多重耐藥菌感染的預(yù)防與控制(胡必杰)

精品課件12024/12/1Dr.HUBijie12024/12/1Dr.HUBijie1多重耐藥菌感染的預(yù)防與控制復(fù)旦大學(xué)附屬中山醫(yī)院ZhongshanHospitalofFudanUniversity胡必杰BijieHU精品課件2精品課件3對于超級細(xì)菌/多重耐藥菌，

要防被忽悠，更要防止麻木！精品課件4耐藥菌的難題，遠(yuǎn)不止NDM-1！MRSAPDR-不動桿菌銅綠假單胞菌艱難梭菌VREESBL,KPC,NDM-1多重耐藥結(jié)核分枝桿菌精品課件5什么是多重耐藥菌？多重耐藥菌（Multidrug-ResistantOrganism,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(xì)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β-內(nèi)酰胺酶（ESBLs）細(xì)菌、耐碳青霉烯類抗菌藥物腸桿菌科細(xì)菌（CRE）（如產(chǎn)Ⅰ型新德里金屬β-內(nèi)酰胺酶[NDM-1]或產(chǎn)碳青霉烯酶[KPC]的腸桿菌科細(xì)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。精品課件62024/12/1Dr.HUBijie6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、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)院會診病例精品課件7醫(yī)院感染越來越險惡！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)后2周,高熱,CSF引流液鮑曼不動桿菌精品課件82005-2009年上海XX醫(yī)院

鮑曼不動桿菌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年

2005年精品課件9正確認(rèn)識接觸預(yù)防

有效控制多重耐藥菌MDRO精品課件10耐藥菌增加的原因耐藥菌產(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(xì)菌在病人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的轉(zhuǎn)移，耐藥菌在醫(yī)院間甚至社區(qū)進行傳播精品課件11AntimicrobialResistance惡性循環(huán)耐藥性增加更廣譜抗菌藥物SusceptiblepathogenAntimicrobial-Resistant

PathogenAntimicrobialResistanceAntimicrobialUseInfection精品課件122024/12/1Dr.HUBijie12

預(yù)防傳播合理應(yīng)用抗菌藥物有效的診斷和治療預(yù)防感染CampaigntoPreventAntimicrobialResistanceinHealthcareSettings12遏制醫(yī)務(wù)工作者傳播11隔離患者9嚴(yán)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(dāng)?shù)刭Y料10及時停用抗菌藥物預(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！精品課件132010年上海某醫(yī)院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精品課件14NationalPatientSafetyGoals,Hospital&CriticalAccessHospital,20097c.Preventmultipledrug-resistantorganisms(MDRO)infections,especiallymethicillin-resistantStaphylococcusaureus(MRSA)andClostridiumdifficile-associateddisease(CDAD).7d.Preventcatheter-associatedBSI(CABSI)7e.Preventsurgicalsiteinfections(SSI)13a.Patientinvolvementintheircare:respiratory&handhygieneondayofadmission–pt.&family精品課件15美國NationalPatientSafetyGoalNPSG.07.03.01-Implementevidence-basedpracticestopreventhealthcare-associatedinfectionsduetomulti-drugresistantorganisms(MDRO).Theseorganismsarenottransmittedbyair.Theyarespreadbycontactviahandsorcontaminatedenvironment.MRSAC.difficileVREMDRgramnegativebacteria精品課件16SpreadofMDROsCanBeControlledBy:GoodinfectioncontrolpracticesMeticuloushandhygieneforcontactwithpatientandpatient’senvironmentofStandardPrecautionsGoodenvironmentalandequipmentcleaningpracticesHCWknowledgeregardingtheseorganismsandhowtheyarespreadJudicioususeofantibioticsTeachingpatientandfamily精品課件17FIGHTSFollowisolationpracticesIn-servicetrainingforstaffGaugingdisinfectantefficacyHandhygieneTestingenvironmentalsurfacesStandardizedcleaningprocedures精品課件18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（三）加大人員培訓(xùn)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(yán)格實施隔離措施（三）遵守?zé)o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精品課件19精品課件20WHO抵御細(xì)菌耐藥的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)精品課件21最新MDROBundleHandHygiene手衛(wèi)生Contactprecautions接觸隔離Minimizesharedequipment減少設(shè)備共用Environmentalcleaning環(huán)境清潔HAIPreventiveBundles醫(yī)院感染的組合預(yù)防Catheter-associatedBSI導(dǎo)管相關(guān)血流感染Ventilator-associatedpneumonia呼吸機相關(guān)肺炎Catheter-associatedUTI導(dǎo)尿管相關(guān)尿路感染Activesurveillancecultures主動監(jiān)測培養(yǎng)Chlorhexidinebaths洗必泰洗浴Antimicrobialstewardship抗菌藥物管理精品課件22ANTIBIOTICRESISTANTPATHOGENSON/INPATIENTSENVIRONMENTALSURFACESHCWHANDSSUSCEPTABLEPATIENTSISOLATIONHANDHYGENEDISINFECTIONCLEANING精品課件23超級細(xì)菌出現(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篩查與去污染。。。更明智地合理使用抗菌藥物精品課件242024/12/1Dr.HUBijie24手衛(wèi)生精品課件25酒精擦手的優(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,作用快不需要水和毛巾感染控制,不僅僅是手衛(wèi)生!精品課件262024/12/1Dr.HUBijie26接觸隔離精品課件27接觸隔離的要求隔離: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:手接觸的物表多重耐藥菌主動篩查與去污染……精品課件282024/12/1Dr.HUBijie28哪些病原體感染需要隔離？耐藥菌MRSA，不動桿菌艱難梭菌，VREESBL？銅綠假單胞菌？傳染病TB，SARS，諾如病毒……HIV？HBV？耐藥菌危害嚴(yán)重，我國必須制訂政策，進行嚴(yán)格隔離！耐藥菌隔離的警告標(biāo)識精品課件29多重耐藥菌進行專門標(biāo)記（德國某醫(yī)院）精品課件30何時開始隔離？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。精品課件312024/12/1Dr.HUBijie31減少設(shè)備共用精品課件32ICU減少共用物品聽診器血壓計體溫表微量輸液泵……精品課件332024/12/1Dr.HUBijie33環(huán)境清潔精品課件342024/12/1Dr.HUBijie34環(huán)境微生物菌落總數(shù)衛(wèi)生標(biāo)準(zhǔn)

類別范圍空氣物體表面醫(yī)務(wù)人員手Ⅰ層流室≤10≤5≤5Ⅱ普通手術(shù)室等≤200≤5≤5Ⅲ普通病房等≤500≤10≤10Ⅳ傳染科及病房－≤15≤15環(huán)境微生物監(jiān)測要求必須改變！精品課件35PathogenSurvivalintheEnvironmentAdaptedfrom:KramerA,etal.Howlongdonosocomialpathogenspersistoninanimatesurfaces?Asystematicreview.BMCInfectDis.2006;16(6):130.Usedwithpermission.OrganismDurationofpersistence(range)Acinetobacterspp.3days-5monthsClostridiumdifficile(spores)5monthsEscherichiacoli1.5hours-16monthsEnterococcusspp,includingVRE5days-4monthsInfluenzavirus1-2daysNorovirus8hours-7daysStaphylococcusaureus,includingMRSA7days-7months精品課件36

DecontaminationRiskofinfectionbyuseditemsinhealthcare1968EarleHSpauldingCriticalitems:ItemsthatentersteriletissueorvascularsystemSemi-criticalitemsItemsthatcomeincontactwithmucousmembranesornonintactskinNon-criticalitemsItemsthatcomeincontactwithintactskin精品課件37手頻繁接觸的物體表面，

是高度危險的！精品課件38精品課件39High-touchequalshigh-risk:

surfacecleaningplushandhygiene

keytoHAIpreventionWiththeeverincreasingproliferationofsuperbugs,comesnotonlyaneedfornewproductsandprotocolsbutalsoalookbackatfundamentalinterventions."Handhygieneandenvironmentalcleaninganddisinfectionarethetwoprimaryinterventionsthatwecanmakeandthosearedefinitelybacktobasics,"saidSueBarnes,nationalleader,infectionpreventionandcontrolandpatientsafety,KaiserPermanenteProgramOffices,andamemberoftheNationalAPICcommunicationscommittee.HealthcarePurchasingNews,June,2009精品課件40ICU中,容易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鍵盤、鼠標(biāo)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精品課件41ICU環(huán)境中耐藥鮑曼不動桿菌污染嚴(yán)重精品課件42Removesorganicsoil/visiblesoilRemovespotentiallyinfectiousmicroorganismsRemovessoilwhichprotectsm.o.duringdisinfectionCarefulcleaningMechanicalenergy -friction,flushing,scrubbingChemicalproducts -detergentsorenzymesRightMethod -manual&machinalManualCleaning精品課件43ManualCleaningNOSAFEProducts!精品課件44

Everybodyisan“EXPERT” Difficulttomonitor

Responsibilitiesnotclear Health-riskManualCleaningNOSAFEProcedure!精品課件45

CommoninHouseholdsNotCommoninHealthcaresettingsEasytouseStandardization&ValidationBetterResultSavesNursingTimeMonitoringThermalDisinfection

MachinalCleaningMachinalCleaningisSafer精品課件46病區(qū)的基本配置:清洗消毒機精品課件47日本尿壺與便盆的消毒精品課件48關(guān)注頻繁手接觸物體表面的去污染精品課件49

MICROFIBER

The“cleaner”cleaningsystem精品課件50關(guān)東病院設(shè)備科-保養(yǎng)與維修精品課件51HowCanWeEvaluateEnvironmentalCleaningDirectobservationCulturetheenvironmentATPbioluminescenceToolFluorescentmarkingtool03/26/2010TSICP51精品課件52

TESTINGOFSURFACES精品課件53ATPbioluminescence

SwabsurfaceluciferasetaggingofATPHandheldluminometerUsedinthecommercialfoodpreparationindustrytoevaluatesurfacecleaningbeforereuseandasaneducationaltoolformorethan30years.精品課件54ATPispresentinblood,skincells,otherbodilyfluidsandmicrobes.ATP存在于血液,皮膚細(xì)胞,其它體液和微生物中。精品課件55DazoSolution

(Initiallycalled“GOO”)精品課件56精品課件57BaselineEnvironmentalEvaluationof36AcuteCareHospitals%ofObjectsCleanedHospitalsMean=48.5%(20,056Objects)精品課件58PROPORTIONOFOBJECTSCLEANEDASPARTOFTERMINALROOMCLEANINGIN20ACUTECAREHOSPITALS

%精品課件5917HOSPITALS10HOSPITALS8HOSPITALSTerminalRoomCleaningProject–ThreeProgrammaticResponses精品課件60HospitalsEnvironmentalHygieneStudyGroup

36HospitalResults

%ofObjectsCleaned

PREINTERVENTION

POSTINTERVENTIONP=<.0001ResourceNeutral精品課件61TERMINALROOMCLEANINGINFECTIONPREVENTION

TARGETS

SinkandFaucetsToiletSurfacesToiletFlushHandleBedpanCleanerToiletAreaHandholdsToiletAreaDoorKnobsorPushPlatesBedsideTableTrayTablePatientChairSideRailsRoomDoorKnobsCallBoxTelephoneBathroomLightSwitchesSpecificOpportunitiesforImprovement精品課件62EvaluatingPatientZoneEnvironmentalHygiene精品課件63如何選擇表面消毒劑殺菌譜和殺菌速度需要多長時間來殺死病菌？是否對有機物污染敏感？材料和器械兼容性毒性手套兼容性精品課件64LowandIntermediateLevelDisinfectants

Use:non-criticalitemsthatwillcomeincontactwithintactskin

Low-leveldisinfectant:agentthatdestroysallvegetativebacteria(excepttuberclebacilli),lipidviruses,somenon-lipidviruses,andsomefungi,butnotbacterialsporesIntermediate-leveldisinfectant:agentthatdestroysallvegetativebacteria,includingtuberclebacilli,lipidandsomenon-lipidviruses,andfungi,butnotbacterialsporesHICPACGuidelineforDisinfectionandSterilizationinHealthcareFacilities,2008.精品課件65ExamplesofLow&IntermediateLevelDisinfectantsQuaternaryammoniumgermicidaldetergentsolution(quat)Sodiumhypochlorite5.25-6.15%householdbleachdiluted1:500provides>100ppmavailablechlorinePhenolicgermicidaldetergentsolutionIodophorgermicidaldetergentsolutionEthylorisopropylalcohol(70-90%)Hydrogenperoxidesolutions精品課件66Clean/disinfect:Onaregularbasis,Whenspillsoccur,WhenvisiblysoiledFollowmanufacturers’instructionsforproperuse:use-dilution,dwelltime,materialcompatibility,storage,shelf-life.1:10BleachrecommendedforC.difficileCleaning&DisinfectingNon-criticalItems精品課件672024/12/1Dr.HUBijie67主動監(jiān)測培養(yǎng)精品課件68ReservoirforSpreadofAntibioticResistantPathogensClinicalInfectionsColonized(Asymptomatic)Patients精品課件692024/12/1Dr.HUBijie69對超級細(xì)菌MRSA感染的“零寬容”主動篩查:快速監(jiān)測積極隔離:包括疑似病例的隔離就地消滅:包括環(huán)境消毒精品課件70Outcomes:ActiveSurveillanceControlsMRSABSIsHuangetal.,CID2006;43:971-8精品課件71美國20個州立法:

住院病人主動篩查、隔離MRSA和VRE精品課件72進行主動篩查的人群全部新入住ICU的病人？使用機械通氣的病人？具有高危因素的ICU病人？全體住院病人？醫(yī)務(wù)人員？精品課件732024/12/173ICU病人MDROs主動監(jiān)測培養(yǎng)鼻拭子MRSA肛拭子ESBLs鮑曼不動桿菌銅綠假單胞菌精品課件742024/12/1Dr.HUBijie74醫(yī)院感染的組合預(yù)防精品課件75ICU需要重點防范的醫(yī)院感染呼吸機相關(guān)肺炎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精品課件762024/12/1Dr.HUBijie76美國目前推行的預(yù)防VAPbundle床頭抬高至少30度Headofbed-≥30°每天一次停用鎮(zhèn)靜劑并評價是否可以撤機SedationHoliday/weaning盡早停用應(yīng)激性潰瘍預(yù)防藥物PepticUlcerDisease(PUD)Prophylaxis口腔護理：用洗必泰沖洗每2～6小時Oralcare深靜脈血栓預(yù)防DeepVeinThrombosis(DVT)Prophylaxis插管氣囊上方分泌物的吸引（？）精品課件772024/12/1Dr.HUBijie77預(yù)防CR-BSI:bundle留置導(dǎo)管術(shù)時最大無菌屏障Maximalsterilebarriers洗必泰皮膚消毒Chlorhexidineskinantisepsis盡量使用鎖骨下靜脈部位穿刺Sitechoice嚴(yán)格執(zhí)行手衛(wèi)生規(guī)則HANDHYGIENE每天評估是否需要繼續(xù)留置導(dǎo)管抗菌導(dǎo)管Antibiotic-coatedorantiseptic-impregnatedcatheter插管后的護理Post-insertioncare精品課件782024/12/1Dr.HUBijie78洗必泰洗浴精品課件79洗必泰對于鮑曼不動桿菌的控制精品課件80Impactof4%Chlorhexidine(CHG)Whole-BodyWashingonMultidrug-resistantAcinetobacterbaumannii(ACBA)SkinColonisation-PatientsinaMICUAllpatientsdailywhole-bodydisinfectionwithCHGOf320patientsatadmission,55(17%)ACBA-positiveskinswabsPrevalenceofACBAskincolonisationamongremainingpatientswas5.5%at24hand1%at48h(P=0.002,OR:2.4)ACBA-BSIsdecreasedfrom4.6to0.6per100patients(P<0.001;OR:7.6)Dailywhole-bodyCHGdisinfectionsignificantlyreducedACBAskincolonisationandBSIs精品課件81洗必泰全身擦浴顯著降低病原菌皮膚的定植（MRSA.VRE、鮑曼等）減少交叉感染降低CRBSI的發(fā)生率減少抗生素的使用精品課件822024/12/1Dr.HUBijie82抗菌藥物管理精品課件83AntibioticStewardshipIDDivisionInfectiousDiseasesSpecialistDepartmentofPharmacyClinicalPharmacistHealthadministrationAntibioticUtilizationReviewSubcommitteeElectronicantibioticstewardshipcomputerizedantimicrobialapprovalsysteminahospitalsettingEducationandinteractionInfectioncontrolprofessional精品課件84抗菌治