多重耐藥菌感染的預(yù)防與控制課件

2025/1/8Dr.HUBijie12025/1/8Dr.HUBijie1多重耐藥菌感染的預(yù)防與控制對于超級細(xì)菌/多重耐藥菌，

要防被忽悠，更要防止麻木！耐藥菌的難題，遠(yuǎn)不止NDM-1！MRSAPDR-不動(dòng)桿菌銅綠假單胞菌艱難梭菌VREESBL，KPC，NDM-1多重耐藥結(jié)核分枝桿菌什么是多重耐藥菌？2025/1/8Dr.HUBijie52008年7月某醫(yī)院會診病例醫(yī)院感染越來越險(xiǎn)惡！18.6%41.9%32.2%44%59.3%

2006年

2007年

2008年

2009年

2005年正確認(rèn)識接觸預(yù)防

有效控制多重耐藥菌MDRO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(jìn)行了篩選耐藥菌傳播增加：通過醫(yī)護(hù)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(jìn)行傳播AntimicrobialResistance惡性循環(huán)耐藥性增加更廣譜抗菌藥物SusceptiblepathogenAntimicrobial-Resistant

PathogenAntimicrobialResistanceAntimicrobialUseInfection2025/1/8Dr.HUBijie11

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(shí)停用抗菌藥物預(yù)防抗菌藥物耐藥的12項(xiàng)措施對感染控制措施的描述，太簡單！2010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(dòng)桿菌，PFGE結(jié)果MMT1T2T3T8T7T6T5T12T11T10T9制定并執(zhí)行一套完整的、有資金支持的國家計(jì)劃加強(qiáng)監(jiān)測與實(shí)驗(yàn)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(jìn)藥物的合理使用加大感染防控力度促進(jìn)創(chuàng)新和新工具的研發(fā)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(jī)相關(guān)肺炎Catheter-associatedUTI導(dǎo)尿管相關(guān)尿路感染Activesurveillancecultures主動(dòng)監(jiān)測培養(yǎng)Chlorhexidinebaths洗必泰洗浴Antimicrobialstewardship抗菌藥物管理ANTIBIOTICRESISTANTPATHOGENSON/INPATIENTSENVIRONMENTALSURFACESHCWHANDSSUSCEPTABLEPATIENTSISOLATIONHANDHYGENEDISINFECTIONCLEANING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(dòng)篩查與去污染。。。更明智地合理使用抗菌藥物2025/1/8Dr.HUBijie19手衛(wèi)生酒精擦手的優(yōu)點(diǎn)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(fèi)少所用時(shí)間少，作用快不需要水和毛巾感染控制，不僅僅是手衛(wèi)生!2025/1/8Dr.HUBijie21接觸隔離接觸隔離的要求隔離：盡量將患者安置于單間個(gè)人防護(hù)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(jì)、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(dòng)篩查與去污染……2025/1/8Dr.HUBijie23哪些病原體感染需要隔離？耐藥菌MRSA，不動(dòng)桿菌艱難梭菌，VREESBL？銅綠假單胞菌？傳染病TB，SARS，諾如病毒……HIV？HBV？耐藥菌隔離的警告標(biāo)識何時(shí)開始隔離？何時(shí)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。患者隔離期間需要定期監(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。2025/1/8Dr.HUBijie25減少設(shè)備共用ICU減少共用物品聽診器血壓計(jì)體溫表微量輸液泵……2025/1/8Dr.HUBijie27環(huán)境清潔2025/1/8Dr.HUBijie28環(huán)境微生物菌落總數(shù)衛(wèi)生標(biāo)準(zhǔn)

環(huán)境微生物監(jiān)測要求必須改變！手頻繁接觸的物體表面，

是高度危險(xiǎn)的！ICU中，容易被污染的物表溫度計(jì)輸液泵和支架氧氣流量表呼吸機(jī)控制面板/旋鈕生命監(jiān)測儀面板/旋鈕血壓計(jì)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ICU環(huán)境中耐藥鮑曼不動(dòng)桿菌污染嚴(yán)重

Removesorganicsoil/visiblesoilRemovespotentiallyinfectiousmicroorganismsRemovessoilwhichprotectsm.o.duringdisinfectionCarefulcleaning

Mechanicalenergy -friction,flushing,scrubbingChemicalproducts -detergentsorenzymesRightMethod -manual&machinalManualCleaningManualCleaningNOSAFEProducts!

Everybodyisan“EXPERT” Difficulttomonitor

Responsibilitiesnotclear Health-riskManualCleaningNOSAFEProcedure!

CommoninHouseholdsNotCommoninHealthcaresettingsEasytouseStandardization&ValidationBetterResultSavesNursingTimeMonitoringThermalDisinfection

MachinalCleaningMachinalCleaningisSafer病區(qū)的基本配置：清洗消毒機(jī)日本尿壺與便盆的消毒關(guān)注頻繁手接觸物體表面的去污染

MICROFIBER

The“cleaner”cleaningsystem關(guān)東病院設(shè)備科-保養(yǎng)與維修HowCanWeEvaluateEnvironmentalCleaningDirectobservationCulturetheenvironmentATPbioluminescenceToolFluorescentmarkingtool03/26/2010TSICP42

TESTINGOFSURFACESATPbioluminescence

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

DazoSolution

(Initiallycalled“GOO”)CHAIRREMOTECONTROLBEDRAIL&CONTROLSBEDSIDESTANDOVERBEDTABLETELEPHONECOMPUTERS&CABLESBEDPANCLEANERLIGHTSWITCHESSINKTOPSDOORHANDLESTOILETHANDLETOILETSEATSUPPORTRAILBaselineEnvironmentalEvaluationof36AcuteCareHospitals%ofObjectsCleanedHospitalsMean=48.5%(20,056Objects)PROPORTIONOFOBJECTSCLEANEDASPARTOFTERMINALROOMCLEANINGIN20ACUTECAREHOSPITALS

%17HOSPITALS10HOSPITALS8HOSPITALSTerminalRoomCleaningProject–ThreeProgrammaticResponsesHospitalsEnvironmentalHygieneStudyGroup

36HospitalResults

%ofObjectsCleaned

PREINTERVENTION

POSTINTERVENTIONP=<.0001ResourceNeutralTERMINALROOMCLEANINGINFECTIONPREVENTION

TARGETS

SinkandFaucetsToiletSurfacesToiletFlushHandleBedpanCleanerToiletAreaHandholdsToiletAreaDoorKnobsorPushPlatesBedsideTableTrayTablePatientChairSideRailsRoomDoorKnobsCallBoxTelephoneBathroomLightSwitchesSpecificOpportunitiesforImprovementEvaluatingPatientZoneEnvironmentalHygiene如何選擇表面消毒劑殺菌譜和殺菌速度需要多長時(shí)間來殺死病菌？是否對有機(jī)物污染敏感？材料和器械兼容性毒性手套兼容性LowandIntermediateLevelDisinfectants

Use:non-criticalitemsthatwillcomeincontactwithintactskin

Low-leveldisinfectant:agentthatdestroysallvegetativebacteria(excepttuberclebacilli),lipidviruses,somenon-lipidviruses,andsomefungi,butnotbacterialsporesIntermediate-leveldisinfectant:agentthatdestroysallvegetativebacteria,includingtuberclebacilli,lipidandsomenon-lipidviruses,andfungi,butnotbacterialsporesHICPACGuidelineforDisinfectionandSterilizationinHealthcareFacilities,2008.ExamplesofLow&IntermediateLevelDisinfectantsQuaternaryammoniumgermicidaldetergentsolution(quat)Sodiumhypochlorite5.25-6.15%householdbleachdiluted1:500provides>100ppmavailablechlorinePhenolicgermicidaldetergentsolutionIodophorgermicidaldetergentsolutionEthylorisopropylalcohol(70-90%)HydrogenperoxidesolutionsClean/disinfect:Onaregularbasis,Whenspillsoccur,WhenvisiblysoiledFollowmanufacturers’instructionsforproperuse:use-dilution,dwelltime,materialcompatibility,storage,shelf-life.1:10BleachrecommendedforC.difficileCleaning&DisinfectingNon-criticalItems2025/1/8Dr.HUBijie60主動(dòng)監(jiān)測培養(yǎng)ReservoirforSpreadofAntibioticResistantPathogensClinicalInfectionsColonized(Asymptomatic)Patients2025/1/8Dr.HUBijie62對超級細(xì)菌MRSA感染的“零寬容”主動(dòng)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Outcomes:ActiveSurveillanceControlsMRSABSIsHuangetal.,CID2006;43:971-8美國20個(gè)州立法：

住院病人主動(dòng)篩查、隔離MRSA和VRE進(jìn)行主動(dòng)篩查的人群全部新入住ICU的病人？使用機(jī)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？2025/1/866ICU病人MDROs主動(dòng)監(jiān)測培養(yǎng)鼻拭子MRSA肛拭子ESBLs鮑曼不動(dòng)桿菌銅綠假單胞菌2025/1/8Dr.HUBijie67醫(yī)院感染的組合預(yù)防ICU需要重點(diǎn)防范的醫(yī)院感染呼吸機(jī)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)outbreak2025/1/8Dr.HUBijie69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(jià)是否可以撤機(jī)SedationHoliday/weaning盡早停用應(yīng)激性潰瘍預(yù)防藥物PepticUlcerDisease(PUD)Prophylaxis口腔護(hù)理：用洗必泰沖洗每2～6小時(shí)Oralcare

深靜脈血栓預(yù)防DeepVeinThrombosis(DVT)Prophylaxis插管氣囊上方分泌物的吸引（？）2025/1/8Dr.HUBijie70預(yù)防CR-BSI：bundle2025/1/8Dr.HUBijie71洗必泰洗浴洗必泰對于鮑曼不動(dòng)桿菌的控制Impactof4%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2025/1/8Dr.HUBijie75抗菌藥物管理AntibioticStewardshipIDDivisionInfectiousDiseasesSpecialistDepartmentofPharmacyClinicalPharmacistHealthadministrationAntibioticUtilizationReviewSubcommitteeElectronicantibioticstewardsh