多重耐药菌感染的预防与控制PPT

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1. 多重耐药菌感染的预防与控制PPT课件
2. 对于超级细菌/多重耐药菌，要防被忽悠，更要防止麻木！
3. 耐药菌的难题，远不止NDM-1！MRSA PDR-不动杆菌铜绿假单胞菌艰难梭菌 VRE ESBL，KPC，NDM-1 多重耐药结核分枝杆菌
4. 什么是多重耐药菌？多重耐药菌（Multidrug-Resistant Organism，MDRO），主要是指对临床使用的三类或三类以上抗菌药物同时呈现耐药的细菌。常见多重耐药菌包括耐甲氧西林金黄色葡萄球菌（MRSA）、耐万古霉素肠球菌（VRE）、产超广谱β-内酰胺酶（ESBLs）细菌、耐碳青霉烯类抗菌药物肠杆菌科细菌（CRE）（如产Ⅰ型新德里金属β-内酰胺酶[NDM-1]或产碳青霉烯酶[KPC]的肠杆菌科细菌）、耐碳青霉烯类抗菌药物鲍曼不动杆菌（CR-AB）、多重耐药/泛耐药铜绿假单胞菌（MDR/PDR-PA)和多重耐药结核分枝杆菌等。
5. 2019/5/22Dr.HU Bijie5临床情景某男，65岁脑胶质瘤术后20天高热，黄痰，呼吸困难留置中心静脉导管、导尿管和人工气道机械通气胸片肺炎痰培养：PDR-AB 血培养：阴沟肠杆菌尿培养：两种念珠菌结局术后1月死亡花费：10万元？2008年7月某医院会诊病例
6. 医院感染越来越险恶！案例某男，90岁，COPD多年，反复感染，近日鲍曼不动杆菌肺部感染某男，56岁，肺癌术后一周，高热、呼吸衰竭，重症肺炎，鲍曼不动杆菌某男，22岁，颅脑手术后2周，高热，CSF引流液鲍曼不动杆菌
7. 2005-2009年上海XX医院鲍曼不动杆菌对亚胺培南耐药率变化18.6%41.9%32.2%44%59.3% 2006年 2007年 2008年 2009年 2005年
8. 正确认识接触预防有效控制多重耐药菌MDRO
9. 耐药菌增加的原因耐药菌产生增加（抗生素选择性压力）：由于医生过多地使用抗生素，造成对基因突变及耐药基因转移的耐药菌进行了筛选耐药菌传播增加：通过医护人员尤其手的接触，细菌在病人间交叉寄生造成耐药菌株在医院内的传播，以及随后通过宿主病人的转移，耐药菌在医院间甚至社区进行传播
10. Antimicrobial Resistance恶性循环耐药性增加更广谱抗菌药物Susceptible pathogenAntimicrobial-Resistant PathogenAntimicrobial ResistanceAntimicrobial UseInfection
11. 2019/5/22Dr.HU Bijie11预防传播合理应用抗菌药物有效的诊断和治疗预防感染Campaign to Prevent Antimicrobial Resistance in Healthcare Settings12 遏制医务工作者传播11 隔离患者9 严格掌握万古霉素应用指证1 接种疫苗2 拔除导管6 专家会诊7 治疗感染，而非污染3 针对性病原治疗8 治疗感染，而非寄殖4 控制抗菌药物应用5 应用当地资料10 及时停用抗菌药物预防抗菌药物耐药的12项措施对感染控制措施的描述，太简单！
12. 2010年上海某医院ICU中22例病人痰培养检出多重耐药菌－鲍曼不动杆菌，PFGE结果MMT1T2T3T8T7T6T5T12T11T10T9
13. National Patient Safety Goals, Hospital & Critical Access Hospital, 20097c. Prevent multiple drug-resistant organisms (MDRO) infections, especially methicillin-resistant Staphylococcus 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
14. 美国National Patient Safety GoalNPSG.07.03.01-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. MRSA C. difficile VRE MDR gram negative bacteria
15. Spread of MDROs Can Be Controlled By:Good infection control practices Meticulous hand hygiene for contact with patient and patient’s environment of Standard Precautions Good environmental and equipment cleaning practices HCW knowledge regarding these organisms and how they are spread Judicious use of antibiotics Teaching patient and family
16. FIGHTSFollow isolation practices In-service training for staff Gauging disinfectant efficacy Hand hygiene Testing environmental surfaces Standardized cleaning procedures
17. 卫生部办公厅关于印发《多重耐药菌医院感染预防与控制技术指南（试行）》的通知（2011.1.17）一、加强多重耐药菌医院感染管理（一）重视多重耐药菌医院感染管理（二）加强重点环节管理（三）加大人员培训力度二、强化预防与控制措施（一）加强医务人员手卫生（二）严格实施隔离措施（三）遵守无菌技术操作规程（四）加强清洁和消毒工作三、合理使用抗菌药物四、建立和完善对多重耐药菌的监测（一）加强多重耐药菌监测工作（二）提高临床微生物实验室的检测能力
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19. WHO抵御细菌耐药的6项政策制定并执行一套完整的、有资金支持的国家计划加强监测与实验室能力确保不间断获得质量有保证的基本药物规范并促进药物的合理使用加大感染防控力度促进创新和新工具的研发
20. 最新MDRO BundleHand Hygiene 手卫生 Contact precautions 接触隔离 Minimize shared equipment 减少设备共用 Environmental cleaning 环境清洁 HAI Preventive Bundles 医院感染的组合预防 Catheter-associated BSI 导管相关血流感染 Ventilator-associated pneumonia 呼吸机相关肺炎 Catheter-associated UTI 导尿管相关尿路感染 Active surveillance cultures 主动监测培养 Chlorhexidine baths 洗必泰洗浴 Antimicrobial stewardship 抗菌药物管理
21. ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTSENVIRONMENTAL SURFACESHCW HANDSSUSCEPTABLE PATIENTSISOLATIONHAND HYGENEDISINFECTION CLEANING
22. 超级细菌出现/MDRO泛滥，我们需要改变什么呢？接触传播的隔离手卫生：洗手液、抗菌洗手液、手消毒液医院环境消毒：手接触的物表隔离衣、口罩与手套隔离多重耐药菌主动筛查与去污染。。。更明智地合理使用抗菌药物
23. 2019/5/22Dr.HU Bijie23手卫生
24. 酒精擦手的优点比洗手有更高的依从性比普通洗手和用抗菌产品洗手更有效比洗手对手部皮肤伤害少比洗手和戴手套浪费少所用时间少，作用快不需要水和毛巾感染控制，不仅仅是手卫生!
25. 2019/5/22Dr.HU Bijie25接触隔离
26. 接触隔离的要求隔离：尽量将患者安置于单间个人防护用品：手套、围裙或隔离衣、面罩手卫生：洗手液、抗菌洗手液、手消毒液物品专用：如血压计、听诊器。不能专用者，则清洁、消毒后才能用于其他病人医院环境消毒：手接触的物表多重耐药菌主动筛查与去污染 ……
27. 2019/5/22Dr.HU Bijie27哪些病原体感染需要隔离？耐药菌 MRSA，不动杆菌艰难梭菌，VRE ESBL？铜绿假单胞菌？传染病 TB，SARS，诺如病毒…… HIV？HBV？耐药菌危害严重，我国必须制订政策，进行严格隔离！耐药菌隔离的警告标识
28. 多重耐药菌进行专门标记（德国某医院）
29. 何时开始隔离？何时解除隔离？发现多重耐药菌感染患者和定植患者后，要尽快反馈相关临床科室，指导采取有效治疗和感染控制措施。患者隔离期间需要定期监测多重耐药菌感染情况，直至连续3次（每次间隔应大于24h）多重耐药菌培养阴性或感染已经痊愈方可解除隔离。
30. 2019/5/22Dr.HU Bijie30减少设备共用
31. ICU减少共用物品听诊器血压计体温表微量输液泵 ……
32. 2019/5/22Dr.HU Bijie32环境清洁
33. 2019/5/22Dr.HU Bijie33 环境微生物菌落总数卫生标准类别范围空气物体表面医务人员手 Ⅰ 层流室 ≤10 ≤5 ≤5 Ⅱ 普通手术室等 ≤200 ≤5 ≤5 Ⅲ 普通病房等 ≤500 ≤10 ≤10 Ⅳ 传染科及病房－ ≤15 ≤15 环境微生物监测要求必须改变！
34. Pathogen Survival in the EnvironmentAdapted from: Kramer A, 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 monthsEnterococcus spp, including VRE5 days-4 months Influenza virus1-2 daysNorovirus8 hours-7 daysStaphylococcus aureus, including MRSA7 days-7 months
35. DecontaminationRisk of infection by used items in healthcare 1968 Earle H Spaulding Critical items: Items that enter sterile tissue or vascular system Semi-critical items Items that come in contact with mucous membranes or non intact skin Non-critical items Items that come in contact with intact skin
36. 手频繁接触的物体表面，是高度危险的！
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38. High-touch equals high-risk: surface cleaning plus hand hygiene key to HAI preventionWith the ever increasing proliferation of 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, infection prevention and control and patient safety, Kaiser Permanente Program Offices, and a member of the National APIC communications committee.Healthcare Purchasing News, June, 2009
39. ICU中，容易被污染的物表温度计输液泵和支架氧气流量表呼吸机控制面板/旋钮生命监测仪面板/旋钮血压计袖带听诊器电脑键盘、鼠标电话呼叫按钮床头桌床上托盘电视遥控器床上用台灯床边便桶床架和控制器
40. ICU环境中耐药鲍曼不动杆菌污染严重
41. Removes organic soil / visible soil Removes potentially infectious micro organisms Removes soil which protects m.o. during disinfection Careful cleaning Mechanical energy - friction, flushing, scrubbing Chemical products - detergents or enzymes Right Method - manual & machinal Manual Cleaning
42. Manual CleaningNO SAFE Products!
43. Everybody is an “EXPERT” Difficult to monitor Responsibilities not clear Health-risk Manual CleaningNO SAFE Procedure!
44. Common in Households Not Common in Healthcare settings Easy to use Standardization & Validation Better Result Saves Nursing Time Monitoring Thermal Disinfection Machinal CleaningMachinal Cleaning is Safer
45. 病区的基本配置：清洗消毒机
46. 日本尿壶与便盆的消毒
47. 关注频繁手接触物体表面的去污染
48. MICRO FIBER The “cleaner” cleaning system
49. 关东病院设备科-保养与维修
50. How Can We Evaluate Environmental Cleaning Direct observation Culture the environment ATP bioluminescence Tool Fluorescent marking tool03/26/2010TSICP50
51. TESTING OF SURFACES
52. 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 educational tool for more than 30 years.
53. ATP is present in blood, skin cells, other bodily fluids and microbes. ATP存在于血液，皮肤细胞，其它体液和微生物中。
54. Dazo Solution(Initially called “GOO”)
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56. Baseline Environmental Evaluation of 36 Acute Care Hospitals% of Objects CleanedHospitalsMean = 48.5 %(20,056 Objects)
57. PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS%
58. 17 HOSPITALS10 HOSPITALS8 HOSPITALSTerminal Room Cleaning Project – Three Programmatic Responses
59. Hospitals Environmental Hygiene Study Group36 Hospital Results % of Objects Cleaned PRE INTERVENTION POST INTERVENTIONP = <.0001Resource Neutral
60. TERMINAL ROOM CLEANING INFECTION PREVENTION TARGETS Sink and Faucets Toilet Surfaces Toilet Flush Handle Bedpan Cleaner Toilet Area Handholds Toilet Area Door Knobs or Push Plates Bedside Table Tray Table Patient Chair Side Rails Room Door Knobs Call Box Telephone Bathroom Light SwitchesSpecific Opportunities for Improvement
61. Evaluating Patient Zone Environmental Hygiene
62. 如何选择表面消毒剂杀菌谱和杀菌速度需要多长时间来杀死病菌？是否对有机物污染敏感？材料和器械兼容性毒性手套兼容性
63. Low and Intermediate Level Disinfectants Use: non-critical items that will come in contact with intact skin Low-level disinfectant: agent that destroys all vegetative bacteria (except tubercle bacilli), lipid viruses, some non-lipid viruses, and some fungi, but not bacterial spores Intermediate-level disinfectant: agent that destroys all vegetative bacteria, including tubercle bacilli, lipid and some non-lipid viruses, and fungi, but not bacterial spores HICPAC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.
64. Examples of Low & Intermediate Level DisinfectantsQuaternary ammonium germicidal detergent solution (quat) Sodium hypochlorite 5.25-6.15% household bleach diluted 1:500 provides >100 ppm available chlorine Phenolic germicidal detergent solution Iodophor germicidal detergent solution Ethyl or isopropyl alcohol (70-90%) Hydrogen peroxide solutions
65. Clean/disinfect: On a regular basis, When spills occur, When visibly soiled Follow manufacturers’ instructions for proper use: use-dilution, dwell time, material compatibility, storage, shelf-life. 1:10 Bleach recommended for C. difficileCleaning & Disinfecting Non-critical Items
66. 2019/5/22Dr.HU Bijie66主动监测培养
67. Reservoir for Spread of Antibiotic Resistant PathogensClinical InfectionsColonized (Asymptomatic) Patients
68. 2019/5/22Dr.HU Bijie68对超级细菌MRSA感染的“零宽容”主动筛查：快速监测积极隔离：包括疑似病例的隔离就地消灭：包括环境消毒
69. Outcomes: Active Surveillance Controls MRSA BSIsHuang et al., CID 2006;43:971-8
70. 美国20个州立法：住院病人主动筛查、隔离MRSA和VRE
71. 进行主动筛查的人群全部新入住ICU的病人？使用机械通气的病人？具有高危因素的ICU病人？全体住院病人？医务人员？
72. 2019/5/2272ICU病人MDROs主动监测培养鼻拭子 MRSA 肛拭子 ESBLs 鲍曼不动杆菌铜绿假单胞菌
73. 2019/5/22Dr.HU Bijie73医院感染的组合预防
74. ICU需要重点防范的医院感染呼吸机相关肺炎VAP 插管相关的血流感染CA-BSI 插管相关的尿路感染CA-UTI 多重耐药菌感染MDROs 医院感染暴发outbreak
75. 2019/5/22Dr.HU Bijie75美国目前推行的预防VAP bundle床头抬高至少30度Head of bed - ≥ 30 ° 每天一次停用镇静剂并评价是否可以撤机Sedation Holiday/weaning 尽早停用应激性溃疡预防药物Peptic Ulcer Disease (PUD) Prophylaxis 口腔护理：用洗必泰冲洗每2～6小时Oral care 深静脉血栓预防Deep Vein Thrombosis (DVT) Prophylaxis 插管气囊上方分泌物的吸引（？）
76. 2019/5/22Dr.HU Bijie76预防CR-BSI： bundle留置导管术时最大无菌屏障Maximal sterile barriers 洗必泰皮肤消毒Chlorhexidine skin antisepsis 尽量使用锁骨下静脉部位穿刺Site choice 严格执行手卫生规则HAND HYGIENE 每天评估是否需要继续留置导管抗菌导管Antibiotic-coated or antiseptic- impregnated catheter 插管后的护理Post-insertion care
77. 2019/5/22Dr.HU Bijie77洗必泰洗浴
78. 洗必泰对于鲍曼不动杆菌的控制
79. Impact of 4% Chlorhexidine (CHG) Whole-Body Washing on Multidrug-resistant Acinetobacter baumannii (ACBA) Skin Colonisation-Patients in a MICUAll patients daily whole-body disinfection with CHG Of 320 patients at admission, 55(17%)ACBA-positive skin swabs Prevalence of ACBA skin colonisation among remaining patients was 5.5% at 24h and 1% at 48h (P=0.002,OR:2.4) ACBA-BSIs decreased from 4.6 to 0.6 per 100 patients (P<0.001;OR:7.6) Daily whole-body CHG disinfection significantly reduced ACBA skin colonisation and BSIs
80. 洗必泰全身擦浴显著降低病原菌皮肤的定植（MRSA、VRE、鲍曼等）减少交叉感染降低CRBSI的发生率减少抗生素的使用
81. 2019/5/22Dr.HU Bijie81抗菌药物管理
82. Antibiotic StewardshipID Division Infectious Diseases Specialist Department of Pharmacy Clinical Pharmacist Health administration Antibiotic Utilization Review Subcommittee Electronic antibiotic stewardship computerized antimicrobial approval system in a hospital setting Education and interaction Infection control professional
83. 抗菌治疗策略(Antibiotic Therapy Strategies) －降阶梯治疗策略（De-Escalation Therapy －短程治疗策略(short-course therapy) －联合治疗（combination therapy）－优化药动学/药效学原则（Optimizing PK/PD principles）－消除定植策略（Antimicrobial Decolonization Strategies）抗菌药物管理策略(Antibiotic Management Strategies) －指南（Guidelines）－限制处方（formulary restriction）－抗生素轮换(Antibiotic Cycling) －抗生素替换/干预策略(substitution/intervention）优化抗感染治疗策略 Optimizing antimicrobial therapy
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86. 卫生部将采取一系列措施，进一步加强抗菌药物临床应用管理制定抗菌药物临床应用管理办法，严格落实抗菌药物分级管理和处方点评制度；加强抗菌药物临床应用和细菌耐药监测网建设，对医疗机构抗菌药物临床应用和细菌耐药情况进行动态监测和预警；开展全国抗菌药物临床应用专项整治行动，引入社会监督机制，加大抗菌药物不合理应用行为的监督和处理力度；继续开展医务人员培训和公众宣传教育工作，提高抗菌药物临床合理应用水平，强化公众合理使用抗菌药物意识。
87. 2011年上海市医院感染质控管理的工作重点抗菌药物管理进一步规范围术期抗菌药物使用提高血培养的送检率多重耐药菌控制推广ICU多重耐药菌的主动培养加强ICU环境消毒 CRBSI和VAP的预防引入几种新的干预措施抵御耐药性今天不采取行动，明天就无药可用！
88. 卫生行业科研专项项目临床多重耐药菌医院感染预防及控制研究主要研究内容研究不同感染控制方法，包括提高手卫生依从性、环境清洁、医疗设备和手高频接触物品的表面消毒、隔离、耐药菌的主动筛查和清除、抗菌药物干预，对降低几种重要多重耐药菌在医院内尤其是ICU内定植、感染和暴发的效果研究抗菌药物干预策略（如轮换策略、替代策略），对降低ICU内多重耐药菌感染的作用研究不同的单一干预技术和组合干预技术，对预防耐药菌引起的导管相关血流感染（CR-BSI）和呼吸机相关肺炎（VAP）的作用制定我国多重耐药菌医院感染控制操作规程、ICU环境清洁、消毒操作规程和评价指标，研究其在不同地区和不同等级医院的可行性和有效性

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