多重耐藥菌感染的預(yù)防與控制(胡必杰)ppt

1、2022/7/16Dr.HU Bijie12022/7/16Dr.HU Bijie1多重耐藥菌感染的預(yù)防(yfng)與控制復(fù)旦大學附屬中山(zhn shn)醫(yī)院Zhongshan Hospital of Fudan University胡必杰 Bijie HU共九十一頁共九十一頁對于超級細菌/多重耐藥菌，要防被忽悠(h you)，更要防止麻木！共九十一頁耐藥菌的難題(nnt)，遠不止NDM-1！MRSAPDR-不動桿菌銅綠(tngl)假單胞菌艱難梭菌VREESBL，KPC，NDM-1多重耐藥結(jié)核分枝桿菌共九十一頁什么(shn me)是多重耐藥菌？多重耐藥菌（Multidrug-Resistan

2、t Organism，MDRO），主要是指對臨床使用的三類或三類以上抗菌藥物同時呈現(xiàn)耐藥的細菌。常見多重耐藥菌包括耐甲氧西林金黃色葡萄球菌（MRSA）、耐萬古霉素腸球菌（VRE）、產(chǎn)超廣譜-內(nèi)酰胺酶（ESBLs）細菌、耐碳青霉烯類抗菌藥物腸桿菌(gnjn)科細菌（CRE）（如產(chǎn)型新德里金屬-內(nèi)酰胺酶NDM-1或產(chǎn)碳青霉烯酶KPC的腸桿菌科細菌）、耐碳青霉烯類抗菌藥物鮑曼不動桿菌（CR-AB）、多重耐藥/泛耐藥銅綠假單胞菌（MDR/PDR-PA)和多重耐藥結(jié)核分枝桿菌等。共九十一頁2022/7/16Dr.HU Bijie6臨床情景某男，65歲腦膠質(zhì)瘤術(shù)后20天高熱，黃痰，呼吸困難留置中心靜脈導(dǎo)管

3、、導(dǎo)尿管和人工氣道機械通氣胸片肺炎痰培養(yǎng)：PDR-AB血培養(yǎng)：陰溝(yngu)腸桿菌尿培養(yǎng)：兩種念珠菌結(jié)局術(shù)后1月死亡花費：10萬元？2008年7月某醫(yī)院(yyun)會診病例共九十一頁醫(yī)院感染(gnrn)越來越險惡！案例某男，90歲，COPD多年，反復(fù)感染，近日鮑曼不動桿菌肺部感染某男，56歲，肺癌術(shù)后一周，高熱、呼吸衰竭，重癥肺炎，鮑曼不動桿菌某男，22歲，顱腦手術(shù)(shush)后2周，高熱，CSF引流液鮑曼不動桿菌共九十一頁2005-2009年上海XX醫(yī)院鮑曼不動桿菌(gnjn)對亞胺培南耐藥率變化18.6%41.9%32.2%44%59.3% 2006年 2007年 2008年 2009

4、年 2005年共九十一頁正確認識接觸(jich)預(yù)防有效控制多重耐藥菌MDRO共九十一頁耐藥菌增加(zngji)的原因耐藥菌產(chǎn)生增加（抗生素選擇性壓力）：由于醫(yī)生過多地使用抗生素，造成對基因突變及耐藥基因轉(zhuǎn)移的耐藥菌進行了篩選耐藥菌傳播增加：通過醫(yī)護人員尤其手的接觸，細菌在病人(bngrn)間交叉寄生造成耐藥菌株在醫(yī)院內(nèi)的傳播，以及隨后通過宿主病人(bngrn)的轉(zhuǎn)移，耐藥菌在醫(yī)院間甚至社區(qū)進行傳播共九十一頁Antimicrobial Resistance惡性循環(huán)( xng xn hun)耐藥性增加 更廣譜抗菌藥物Susceptible pathogenAntimicrobial-Resist

5、ant PathogenAntimicrobial ResistanceAntimicrobial UseInfection共九十一頁2022/7/16Dr.HU Bijie12 預(yù)防傳播(chunb)合理應(yīng)用抗菌藥物有效的診斷和治療預(yù)防感染Campaign to Prevent Antimicrobial Resistance in Healthcare Settings12 遏制( zh)醫(yī)務(wù)工作者傳播11 隔離患者9 嚴格掌握萬古霉素應(yīng)用指證1 接種疫苗2 拔除導(dǎo)管6 專家會診7 治療感染，而非污染3 針對性病原治療8 治療感染，而非寄殖4 控制抗菌藥物應(yīng)用5 應(yīng)用當?shù)刭Y料10 及時停用

6、抗菌藥物預(yù)防抗菌藥物耐藥的12項措施對感染控制措施的描述，太簡單！共九十一頁2010年上海某醫(yī)院(yyun)ICU中22例病人痰培養(yǎng)檢出多重耐藥菌鮑曼不動桿菌，PFGE結(jié)果MMT1T2T3T8T7T6T5T12T11T10T9共九十一頁National Patient Safety Goals, Hospital & Critical Access Hospital, 20097c. Prevent multiple drug-resistant organisms (MDRO) infections, especially methicillin-resistant Staphylococc

7、us aureus (MRSA) and Clostridium difficile-associated disease (CDAD).7d. Prevent catheter-associated BSI (CABSI)7e. Prevent surgical site infections (SSI)13a. Patient involvement in their care: respiratory & hand hygiene on day of admission pt. & family共九十一頁美國(mi u)National Patient Safety GoalNPSG.0

8、7.03.01-Implement evidence-based practices to prevent health care-associated infections due to multi-drug resistant organisms (MDRO). These organisms are not transmitted by air. They are spread by contact via hands or contaminated environment. MRSAC. difficileVRE MDR gram negative bacteria共九十一頁Sprea

9、d of MDROs Can Be Controlled By:Good infection control practicesMeticulous hand hygiene for contact with patient and patients environment of Standard PrecautionsGood environmental and equipment cleaning practicesHCW knowledge regarding these organisms and how they are spreadJudicious use of antibiot

10、icsTeaching patient and family共九十一頁FIGHTSFollow isolation practicesIn-service training for staff Gauging disinfectant efficacyHand hygieneTesting environmental surfacesStandardized cleaning procedures共九十一頁衛(wèi)生部辦公廳關(guān)于印發(fā)多重耐藥菌醫(yī)院感染預(yù)防(yfng)與控制技術(shù)指南（試行）的通知（2011.1.17）一、加強多重耐藥菌醫(yī)院感染管理（一）重視多重耐藥菌醫(yī)院感染管理（二）加強重點環(huán)節(jié)管理（

11、三）加大人員培訓力度二、強化預(yù)防與控制措施（一）加強醫(yī)務(wù)人員手衛(wèi)生（二）嚴格實施隔離措施（三）遵守(znshu)無菌技術(shù)操作規(guī)程（四）加強清潔和消毒工作三、合理使用抗菌藥物四、建立和完善對多重耐藥菌的監(jiān)測（一）加強多重耐藥菌監(jiān)測工作（二）提高臨床微生物實驗室的檢測能力共九十一頁共九十一頁WHO抵御細菌(xjn)耐藥的6項政策 制定并執(zhí)行一套完整的、有資金支持的國家計劃加強監(jiān)測與實驗室能力確保不間斷獲得(hud)質(zhì)量有保證的基本藥物規(guī)范并促進藥物的合理使用加大感染防控力度促進創(chuàng)新和新工具的研發(fā)共九十一頁最新MDRO BundleHand Hygiene 手衛(wèi)生Contact precaution

12、s 接觸隔離Minimize shared equipment 減少設(shè)備共用(n yn)Environmental cleaning 環(huán)境清潔HAI Preventive Bundles 醫(yī)院感染的組合預(yù)防Catheter-associated BSI 導(dǎo)管相關(guān)血流感染Ventilator-associated pneumonia 呼吸機相關(guān)肺炎Catheter-associated UTI 導(dǎo)尿管相關(guān)尿路感染Active surveillance cultures 主動監(jiān)測培養(yǎng)Chlorhexidine baths 洗必泰洗浴Antimicrobial stewardship 抗菌藥物管理共

13、九十一頁ANTIBIOTIC RESISTANT PATHOGENSON / INPATIENTSENVIRONMENTAL SURFACESHCWHANDSSUSCEPTABLE PATIENTSISOLATIONHAND HYGENEDISINFECTION CLEANING共九十一頁超級細菌(xjn)出現(xiàn)/MDRO泛濫，我們需要改變什么呢？接觸傳播的隔離手衛(wèi)生：洗手液、抗菌洗手液、手消毒液醫(yī)院環(huán)境消毒：手接觸的物表隔離衣、口罩與手套隔離多重耐藥菌主動(zhdng)篩查與去污染。更明智地合理使用抗菌藥物共九十一頁2022/7/16Dr.HU Bijie24手衛(wèi)生(wishng)共九十一頁酒

14、精(jijng)擦手的優(yōu)點比洗手有更高的依從性比普通洗手和用抗菌產(chǎn)品洗手更有效比洗手對手部皮膚傷害少比洗手和戴手套浪費少所用時間少，作用(zuyng)快不需要水和毛巾感染控制，不僅僅是手衛(wèi)生!共九十一頁2022/7/16Dr.HU Bijie26接觸(jich)隔離共九十一頁接觸(jich)隔離的要求隔離：盡量將患者安置于單間個人防護用品：手套、圍裙或隔離衣、面罩手衛(wèi)生：洗手液、抗菌洗手液、手消毒液物品專用：如血壓計、聽診器。不能專用者，則清潔、消毒后才能用于其他病人醫(yī)院環(huán)境消毒：手接觸(jich)的物表多重耐藥菌主動篩查與去污染共九十一頁2022/7/16Dr.HU Bijie28哪些病原體

15、感染需要(xyo)隔離？耐藥菌MRSA，不動桿菌(gnjn)艱難梭菌，VREESBL？銅綠假單胞菌？傳染病TB，SARS，諾如病毒HIV？HBV？耐藥菌危害嚴重，我國必須制訂政策，進行嚴格隔離！耐藥菌隔離的警告標識共九十一頁多重耐藥菌進行專門(zhunmn)標記（德國某醫(yī)院）共九十一頁何時開始(kish)隔離？何時解除隔離？發(fā)現(xiàn)多重耐藥菌感染患者和定植患者后，要盡快反饋相關(guān)臨床科室，指導(dǎo)采取有效治療和感染控制措施?；颊吒綦x期間需要定期監(jiān)測多重耐藥菌感染情況，直至(zhzh)連續(xù)3次（每次間隔應(yīng)大于24h）多重耐藥菌培養(yǎng)陰性或感染已經(jīng)痊愈方可解除隔離。共九十一頁2022/7/16Dr.HU Bi

16、jie31減少(jinsho)設(shè)備共用共九十一頁ICU減少共用(n yn)物品聽診器血壓計體溫表微量輸液泵共九十一頁2022/7/16Dr.HU Bijie33環(huán)境(hunjng)清潔共九十一頁2022/7/16Dr.HU Bijie34 環(huán)境(hunjng)微生物菌落總數(shù)衛(wèi)生標準類別 范圍(fnwi) 空氣 物體表面 醫(yī)務(wù)人員手 層流室 10 5 5 普通手術(shù)室等 200 5 5 普通病房等 500 10 10 傳染科及病房 15 15環(huán)境微生物監(jiān)測要求必須改變！共九十一頁Pathogen Survival in the EnvironmentAdapted from: Kramer A,

17、et al. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis. 2006;16(6):130. Used with permission.OrganismDuration of persistence (range)Acinetobacter spp.3 days-5 monthsClostridium difficile (spores)5 monthsEscherichia coli1.5 hours-16 monthsEnterococc

18、us spp, including VRE5 days-4 months Influenza virus1-2 daysNorovirus8 hours-7 daysStaphylococcus aureus, including MRSA7 days-7 months共九十一頁DecontaminationRisk of infection by used items in healthcare1968 Earle H Spaulding Critical items: Items that enter sterile tissue or vascular systemSemi-critic

19、al itemsItems that come in contact with mucous membranes or non intact skinNon-critical itemsItems that come in contact with intact skin共九十一頁手頻繁接觸的物體(wt)表面，是高度危險的！共九十一頁共九十一頁High-touch equals high-risk: surface cleaning plus hand hygiene key to HAI preventionWith the ever increasing proliferation of

20、superbugs, comes not only a need for new products and protocols but also a look back at fundamental interventions. Hand hygiene and environmental cleaning and disinfection are the two primary interventions that we can make and those are definitely back to basics, said Sue Barnes, national leader, in

21、fection prevention and control and patient safety, Kaiser Permanente Program Offices, and a member of the National APIC communications committee.Healthcare Purchasing News, June, 2009 共九十一頁ICU中，容易(rngy)被污染的物表溫度計輸液泵和支架氧氣流量表呼吸機控制面板/旋鈕生命監(jiān)測儀面板/旋鈕血壓計袖帶聽診器電腦(dinno)鍵盤、鼠標電話呼叫按鈕床頭桌床上托盤電視遙控器床上用臺燈床邊便桶床架和控制器共九十

22、一頁ICU環(huán)境中耐藥鮑曼不動桿菌(gnjn)污染嚴重共九十一頁 Removes organic soil / visible soil Removes potentially infectious micro organisms Removes soil which protects m.o. during disinfectionCareful cleaning Mechanical energy- friction, flushing, scrubbingChemical products - detergents or enzymesRight Method- manual & mach

23、inalManual Cleaning共九十一頁Manual CleaningNO SAFE Products!共九十一頁 Everybody is an “EXPERT” Difficult to monitor Responsibilities not clear Health-risk Manual CleaningNO SAFE Procedure!共九十一頁 Common in Households Not Common in Healthcare settings Easy to use Standardization & Validation Better Result Save

24、s Nursing Time Monitoring Thermal Disinfection Machinal CleaningMachinal Cleaning is Safer共九十一頁病區(qū)的基本配置(pizh)：清洗消毒機共九十一頁日本尿壺與便盆(binpn)的消毒共九十一頁關(guān)注(gunzh)頻繁手接觸物體表面的去污染共九十一頁 MICRO FIBER The “cleaner” cleaning system共九十一頁關(guān)東(Gundng)病院設(shè)備科-保養(yǎng)與維修共九十一頁How Can We Evaluate Environmental CleaningDirect observatio

25、nCulture the environmentATP bioluminescence ToolFluorescent marking tool03/26/2010TSICP51共九十一頁 TESTING OF SURFACES共九十一頁ATP bioluminescence Swab surface luciferase tagging of ATP Hand held luminometerUsed in the commercial food preparation industry to evaluate surface cleaning before reuse and as an

26、educational tool for more than 30 years.共九十一頁ATP is present in blood, skin cells, other bodily fluids and microbes.ATP存在于血液(xuy)，皮膚細胞，其它體液和微生物中。 共九十一頁Dazo Solution(Initially called “GOO”)共九十一頁共九十一頁Baseline Environmental Evaluation of 36 Acute Care Hospitals% of Objects CleanedHospitalsMean = 48.5 %(

27、20,056 Objects)共九十一頁PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS%共九十一頁17 HOSPITALS10 HOSPITALS8 HOSPITALSTerminal Room Cleaning Project Three Programmatic Responses共九十一頁Hospitals Environmental Hygiene Study Group36 Hospital Results % of Objects Cleaned P

28、RE INTERVENTION POST INTERVENTIONP = 100 ppm available chlorinePhenolic germicidal detergent solutionIodophor germicidal detergent solutionEthyl or isopropyl alcohol (70-90%) Hydrogen peroxide solutions共九十一頁Clean/disinfect:On a regular basis, When spills occur, When visibly soiled Follow manufacture

29、rs instructions for proper use:use-dilution, dwell time,material compatibility, storage, shelf-life.1:10 Bleach recommended for C. difficileCleaning & Disinfecting Non-critical Items共九十一頁2022/7/16Dr.HU Bijie67主動監(jiān)測(jin c)培養(yǎng)共九十一頁Reservoir for Spread of Antibiotic Resistant PathogensClinical Infections

30、Colonized (Asymptomatic) Patients共九十一頁2022/7/16Dr.HU Bijie69對超級(choj)細菌MRSA感染的“零寬容”主動篩查：快速監(jiān)測積極(jj)隔離：包括疑似病例的隔離就地消滅：包括環(huán)境消毒共九十一頁Outcomes: Active Surveillance Controls MRSA BSIsHuang et al., CID 2006;43:971-8共九十一頁美國(mi u)20個州立法：住院病人主動篩查、隔離MRSA和VRE共九十一頁進行(jnxng)主動篩查的人群全部新入住ICU的病人？使用(shyng)機械通氣的病人？具有高危因素

31、的ICU病人？全體住院病人？醫(yī)務(wù)人員？共九十一頁2022/7/1673ICU病人(bngrn)MDROs主動監(jiān)測培養(yǎng)鼻拭子MRSA肛拭子ESBLs鮑曼不動桿菌(gnjn)銅綠假單胞菌共九十一頁2022/7/16Dr.HU Bijie74醫(yī)院感染(gnrn)的組合預(yù)防共九十一頁ICU需要重點防范(fngfn)的醫(yī)院感染呼吸機相關(guān)肺炎(fiyn)VAP插管相關(guān)的血流感染CA-BSI插管相關(guān)的尿路感染CA-UTI多重耐藥菌感染MDROs醫(yī)院感染暴發(fā)outbreak共九十一頁2022/7/16Dr.HU Bijie76美國目前推行(tuxng)的預(yù)防VAP bundle床頭(chun tu)抬高至少3

32、0度Head of bed - 30 每天一次停用鎮(zhèn)靜劑并評價是否可以撤機Sedation Holiday/weaning盡早停用應(yīng)激性潰瘍預(yù)防藥物Peptic Ulcer Disease (PUD) Prophylaxis口腔護理：用洗必泰沖洗每26小時Oral care 深靜脈血栓預(yù)防Deep Vein Thrombosis (DVT) Prophylaxis插管氣囊上方分泌物的吸引（？）共九十一頁2022/7/16Dr.HU Bijie77預(yù)防(yfng)CR-BSI： bundle留置導(dǎo)管術(shù)時最大無菌屏障Maximal sterile barriers洗必泰皮膚消毒Chlorhexid

33、ine skin antisepsis盡量使用鎖骨下靜脈部位(bwi)穿刺Site choice嚴格執(zhí)行手衛(wèi)生規(guī)則HAND HYGIENE每天評估是否需要繼續(xù)留置導(dǎo)管抗菌導(dǎo)管Antibiotic-coated or antiseptic- impregnated catheter插管后的護理Post-insertion care共九十一頁2022/7/16Dr.HU Bijie78洗必泰洗浴(x y)共九十一頁洗必泰對于(duy)鮑曼不動桿菌的控制共九十一頁Impact of 4% Chlorhexidine (CHG) Whole-Body Washing on Multidrug-resi

34、stant Acinetobacter baumannii (ACBA) Skin Colonisation-Patients in a MICUAll patients daily whole-body disinfection with CHGOf 320 patients at admission, 55(17%)ACBA-positive skin swabsPrevalence of ACBA skin colonisation among remaining patients was 5.5% at 24h and 1% at 48h (P=0.002,OR:2.4)ACBA-BS

35、Is decreased from 4.6 to 0.6 per 100 patients (P0.001;OR:7.6)Daily whole-body CHG disinfection significantly reduced ACBA skin colonisation and BSIs共九十一頁洗必泰全身(qun shn)擦浴顯著降低病原菌皮膚的定植（MRSA、VRE、鮑曼等）減少(jinsho)交叉感染降低CRBSI的發(fā)生率減少抗生素的使用共九十一頁2022/7/16Dr.HU Bijie82抗菌藥物(yow)管理共九十一頁Antibiotic StewardshipID Divi

36、sionInfectious Diseases SpecialistDepartment of PharmacyClinical PharmacistHealth administrationAntibiotic Utilization Review Subcommittee Electronic antibiotic stewardshipcomputerized antimicrobial approval system in a hospital setting Education and interactionInfection control professional共九十一頁抗菌治

37、療策略(Antibiotic Therapy Strategies) 降階梯治療策略（De-Escalation Therapy 短程治療策略(short-course therapy) 聯(lián)合治療（combination therapy） 優(yōu)化藥動學/藥效學原則（Optimizing PK/PD principles） 消除(xioch)定植策略（Antimicrobial Decolonization Strategies） 抗菌藥物管理策略(Antibiotic Management Strategies) 指南（Guidelines） 限制處方（formulary restriction） 抗生素輪換(Antibiotic Cycling) 抗生素替換/干預(yù)策略(subst