医院获得性感染的预防：更新指南.docx

医院获得性感染的预防：更新指南2014年12月21日指南导读, Prevention of Healthcare-Associated Infections: Updated GuidanceLaura A. Stokowski, RN, MSReviewed by:Deborah S. Yokoe, MD, MPHDecember 10, 2014From MEDSCAPE website2008年，美国健康卫生流行病学会(Society for Healthcare Epidemiology of America, SHEA)与其合作者美国感染性疾病学会，美国医院协会，感染控制和流行病学专业协会以及联合委员会共同发布了有关预防医院获得性感染(HAI)循证策略的综合概要。2014年，对这一概要进行了更新，以反映HAI预防领域的最新证据。In 2008, the Society for Healthcare Epidemiology of America (SHEA) published a comprehensive compendium of evidence-based strategies to prevent healthcare-associated infections (HAIs) with its partners, the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology, and the Joint Commission.1In 2014, this compendium was updated to reflect new evidence in the field of HAI prevention.2本套幻灯片总结了有关预防HAI的基本和最新策略的推荐意见，为一线医疗工作者(HCP)提供参考。全部概要针对各种HAI分为不同章节，并有单独一章讨论手卫生。This slideshow provides the highlights of recommended basic and advanced strategies to prevent HAIs, and are aimed at frontline healthcare personnel (HCP). The complete compendium, divided into separate chapters on each HAI with an additional chapter on hand hygiene, is availablehere.概要全文涉及预防策略、行为指标、监测、报告、实施策略、干预实例的细节，以及不予推荐的措施。Full-text chapters provide further details on prevention strategies, performance measures, surveillance, reporting, implementation strategies, and examples of interventions and approaches that are not recommended.Images from CDC/Alamy/Science Source导管相关性泌尿系感染Catheter-Associated Urinary Tract Infection (CAUTI)CAUTI最主要的危险因素是尿管(UC)留置时间。为减少UC过度应用：The chief risk factor for CAUTI is the duration that a urinary catheter (UC) remains in situ. To reduce overuse of UCs: 明确本单位使用UC的适应症 Develop facility indications for use of UCs; 教育HCP有关替代UC的其他措施；以及 Educate HCP about alternatives to UCs; and 仅在必要时置入UC，且仅当有适应症时继续保留 Insert UCs only when necessary, and leave in only as long as indications remain.Read SHEAs2014 CAUTI prevention update.Image from DreamstimeCAUTI的预防CAUTI Prevention基本措施The basics: 采用严格无菌操作技术，使用无菌物品（手套，隔离衣，海绵，消毒剂，润滑剂） Use strict aseptic insertion technique with sterile supplies (gloves, drapes, sponges, disinfectant, lubricant); 采用无菌密闭引流系统 Maintain a sterile closed drainage system; 固定UC及管路防止牵拉 Secure UC and tubing to prevent traction; 确保尿液引流通畅 Maintain unobstructed urine flow; 常规进行手卫生 Use routine hand hygiene; 如果发生污染、脱开或渗漏，更换UC和尿液收集系统；且 Replace the UC and collection system if contaminated, disconnected, or leaking; and 采用无菌技术从无针头留样口或引流袋留取标本 Take samples aseptically from a needleless port or drainage bag.考虑制定有关术后尿潴留的处理方案，如由护士进行间断置管及采用膀胱扫描。强调有效的策略及改进空间。与一线HCP共享资料以监测CAUTI预防措施的效果。Consider a protocol for managing postoperative urinary retention, such as nurse-directed intermittent catheterization and use of bladder scanners. Spotlight effective strategies and areas for improvement. Share data with frontline HCP to track CAUTI prevention progress.Image from Dreamstime手术部位感染Surgical-Site Infection (SSI)SSI是当前最常见且医疗费用最高的HAI。基本的措施包括：SSIs are now the most common and most costly HAI. The basics: 根据指南应用预防性抗生素 Give antimicrobial prophylaxis according to guidelines; 避免清除手术部位的毛发；不要使用剃须刀 Avoid removing hair from the operative site; dont use razors; 控制术后血糖水平 Control postoperative blood glucose levels; 维持围手术期体温正常 Maintain perioperative normothermia; 注意改善机械通气患者的组织氧合 Give supplemental oxygen to improve tissue oxygenation to patients on mechanical ventilation; 如无禁忌，采用含酒精的备皮药物 Use an alcohol-containing skin prep agent unless there are contraindications; 胃肠道/胆道手术时使用放渗漏的塑料护皮贴 Use impervious plastic wound protectors for gastrointestinal/biliary tract surgery; 使用清单以改进最佳医疗实践的依从性，并进行监测 Use a checklist to improve compliance with best practices, and perform surveillance; and 对手术室人员、患者及其家属进行有关SSI预防的教育 Educate operating room staff, patients, and families about SSI prevention.Read SHEAs 2014 SSI prevention update.Image from Science Photo Library难辨梭状芽孢杆菌感染Clostridium difficileInfection (CDI)CDI的危险因素包括抗生素暴露或入住医疗机构。CDI能够使住院日延长3-6天。CDI的危险因素包括氟喹诺酮、其他抗生素及抑制胃酸。受到污染的物品和环境是CDI的重要来源。The risk factors for CDI include exposure to antibiotics or to healthcare settings. CDI increases length of stay by 3-6 days. The risk factors for CDI now include fluoroquinolones, other antibiotics, and gastric acid suppression. Contaminated equipment and environmental services are reservoirs of transmission of CDI.基本措施包括：(1)实施抗生素监管/恰当使用抗生素；(2)采用接触隔离措施（单间病房或隔离患者；戴手套/穿隔离衣）；(3)注意手卫生；(4)使用专用设备，清洁公用设备（不要使用电子测温计）；(5)进行充分的环境清洁/消毒；(6)使用报警系统以及时通知医务人员有关CDI的情况；交班时交流有关CDI的诊断；(7)对保洁人员、患者及来访者就CDI预防进行宣教。The basics: (1) Apply antimicrobial stewardship/appropriate use of antibiotics; (2) Use contact precautions (single patient room preferred or cohort patients; wear glove/gown); (3) Perform hand hygiene; (4) Use dedicated equipment and clean shared equipment (no electronic thermometers); (5) Perform adequate environmental cleaning/disinfection; (6) Use an alert system to promptly notify clinical staff of CDI; communicate CDI diagnosis at facility transfer; and (7) Educate environmental services, patients, visitors on CDI prevention.Image from Centers for Disease Control and PreventionCDI: 特殊措施CDI: Special Approaches当出现爆发流行或基本措施效果不满意时：For outbreaks or when basic approaches are inadequate: 对腹泻患者进行接触隔离直至得到CDI检测结果 Put patients with diarrhea in contact precautions until CDI testing results are available; 使用肥皂和水（而不是含有酒精的刷手液）进行手卫生 Perform hand hygiene with soap and water vs alcohol-based hand rubs; 对CDI患者实施延长接触隔离措施直至出院 Extend contact precautions for CDI patients until discharge; 加强对依从性的监测 Intensify compliance monitoring; and 使用含有漂白剂或EPA批准的具有杀孢子作用的其他消毒剂进行环境清洁 Use a bleach-based or other EPA-approved sporicidal disinfectant for environmental cleaning.Read SHEAs 2014 CDI prevention updateImage from Alamy耐甲氧西林金黄色葡萄球菌Methicillin-ResistantStaphylococcus aureus近期有关预防MRSA传播的措施取得了部分效果，但是一些患者仍然是高危人群Recent efforts to prevent the transmission of MRSA have had some success, but certain patient groups remain at high risk.基本措施包括：The basics: 实施MRSA监测计划：鉴别有MRSA感染或感染史的患者，追踪医院获得性MRSA Implement a MRSA monitoring program: identify patients with current or history of MRSA, and track hospital-onset MRSA; 对MRSA定植或感染患者实施接触隔离 Use contact precautions for MRSA-colonized and MRSA-infected patients; 对设备和环境进行清洁/消毒 Clean/disinfect equipment and the patient environment; 采用报警系统以及时通知医务人员MRSA病例入院或转入情况，或新发MRSA定植或感染病例 Use an alert system to promptly notify clinical staff of a readmission or transfer with MRSA, or new colonization or cases of MRSA infection; 与医务人员分享MRSA资料及预后指标 Share MRSA data and outcome measures with staff; and 对患者及家属进行有关MRSA预防的宣教 Educate patients and families about MRSA prevention.MRSA特殊措施MRSA Special Approaches对于MRSA感染率很高的医疗机构：For facilities with high MRSA rates: 采用主动监测措施：对患者和HCP进行筛查 Use active surveillance testing: patient and HCP screening; and 采用MRSA去定植治疗在ICU针对性或普遍实施（每日洗必泰沐浴+/-鼻腔内使用莫匹罗星） Use MRSA decolonization therapytargeted or universal in the intensive care unit (ICU) (daily chlorhexidine bathing +/- intranasal mupirocin); and 接触所有成年ICU患者时穿隔离衣/戴手套 Use gown/glove for contact with all adult ICU patients.Read SHEAs 2014 MRSA prevention update.Image from Science Source中心静脉导管相关血行性感染Central Line-Associated Bloodstream Infection (CLABSI)基本措施包括: (1) 遵循留置中心静脉导管(CVC)的循证指证; 避免不必要留置CVC; (2) 对相关HCP团队进行宣教; (3) 置管: 采用最大限度的隔离措施, 全合一套装, 留置颈内静脉CVC时采用超声引导, 使用含酒精/洗必泰的消毒剂备皮; (4) 采用清单监测感染预防措施的依从性; (5) 每5-7天更换敷料，或发生污染、潮湿时立即更换; (6) 对ICU患者（年龄 2个月）每日洗必泰沐浴; (7) 置管或操作前进行手卫生; (8) 对肥胖的成年患者，计划留置CVC时避免使用股静脉; (9) 保证适当的护患比; (10) 进行CVC操作前消毒导管接头、无针头接头及药物注射口等; (11) 拔除不必要的CVC; (12) 对CLABSI进行检测，并将相关数据与医务人员分享。The basics: (1) Use evidence-based indications for central venous catheter (CVC); avoid unnecessary CVC placement; (2) Educate the HCP team involved; (3) Insertion: use maximum barrier precautions, all-inclusive kits, ultrasonographic guidance for internal jugular CVC, and alcohol/chlorhexidine skin prep; (4) Use a checklist for adherence to infection prevention practices; (5) Change dressing every 5-7 days, or immediately if soiled, loose, or damp; (6) Perform daily chlorhexidine bathing of ICU patients ( 2 months of age); (7) Perform hand hygiene before catheter insertion or manipulation; (8) In obese adult patients, avoid the femoral vein for planned CVC insertion; (9) Ensure appropriate nurse-to-patient ratios; (10) Disinfect catheter hubs, needleless connectors, and injection ports before accessing CVCs; (11) Remove nonessential CVCs; and (12) Perform surveillance for CLABSI, and share data with clinical staff.Image from AlamyCLABSI特殊措施CLABSI Special Approaches尽管实施上述基本措施，部分患者CLABSI比例仍非常高For populations with CLABSI rates that are unacceptably high despite basic practices: 成年患者使用消毒剂或抗生素浸润导管 Use antiseptic or antimicrobial-impregnated CVCs in adults; 对年龄 2个月的患者使用含洗必泰的CVC敷料 Use chlorhexidine-containing dressings for CVCs in patients 2 months of age; 使用含消毒剂的肝素帽/接头保护装置 Use an antiseptic-containing cap/port protector; 使用CVC抗生素锁 Use antimicrobial locks for CVCs; and 血液透析后每周经CVC使用重组组织纤溶酶原激活物 Use recombinant tissue plasminogen activating factor weekly through the CVC after hemodialysis.Read SHEAs 2014 MRSA prevention update.Image from Science Source成年患者的呼吸机相关肺炎Ventilator-Associated Pneumonia (VAP) in Adults基本措施包括：The basics: 如有可能，避免气管插管 Avoid intubation if possible; 尽量减少镇静，每日中断镇静（自主清醒试验） Minimize sedation, and interrupt sedation daily (spontaneous awakening trial); 每日评估拔除气管插管的可能（自主呼吸试验） Assess readiness to extubate daily (spontaneous breathing trial); 联合进行自主清醒试验和自主呼吸试验 Pair spontaneous awakening trials with spontaneous breathing trials; 鼓励运动/活动 Encourage exercise/mobilization; 尽量减少气管插管套囊上分泌物潴留；对高危患者（机械通气 48-72小时）使用带有声门下引流的气管插管 Minimize pooling of secretions above the endotracheal tube cuff; use endotracheal tubes with a subglottic secretion drainage port for high-risk patients ( 48-72 hours of ventilation); 抬高床头30-45 Elevate head of bed 30-45; and 如果呼吸机管路发生污染或出现故障，予以更换 Change the ventilator circuit if visibly soiled or malfunctioning.Read SHEAs 2014 VAP prevention update.Image from Science Photo Library新生儿VAPVAP in Neonates基本措施包括The basics: 避免气管插管（如有可能，使用无创通气） Avoid intubation (use noninvasive approaches if possible); 尽量缩短机械通气时间 Minimize the duration of mechanical ventilation; 避免镇静 Avoid sedation; 每日评估拔除气管插管可能性 Assess readiness for extubation daily; 常规进行口腔清洁（仅使用无菌水） Provide regular oral care (sterile water only); and 尽量减少呼吸机管路脱开；仅在管路发生污染或故障时予以更换 Minimize breaks in the ventilator circuit; change only if soiled or malfunctioning.Image from Alamy儿科患者的vAPVAP in the Pediatric Population基本措施包括The basics: 如有可能，避免气管插管（采用无创正压通气） Avoid intubation (use noninvasive positive-pressure ventilation) if possible; 尽量缩短机械通气时间 Minimize the duration of mechanical ventilation; 每日评估拔除气管插管的可能性 Assess readiness to extubate daily; 避免非计划拔管/再次插管 Avoid unplanned extubation/reintubation; 常规进行口腔清洁 Provide regular oral care; 除非存在禁忌症，应当抬高床头 Elevate the head of bed unless contraindicated; 不常规更换呼吸机管路（仅当发生污染或故障时予以更换，清除积水） Maintain the ventilator circuits (change only when soiled or malfunctioning, remove condensation); 改变体位前吸引口腔分泌物 Suction oral secretions before position change; and 采用带套囊的气管插管；保持套囊压在防止漏气的最低水平 Use cuffed endotracheal tubes; maintain cuff pressure at the minimal level needed to prevent air leak.Image from Alamy手卫生Hand Hygiene近年来，有关如何改进手卫生依从性有了新的证据。手卫生非常重要，因此有单独的章节讨论这一预防措施。即使在医疗资源富足的机构，手卫生依从性平均在40%左右。The evidence base for how to improve hand hygiene compliance has expanded in recent years. Hand hygiene is so important that a separate chapter of the compendium is now devoted to this preventive strategy. Average rates of hand hygiene compliance hover around 40%, even in well-resourced facilities.3基本措施包括：(1) 选择适当的手卫生产品; (2) 手卫生设备应当设置在方便的地方; (3) 采用含酒精的刷手液，如果发生明显污染，应使用肥皂和水; (4) 解决影响本单位手卫生依从性的因素; (5) 监测手卫生依从性