多重耐药菌感染的预防与控制

2019/10/5,Dr.HU Bijie,1,2019/10/5,Dr.HU Bijie,1,多重耐药菌感染的预防与控制,复旦大学附属中山医院 Zhongshan Hospital of Fudan University 胡必杰 Bijie HU,对于超级细菌/多重耐药菌， 要防被忽悠，更要防止麻木！,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,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-内酰胺酶（ESBLs）细菌、耐碳青霉烯类抗菌药物肠杆菌科细菌（CRE）（如产型新德里金属-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。,2019/10/5,Dr.HU Bijie,6,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,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,2005-2009年上海XX医院 鲍曼不动杆菌对亚胺培南耐药率变化,2005年,正确认识接触预防 有效控制多重耐药菌MDRO,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,Antimicrobial Resistance恶性循环,Susceptible pathogen,2019/10/5,Dr.HU Bijie,12,预防传播 合理应用抗菌药物 有效的诊断和治疗 预防感染,12 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！,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,M,M,T1,T2,T3,T8,T7,T6,T5,T12,T11,T10,T9,National Patient Safety Goals, Hospital & Critical Access Hospital, 2009,7c. 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,美国National Patient Safety Goal,NPSG.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,Spread of MDROs Can Be Controlled By:,Good infection control practices Meticulous hand hygiene for contact with patient and patients 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,FIGHTS,Follow isolation practices In-service training for staff Gauging disinfectant efficacy Hand hygiene Testing environmental surfaces Standardized cleaning procedures,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,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,最新MDRO Bundle,Hand 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,ANTIBIOTIC RESISTANT PATHOGENS ON / IN PATIENTS,ENVIRONMENTAL SURFACES,HCW HANDS,SUSCEPTABLE PATIENTS,ISOLATION,HAND HYGENE,DISINFECTION CLEANING,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,2019/10/5,Dr.HU Bijie,24,手卫生,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!,2019/10/5,Dr.HU Bijie,26,接触隔离,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 ,2019/10/5,Dr.HU Bijie,28,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,多重耐药菌进行专门标记（德国某医院）,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。,2019/10/5,Dr.HU Bijie,31,减少设备共用,ICU减少共用物品,听诊器 血压计 体温表 微量输液泵 ,2019/10/5,Dr.HU Bijie,33,环境清洁,2019/10/5,Dr.HU Bijie,34,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 层流室 10 5 5 普通手术室等 200 5 5 普通病房等 500 10 10 传染科及病房 15 15,环境微生物监测要求必须改变！,Pathogen Survival in the Environment,Adapted 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.,Decontamination,Risk 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,手频繁接触的物体表面， 是高度危险的！,High-touch equals high-risk: surface cleaning plus hand hygiene key to HAI prevention,With 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,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,ICU环境中耐药鲍曼不动杆菌污染严重,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,Manual Cleaning,NO SAFE Products!,Everybody is an “EXPERT” Difficult to monitor Responsibilities not clear Health-risk,Manual Cleaning,NO SAFE Procedure!,Common in Households Not Common in Healthcare settings Easy to use Standardization & Validation Better Result Saves Nursing Time Monitoring Thermal Disinfection,Machinal Cleaning,Machinal Cleaning is Safer,病区的基本配置：清洗消毒机,日本尿壶与便盆的消毒,关注频繁手接触物体表面的去污染,MICRO FIBER The “cleaner” cleaning system,关东病院设备科-保养与维修,How Can We Evaluate Environmental Cleaning,Direct observation Culture the environment ATP bioluminescence Tool Fluorescent marking tool,03/26/2010,TSICP,51,TESTING OF SURFACES,ATP bioluminescence,Swab surface luciferase tagging of ATP Hand held luminometer,Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.,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。,Dazo Solution (Initially called “GOO”),Baseline Environmental Evaluation of 36 Acute Care Hospitals,% of Objects Cleaned,Hospitals,Mean = 48.5 %,(20,056 Objects),PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS,%,17 HOSPITALS,10 HOSPITALS,8 HOSPITALS,Terminal Room Cleaning Project Three Programmatic Responses,Hospitals Environmental Hygiene Study Group 36 Hospital Results,% of Objects Cleaned,PRE INTERVENTION,POST INTERVENTION,P = .0001,Resource Neutral,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 Switches,Specific Opportunities for Improvement,Evaluating Patient Zone Environmental Hygiene,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,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.,Examples of Low & Intermediate Level Disinfectants,Quaternary 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,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. difficile,Cleaning & Disinfecting Non-critical Items,2019/10/5,Dr.HU Bijie,67,主动监测培养,Reservoir for Spread of Antibiotic Resistant Pathogens,Clinical Infections,Colonized (Asymptomatic) Patients,2019/10/5,Dr.HU Bijie,69,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,Outcomes: Active Surveillance Controls MRSA BSIs,Huang et al., CID 2006;43:971-8,美国20个州立法： 住院病人主动筛查、隔离MRSA和VRE,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？,2019/10/5,73,ICU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,2019/10/5,Dr.HU Bijie,74,医院感染的组合预防,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,2019/10/5,Dr.HU Bijie,76,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26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（？）,2019/10/5,Dr.HU Bijie,77,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,2019/10/5,Dr.HU Bijie,78,洗必泰洗浴,洗必泰对于鲍曼不动杆菌的控制,Impact of 4% Chlorhexidine (CHG) Whole-Body Washing on Multidrug-resistant Acinetobacter baumannii (ACBA) Skin Colonisation-Patients in a MICU,All 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 (P0.001;OR:7.6) Daily whole-body CHG disinfection significantly reduced ACBA skin colonisation and BSIs,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,2019/10/5,Dr.HU Bijie,82,抗菌药物管理,Antibiotic Stewardship,ID 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 In