÷åéñïõñãéêÞ ôïìÞ (ôï áíþôåñï 2 äüóåéò).

• Ãéá Íïóïêïìåßá êáé ÊëéíéêÝò ìå åðéäçìßá Þ ìåãÜëçóõ÷íüôçôá åí ôù âÜèåé ÷åéñïõñãéêþí ëïéìþîåùí(óôåñíßôéäá, ìåóïèùñáêßôéäá) áðü gram-áñíçôéêÜìéêñüâéá, ðñïôåßíåôáé 1çò ãåíéÜò êåöáëïóðïñßíç ãéá48 þñåò ìå ðñïóèÞêç áðïôåëåóìáôéêïý óôï áíôßóôïé-÷ï ìéêñüâéï áíôéâéïôéêïý (Level of Evidence C). Óåáóèåíåßò ìå åðçñåáóìÝíç íåöñéêÞ ëåéôïõñãßá, ðñï-ôåßíåôáé ç ðñïóèÞêç áíôéâéïôéêïý ìå äñÜóç Ýíáíôégram-áñíçôéêþí ìéêñïâßùí êáé ìéêñÞ åðßäñáóç óôçíåöñéêÞ ëåéôïõñãßá (ð÷. ëåâïöëïîáóßíç) Þ ìéáò ìüíïäüóçò áìéíïãëõêïóßäçò (Level of Evidence C).

• Ç äéáóôáõñïýìåíç áíôßäñáóç ìåôáîý ðåíéêéëßíçòêáé êåöáëïóðïñéíþí êõìáßíåôáé áðü 2 ùò 20%.35,36

Óå áóèåíÞ ìå éóôïñéêü IgE-mediated áíôßäñáóçò óåðåíéêéëßíç Þ êåöáëïóðïñßíç (áíáöõëáîßá, óïâáñïýâáèìïý åîÜíèçìá, áããåéïïßäçìá), óõóôÞíåôáé ç ÷ï-ñÞãçóç âáíêïìõêßíçò, ü÷é ãéá ðåñéóóüôåñï áðü 48þñåò (Level of Evidence A). Óå áóèåíÞ ìå éóôïñéêü

4. (Altemeier 1984)

(Class) SSI

1 ( ),

,.

1-5% < 1%

2 -

,,

(spillage).5-15% < 7%

3 ( )

() ( . .

/ 4 ).

15% < 15%

4 ,/

4 ( . . , ).

30%


IgE-non mediated áíôßäñáóçò óå ðåíéêéëßíç Þ êåöá-ëïóðïñßíç (áðëü åîÜíèçìá) Þ áóáöÝò éóôïñéêü,ðñïôåßíåôáé âáíêïìõêßíç Þ êåöáëïóðïñßíç ìå ôçíðáñáäï÷Þ, ùóôüóï, ôçò ìéêñÞò ðéèáíüôçôáò óïâá-ñþí áëëåñãéêþí áíôéäñÜóåùí óôéò êåöáëïóðïñßíåò(Level of Evidence B).

• Ç ôïðéêÞ ÷ñÞóç âáíêïìõêßíçò Þ ãåíôáìõêßíçò óôáäýï Üêñá ôïõ óôÝñíïõ, ßóùò âïçèÜ, ùóôüóï, ðáñá-ìÝíåé áìöéëåãüìåíï èÝìá. Ïé (ëßãåò) ôõ÷áéïðïéçìÝ-íåò ìåëÝôåò êáé ïé (áêüìç ëéãüôåñåò) óõóôçìáôéêÝòáíáóêïðÞóåéò êáôÝëçîáí óôï óõìðÝñáóìá ôçòõðáñêôÞò áäõíáìßáò åîáãùãÞò áóöáëþí óõìðåñá-óìÜôùí38-41 (Level of Evidence B).

• Ç ðñïåã÷åéñçôéêÞ åêñßæùóç ñéíéêÞò öïñåßáò S.aureus ìå ìïõðõñïóßíç ðñïôÜèçêå íá ãßíåôáé óõóôç-ìáôéêÜ óå üëïõò ôïõò áóèåíåßò, áí äåí õðÜñ÷åé áñ-íçôéêüò ãéá áðïéêéóìü ðñïåã÷åéñçôéêüò Ýëåã÷ïò(Level of Evidence A), êáèþò ïé ìåëÝôåò ìÝ÷ñé ôï2007 êáôÝãñáöáí óõó÷Ýôéóç ñéíéêÞò êáé äåñìáôéêÞòöïñåßáò S. aureus ìå ëïßìùîç áðü ôï ßäéï óôÝëå÷ïò(áõôü ôçò öïñåßáò) óå ðïóïóôü 90%.42-46 Ç áíÜðôõ-îç, ùóôüóï, áíôï÷Þò óôç ìïõðõñïóßíç, ýóôåñá áðüðáñáôåôáìÝíç ÷ñÞóç áõôÞò óå áíïéêôÜ ôñáýìáôáêáé äåñìáôßôéäåò, äçìéïýñãçóå ðñþéìá ðñïâëÞìáôáêáé áðÝêëåéóå ôç óõóôçìáôéêÞ ÷ïñÞãçóÞ ôçò, ÷ùñßòôáõôü÷ñïíï Ýëåã÷ï ôçò åõáéóèçóßáò üëùí ôùí óôåëå-÷þí S. aureus åíüò Íïóïêïìåßïõ óå áõôÞí. Óôéò ðå-

ñéóóüôåñåò ðåñéðôþóåéò, ôï ìÝôñï åíôÜ÷èçêå óå Ýíáãåíéêü ðñüãñáììá Ýëåã÷ïõ ôùí íïóïêïìåéáêþí ëïé-ìþîåùí.34,47,48 Ôï ðïóïóôü áðïéêéóìïý (öïñåßáò) ìåMRSA, óôï óýíïëï ôùí áóèåíþí, ðÜíù áðü ôï ïðïß-ï ðñïôåßíåôáé Þ åíäåßêíõôáé ç ÷ïñÞãçóç ìïõðõñïóß-íçò, äåí êáèïñßóôçêå áðü ôéò êáôåõèõíôÞñéåò ïäçãß-åò 2006-2007.

Ðñüóöáôá (2010), ç ÓõìâïõëåõôéêÞ ÅðéôñïðÞ ãéá ôïí¸ëåã÷ï ôùí Ëïéìþîåùí óôçí ÁìåñéêÞ (HospitalInfection Control Practices Advisory Committee, HIC-PAC), åîÝäùóå ðåñßëçøç ìå íÝåò ÊáôåõèõíôÞñéåò Ïäç-ãßåò ãéá ôçí áíôéìéêñïâéáêÞ ÷çìåéïðñïöýëáîç (×ÐÖ)óôç ÷åéñïõñãéêÞ ãåíéêÜ (Draft Therapeutic Guidelineson Antimicrobial Prophylaxis in Surgery).24 Ïé ïäçãßåòóôçñß÷ôçêáí óå ðáëéüôåñåò êáôåõèõíôÞñéåò ïäçãßåò ôçòßäéáò ÅðéôñïðÞò3 êáé óå íåþôåñá äåäïìÝíá31,49 êáéáöïñïýóáí ôçí ÷çìåéïðñïöýëáîç óôï óýíïëü ôçò áëëÜêáé ôç ÷çìåéïðñïöýëáîç óôçí Êáñäéï÷åéñïõñãéêÞ. ÏéåðéêáéñïðïéçìÝíåò ãåíéêÝò áñ÷Ýò ÷çìåéïðñïöýëáîçòêáé ïé åéäéêüôåñåò ïäçãßåò ðïõ áöïñïýí ôçí Êáñäéï-÷åéñïõñãéêÞ óõíïøßæïíôáé ùò åîÞò:

• Ôá ìéêñüâéá óôá ïðïßá óôï÷åýåé ç ×ÐÖ ðñÝðåé íáðñïêáèïñßæïíôáé êáôÜ ôçí ðñïåã÷åéñçôéêÞ ðåñßïäïêáé åîáñôþíôáé áðü ôï åßäïò ôçò åðÝìâáóçò, ôçí åí-äïãåíÞ ÷ëùñßäá ôïõ áóèåíïýò êáé ôçí ôïðéêÞ ìéêñï-


Åéêüíá 1. Óõó÷Ýôéóç óõ÷íüôçôáò ÷åéñïõñãéêþí ëïéìþîåùí ìå ôï NISS score


âéïëïãéêÞ ïéêïëïãßá (ôçò ÊëéíéêÞò êáé ôïõ Íïóïêï-ìåßïõ).

• Ôá áíôéâéïôéêÜ ðïõ ÷ïñçãïýíôáé ãéá ×ÐÖ ðñÝðåé íáðåñéëáìâÜíïõí óôï öÜóìá äñÜóçò ôïõò ôá ìéêñüâéáôïõ ÷åéñïõñãéêïý ðåäßïõ. Ç åðéëïãÞ ôùí áíôéâéïôé-êþí áõôþí ðñÝðåé íá ëáìâÜíåé õðüøç ôçí ôïðéêÞ ìé-êñïâéïëïãéêÞ ÷ëùñßäá êáé ôá ðïóïóôÜ áíôï÷Þò ôùíóõ÷íüôåñùí ìéêñïâßùí óôá áíôéâéïôéêÜ.

• Óôåíïý öÜóìáôïò êáé ÷áìçëïý êüóôïõò áíôéâéïôéêÜÞôáí êáé ðáñáìÝíïõí ôá êáôáëëçëüôåñá ãéá ôéò ðå-ñéóóüôåñåò åíäåßîåéò ×ÐÖ, óõìðåñéëáìâáíïìÝíçòêáé ôçò Êáñäéï÷åéñïõñãéêÞò.

• Ç ×ÐÖ ÷ïñçãåßôáé åíôüò (within) 30-60 ëåðôþíðñéí ôçí Ýíáñîç ôçò åðÝìâáóçò (âë. ÷åéñïõñãéêÞò ôï-ìÞò) êáé ç Ýã÷õóÞ ôùí áíôéâéïôéêþí ïëïêëçñþíåôáéðñéí ôçí ÷åéñïõñãéêÞ ôïìÞ.31, 50 ÅéäéêÜ ãéá ôç âáíêï-ìõêßíç êáé ôéò öëïõïñïêéíïëüíåò, ç Ýã÷õóç îåêéíÜ å-íôüò ôïõëÜ÷éóôïí 60-120 ëåðôþí ðñéí ôç ÷åéñïõñãéêÞôïìÞ êáé ïëïêëçñþíåôáé ðñéí áðü áõôÞ.

• Ç ÷ïñÞãçóç ôùí öáñìÜêùí ôçò ãåíéêÞò áíáéóèçóßáòóêüðéìï åßíáé íá áðÝ÷åé ÷ñïíéêÜ (-5-10 ëåðôÜ) áðüôçí ×ÐÖ åîáéôßáò ôïõ åíäå÷üìåíïõ êßíäýíïõ áëëåñ-ãéêÞò áíôßäñáóçò.

• Ôá íåþôåñá äåäïìÝíá ðñïôåßíïõí ìå ìåãáëýôåñçÝìöáóç ôïí õðïëïãéóìü ôçò áñ÷éêÞò äüóçò ×ÐÖ ìåâÜóç ôï âÜñïò óþìáôïò (ÂÓ) ôïõ áóèåíïýò,50 åíþ ëß-ãá íÝá äåäïìÝíá ðñïÝêõøáí óôçí ðïñåßá ôïõ ÷ñü-íïõ ãéá ôçí êáôÜëëçëá ðñïóáñìïóìÝíç óôï ÂÓ äüóçáíôéâéïôéêïý (weight-based dose).51-53 Ç áñ÷éêÞ äüóçôïõ áíôéâéïôéêïý ðñïôåßíåôáé íá åßíáé äéðëÜóéá áðüôç óõíÞèç äüóç ðïõ ÷ïñçãåßôáé ãéá èåñáðåßá ëïßìù-îçò.

• Ïé ðá÷ýóáñêïé áóèåíåßò (äåßêôçò ìÜæáò óþìáôïò,body mass index, BMI >30kg/m2), äåí åêðñïóùðïý-íôáé óõ÷íÜ óôéò ó÷åôéêÝò ìåëÝôåò êáé ìÝ÷ñé óÞìåñáäå èåùñïýíôáé "åéäéêüò ðëçèõóìüò" (subgroup popu-lation), þóôå íá åîÜãïíôáé áóöáëÞ óõìðåñÜóìáôáãéá ôçí êáôÜëëçëç äüóç ôùí áíôéâéïôéêþí ôçò×ÐÖ.54 Áêüìç êáé ìå áõôÝò ôéò íåþôåñåò ïäçãßåò,óáöÞò óýóôáóç ãéá ôçí éäáíéêÞ äüóç ôïõ áíôéâéïôé-êïý ôçò ×ÐÖ (ðñïóáñìïóìÝíçò óôï ÂÓ ôïõ áóèåíÞ)ðïõ èá ïäçãïýóå óå ìåßùóç ôùí ×Ë, äå äßíåôáé.Ðñïôåßíåôáé, ùóôüóï, äéðëáóéáóìüò ôçò äüóçò ôùíêåöáëïóðïñéíþí, åìðåéñéêÞ áýîçóç ôçò âáíêïìõêß-íçò áíÜëïãá ìå ôï ÂÓ êáé ìéêñÝò ôñïðïðïéÞóåéò áíÜ-ëïãá ìå ôç íåöñéêÞ ëåéôïõñãßá, þóôå ïé óõãêåíôñþ-óåéò óôïí ïñü íá ðñïóïìïéÜæïõí áõôÝò ôùí áóèåíþíìå öõóéïëïãéêü ÂÓ.53

• Óå ðåñßðôùóç óïâáñÞò äéåã÷åéñçôéêÞò áéìïññáãßáòóå åíÞëéêåò (>1500 ml), åðéðñüóèåôç äüóç ×ÐÖ óõ-óôÞíåôáé íá ÷ïñçãåßôáé ýóôåñá áðü áíáðëÞñùóç ôïõ

ìåãáëýôåñïõ üãêïõ ôùí õãñþí ôùí õãñþí (ãéá ðáé-äéÜ ýóôåñá áðü áðþëåéá áßìáôïò 25 ml/kg).55-57

• ÅðáíáëçðôéêÝò äüóåéò óå Üëëåò (ðëçí ôçò áéìïññá-ãßáò) êáôáóôÜóåéò ðñïôåßíåôáé ãéá áíôéâéïôéêÜ ìå ìé-êñÞ äéÜñêåéá äñÜóçò (ð.÷. â-ëáêôáìéêÜ), óå åðåìâÜ-óåéò ìå äéÜñêåéá ðÜíù áðü 3 þñåò58-62 êáé óå êáôá-óôÜóåéò êáôÜ ôéò ïðïßåò ìåéþíåôáé ï ÷ñüíïò çìßóåéáòæùÞò (t ½) ôïõ áíôéâéïôéêïý (ð.÷. åêôåôáìÝíï Ýãêáõ-ìá). Äåí óõóôÞíåôáé åðáíÜëçøç äüóçò óå êáôáóôÜ-óåéò ðïõ ðáñáôåßíïõí ôïí t ½ (ð.÷., íåöñéêÞ äõóëåé-ôïõñãßá). ÓõíÞèùò ç åðáíáëçðôéêÞ äüóç ÷ïñçãåßôáéäéåã÷åéñçôéêÜ êÜèå äýï t 1/2 ôïõ áíôéâéïôéêïý, óôçíßäéá ìå ôçí áñ÷éêÞ Þ óå õðïäéðëÜóéá äüóç.

• Ç ìéêñüôåñç äéÜñêåéá ×ÐÖ ðïõ áðïôåëåóìáôéêÜìåéþíåé ôéò ×Ë äåí åßíáé áðïëýôùò ãíùóôÞ. Ïé åéäé-êïß óôï èÝìá óõìöùíïýí üôé ìåôåã÷åéñçôéêÞ ×ÐÖäåí áðáéôåßôáé óôçí ðëåéïøçößá ôùí åðåìâÜóåùíåêôüò áðü ôéò åðåìâÜóåéò óôçí Êáñäéï÷åéñïõñãéêÞêáé óå êÜðïéåò Üëëåò êáôçãïñßåò ðïõ äåí ðåñéëáì-âÜíïíôáé óôï ðáñüí êåöÜëáéï (ð.÷. óôéò ïöèáëìïëï-ãéêÝò), ãéá ôéò ïðïßåò ðñïôåßíåôáé äéÜñêåéá <48 þ-ñåò.63-65 ×ïñÞãçóç ×ÐÖ (ãéá åðåìâÜóåéò êÜèå åß-äïõò, áêüìç êáé óôçí Êáñäéï÷åéñïõñãéêÞ) ãéá ðå-ñéóóüôåñï áðü 48 þñåò áíôåíäåßêíõôáé, êáé ìÜëéóôá,óå áñêåôÝò ÷þñåò, åßôå áðáãïñåýåôáé åßôå áðïññß-ðôåôáé áðü ôá Öáñìáêåßá ôùí Íïóïêïìåßùí.

• Ç ìåôåã÷åéñçôéêÞ ðáñïõóßá ðáñï÷åôåýóåùí óôï ÷åé-ñïõñãéêü ðåäßï Þ óå Üëëá ìÝñç ôïõ óþìáôïò, óå êá-ìéÜ ðåñßðôùóç äåí åðéôñÝðåé Þ åðéâÜëåé õðÝñâáóçôïõ ðáñáðÜíù êáíüíá. Êáìßá Ýíäåéîç êáé ãéá êáíÝ-íá åßäïò ÷åéñïõñãéêþí åðåìâÜóåùí (óõìðåñéëáìâá-íüìåíùí êáé áõôþí óôçí Êáñäéï÷åéñïõñãéêÞ) äåíõößóôáôáé, ãéá óõíôáãïãñÜöçóç åðáíáëçðôéêÞò äü-óçò Þ äüóåùí ×ÐÖ êáôÜ ôçí áöáßñåóç ðáñï÷åôåý-óåùí êáé êÜèå åßäïõò êáèåôÞñùí êáé öëåâéêþíãñáììþí áðü ôïí áóèåíÞ.31,22,66-71

• Ç Ýíäåéîç êáé ôï åßäïò ôçò ×ÐÖ óõóôÞíåôáé íá áíá-ãñÜöïíôáé óôïí áôïìéêü öÜêåëï ôïõ áóèåíïýò êáôÜôçí ðñïåã÷åéñçôéêÞ åêôßìçóç êáé óôï áíáéóèçóéïëï-ãéêü äéÜãñáììá, ôáõôü÷ñïíá ìå óôïé÷åßá ðïõ áöï-ñïýí ôçí áíáãêáéüôçôá Þ ìç ôçò ÷ïñÞãçóçò, ôï åßäïòôçò åðÝìâáóçò, áëëåñãßåò ôïõ áóèåíïýò, ôïí ÷ñüíïÝíáñîçò ÷ïñÞãçóçò, ôç äüóç/äüóåéò êáèþò êáé åíäå-÷üìåíç áíÜãêç ôñïðïðïßçóçò ôïõ áíôéâéïôéêïý ðïõðñïôåßíåôáé áðü ôéò ôïðéêÝò êáé äéåèíåßò ó÷åôéêÝòïäçãßåò.

• Óå ðåñßðôùóç óïâáñÞò áíåðéèýìçôçò åíÝñãåéáò óåÝíá áíôéâéïôéêü, ðñïôåßíåôáé ç áðïöõãÞ áõôïý.Áóèåíåßò ìå éóôïñéêü áíáöõëáîßáò, ëáñõããéêïý ïé-äÞìáôïò, âñïã÷üóðáóìïõ, õðüôáóçò, ôïðéêïý ïéäÞ-ìáôïò, ïõñôéêÜñéáò Þ êíçóìþäïõò åîáíèÞìáôïò, ðïõ




óõíÝâçóáí Üìåóá ìåôÜ áðü ÷ïñÞãçóç ðåíéêéëëéíïý-÷ïõ óêåõÜóìáôïò, ðáñïõóéÜæïõí äõíçôéêÜ êßíäõíïãéá áíôßäñáóç Üìåóçò õðåñåõáéóèçóßáò óå â-ëáêôá-ìéêÜ áíôéâéïôéêÜ. ÊÜèå ïäçãßá óå ôïðéêü Þ åèíéêüåðßðåäï ãéá ðåñéåã÷åéñçôéêÞ ÷çìåéïðñïöýëáîç ìå â-ëáêôáìéêÜ, ðñÝðåé íá ðåñéëáìâÜíåé åíáëëáêôéêÜó÷Þìáôá ãéá áëëåñãßá óå áõôÜ (ðåíéêéëßíç Þ êåöáëï-óðïñßíç). Ôá åíáëëáêôéêÜ áõôÜ ó÷Þìáôá åßíáé óçìá-íôéêÜ ãéá ôçí áóöÜëåéá ôùí áóèåíþí. Ôáõôü÷ñïíá,âÝâáéá, õößóôáôáé ðéèáíüôçôá "õðåñäéÜãíùóçò"(over-diagnosis) áëëåñãßáò, ìå áðïôÝëåóìá áäõíáìßá÷ñÞóçò â-ëáêôáìéêþí áíôéâéïôéêþí, üôáí áõôÜ åßíáé(êáé åßíáé óôçí ðëåéïøçößá ôùí ðåñéðôþóåùí) ôáêáôáëëçëüôåñá.

• Óôçí åðéëïãÞ ôçò åíáëëáêôéêÞò ×ÐÖ óå áëëåñãßáóôá â-ëáêôáìéêÜ áíôéâéïôéêÜ, ëáìâÜíïíôáé õðüøç ôá÷áñáêôçñéóôéêÜ ôïõ áóèåíïýò (çëéêßá, íåöñéêÞ êáéçðáôéêÞ ëåéôïõñãßá).

• Ìå óáöÞíåéá, ðëÝïí, ïé åðéêáéñïðïéçìÝíåò ïäçãßåòôïõ 2010 ðñïôåßíïõí íá áðïöåýãåôáé ï óõíäõáóìüò(Ýóôù êáé ìéáò ìéêñÞò äüóçò) ãåíôáìõêßíçò ìå âáí-êïìõêßíç, ëüãù ôçò áõîçìÝíçò ðéèáíüôçôáò íåöñï-ôïîéêüôçôáò, éäéáßôåñá óå çëéêéùìÝíïõò áóèåíåßò, ìåÞ ÷ùñßò ðñïûðÜñ÷ïõóá íåöñéêÞ äõóëåéôïõñãßá.

• Ç áðïôåëåóìáôéêüôçôá êáé ç áóöÜëåéá ôçò ôïðéêÞòåöáñìïãÞò áíôéâéïôéêþí êáé ôùí ðëýóåùí ìå áíôéâéï-ôéêÜ (ãåíôáìõêßíç êáé âáíêïìõêßíç óôï óôÝñíï, ðÜ-íôá óå óõíäõáóìü ìå åíäïöëÝâéá ×ÐÖ) ãéá ðñüëç-øç ìåóïèùñáêßôéäáò, äåí åßíáé åðáñêþò ôåêìçñéù-ìÝíç êáé äå óõóôÞíåôáé (üðùò Üëëùóôå êáé óôéò ðá-ëáéüôåñåò ïäçãßåò) ùò ôáêôéêÞ ñïõôßíáò.41,45,72-77

• Åê íÝïõ, ïé ïäçãßåò ðñïóðÜèçóáí íá äéåñåõíÞóïõíôçí áðïôåëåóìáôéêüôçôá êáé ôç ó÷Ýóç êüóôïõò-ïöÝ-ëïõò ôçò ðñïåã÷åéñçôéêÞò åêñßæùóçò ñéíéêÞò öïñåßáò(decolonization) MRSA ìå ìïõðõñïóßíç, êáèþò êá-ëÞò ðïéüôçôáò âéâëéïãñáöéêÞ ôåêìçñßùóç ãéá ôç ìåß-ùóç ôùí ×Ë áðü MRSA ðñïÝêõøå ìåôÜ ôï 2007.78-80

Ç åíäïññéíéêÞ ÷ïñÞãçóç ìïõðõñïóßíçò åãêñßèçêåáðü ôïí Ïñãáíéóìü Ôñïößìùí êáé ÖáñìÜêùí (Foodand Drug Administration, FDA) ãéá åêñßæùóç ñéíé-êÞò öïñåßáò MRSA óå åíÞëéêåò áóèåíåßò êáé óåðñïóùðéêü íïóïêïìåßùí, ùò ìÝñïò óõíïëéêïý ðñï-ãñÜììáôïò åëÝã÷ïõ ôùí íïóïêïìåéáêþí ëïéìþîåùíêáé êáôÜ ôç äéÜñêåéá ôïðéêþí åðéäçìéþí.81-84 Áí êáéç ðëåéïøçößá ôùí ìÝ÷ñé óÞìåñá ìåëåôþí êáôÝäåéîåüôé ç óõóôçìáôéêÞ åíäïññéíéêÞ ÷ïñÞãçóç ìïõðõñï-óßíçò åßíáé áóöáëÞò êáé äõíçôéêÜ ùöÝëéìç ùò åðé-êïõñéêÞ áãùãÞ ôçò ×ÐÖ ãéá ôç ìåßùóç ôùí ×Ë áðüS. aureus, ùóôüóï, ç éäáíéêÞ óôéãìÞ Ýíáñîçò êáé çäéÜñêåéá äåí åßíáé åðáñêþò äéåõêñéíéóìÝíåò. ÐáñÜë-ëçëá, ç áíÜðôõîç óå óôåëÝ÷ç S. aureus óôçí ðïñåßá

ôïõ ÷ñüíïõ áíôï÷Þò óôç ìïõðõñïóßíçò, åîáêïëïõèåßíá ðñïêáëåß ðñïâëçìáôéóìü.77,82 Óõíåðþò, ç åêñßæù-óç ñéíéêÞò öïñåßáò ìðïñåß íá ðñïôáèåß óáí åðéêïõ-ñéêü ìÝôñï ãéá ôïí Ýëåã÷ï ôùí ëïéìþîåùí áðü MRSA,óå êëéíéêÝò Þ Íïóïêïìåßá ìå óçìáíôéêÞ åðßðôùóçáõôþí, ìå Üãñõðíç, ùóôüóï, åðéôÞñçóç ôçò ìéêñïâéá-êÞò áíôï÷Þò óôç ìïõðõñïóßíç êáé ðÜíôá óå óõíåííü-çóç ìå ôéò ôïðéêÝò ÅðéôñïðÝò Íïóïêïåìéáêþí Ëïé-ìþîåùí (ÅÍË) êáé ôï ÊÅÅËÐÍÏ.8

• Ç ÷çìåéïðñïöýëáîç óõìâÜëåé óôçí áëëáãÞ ôçò áôï-ìéêÞò êáé ôçò óõíïëéêÞò, óå åðßðåäï ÊëéíéêÞò, Íïóï-êïìåßïõ êáé ÷þñáò, ìéêñïâéáêÞò ÷ëùñßäáò, ïäçãþ-íôáò óå áðïéêéóìü ìå Üëëïôå Üëëá ìéêñüâéá êáé óåáíÜðôõîç ìéêñïâéáêÞò áíôï÷Þò.84 Áðïéêéóìüò óõì-âáßíåé êõñßùò (áëëÜ ü÷é ìüíï) ìå Clostridium diffi-cile, åíôåñüêïêêïõò (Enterococcus sp.), Pseudomonasêáé Serratia sp., ìå ôáõôü÷ñïíç áíÜðôõîç óôåëå÷þíáíèåêôéêþí óôá óõíÞèç áíôéâéïôéêÜ. ÐáñÜãïíôåòêéíäýíïõ ãéá åìöÜíéóç êïëßôéäáò áðü C. difficileáðïôåëïýí ï áñéèìüò ôùí áíôéâéïôéêþí ôçò ×ÐÖ, ïáñéèìüò ôùí äüóåùí êáé ç ìåãáëýôåñç áðü ôç óõíé-óôþìåíç äéÜñêåéá ÷ïñÞãçóçò ×ÐÖ.85 ÁíÜðôõîç ìé-êñïâéáêÞò áíôï÷Þò óå óôåëÝ÷ç Pseudomonas êáéSerratia ëüãù áíôéìéêñïâéáêÞò ÷çìåéïðñïöýëáîçòÝ÷åé ìå óáöÞíåéá êáôáäåé÷èåß óôï ðáñåëèüí.86 Ðå-ñéïñéóìüò ôçò óõ÷íüôçôáò êáé ôçò äéÜñêåéáò ôçò×ÐÖ, êõñßùò ôùí êåöáëïóðïñéíþí êáé ôçò êëéíäá-ìõêßíçò, êáèþò êáé åðéëïãÞ áõôþí ìå âÜóç ôá ôïðé-êÜ åðéäçìéïëïãéêÜ äåäïìÝíá ôçò ÊëéíéêÞò êáé ôïõÍïóïêïìåßïõ, áðïôåëïýí óçìáíôéêÝò åíÝñãåéåò ðñïòôçí êáôåýèõíóç ôçò ìåßùóçò ôùí ðáñáðÜíù áíåðé-èýìçôùí åíåñãåéþí ôçò ×ÐÖ.

Óôçí ðåñßëçøç ôïõ 2010, íÝá âéâëéïãñáöéêÞ ôåêìçñßù-óç ðñïÝêõøå ãéá ôçí Üðïøç üôé ç öïñåßá Þ ï áðïéêé-óìüò ìå ðïëõáíèåêôéêÜ ìéêñüâéá (MRSA, VancomycinResistant Enterococcus-VRE, multi-resistant Pseudomonas aeruginosa, Acinetobacter sp., multi-resistantKlebsiella sp.) óõíäÝåôáé ìå óõ÷íüôåñåò ÷åéñïõñãéêÝòëïéìþîåéò óå ó÷Ýóç ìå áõôÝò ðïõ ðáñáôçñïýíôáé óåáóèåíåßò ðïõ äåí åßíáé öïñåßò ôùí ðáñáðÜíù ìéêñïâß-ùí. Ôïíßóôçêå ç óõó÷Ýôéóç ìåôáîý áðïéêéóìïý ìå ðï-ëõáíèåêôéêÜ ìéêñüâéá êáé ëïßìùîçò áðü áõôÜ, éäßùò óååðåìâÜóåéò õøçëïý êéíäýíïõ, üðùò ïé êáñäéï÷åéñïõñãé-êÝò (áïñôïóôåöáíéáßá ðáñÜêáìøç, åðåìâÜóåéò âáëâß-äùí)87-95 êáé ïñßóôçêáí ìå óáöÞíåéá ïé ðáñÜãïíôåò êéí-äýíïõ ãéá ðïëõáíèåêôéêÜ ìéêñüâéá (Ðßíáêáò 5). Ãéááóèåíåßò ìå áõîçìÝíç õðïøßá öïñåßáò ðïëõáíèåêôé-êþí ìéêñïâßùí ðïõ ðñüêåéôáé íá õðïâëçèïýí óå õøç-ëïý êéíäýíïõ ãéá ×Ë åðÝìâáóç (áïñôïóôåöáíéáßá ðá-


ñÜêáìøç, åðåìâÜóåéò âáëâßäùí), ðñïôåßíïíôáé ôá ðá-ñáêÜôù:

• Áíß÷íåõóç öïñåßáò ãéá ôá ðáñáðÜíù ìéêñüâéá ðñï-åã÷åéñçôéêÜ ìå ëÞøç åðé÷ñéóìÜôùí

• Ôñïðïðïßçóç ôçò ×ÐÖ þóôå íá êáëýðôïíôáé ôá ìé-êñüâéá áõôÜ (âë. äïêéìáóßåò åõáéóèçóßáò áíôéâéïôé-êþí, áíôéâéïãñÜììáôá).

ÅéäéêÜ ãéá ôïí MRSA óôçí Êáñäéï÷åéñïõñãéêÞ, ç ðñï-åã÷åéñçôéêÞ áíß÷íåõóç öïñåßáò óå üëïõò áíåîáéñÝôùòôïõò áóèåíåßò ðïõ èá õðïâëçèïýí óå êáñäéï÷åéñïõñãé-êÞ åðÝìâáóç (êáé ü÷é ìüíï óå áõôïýò ðïõ Ý÷ïõí ðáñÜ-ãïíôåò êéíäýíïõ ãéá MRSA, universal MRSA screen-ing) èåùñåßôáé áìöéëåãüìåíç.78-80

Ç áðïôåëåóìáôéêüôçôá ôïõ ìÝôñïõ óôá ðëáßóéá óõíïëé-êþí ðñïãñáììÜôùí åëÝã÷ïõ ôùí íïóïêïìåéáêþí ëïé-ìþîåùí áðü MRSA (óõìðåñéëáìâáíïìÝíùí ôùí ×Ë)öáßíåôáé íá éó÷ýåé, ùóôüóï, ç ó÷Ýóç êüóôïõò-ùöÝëåéáò(cost-effectiveness) ôïõ ìÝôñïõ óõæçôåßôáé áêüìç. Óåôïðéêü åðßðåäï, ç áíÜãêç åöáñìïãÞò ôïõ ìÝôñïõ êñßíå-ôáé áðü ôá ôïðéêÜ åðéäçìéïëïãéêÜ äåäïìÝíá ãéá ôïíMRSA êáé óõíáðïöáóßæåôáé áðü ôçí åêÜóôïôå ÊëéíéêÞêáé ôçí ôïðéêÞ ÅÍË.Ç ÷ïñÞãçóç âáíêïìõêßíçò ùò ÷çìåéïðñïöýëáîç óôçíÊáñäéï÷åéñïõñãéêÞ ìå óêïðü ôç ìåßùóç ôùí ×Ë áðüMRSA, ðåñéïñßæåôáé óå óõãêåêñéìÝíåò åíäåßîåéò(Ðßíáêáò 6).

Áóèåíåßò ìå ãíùóôÞ áíïóïêáôáóôïëÞ (áóèåíåßò ðïõõðïâëÞèçêáí óå áêôéíïèåñáðåßá, ÷çìåéïèåñáðåßá,êïñôéæïíïèåñáðåßá), áóèåíåßò ìå óáê÷áñþäç äéáâÞôçÞ ÷ñüíéá íïóÞìáôá (êáñäéáêÞ, íåöñéêÞ, çðáôéêÞ áíå-ðÜñêåéá), ðá÷ýóáñêïé áóèåíåßò Þ áóèåíåßò ìå êá÷å-îßá, äéáôñÝ÷ïõí áõîçìÝíï êßíäõíï ãéá ×Ë, ùóôüóï, ïé×Ë ðïõ ðáñïõóéÜæïõí ðñïÝñ÷ïíôáé óõíÞèùò áðü ìé-êñüâéá óôá ïðïßá óôï÷åýåé ç êëáóéêÞ ×ÐÖ. Óõíåðþò,ãéá ôïõò áóèåíåßò áõôïýò äåí ðñïôåßíåôáé ôñïðïðïéç-ìÝíç ×ÐÖ. ÐñïöõëáêôéêÞ ÷ïñÞãçóç áíôéâéïôéêþí óå áóèåíåßò ôçòÊáñäéï÷åéñïõñãéêÞò ìüíï ãéá ðñüëçøç ìåôåã÷åéñçôé-êþí áíáðíåõóôéêþí ëïéìþîåùí êáé ëïéìþîåùí ôïõ ïõ-ñïðïéçôéêïý äåí óõóôÞíåôáé. Ìå óáöÞíåéá ïé íÝåò ïäç-ãßåò êáôáëÞãïõí óôï óõìðÝñáóìá áõôü ëáìâÜíïíôáòõðüøç ôá áðïôåëÝóìáôá äýï ìåôá-áíáëýóåùí. ÁõôÝòóýãêñéíáí ôçí êåöôñéáîüíç (ceftriaxone, êåöáëïóðï-ñßíçò 3çò ãåíéÜò) ìå Üëëá áíôéâéïôéêÜ, ùò ðñïò ôçí éêá-íüôçôá ìåßùóçò ôùí ìåôåã÷åéñçôéêþí ëïéìþîåùí ôïõ á-íáðíåõóôéêïý êáé ïõñïðïéçôéêïý óõóôÞìáôïò. Ç ìéáìåôá-áíÜëõóç96 ðåñéëÜìâáíå 48 ôõ÷áéïðïéçìÝíåò ìåëÝ-ôåò (êáé êáñäéïèùñáêéêÝò åðåìâÜóåéò) êáé êáôÝäåéîå

üôé ïé ëïéìþîåéò ôïõ áíáðíåõóôéêïý ìåéþèçêáí óôéò êá-èáñÝò êáé êáèáñÝò-åðéìïëõóìÝíåò åðåìâÜóåéò (OR:0.30) åíþ ïé ïõñïëïéìþîåéò ìüíï óôéò êáèáñÝò-åðéìï-ëõóìÝíåò (OR: 0.54). Ç äåýôåñç ìåôá-áíÜëõóç ìå 43ôõ÷áéïðïéçìÝíåò ìåëÝôåò (êáé êáñäéïèùñáêéêÝò åðåì-âÜóåéò) êáôÝäåéîå ìåßùóç ôùí ïõñïëïéìþîåùí, ÷ùñßòìåßùóç ôùí ëïéìþîåùí ôïõ áíáðíåõóôéêïý.97 ¸ôåñçìåôá-áíÜëõóç óýãêñéíå êåöáëïóðïñßíåò óå ïðïéáäÞ-ðïôå äüóç ìå placebo êáé ìå ðïëëáðëÝò äüóåéò 24ùñçòäéÜñêåéáò ãéá ïñèïðåäéêÝò åðåìâÜóåéò.98 Ïé ìåôåã÷åé-ñçôéêÝò ïõñïëïéìþîåéò ìåéþèçêáí óå ôñåéò ìåëÝôåòðïõ óõìðåñéëÞöèçêáí óôç ìåôá-áíÜëõóç, ìåôÜ áðü ÷ï-ñÞãçóç ×ÐÖ óõãêñéôéêÜ ìå placebo. Åðñüêåéôï, ùóôü-óï, ãéá çëéêéùìÝíïõò áóèåíåßò ìå êáèåôÞñá ïõñïäü-÷ïõ êýóôçò Þ áóõìðôùìáôéêÞ ìéêñïâéïõñßá, ìå ðñïû-ðÜñ÷ïíôåò, äçëáäÞ, ðáñÜãïíôåò êéíäýíïõ ãéá ïõñïëïß-ìùîç. Íåþôåñá äåäïìÝíá ãéá ôçí ÷çìåéïðñïöýëáîç óôçíÊáñäéï÷åéñïõñãéêÞ ðñïÝêõøáí áðü äýï óõóôçìáôéêÝòáíáóêïðÞóåéò êáé ìåôá-áíáëýóåéò ôï 2011.25,26 Ïé ìå-ëÝôåò áõôÝò ðïõ óõìðåñéÝëáâáí óçìáíôéêü áñéèìü ôõ-÷áéïðïéçìÝíùí ìåëåôþí êáôÝëçîáí óôá ðáñáêÜôù óõ-ìðåñÜóìáôá:

• Áí êáé ç ìåßùóç ôùí ×Ë óôçí ÊÑ× åßíáé ðïëõðáñá-ãïíôéêÞ, ùóôüóï, ç ×ÐÖ äéáäñáìáôßæåé óçìáíôéêüñüëï.

• Ï óõ÷íüôåñïò ìéêñïïñãáíéóìüò ãéá ôéò ×Ë óôçíÊáñäéï÷åéñïõñãéêÞ, ðáñÜ ôçí ïëïÝíá áõîáíüìåíçóôïí ÷ñüíï åðßðôùóç ôùí gram-áñíçôéêþí ìéêñïâß-ùí óå Üëëåò êáôçãïñßåò íïóïêïìåéáêþí ëïéìþîåùí,Þôáí êáé ðáñáìÝíåé ï óôáöõëüêïêêïò, åíþ ï áðïéêé-óìüò (öïñåßá) áðïôåëåß áðïäåäåéãìÝíá êáé áðü ôéòìåôá-áíáëýóåéò óçìáíôéêü ðáñÜãïíôá êéíäýíïõ ãéáåðéìüëõíóç ôïõ ÷åéñïõñãéêïý ðåäßïõ.

• Óå üëåò ôéò ìåëÝôåò ãéá ôéò êáñäéï÷åéñïõñãéêÝò åðåì-âÜóåéò, ç ×ÐÖ åðçñÝáóå ôéò ×Ë áðü gram-èåôéêÜìéêñüâéá, åíþ ïé ëïéìþîåéò áðü gram-áñíçôéêÜ ìé-êñüâéá åðçñåÜóôçêáí óå ìéêñüôåñï âáèìü.

• Ìåôåã÷åéñçôéêÞ ðíåõìïíßá, ìéêñïâéáéìßá êáé åíäï-êáñäßôéäá óõó÷åôßóôçêáí ìå áõîçìÝíç óõíïëéêÞèíçôüôçôá, åíþ ãéá ôéò ëïéìþîåéò ÷åéñïõñãéêïý ðåäß-ïõ, áíôßóôïé÷ç óõó÷Ýôéóç äåí êáôáãñÜöçêå.

• Ðñïôåéíüìåíç ÷çìåéïðñïöýëáîç Þôáí êáé ðáñáìÝ-íåé ç 1çò ãåíéÜò êåöáëïóðïñßíç (cefazolin).

• Ç ×ÐÖ ðïõ ðåñéëáìâÜíåé áíôéâéïôéêü ìå äñÜóç êáéÝíáíôé gram-áñíçôéêþí ìéêñïâßùí ìåéþíåé óçìáíôéêÜôçí åðßðôùóç ôçò ìåôåã÷åéñçôéêÞò ðíåõìïíßáò (RR0.66, 95% CI 0.51 - 0.86) êáé ôç óõíïëéêÞ (all cause)èíçôüôçôá óôéò êáñäéï÷åéñïõñãéêÝò åðåìâÜóåéò (RR0.69, 95% CI 0.50 - 0.93), ÷ùñßò, ùóôüóï, íá åðéäñÜ




óôç óõ÷íüôçôá ôùí ×Ë.26 Ïé ðåñéóóüôåñåò ìÝ÷ñé óÞ-ìåñá ìåëÝôåò óýãêñéíáí êåöáëïóðïñßíåò 2çò (ð.÷.êåöïõñïîßìç, cefuroxim) Þ 3çò (ð.÷. êåöôñéáîüíç,ceftriaxone) ãåíéÜò ìå ìéá êåöáëïóðïñßíç 1çò ãåíéÜò(ð.÷. êåöáæïëßíç, cefazolin). Óßãïõñá âïçèÜ ç ÷ñÞóçãéá ×ÐÖ áíôéâéïôéêïý/þí ìå óõíäõáóìÝíç äñÜóçãéá gram-èåôéêÜ êáé gram-áñíçôéêÜ ìéêñüâéá, ÷ùñßò,ùóôüóï, íá õðÜñ÷åé ìÝ÷ñé óÞìåñá ïäçãßá ãéá óõãêå-êñéìÝíï áíôéâéïôéêü Þ óõíäõáóìü áõôþí (áðïõóéÜ-æïõí ìåãÜëåò ôõ÷áéïðïéçìÝíåò ìåëÝôåò). To üðïéïðñïôåéíüìåíï ó÷Þìá Þ áíôéâéïôéêü ðñÝðåé íá ëáìâÜ-íåé õðüøç ôéò áíôï÷Ýò ôùí gram-áñíçôéêþí ìéêñïâß-ùí óå ôïðéêü åðßðåäï.

• Ïé äüóåéò ôùí áíôéâéïôéêþí ãéá ×ÐÖ óôçí åîùóùìá-ôéêÞ êõêëïöïñßá ðñÝðåé íá êáèïñßæïíôáé ìå âÜóçöáñìáêïêéíçôéêÜ êáé öáñìáêïäõíáìéêÜ ÷áñáêôçñé-óôéêÜ ôùí áíôéâéïôéêþí êáé ü÷é áðáñáßôçôá ìå âé-âëéïãñáöéêÞ ôåêìçñßùóç.

• Õößóôáôáé Ýììåóç ôåêìçñßùóç üôé äéÜñêåéá ÷çìåéï-ðñïöýëáîçò ùò 48 þñåò ìðïñåß íá åßíáé ùöÝëéìç(Åéêüíá 3), åßíáé åîßóïõ áðïôåëåóìáôéêÞ üóï êáé ìå-ãáëýôåñç äéÜñêåéá, åíþ äå óõíïäåýåôáé áðü áíÜðôõ-îç ìéêñïâéáêÞò áíôï÷Þò. Ç ×ÐÖ, óå êÜèå ðåñßðôù-óç, äåí ðñÝðåé íá äéáñêåß ðåñéóóüôåñï áðü 48 þñåò.

• ¼ôáí ï MRSA åõèýíåôáé ãéá ôçí ðëåéïøçößá ôùí ×Ëôçò ÊëéíéêÞò Þ ôïõ Íïóïêïìåßïõ, ãéá ×ÐÖ ðñïôåßíï-íôáé ôá ãëõêïðåðôßäéá (âáíêïìõêßíç, 1 äüóç ðñïåã-÷åéñçôéêÜ ìå Þ ÷ùñßò 2ç äüóç ìåôåã÷åéñçôéêÜ óå 12þñåò) óå óõíäõáóìü ìå 2çò Þ 3çò ãåíéÜò êåöáëïóðïñß-íç. Ôï üñéï åðßðôùóçò (óõ÷íüôçôáò) ôïõ MRSA óåÝíá Íïóïêïìåßï Þ åéäéêüôåñá åðß ôïõ óõíüëïõ ôùí×Ë óå ìéá Êáñäéï÷åéñïõñãéêÞ ÊëéíéêÞ, ðÜíù áðü ôïïðïßï (threshold) èåùñåßôáé äéêáéïëïãçìÝíç êáéóêüðéìç ç ×ÐÖ ìå ó÷Þìá ðïõ ðåñéëáìâÜíåé ãëõêï-ðåðôßäéá, äåí ïñßæåôáé ìå óáöÞíåéá áðü ôá ìÝ÷ñé óÞ-ìåñá óõãêåíôñùôéêÜ äåäïìÝíá.

• Áðü ôç óýãêñéóç ìåôáîý ãëõêïðåðôéäßùí êáé â-ëá-êôáìéêþí, ðáñáôçñÞèçêå éóïäýíáìç áðïôåëåóìáôé-êüôçôá, üôáí áõôÜ ÷ïñçãïýíôáí ãéá ßäéá äéÜñêåéá(48 þñåò) êáé ìÜëéóôá, õðåñï÷Þ ôùí ãëõêïðåðôéäßùíóå üôé áöïñÜ ôç ìåßùóç ôïõ óõíüëïõ ôùí íïóïêïìåéá-êþí ëïéìþîåùí.99 Ï ìéêñüò áñéèìüò ôùí ìåëåôþí,ùóôüóï, ðåñéïñßæåé ôç äõíáôüôçôá åîáãùãÞò óõìðå-ñáóìÜôùí ìå ãåíéêüôåñç åöáñìïãÞ.

• Ãéá áëëåñãßá óå â-ëáêôáìéêÜ, ðñïôåßíåôáé ç âáíêï-ìõêßíç ìå ðñïóèÞêç áíôéâéïôéêïý ìå äñÜóç Ýíáíôégram-áñíçôéêþí ìéêñïâßùí.

• ÔïðéêÜ áíôéâéïôéêÜ, ßóùò âïçèïýí, ùóôüóï, ðñïò ôïðáñüí, äå óõóôÞíïíôáé.

Ãéá ôçí åîáãùãÞ áóöáëþí óõìðåñáóìÜôùí áðü ôïí á-íáãíþóôç ôïõ ðáñüíôïò êåéìÝíïõ, áîßæåé íá óçìåéùèåßüôé ïé ìåôá-áíáëýóåéò áõôÝò ðáñïõóéÜæïõí óçìáíôé-êïýò ðåñéïñéóìïýò ðïõ áöïñïýí ôï ìáêñý ÷ñïíéêüäéÜóôçìá êáôÜ ôï ïðïßï äéåîÞ÷èçóáí ïé ìåëÝôåò (40Ýôç), ôçí ðïéêéëßá ÷åéñïõñãéêþí ôå÷íéêþí êáé ìåôåã÷åé-ñçôéêÞò ðáñáêïëïýèçóçò ôùí ×Ë óôçí Êáñäéï÷åé-ñïõñãéêÞ, ôç ìåôáâïëÞ óôïí ÷ñüíï ôùí õðåýèõíùí ãéá×Ë ìéêñïâßùí (áðü ôïí MSSA óôïí MRSA êáé óôágram-áñíçôéêÜ ìéêñüâéá) êáé ôçò áíôï÷Þò áõôþí óôááíôéâéïôéêÜ, ôçí ðïéêéëßá ôùí ïñéóìþí êáé ôùí ìåèü-äùí äéÜãíùóçò êáé êáôáãñáöÞò ôùí ×Ë. Ôáõôü÷ñïíá,ïé ðåñéóóüôåñåò ìåëÝôåò ÷ñçóéìïðïßçóáí ìåèüäïõò ìåáâÝâáéï ðïóïóôü ðñïêáôáëÞøåùí (unclear risk ofbias). Äåí ðáñáôçñÞèçêå, ùóôüóï, óçìáíôéêÞ åôåñïãÝ-íåéá óôéò ìåëÝôåò, ãåãïíüò ðïõ êÜíåé ðåñéóóüôåñïáîéüðéóôá ôá áðïôåëÝóìáôá ôùí ìåôá-áíáëýóåùí áõ-ôþí.

×çìåéïðñïöýëáîç óå ÓõóêåõÝò ÕðïâïÞèçóçò ôçòÁñéóôåñÞò Êïéëßáò Ïé ëïéìþîåéò ôùí Óõóêåõþí ÕðïâïÞèçóçò ôçò Áñéóôå-ñÞò Êïéëßáò (Left Ventricular Assist Devices, LVAD)ðñïêáëïýí óçìáíôéêÞ íïóçñüôçôá êáé áõîÜíïõí ôçèíçôüôçôá, ùóôüóï, äåí áðïêëåßïõí ôç ìåôáìüó÷åõóçêáñäéÜò ïýôå öáßíåôáé íá åðçñåÜæïõí ôçí üøéìç åðéâß-ùóç (long term survival). Ïé ëïéìþîåéò ôçò áããåéáêÞòãñáììÞò (driveline infections) êáé ôçò èÞêçò (pocket)ôïõ ìç÷áíÞìáôïò åßíáé ïé óõ÷íüôåñåò. Ôá gram-èåôéêÜìéêñüâéá ìå êýñéï åêðñüóùðï ôïí óôáöõëüêïêêï êáéôá gram-áñíçôéêÜ ìéêñüâéá ìå óõ÷íüôåñç ôçí øåõäï-ìïíÜäá (Pseudomonas spp.) åßíáé ôá êõñßáñ÷á ðáèïãü-íá. Áí êáé ìåãÜëç ðïéêéëßá êáôáãñÜöåôáé óôç ÷çìåéï-ðñïöýëáîç (×ÐÖ) ðïõ ÷ïñçãåßôáé ãéá ôéò LVAD,ùóôüóï, óõíçèÝóôåñá áíôéâéïôéêÜ Þ ó÷Þìáôá áðïôå-ëïýí ç âáíêïìõêßíç, ìéá êåöáëïóðïñßíç, ï óõíäõá-óìüò â-ëáêôáìéêïý ìå öëïõïñïêéíïëüíç, ìå ðñïóèÞêçÞ ü÷é öëïõêïíáæüëçò êáé ôïðéêÞò åöáñìïãÞò ìïõðõñï-óßíçò. Ìüíï 10 ìåëÝôåò áðü óýíïëï 373 ãéá ôï ÷ñïíéêüäéÜóôçìá 1948-2011, áó÷ïëÞèçêáí ìå ôï óõãêåêñéìÝíïèÝìá äéåîïäéêÜ êáé êñßèçêáí üôé ðáñÝ÷ïõí ôçí êáëýôå-ñç ôåêìçñßùóç.100 Óýìöùíá ìå áõôÝò:• ¸íá â-ëáêôáìéêü (ð.÷. 1çò ãåíéÜò êåöáëïóðïñßíç)

ìðïñåß íá ÷ñçóéìïðïéçèåß óå óõíäõáóìü ìå âáíêï-ìõêßíç, óå õðïøßá MRSA (âë. ðñïáíáöåñüìåíïõòðáñÜãïíôåò êéíäýíïõ ãéá MRSA).

• ÐåñéïñéóìÝíçò äéÜñêåéáò áíôéìõêçôéáóéêÞ áãùãÞìðïñåß íá âïçèÞóåé óå áóèåíåßò ìå õðïøßá ìõêçôéá-óéêÞò ëïßìùîçò.

• Ïé öëïõïñïêéíïëüíåò ðáñÝ÷ïõí åðéðñüóèåôç áíôé-óôáöõëïêïêêéêÞ äñÜóç, ùóôüóï, åêôéìÞèçêáí ìüíï


óå ðÝíôå ìåëÝôåò.• ÔïðéêÞ åöáñìïãÞ ìïõðõñïóßíçò ðñïôåßíåôáé ãéá

ìåßùóç ôùí óôáöõëïêïêêéêþí ëïéìþîåùí.• Ç äéÜñêåéá ôçò ×ÐÖ äåí óõóôÞíåôáé íá õðåñâáßíåé

ôéò 48 -72 þñåò ìåôåã÷åéñçôéêÜ.

Óôçí ðëåéïøçößá ôùí ìåëåôþí ÷ñçóéìïðïéÞèçêáí ìç-÷áíÝò ðáëìéêÞò ñïÞò (pulsatile-flow devices), åíþ ðñü-óöáôç ôõ÷áéïðïéçìÝíç ìåëÝôç äéáðßóôùóå ëéãüôåñåòëïéìþîåéò üôáí ÷ñçóéìïðïéÞèçêáí óõóêåõÝò óõíå÷ïýòñïÞò (continuous-flow HeartMate II).101,102 Ç áðïõóßáóôáèåñïý ó÷Þìáôïò ×ÐÖ, êáèïñéóìÝíçò äéÜñêåéáòêáé ÷ñïíéêÞò óôéãìÞò ÷ïñÞãçóçò ôùí áíôéâéïôéêþí(timing) óå óõíäõáóìü ìå ôçí ðïéêéëßá ôùí ôñüðùí êá-ôáãñáöÞò êáé ôùí ïñéóìþí ôùí LVAD ëïéìþîåùí (êÜ-ðïéåò ðáñïõóéÜæïõí ðïóïóôÜ åðéðïëáóìïý êáé ü÷é åðß-ðôùóçò), êáèéóôïýí äýóêïëç ôç óýãêñéóç ôùí ðïóï-óôþí ðïõ ðåñéãñÜöïíôáé óôéò áíôßóôïé÷åò ìåëÝôåò êáéôçí åîáãùãÞ óõìðåñáóìÜôùí. Ïé äéåèíåßò ïñéóìïß ôùíó÷åôéæüìåíùí ìå LVAD ëïéìþîåùí (LVAD-related

infections) ðáñÝ÷ïíôáé áðü ôï Interagency Registry ofMechanically Assisted Circulatory Support, åíþ ðñü-óöáôá êáé ç International Society of Heart and LungTransplantation (ISHLT) ðñïêåéìÝíïõ íá äéåõêïëýíåéôçí óýãêñéóç ôùí áðïôåëåóìÜôùí ìåôáîý ôùí äéáöü-ñùí Íïóïêïìåßùí ðñüôåéíå óõãêåêñéìÝíåò äéáãíùóôé-êÝò ìåèüäïõò êáé óôñáôçãéêÝò ðñüëçøçò.102 ÌÝ÷ñé óÞ-ìåñá, äåí õðÜñ÷åé ïìïöùíßá ãéá ôçí êáôÜëëçëç ×ÐÖêáôÜ ôçí åìöýôåõóç ôùí LVAD, åíþ áíáìÝíïíôáé óõ-óôÜóåéò ãéá ôç äéÜñêåéá êáé ôï åßäïò ôçò ×ÐÖ, êáèþòêáé ìåãÜëåò ôõ÷áéïðïéçìÝíåò ìåëÝôåò ãéá ôç äéåñåýíç-óç ôùí ðáñáðÜíù.

×ÇÌÅÉÏÐÑÏÖÕËÁÎÇ ÃÉÁ ËÏÉÌÙÄÇÅÍÄÏÊÁÑÄÉÔÉÄÁÓýìöùíá ìå ôéò ðéï ðñüóöáôåò (2009) ÅõñùðáúêÝò Êá-ôåõèõíôÞñéåò Ïäçãßåò (European Society ofCardiologists), ç Ýíäåéîç ãéá ×ÐÖ ðåñéïñßæåôáé ìüíïóå áóèåíåßò ìå êáñäéïðÜèåéåò õøçëïý êéíäýíïõ êáé ìü-íï ãéá ïñéóìÝíåò õøçëïý ñßóêïõ ãéá åíäïêáñäßôéäá ÷åé-


5. ( .)

1. 90 .

2. 90 .

3. .4. .5. .6. ( . - ) .7. .8. , , , , 65,

.

6. 1. - .2. MRSA ( 1 2

).3.

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>15-20% .4. ( . .

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.



ñïõñãéêÝò ïäïíôéáôñéêÝò Þ Üëëåò åðåìâÜóåéò103 (Ðá-ñÜñôçìá 2 êáé 3).

ÊáñäéïðÜèåéåò õøçëïý êéíäýíïõ ãéá åíäïêáñäßôéäá• ÐñïóèåôéêÞ âáëâßäá Þ Üëëïõò åßäïõò ðñüèåóç ãéá

áðïêáôÜóôáóç âáëâéäïðÜèåéáò (ð.÷. âéïðñüèåóç,âáëâéäïðëáóôéêÞ)

• Éóôïñéêü ëïéìþäïõò åíäïêáñäßôéäáò• ÓõããåíÞò êáñäéïðÜèåéá:

• êõáíùôéêÞ, ðïõ äåí Ý÷åé áðïêáôáóôáèåß ÷åéñïõñ-ãéêÜ Þ ðáñïõóéÜæåé õðïëåéììáôéêÞ äéáöõãÞ Þ öÝ-ñåé ðñüèåóç (ìüó÷åõìá, stent…)

• êõáíùôéêÞ, ðïõ áðïêáôáóôÜèçêå ÷åéñïõñãéêÜ êáéöÝñåé ðñüèåóç < 6 ìçíþí

• êáñäéïðÜèåéá ìå ðáñïõóßá äéáöõãÞò óôï óçìåßïôïðïèÝôçóçò ðñüèåóçò, åßôå áõôÞ ôïðïèåôÞèçêå÷åéñïõñãéêÜ åßôå äéáäåñìéêÜ.

ÅðåìâÜóåéò õøçëïý êéíäýíïõ ãéá åíäïêáñäßôéäá• ïäïíôéáôñéêÝò åðåìâÜóåéò: ìüíï áí áõôÝò ðåñéëáì-

âÜíïõí ÷åéñéóìü ôùí ïýëùí Þ ôïõ áêñïñßæéïõ ôùíäïíôéþí Þ ñÞîç ôïõ óôïìáôéêïý âëåííïãüíïõ (åîá-ãùãÞ, èåñáðåßá ðåñéïäïíôßôéäáò, êáèáñéóìüò)

• ãéá åðåìâÜóåéò ðåðôéêïý (óêëçñïèåñáðåßá, ERCP) • ãéá åðåìâÜóåéò ïõñïãåííçôéêïý (ðñïóôáôåêôïìÞ):

• áìïîõêéëëßíç 2gr per os ðñéí ôçí åðÝìâáóç Þ áìðé-êéëëßíç i.m

• ãéá áëëåñãßá óå â-ëáêôáìéêÜ: êëéíäáìõêßíç 600mg Þ êëáñõèñïìõêßíç (Þ áæéèñïìõêßíç) 500mg,per os Þ i.v Þ 1gr âáíêïìõêßíç i.v

• ãéá åðåìâÜóåéò êáôþôåñïõ ðåðôéêïý êáé ïõñïãåí-íçôéêïý (åêôüò ðñïóôáôåêôïìÞò êáé êõóôåïóêüðç-óçò):• ãéá õøçëïý êéíäýíïõ áóèåíåßò: i.v/i.m áìðéêéëëßíç

2gr + ãåíôáìéêßíç 1.5mg/kg, 30min ðñéí ôçí åðÝì-âáóç êáé áìðéêéëëßíç 1gr 6h ìåôÜ ôçí åðÝìâáóç

• ãéá ìÝôñéïõ êéíäýíïõ áóèåíåßò: i.v/i.m áìðéêéëëßíç2gr, 30min ðñéí ôçí åðÝìâáóç.

Äåí ðñïôåßíåôáé ÷çìåéïðñïöýëáîç ãéá:- âñïã÷ïóêüðçóç, ëáñõããïóêüðçóç, óôïìáôïôñá-

÷åéáêÞ/ñéíïôñá÷åéáêÞ äéáóùëÞíùóç- ãáóôñïóêüðçóç, êïëïíïóêüðçóç- êõóôåïóêüðçóç- äéïéóïöÜãåéï õðåñç÷ïãñÜöçìá êáñäéÜò- ÷åéñéóìïýò äÝñìáôïò-ìáëáêþí ìïñßùí.

ÓÕÌÐÅÑÁÓÌÁÔÁÓýìöùíá ìå ôá ìÝ÷ñé óÞìåñá äåäïìÝíá, üðùò áõôÜðñïêýðôïõí áðü êáôåõèõíôÞñéåò ïäçãßåò, óõóôçìáôé-êÝò áíáóêïðÞóåéò êáé ìåôá-áíáëýóåéò, ãéá ôç ÷çìåéï-

ðñïöýëáîç óôçí Êáñäéï÷åéñïõñãéêÞ éó÷ýïõí ôá ðáñá-êÜôù:

1. ×çìåéïðñïöýëáîç åíäåßêíõôáé óå êáèáñÝò (clean)êáé êáèáñÝò-åðéìïëõóìÝíåò (clean-contaminated)åðåìâÜóåéò. Ç ÷ïñÞãçóç áíôéâéïôéêþí óå åðåìâÜ-óåéò ìå ñõðáñü Þ åðéìïëõóìÝíï ÷åéñïõñãéêü ðåäßï(ìå ðáñïýóá ôç ëïßìùîç), áðïôåëåß ìÝñïò ôçò èåñá-ðåõôéêÞò áãùãÞò êáé ü÷é ×ÐÖ.

2. Ôá áíôéâéïôéêÜ ðïõ ÷ïñçãïýíôáé ãéá ×ÐÖ óôçíÊáñäéï÷åéñïõñãéêÞ ðñÝðåé íá ðåñéëáìâÜíïõí óôïöÜóìá äñÜóçò ôïõò ôá ìéêñüâéá ôïõ ÷åéñïõñãéêïýðåäßïõ. Ç åðéëïãÞ ôùí áíôéâéïôéêþí ðñÝðåé íá ëáì-âÜíåé õðüøç ôçí ôïðéêÞ ìéêñïâéïëïãéêÞ ÷ëùñßäá(óå åðßðåäï ÊëéíéêÞò êáé Íïóïêïìåßïõ) êáèþò êáéôá ðïóïóôÜ áíôï÷Þò ôùí óõ÷íüôåñùí ìéêñïâßùí óôááíôéâéïôéêÜ (local epidemiological data).

3. Ï óõ÷íüôåñïò ìéêñïïñãáíéóìüò ãéá ôéò ×Ë óôçíÊáñäéï÷åéñïõñãéêÞ Þôáí êáé ðáñáìÝíåé ï óôáöõëü-êïêêïò, åíþ ï áðïéêéóìüò áðïôåëåß ðáñÜãïíôá êéí-äýíïõ ãéá åðéìüëõíóç ôïõ ÷åéñïõñãéêïý ðåäßïõ.

4. Óôåíïý öÜóìáôïò êáé ÷áìçëïý êüóôïõò áíôéâéïôéêÜèåùñïýíôáé êáôáëëçëüôåñá ãéá ×ÐÖ.

5. Ðñïôåéíüìåíá áíôéâéïôéêÜ ãéá ×ÐÖ óôçí ÊÑ× ðá-ñáìÝíïõí ïé êåöáëïóðïñßíåò (1çò êáé 2çò ãåíéÜò).

6. Ç ×ÐÖ ÷ïñçãåßôáé åíôüò (within) 30-60 ëåðôþí ðñéíôçí Ýíáñîç ôçò åðÝìâáóçò êáé ç Ýã÷õóÞ ôùí áíôé-âéïôéêþí ïëïêëçñþíåôáé ðñéí ôçí ÷åéñïõñãéêÞ ôïìÞ(ãéá áíôéâéïôéêÜ ìå áðáéôïýìåíç áñãÞ Ýã÷õóç, üðùòç âáíêïìõêßíç êáé ïé öëïõïñïêéíïëüíåò, ç ÷ïñÞãç-óç îåêéíÜ åíôüò ôïõëÜ÷éóôïí 60-120 ëåðôþí ðñéí ôç÷åéñïõñãéêÞ ôïìÞ êáé ïëïêëçñþíåôáé ðñéí áðü áõ-ôÞ).

7. Ç ÷ïñÞãçóç ôùí öáñìÜêùí ôçò ãåíéêÞò áíáéóèçóß-áò óêüðéìï åßíáé íá áðÝ÷åé ÷ñïíéêÜ (5-10 ëåðôÜ)áðü ôçí ×ÐÖ (âë. êßíäõíïò áëëåñãéêÞò áíôßäñáóçòêáé áðü áõôÜ).

8. Ðñïôåßíåôáé äéÜñêåéá ×ÐÖ <48 þñåò. Ç äéÜñêåéáôçò ×ÐÖ äåí ðñÝðåé íá ðáñáôåßíåôáé ëüãù ðáñáìï-íÞò êáèåôÞñùí, öëåâéêþí ãñáììþí êáé ðáñï÷åôåý-óåùí êÜèå åßäïõò.

9. Ãéá äéÜñêåéá åîùóùìáôéêÞò êõêëïöïñßáò Üíù ôùí 4ùñþí ðñïôåßíåôáé êáé äåýôåñç äüóç áíôéâéïôéêïýäéåã÷åéñçôéêÜ (êåöáëïóðïñßíçò).

10. Óå áóèåíåßò õøçëïý êéíäýíïõ ãéá ×Ë ìå MRSA Þóå Íïóïêïìåßï ìå ×Ë áðü MRSA >15-20% åðßôïõ óõíüëïõ ôùí ×Ë, ðñïôåßíåôáé ÷ïñÞãçóç âáíêï-ìõêßíçò (1 äüóç ðñïåã÷åéñçôéêÜ ìå Þ ÷ùñßò 2ç äüóçìåôåã÷åéñçôéêÜ óå 12 þñåò) óå óõíäõáóìü ìå ôçíêëáóéêÞ ×ÐÖ (1çò Þ 2çò ãåíéÜò êåöáëïóðïñßíç).

11. Óå áëëåñãßá óôá â-ëáêôáìéêÜ áíôéâéïôéêÜ ðñïôåß-íåôáé ç âáíêïìõêßíç ìå ðñïóèÞêç áíôéâéïôéêïý ìå


ABSTRACT Antibiotic prophylaxis in Cardiac SurgeryKostoula Arvaniti

Surgical Site Infections (SSIs) in Cardiac Surgery are particularly sternal and mediastinal infections (deep sternal infections:sternitis, mediastinitis) and less commonly endocarditis, complicate about 0.4-4% of surgical procedures and have implicationsfor significantly increasing morbidity and mortality. Staplylococcus aureus and Coagulase Negative Staplylococci (CNS) arethe most implicated pathogens. The optimal antibiotic prophylaxis (AP) has become complex over time due to the emergenceand wide spread of Methicillin Resistant Staphylococcus Aureus (MRSA) and Methicillin Resistant CNS (MR-CNS). Narrowspectrum and inexpensive antibiotics, like first and second generation cephalosporins, were and still remain the mostappropriate choice for AP in cardiac surgery, as in most other surgical procedures. Surgical prophylaxis is administered within30-60 minutes before incision (for antibiotics with a mandatory slow infusion rate, the administration should be started andcompleted at least 60-120 minutes before incision). Anesthetic agents should be administered separately (time distance of 5-10 minutes) for possible allergic reactions. A duration of AP for ?48 hours is proposed as effective in preventing SSIs in cardiacsurgery, without exposing to the risk of antibiotic resistance or to other antibiotic-related side effects. In no condition, the APduration should be extended more than 48 hours just because of remaining tubes or catheters of any kind. For prolongedsurgical interventions (more than 4 hours) with extracorporeal circulation ongoing, an additional AP dose is recommended(cephalospsorin). Vancomycin is indicated as AP in high risk for MRSA infection patients, in hospital settings with >15-20%prevalence of MRSA among nosocomial infections, as a unique dose intraoperatively, combined with the classic 1st or 2ndgeneration cephalospsorin, with or without a second dose 12 hours postoperatively). In patients allergic to b-lactamicantibiotics, a combination of vancomycin with an antibiotic active against gram negative bacteria is proposed (preferably notan aminoglycoside, a quinolone is an option). For patients with risk factors for multi-resistant bacteria and an early re-operation for a non-infectious cause (eg. hematoma), antibiotics with coverage of these bacteria are proposed for a durationof 24-48 hours. Eradication of nasal MRSA carriage with topical application of mupirocin could possibly be proposed as asupplementary measure for preventing any kind of nosocomial MRSA infection. However, such a policy should be performedwith a concomitant surveillance of mupirocin resistance and in cooperation with local Infection Committees. Localadministration of antibiotics as routine practice for SSIs prevention in cardiac surgery is not recommended as not proveneffective. Surgical antibiotic prophylaxis should take into consideration local data concerning incidence rates and resistancepatterns of the most common hospital bacteria (local epidemiological data). Efforts to improve AP in terms of antibioticchoice and appropriate duration can certainly help controlling the unjustified use of antibiotics in the hospital setting.

Keywords: surgical prophylaxis, antibiotic prophylaxis, antimicrobial prophylaxis, cardiac surgery.


äñÜóç Ýíáíôé gram-áñíçôéêþí ìéêñïâßùí (ü÷é áìé-íïãëõêïóßäç, ðéèáíÞ åðéëïãÞ êÜðïéá êéíïëüíç).

12. Óå áóèåíåßò ìå ãíùóôü Þ ýðïðôï áðïéêéóìü ìå ðï-ëõáíèåêôéêÜ ìéêñüâéá êáé óå ðñþéìç åðáíåðÝìâá-óç ãéá ìç ëïéìþäåò áßôéï, óõóôÞíåôáé ×ÐÖ ìå ó÷Þ-ìá ðïõ êáëýðôåé êáé ôá ìéêñüâéá áõôÜ, ãéá 24-48þñåò óõíïëéêÜ.

13. Ç åêñßæùóç ñéíéêÞò öïñåßáò MRSA ìå ìïõðõñïóß-íç ìðïñåß íá ðñïôáèåß ùò åðéêïõñéêü ìÝôñï ãéá ôïíÝëåã÷ï ôùí íïóïêïìåéáêþí ëïéìþîåùí áðü MRSA,ìå Üãñõðíç, ùóôüóï, åðéôÞñçóç ôçò áíôï÷Þò óôïáíôéâéïôéêü êáé óå óõíåííüçóç ìå ôéò ÅÍË ôùí Íï-óïêïìåßùí.

14. ÔïðéêÞ åöáñìïãÞ Üëëïõ åßäïõò áíôéâéïôéêþí êáéðëýóåéò ìå áíôéâéïôéêÜ/áíôéóçðôéêÜ äåí åßíáé åðáñ-êþò ôåêìçñéùìÝíåò êáé äå óõóôÞíïíôáé ùò ôáêôéêÞñïõôßíáò.

15. Ãéá êÜèå Íïóïêïìåßï êñßíåôáé óêüðéìç ç Ýêäïóçôïðéêþí ïäçãéþí ÷çìåéïðñïöýëáîçò êáé ç óõíå÷ÞòáíáðñïóáñìïãÞ ôïõò óå ôïðéêÜ, åèíéêÜ êáé äéåèíÞäåäïìÝíá ðïõ áöïñïýí ôç óõ÷íüôçôá ôùí ×Ë êáé

ôùí õðåýèõíùí ìéêñïâßùí, ôá ðïóïóôÜ ìéêñïâéá-êÞò áíôï÷Þò êáé ôá åðéêáéñïðïéçìÝíá óõìðåñÜóìá-ôá åðéóôçìïíéêþí áíáêïéíþóåùí.

16. Ç ÷çìåéïðñïöýëáîç óõìâÜëåé óôçí áëëáãÞ ôçòáôïìéêÞò êáé ôçò óõíïëéêÞò, óå åðßðåäï ÊëéíéêÞò,Íïóïêïìåßïõ êáé ÷þñáò, ìéêñïâéáêÞò ÷ëùñßäáò,ïäçãþíôáò óå áðïéêéóìü ìå Üëëïôå Üëëá ìéêñüâéáêáé óå áíÜðôõîç ìéêñïâéáêÞò áíôï÷Þò. Ðåñéïñé-óìüò ôçò óõ÷íüôçôáò êáé ôçò äéÜñêåéáò ôçò ×ÐÖ,êõñßùò ôùí êåöáëïóðïñéíþí êáé ôçò êëéíäáìõêß-íçò, êáèþò êáé åðéëïãÞ áõôþí ìå âÜóç ôá ôïðéêÜåðéäçìéïëïãéêÜ äåäïìÝíá ôçò ÊëéíéêÞò êáé ôïõ Íï-óïêïìåßïõ, áðïôåëïýí óçìáíôéêÝò åíÝñãåéåò ðñïòôçí êáôåýèõíóç ôçò ìåßùóçò ôùí áíåðéèýìçôùíåíåñãåéþí ôùí áíôéâéïôéêþí óôï óýíïëü ôïõò.



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