ICU醫(yī)院感染控制進(jìn)展ppt課件

1、,1,ICU,2008-10-3,Dr.HU Bijie,2,2008年7月某醫(yī)院會(huì)診病例 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(jī)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,2008-10-3,Dr.HU Bijie,3,臨床醫(yī)生必須關(guān)注感染預(yù)防！ 正確認(rèn)識(shí)感染預(yù)防的 重要性； 要摒棄形式化感控； 國外感控理念和方 法，變化巨大； 中國感控期待與國際 接軌； 只有臨床醫(yī)生參與， 感控才能有突破,2008-10-3,Dr.HU Bijie,4,美國ICU床位在增加 8% hospital beds in

2、USA are ICU beds in 1991 Between 1985 and 2000 CCM beds increased (69,300 to 87,400, 26.1%), especially in small (27%) and medium (44.2%) hospitals non-CCM beds decreased (820,300 to 566,900, - 30.9%), most prominently in large (-44.2%) and extra- large (-46.1%) hospitals. proportion of total hospit

3、al beds assigned to CCM increased (71.8%), most markedly in large (93.5%) and extra-large (85.7%) hospitals.,2008-10-3,Dr.HU Bijie Critical care medicine 2006, 34:2105-2112,5,歐美已經(jīng)將ICU感染列為重點(diǎn),2008-10-3,Dr.HU Bijie,6,Hospitals in Europe Link,for Infection Control,through Surveillance,HELICS IV Euro dat

4、abase National/regional summaries,ICU surveillance 2008-10-3,SSI surveillance Dr.HU Bijie,Prevalence surveys,7,衛(wèi)生部醫(yī)院管理評(píng)價(jià)指南（2008年版） 12醫(yī)院感染管理與持續(xù)改進(jìn) （1）根據(jù)國家有關(guān)的法律、法規(guī)，按照醫(yī)院感染管理辦法要求，制定并落 實(shí)醫(yī)院感染管理的各項(xiàng)規(guī)章制度。 （2）根據(jù)醫(yī)院感染管理辦法要求和醫(yī)院功能任務(wù)，建立完善的醫(yī)院感染管 理組織體系。 （3）醫(yī)院感染管理部門實(shí)行目標(biāo)管理責(zé)任制，職責(zé)明確。 （4）醫(yī)院的建筑布局、設(shè)施和工作流程符合醫(yī)院感染控制要求。 （5）落實(shí)醫(yī)院

5、感染的病例監(jiān)測(cè)、消毒滅菌監(jiān)測(cè)、必要的環(huán)境衛(wèi)生學(xué)監(jiān)測(cè)和醫(yī)院 感染報(bào)告制度。 （6）加強(qiáng)對(duì)醫(yī)院感染控制重點(diǎn)部門的管理，包括感染性疾病科、口腔科、手術(shù) 室、重癥監(jiān)護(hù)室、新生兒病房、產(chǎn)房、內(nèi)窺鏡室、血液透析室、導(dǎo)管室、臨床 檢驗(yàn)部門和消毒供應(yīng)室等。 （7）加強(qiáng)對(duì)醫(yī)院感染控制重點(diǎn)項(xiàng)目的管理，包括呼吸機(jī)相關(guān)性肺炎、血管內(nèi)導(dǎo) 管所致血行感染、留置導(dǎo)尿管所致尿路感染、手術(shù)部位感染、透析相關(guān)感染等。 （8）醫(yī)務(wù)人員嚴(yán)格執(zhí)行無菌技術(shù)操作、消毒隔離工作制度、手衛(wèi)生規(guī)范、職業(yè) 暴露防護(hù)制度。 （9）對(duì)消毒藥械和一次性使用醫(yī)療器械、器具相關(guān)證明進(jìn)行審核，按規(guī)定可以 重復(fù)使用的醫(yī)療器械，實(shí)施嚴(yán)格的清洗、消毒或者滅菌，并進(jìn)

6、行效果監(jiān)測(cè)。 （10）開展耐藥菌株監(jiān)測(cè)，指導(dǎo)合理選用抗菌藥物。協(xié)助抗菌藥物臨床應(yīng)用監(jiān) 測(cè)與管理。 （11）加強(qiáng)衛(wèi)生安全防護(hù)工作，保障職工安全。,2008-10-3,Dr.HU Bijie,8,常見ICU感染問題 侵入性操作相關(guān)感染問題 導(dǎo)管相關(guān)血流感染 呼吸機(jī)相關(guān)肺炎 導(dǎo)尿管相關(guān)尿路感染 多重耐藥菌感染問題 MRSA，VRE PDR-不動(dòng)桿菌，ESBLs 艱難梭菌，真菌感染 免疫抑制患者感染問題 醫(yī)院感染暴發(fā)問題,2008-10-3,Dr.HU Bijie,9,美國醫(yī)院拯救十萬生命運(yùn)動(dòng) 始于2004年12月14日 目的是改善操作規(guī)程，在2006年6月前避免 100,000住院病人不必要的死亡

7、發(fā)起創(chuàng)議的醫(yī)院超過2000所 預(yù)防三種主要的醫(yī)院感染 SSI VAP CA-BSI,2008-10-3,Dr.HU Bijie,10,2008-10-3 Dr.HU Bijie,新起點(diǎn)：五百萬生命運(yùn)動(dòng),增 加：預(yù)防耐藥菌傳播和加強(qiáng)手衛(wèi)生,Institute of Healthcare Improvement (IHI) and several organizations,Seven changes that save lives,Prevent catheter related BSI Prevent SSI Prevent VAP,Prevent adverse drug events De

8、ploy rapid response teams,Deliver reliable, evidence based care for acute MI Hand hygiene,As of 3,000 hospitals have joined the campaign 5,000,000 lives campaign,Prevent transmission of MRSA, VRE and C. difficile,(),11,我國醫(yī)院感染管理模式需要調(diào)整 多做干預(yù) 感控目的：降低危險(xiǎn)因素，減少發(fā)病 沒有干預(yù)（新技術(shù)、新方法、新流程），就沒有改變 科學(xué)的干預(yù)方法：循證感控 少做監(jiān)測(cè) 已經(jīng)

9、了解本底發(fā)病率和危險(xiǎn)因素 “完美”的監(jiān)測(cè)永無止境，少做或不做意義不大的監(jiān)測(cè) 轉(zhuǎn)向目標(biāo)性監(jiān)測(cè) 強(qiáng)調(diào)過程監(jiān)測(cè)比結(jié)果監(jiān)測(cè)更重要,2008-10-3,Dr.HU Bijie,Mortality Reduction 2004-2007,2008-10-3,Dr.HU Bijie,Missouri Baptist Medical Center 12 BJC HealthCare St. Louis, Missouri,1,2,3,4,5,Dr.HU Bijie,13,The organization ensures appropriate practices to prevent nosocomial i

10、nfection Monitor 15:231238.,22,Benefits of CHG 2% CHG in tincture of isopropyl alcohol has rapid bactericidal activity and is effective within 30 seconds after application versus 2-minute period for povidone iodine CHG provides persistent bactericidal activity on the skin and maintains its activity

11、in the presence of other organic material Minimal systemic absorption Back and forth, up and down motion Motion promotes penetration of the cleanser within multiple layers of the epidermis Clear solution Orange tinted solution now available,2008-10-3,Dr.HU Bijie,23,Chlorhexidine for Skin Asepsis Stu

12、dies have compared chlorhexidine gluconate (CHG) versus povidone iodine as a skin antiseptic for catheter insertion and routine insertion site care Recent meta-analysis, the use of CHG rather than povidone iodine was found to reduce the risk of CLA-BSIs by approximately 50% in hospitalized patients

13、who required short term catheterization Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002;136:792801.,2008-10-3,Dr.HU Bijie,24,Site Selection: Avoid Femoral Lines Insertion o

14、f CVCs can lead to serious and sometimes life-threatening complications, whether of mechanical, infectious, or thrombotic origin Higher rate of infectious complications in study comparing femoral lines versus subclavian lines 19.8% vs 4.5%,2008-10-3,Dr.HU Bijie,25,Empowerment of Nursing One of the m

15、ost important steps in preventing CLA-BSIs is to empower the nursing staff to stop the central line insertion procedure if the guidelines were not followed,2008-10-3,Dr.HU Bijie,26,Avoid and Remove Unnecessary Lines Once placed, there should be periodic, if not daily assessment, of its continued nee

16、d, with emphasis on prompt removal,2008-10-3,Dr.HU Bijie,Casesper1000catheterdays,May-99,Mar-99,Jan-99,Nov-99,Sep-99,May-00,Jul-99,Mar-00,Jan-00,Nov-00,Sep-00,May-01,Jul-00,Mar-01,Jan-01,Nov-01,Sep-01,May-02,Jul-01,Mar-02,Jan-02,Nov-02,Sep-02,Jul-02,Mar-03,Jan-03,8,27,導(dǎo)管相關(guān)BSI干預(yù)流行病學(xué) /操作改進(jìn) 39 month pe

17、riod 237 cath.-rel. bloodstream infections avoided BUMC Estimated annual cost savings in cost avoidance = $2.5 - 4 x 106 Fig 5. CVC-Related Bloodstream Infections, 1999-2003, Brookdale University Medical Center,22,20 18 16,Silver-Chlorhexidine Catheters Used Since 1997,Jan 01: Silver-Platinum Cathet

18、ers Introduced Dec 99: Awareness and Education Program Started,14,Mean Rate,12,Oct 01: Sterile Barrier Kits Introduced,10,Jan 02: 2% CHG-70% isopropyl alcohol Skin Prep introduced 6 4 2 0,Monthly Rate,Mean Rate,2008-10-3,Dr.HU Bijie Garcia R, et.al. Abstract, APIC- Used with Permission,28,呼吸機(jī)相關(guān)肺炎 VA

19、P,2008-10-3,Dr.HU Bijie,上海市呼吸機(jī)相關(guān)肺炎與NNIS比較 感染率,ICU類型 CCU 心胸ICU 內(nèi)科ICU 混合ICU 神經(jīng)外科ICU 兒科ICU 外科ICU 創(chuàng)傷ICU,2005年 20.55 17.77 28.86 24.74 24.05 15.53 25.34 40.32,2006年 20.82 14.84 32.41 25.34 25.11 13.05 24.72 27.51,呼吸ICU 2008-10-3,19.01,27.08,Dr.HU Bijie,29,30, Dr.HU,預(yù)防醫(yī)院內(nèi)肺炎的有效方法, 降低口咽部和上消化道定植 經(jīng)?？谇恍l(wèi)生 選擇性消化

20、道脫污染(SDD) 通氣時(shí)間較長的病人避免鼻腔插管 防止口咽部分泌物吸入 半臥位 經(jīng)常校正鼻飼管位子，調(diào)整進(jìn)食速度和量以避免反流 使用超過幽門的鼻飼管如鼻十二指腸、空腸管 使用ETT管，能進(jìn)行聲門下吸引 保護(hù)胃粘膜的特性 盡可能腸內(nèi)營養(yǎng) 使用硫糖鋁，胃粘膜保護(hù)劑 治療休克和低氧血癥 減少外源性污染 合適的手衛(wèi)生 氣管腔內(nèi)吸引時(shí)保持遠(yuǎn)端無菌 密閉氣管腔內(nèi)吸引系統(tǒng) 2008-10-3使用濕鼻替代加熱的濕化器 Bijie 減少回路管道的更換頻率,31,美國目前推行的預(yù)防VAP bundle 床頭抬高至少30度Head of bed - 30 每天一次停用鎮(zhèn)靜劑并評(píng)價(jià)是否可以撤機(jī)Sedation Ho

21、liday/weaning 盡早停用應(yīng)激性潰瘍預(yù)防藥物Peptic Ulcer Disease (PUD) Prophylaxis 口腔護(hù)理：用洗必泰沖洗每26小時(shí)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（？）,2008-10-3,Dr.HU Bijie,32,VAP預(yù)防措施的證據(jù) 預(yù)防與胃管給食有關(guān)的吸入如果無反指征， 將頭部的床搖高形成3045度角（IB） 仰臥位與半臥位 VAP發(fā)病率 仰臥 23 半臥 5 Lancet 1999; 354:1851-58,2008-10-3,Dr.HU Bij

22、ie,33,2008-10-3 online 26,Meta-analysis of RCT investigating,the relationship between ventilator-circuit-change,frequency and the risk of VAP,呼吸機(jī)回路管道更換,systematic review and meta-analysis pneumonia in mechanically ventilated adults: Oral decontamination for prevention of 2007;334;889-; originally pu

23、blishedDr.HU Bijie Mar 2007; BMJ,34,VAP預(yù)防措施方面新的證據(jù)與進(jìn)展 使用氣囊上方帶側(cè) 腔的氣管插管，有 利于積存于聲門下 氣囊上方分泌物的 引流 氣囊放氣或拔除氣 管插管前應(yīng)確認(rèn)氣 囊上方的分泌物已 被清除,2008-10-3,Dr.HU Bijie,Rate/1000vent.days,Ja,n-,0,M4,ar,-0,M4,ay,-0,4,Ju,l-0,Se4,p-,0,N4,ov,-0,Ja4,n-,0,M5,ar,-0,M5,ay,-0,5,Ju,l-0,Se5,p-,0,N5,ov,-0,Ja5,n-,0,M6,ar,-0,M6,ay,-0,6,

24、Ju,l-0,Se6,p-,0,N6,ov,-0,Ja6,n-,0,M7,ar,-0,M7,ay,-0,7,12.0,35,Ventilator Associated Pneumonia Rates Combined 2004-2007 14.0 Preintervention Mean 3.8,10.0 8.0 6.0 4.0 2.0,Oral Care,Post Intervention Mean 0.9 p0.01 NNIS 5.1,0.0 Month/Year,Rate,Mean,NNIS,2008-10-3,Dr.HU Bijie,36,導(dǎo)尿管相關(guān)尿路感染 CR-UTI,2008-1

25、0-3,Dr.HU Bijie,37,多重耐藥菌感染 MDROs,2008-10-3,Dr.HU Bijie,Dr.HU Bijie,38,Campaign to Prevent Antimicrobial Resistance in Healthcare Settings 耐藥菌愈演愈烈，,感染預(yù)防的價(jià)值越來越大！,12 遏制醫(yī)務(wù)工作者傳播 11 隔離患者 10 及時(shí)停用抗菌藥物 9 嚴(yán)格掌握萬古霉素應(yīng)用指證 8 治療感染，而非寄殖 7 治療感染，而非污染 6 專家會(huì)診 5 應(yīng)用當(dāng)?shù)刭Y料 4 控制抗菌藥物應(yīng)用 3 針對(duì)性病原治療 2 拔除導(dǎo)管,預(yù)防傳播 合理應(yīng)用抗菌藥物 有效的診斷和治療 預(yù)

26、防感染,1 接種疫苗 2008-10-3,預(yù)防抗菌藥物耐藥的12項(xiàng)措施,R,R,39,ICU內(nèi)出現(xiàn)了PDR-鮑曼不動(dòng)桿菌 怎么辦？,阿米卡星 慶大霉素 氨芐西林+舒巴坦 哌拉西林+他唑巴坦,R R,2008-10-3,頭孢吡肟 頭孢他啶 亞胺培南 環(huán)丙沙星 TMPco,Dr.HU Bijie,R R R R R,40,對(duì)超級(jí)細(xì)菌MRSA感染 的“零寬容”,主動(dòng)篩查：快速監(jiān)測(cè) 積極隔離：包括疑似病例的隔離 就地消滅：包括環(huán)境消毒,2008-10-3,Dr.HU Bijie,41,哪些病原體感染需要隔離？, 耐藥菌 MRSA，不動(dòng)桿菌 艱難梭菌，VRE ESBL？銅綠假單胞菌？ 傳染病 TB，SA

27、RS，諾如病毒 HIV？HBV？,耐藥菌危害嚴(yán) 重，我國必須 制訂政策，進(jìn) 行嚴(yán)格隔離！,2008-10-3,Dr.HU Bijie,耐藥菌隔離的警告標(biāo)識(shí),42,2008-10-3,Dr.HU Bijie,numberofreports,43,C. difficile voluntary reporting 1991 2005: England, Wales and Northern Ireland 50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 1990 1991 1992 1993 1994 1995 1996 19

28、97 1998 1999 2000 2001 2002 2003 2004 2005,2008-10-3,year Dr.HU Bijie,Percentpositive,44,Percentage of C. difficile-positive cultures n=9 rooms,80 70 60 50 40 30 20 10 0,Bedrail Bedside table Phone Call button Toilet Door handle,Before cleaning,After,After,*Similar results found after ES cleaning following,housekeeping disinfection by cleaning research team*,interventions,2008-10-3,Dr.HU Bijie Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.,4