多重耐藥菌感染的預(yù)防與控制(胡必杰)

2024/11/4Dr.HUBijie12024/11/4Dr.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BijieHU1精品課件2精品課件對(duì)于超級(jí)細(xì)菌/多重耐藥菌，

要防被忽悠，更要防止麻木！3精品課件耐藥菌的難題，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4精品課件什么是多重耐藥菌？多重耐藥菌（Multidrug-ResistantOrganism，MDRO），主要是指對(duì)臨床使用的三類或三類以上抗菌藥物同時(shí)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(wàn)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(dòng)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。5精品課件2024/11/4Dr.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(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)：兩種念珠菌結(jié)局術(shù)后1月死亡花費(fèi)：10萬(wàn)元？2008年7月某醫(yī)院會(huì)診病例6精品課件醫(yī)院感染越來(lái)越險(xiǎn)惡！案例某男，90歲，COPD多年，反復(fù)感染，近日鮑曼不動(dòng)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(dòng)桿菌某男，22歲，顱腦手術(shù)后2周，高熱，CSF引流液鮑曼不動(dòng)桿菌7精品課件2005-2009年上海XX醫(yī)院

鮑曼不動(dòng)桿菌對(duì)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8精品課件正確認(rèn)識(shí)接觸預(yù)防

有效控制多重耐藥菌MDRO9精品課件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(guò)多地使用抗生素，造成對(duì)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(guò)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(guò)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10精品課件AntimicrobialResistance惡性循環(huán)耐藥性增加更廣譜抗菌藥物SusceptiblepathogenAntimicrobial-Resistant

PathogenAntimicrobialResistanceAntimicrobialUseInfection11精品課件2024/11/4Dr.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(wàn)古霉素應(yīng)用指證1接種疫苗2拔除導(dǎo)管6專家會(huì)診7治療感染，而非污染3針對(duì)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(duì)感染控制措施的描述，太簡(jiǎn)單！12精品課件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MMT1T2T3T8T7T6T5T12T11T10T913精品課件NationalPatientSafetyGoals,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.&family14精品課件美國(guó)NationalPatientSafetyGoalNPSG.07.03.01-Implementevidence-basedpracticestopreventhealthcare-associatedinfectionsduetomulti-drugresistantorganisms(MDRO).Theseorganismsarenottransmittedbyair.Theyarespreadbycontactviahandsorcontaminatedenvironment.MRSAC.difficileVREMDRgramnegativebacteria15精品課件SpreadofMDROsCanBeControlledBy:GoodinfectioncontrolpracticesMeticuloushandhygieneforcontactwithpatientandpatient’senvironmentofStandardPrecautionsGoodenvironmentalandequipmentcleaningpracticesHCWknowledgeregardingtheseorganismsandhowtheyarespreadJudicioususeofantibioticsTeachingpatientandfamily16精品課件FIGHTSFollowisolationpracticesIn-servicetrainingforstaffGaugingdisinfectantefficacyHandhygieneTestingenvironmentalsurfacesStandardizedcleaningprocedures17精品課件衛(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(qiáng)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(qiáng)重點(diǎn)環(huán)節(jié)管理（三）加大人員培訓(xùn)力度二、強(qiáng)化預(yù)防與控制措施（一）加強(qiáng)醫(yī)務(wù)人員手衛(wèi)生（二）嚴(yán)格實(shí)施隔離措施（三）遵守?zé)o菌技術(shù)操作規(guī)程（四）加強(qiáng)清潔和消毒工作三、合理使用抗菌藥物四、建立和完善對(duì)多重耐藥菌的監(jiān)測(cè)（一）加強(qiáng)多重耐藥菌監(jiān)測(cè)工作（二）提高臨床微生物實(shí)驗(yàn)室的檢測(cè)能力18精品課件19精品課件WHO抵御細(xì)菌耐藥的6項(xiàng)政策制定并執(zhí)行一套完整的、有資金支持的國(guó)家計(jì)劃加強(qiáng)監(jiān)測(cè)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)20精品課件最新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(cè)培養(yǎng)Chlorhexidinebaths洗必泰洗浴Antimicrobialstewardship抗菌藥物管理21精品課件ANTIBIOTICRESISTANTPATHOGENSON/INPATIENTSENVIRONMENTALSURFACESHCWHANDSSUSCEPTABLEPATIENTSISOLATIONHANDHYGENEDISINFECTIONCLEANING22精品課件超級(jí)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23精品課件2024/11/4Dr.HUBijie24手衛(wèi)生24精品課件酒精擦手的優(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(duì)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!25精品課件2024/11/4Dr.HUBijie26接觸隔離26精品課件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……27精品課件2024/11/4Dr.HUBijie28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？耐藥菌危害嚴(yán)重，我國(guó)必須制訂政策，進(jìn)行嚴(yán)格隔離！耐藥菌隔離的警告標(biāo)識(shí)28精品課件多重耐藥菌進(jìn)行專門標(biāo)記（德國(guó)某醫(yī)院）29精品課件何時(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?；颊吒綦x期間需要定期監(jiān)測(cè)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。30精品課件2024/11/4Dr.HUBijie31減少設(shè)備共用31精品課件ICU減少共用物品聽診器血壓計(jì)體溫表微量輸液泵……32精品課件2024/11/4Dr.HUBijie33環(huán)境清潔33精品課件2024/11/4Dr.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(cè)要求必須改變！34精品課件PathogenSurvivalintheEnvironmentAdaptedfrom:KramerA,etal.Howlongdonosocomialpathogenspersistoninanimatesurfaces?Asystematicreview.BMCInfectDis.2006;16(6):130.Usedwithpermission.OrganismDurationofpersistence(range)Acinetobacterspp.3days-5monthsClostridiumdifficile(spores)5monthsEscherichiacoli1.5hours-16monthsEnterococcusspp,includingVRE5days-4monthsInfluenzavirus1-2daysNorovirus8hours-7daysStaphylococcusaureus,includingMRSA7days-7months35精品課件

DecontaminationRiskofinfectionbyuseditemsinhealthcare1968EarleHSpauldingCriticalitems:ItemsthatentersteriletissueorvascularsystemSemi-criticalitemsItemsthatcomeincontactwithmucousmembranesornonintactskinNon-criticalitemsItemsthatcomeincontactwithintactskin36精品課件手頻繁接觸的物體表面，

是高度危險(xiǎn)的！37精品課件38精品課件High-touchequalshigh-risk:

surfacecleaningplushandhygiene

keytoHAIpreventionWiththeeverincreasingproliferationofsuperbugs,comesnotonlyaneedfornewproductsandprotocolsbutalsoalookbackatfundamentalinterventions."Handhygieneandenvironmentalcleaninganddisinfectionarethetwoprimaryinterventionsthatwecanmakeandthosearedefinitelybacktobasics,"saidSueBarnes,nationalleader,infectionpreventionandcontrolandpatientsafety,KaiserPermanenteProgramOffices,andamemberoftheNationalAPICcommunicationscommittee.HealthcarePurchasingNews,June,200939精品課件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(cè)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(tái)燈床邊便桶床架和控制器40精品課件ICU環(huán)境中耐藥鮑曼不動(dòng)桿菌污染嚴(yán)重41精品課件

Removesorganicsoil/visiblesoilRemovespotentiallyinfectiousmicroorganismsRemovessoilwhichprotectsm.o.duringdisinfectionCarefulcleaning

Mechanicalenergy -friction,flushing,scrubbingChemicalproducts -detergentsorenzymesRightMethod -manual&machinalManualCleaning42精品課件ManualCleaningNOSAFEProducts!43精品課件

Everybodyisan“EXPERT” Difficulttomonitor

Responsibilitiesnotclear Health-riskManualCleaningNOSAFEProcedure!44精品課件

CommoninHouseholdsNotCommoninHealthcaresettingsEasytouse

Standardization&ValidationBetterResultSavesNursingTimeMonitoringThermalDisinfection

MachinalCleaningMachinalCleaningisSafer45精品課件病區(qū)的基本配置：清洗消毒機(jī)46精品課件日本尿壺與便盆的消毒47精品課件關(guān)注頻繁手接觸物體表面的去污染48精品課件

MICROFIBER

The“cleaner”cleaningsystem49精品課件關(guān)東病院設(shè)備科-保養(yǎng)與維修50精品課件HowCanWeEvaluateEnvironmentalCleaningDirectobservationCulturetheenvironmentATPbioluminescenceToolFluorescentmarkingtool03/26/2010TSICP5151精品課件

TESTINGOFSURFACES52精品課件ATPbioluminescence

SwabsurfaceluciferasetaggingofATPHandheldluminometerUsedinthecommercialfoodpreparationindustrytoevaluatesurfacecleaningbeforereuseandasaneducationaltoolformorethan30years.53精品課件ATPispresentinblood,skincells,otherbodilyfluidsandmicrobes.ATP存在于血液，皮膚細(xì)胞，其它體液和微生物中。

54精品課件DazoSolution

(Initiallycalled“GOO”)55精品課件56精品課件BaselineEnvironmentalEvaluationof36AcuteCareHospitals%ofObjectsCleanedHospitalsMean=48.5%(20,056Objects)57精品課件PROPORTIONOFOBJECTSCLEANEDASPARTOFTERMINALROOMCLEANINGIN20ACUTECAREHOSPITALS

%58精品課件17HOSPITALS10HOSPITALS8HOSPITALSTerminalRoomCleaningProject–ThreeProgrammaticResponses59精品課件HospitalsEnvironmentalHygieneStudyGroup

36HospitalResults

%ofObjectsCleaned

PREINTERVENTION

POSTINTERVENTIONP=<.0001ResourceNeutral60精品課件TERMINALROOMCLEANINGINFECTIONPREVENTION

TARGETS

SinkandFaucetsToiletSurfacesToiletFlushHandleBedpanCleanerToiletAreaHandholdsToiletAreaDoorKnobsorPushPlatesBedsideTableTrayTablePatientChairSideRailsRoomDoorKnobsCallBoxTelephoneBathroomLightSwitchesSpecificOpportunitiesforImprovement61精品課件EvaluatingPatientZoneEnvironmentalHygiene62精品課件如何選擇表面消毒劑殺菌譜和殺菌速度需要多長(zhǎng)時(shí)間來(lái)殺死病菌？是否對(duì)有機(jī)物污染敏感？材料和器械兼容性毒性手套兼容性63精品課件LowandIntermediateLevelDisinfectants

Use:non-criticalitemsthatwillcomeincontactwithintactskin

Low-leveldisinfectant:agentthatdestroysallvegetativebacteria(excepttuberclebacilli),lipidviruses,somenon-lipidviruses,andsomefungi,butnotbacterialsporesIntermediate-leveldisinfectant:agentthatdestroysallvegetativebacteria,includingtuberclebacilli,lipidandsomenon-lipidviruses,andfungi,butnotbacterialsporesHICPACGuidelineforDisinfectionandSterilizationinHealthcareFacilities,2008.64精品課件ExamplesofLow&IntermediateLevelDisinfectantsQuaternaryammoniumgermicidaldetergentsolution(quat)Sodiumhypochlorite5.25-6.15%householdbleachdiluted1:500provides>100ppmavailablechlorinePhenolicgermicidaldetergentsolutionIodophorgermicidaldetergentsolutionEthylorisopropylalcohol(70-90%)Hydrogenperoxidesolutions65精品課件Clean/disinfect:Onaregularbasis,Whenspillsoccur,WhenvisiblysoiledFollowmanufacturers’instructionsforproperuse:use-dilution,dwelltime,materialcompatibility,storage,shelf-life.1:10BleachrecommendedforC.difficileCleaning&DisinfectingNon-criticalItems66精品課件2024/11/4Dr.HUBijie67主動(dòng)監(jiān)測(cè)培養(yǎng)67精品課件ReservoirforSpreadofAntibioticResistantPathogensClinicalInfectionsColonized(Asymptomatic)Patients68精品課件2024/11/4Dr.HUBijie69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69精品課件Outcomes:ActiveSurveillanceControlsMRSABSIsHuangetal.,CID2006;43:971-870精品課件美國(guó)20個(gè)州立法：

住院病人主動(dòng)篩查、隔離MRSA和VRE71精品課件進(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？72精品課件2024/11/473ICU病人MDROs主動(dòng)監(jiān)測(cè)培養(yǎng)鼻拭子MRSA肛拭子ESBLs鮑曼不動(dòng)桿菌銅綠假單胞菌73精品課件2024/11/4Dr.HUBijie74醫(yī)院感染的組合預(yù)防74精品課件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)outbreak75精品課件2024/11/4Dr.HUBijie76美國(guó)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(píng)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（？）76精品課件2024/11/4Dr.HUBijie77預(yù)防CR-BSI：

bundle留置導(dǎo)管術(shù)時(shí)最大無(wú)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(píng)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(hù)理Post-insertioncare77精品課件2024/11/4Dr.HUBijie78洗必泰洗浴78精品課件洗必泰對(duì)于鮑曼不動(dòng)桿菌的控制79精品課件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-bodyCHGdisinfectionsignificantlyreducedACBAskincolonisationandBSIs80精品課件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81精品課件2024/11/4Dr.HUBijie82抗菌藥物管理82精品課件AntibioticStewardshipIDDivisionInfectiousDiseasesSpecialistDepartmentofPharmacyClinicalPharmacistHealthadministrationAntibioticUtilizationReviewSubcommitteeElectronicantibioticstewardshipcomputerizedantimicrobialapprovalsysteminahospitalsettingEducationandinteractionInfectioncontrolprofessional83精品課件抗菌治療策略(AntibioticTherapy