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(duì)于超級(jí)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(huì)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(shí)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(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(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(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)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ANTIBIOTICRESISTANTPATHOGENSON/INPATIENTSENVIRONMENTALSURFACESHCWHANDSSUSCEPTABLEPATIENTSISOLATIONHANDHYGENEDISINFECTIONCLEANING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(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!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(shí)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。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(cè)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(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(duì)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(cè)培養(yǎng)ReservoirforSpreadofAntibioticResistantPathogensClinicalInfectionsColonized(Asymptomatic)Patients2025/1/8Dr.HUBijie62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(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(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（？）2025/1/8Dr.HUBijie70預(yù)防CR-BSI：bundle2025/1/8Dr.HUBijie71洗必泰洗浴洗必泰對(duì)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