多重耐药菌感染的预防与控制胡必杰

2018/1/25,Dr.HU Bijie,1,2018/1/25,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！,MRSAPDR-不动杆菌铜绿假单胞菌艰难梭菌VREESBL，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。,2018/1/25,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,2018/1/25,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. MRSAC. difficileVRE MDR gram negative bacteria,Spread of MDROs Can Be Controlled By:,Good infection control practicesMeticulous hand hygiene for contact with patient and patients environment of Standard PrecautionsGood environmental and equipment cleaning practicesHCW knowledge regarding these organisms and how they are spreadJudicious use of antibioticsTeaching patient and family,FIGHTS,Follow isolation practicesIn-service training for staff Gauging disinfectant efficacyHand hygieneTesting environmental surfacesStandardized 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 PATHOGENSON / INPATIENTS,ENVIRONMENTAL SURFACES,HCWHANDS,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,2018/1/25,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!,2018/1/25,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,2018/1/25,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，VREESBL？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。,2018/1/25,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,2018/1/25,Dr.HU Bijie,33,环境清洁,2018/1/25,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 healthcare1968 Earle H Spaulding Critical items: Items that enter sterile tissue or vascular systemSemi-critical itemsItems that come in contact with mucous membranes or non intact skinNon-critical itemsItems 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 disinfectionCareful cleaning Mechanical energy- friction, flushing, scrubbingChemical products - detergents or enzymesRight 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 observationCulture the environmentATP bioluminescence ToolFluorescent 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 Group36 Hospital Results,% of Objects Cleaned,PRE INTERVENTION,POST INTERVENTION,P = 100 ppm available chlorinePhenolic germicidal detergent solutionIodophor germicidal detergent solutionEthyl 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,2018/1/25,Dr.HU Bijie,67,主动监测培养,Reservoir for Spread of Antibiotic Resistant Pathogens,Clinical Infections,Colonized (Asymptomatic) Patients,2018/1/25,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？,2018/1/25,73,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,2018/1/25,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,2018/1/25,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（？）,2018/1/25,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,2018/1/25,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 CHGOf 320 patients at admission, 55(17%)ACBA-positive skin swabsPrevalence 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,2018/1/25,Dr.HU Bijie,82,抗菌药物管理,Antibiotic Stewardship,ID DivisionInfectious Diseases SpecialistDepartment of PharmacyClinical PharmacistHealth administrationAntibiotic Utilization Review Subcommittee Electronic antibiotic stewardshipcomputerized antimicrobial approval system in a hospital setting Education and interactionInfection control professional,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（com