多重耐藥菌感染的預(yù)防與控制(胡必杰)課件

1、2022/8/20Dr.HU Bijie12022/8/20Dr.HU Bijie1多重耐藥菌感染的預(yù)防與控制復(fù)旦大學(xué)附屬中山醫(yī)院Zhongshan Hospital of Fudan University胡必杰 Bijie HU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？多重耐藥菌（Multidrug-Resistant Organism，MDRO），主要是指對(duì)臨床使用的三類(lèi)或三類(lèi)以上抗菌藥物同時(shí)呈現(xiàn)耐藥的細(xì)菌。常見(jiàn)多重耐藥菌包括耐甲氧西

2、林金黃色葡萄球菌（MRSA）、耐萬(wàn)古霉素腸球菌（VRE）、產(chǎn)超廣譜-內(nèi)酰胺酶（ESBLs）細(xì)菌、耐碳青霉烯類(lèi)抗菌藥物腸桿菌科細(xì)菌（CRE）（如產(chǎn)型新德里金屬-內(nèi)酰胺酶NDM-1或產(chǎn)碳青霉烯酶KPC的腸桿菌科細(xì)菌）、耐碳青霉烯類(lèi)抗菌藥物鮑曼不動(dòng)桿菌（CR-AB）、多重耐藥/泛耐藥銅綠假單胞菌（MDR/PDR-PA)和多重耐藥結(jié)核分枝桿菌等。2022/8/20Dr.HU Bijie6臨床情景某男，65歲腦膠質(zhì)瘤術(shù)后20天高熱，黃痰，呼吸困難留置中心靜脈導(dǎo)管、導(dǎo)尿管和人工氣道機(jī)械通氣胸片肺炎痰培養(yǎng)：PDR-AB血培養(yǎng)：陰溝腸桿菌尿培養(yǎng)：兩種念珠菌結(jié)局術(shù)后1月死亡花費(fèi)：10萬(wàn)元？2008年7月某醫(yī)院會(huì)

3、診病例醫(yī)院感染越來(lái)越險(xiǎn)惡！案例某男，90歲，COPD多年，反復(fù)感染，近日鮑曼不動(dòng)桿菌肺部感染某男，56歲，肺癌術(shù)后一周，高熱、呼吸衰竭，重癥肺炎，鮑曼不動(dòng)桿菌某男，22歲，顱腦手術(shù)后2周，高熱，CSF引流液鮑曼不動(dòng)桿菌2005-2009年上海XX醫(yī)院鮑曼不動(dòng)桿菌對(duì)亞胺培南耐藥率變化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(guò)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(guò)醫(yī)護(hù)人員尤其手的接觸，細(xì)菌

4、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(guò)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Antimicrobial Resistance惡性循環(huán)耐藥性增加 更廣譜抗菌藥物Susceptible pathogenAntimicrobial-Resistant PathogenAntimicrobial ResistanceAntimicrobial UseInfection2022/8/20Dr.HU Bijie12 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Campaign to Prevent Antimicrobial Resistance in Healthcare

5、Settings12 遏制醫(yī)務(wù)工作者傳播11 隔離患者9 嚴(yán)格掌握萬(wàn)古霉素應(yīng)用指證1 接種疫苗2 拔除導(dǎo)管6 專(zhuān)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(jiǎn)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MMT1T2T3T8T7T6T5T12T11T10T9National Patient Safety Goals, Hospital & Critical Access Hospital, 20097c. Prevent

6、 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: respira

7、tory & hand hygiene on day of admission pt. & family美國(guó)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 han

8、ds or contaminated environment. MRSAC. difficileVRE MDR gram negative bacteriaSpread 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 k

9、nowledge regarding these organisms and how they are spreadJudicious use of antibioticsTeaching patient and familyFIGHTSFollow isolation practicesIn-service training for staff Gauging disinfectant efficacyHand hygieneTesting environmental surfacesStandardized cleaning procedures衛(wèi)生部辦公廳關(guān)于印發(fā)多重耐藥菌醫(yī)院感染預(yù)防與

10、控制技術(shù)指南（試行）的通知（2011.1.17）一、加強(qiáng)多重耐藥菌醫(yī)院感染管理（一）重視多重耐藥菌醫(yī)院感染管理（二）加強(qiáng)重點(diǎn)環(huán)節(jié)管理（三）加大人員培訓(xùn)力度二、強(qiáng)化預(yù)防與控制措施（一）加強(qiáng)醫(yī)務(wù)人員手衛(wèi)生（二）嚴(yán)格實(shí)施隔離措施（三）遵守?zé)o菌技術(shù)操作規(guī)程（四）加強(qiáng)清潔和消毒工作三、合理使用抗菌藥物四、建立和完善對(duì)多重耐藥菌的監(jiān)測(cè)（一）加強(qiáng)多重耐藥菌監(jiān)測(cè)工作（二）提高臨床微生物實(shí)驗(yàn)室的檢測(cè)能力WHO抵御細(xì)菌耐藥的6項(xiàng)政策 制定并執(zhí)行一套完整的、有資金支持的國(guó)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MDRO Bundl

11、eHand Hygiene 手衛(wèi)生Contact precautions 接觸隔離Minimize shared equipment 減少設(shè)備共用Environmental cleaning 環(huán)境清潔HAI Preventive Bundles 醫(yī)院感染的組合預(yù)防Catheter-associated BSI 導(dǎo)管相關(guān)血流感染Ventilator-associated pneumonia 呼吸機(jī)相關(guān)肺炎Catheter-associated UTI 導(dǎo)尿管相關(guān)尿路感染Active surveillance cultures 主動(dòng)監(jiān)測(cè)培養(yǎng)Chlorhexidine baths 洗必泰洗浴Anti

12、microbial stewardship 抗菌藥物管理ANTIBIOTIC RESISTANT PATHOGENSON / INPATIENTSENVIRONMENTAL SURFACESHCWHANDSSUSCEPTABLE PATIENTSISOLATIONHAND HYGENEDISINFECTION CLEANING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2022/8/20Dr.HU Bijie24手衛(wèi)生酒精擦手的優(yōu)點(diǎn)比洗手有更

13、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!2022/8/20Dr.HU Bijie26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(zhuān)用：如血壓計(jì)、聽(tīng)診器。不能專(zhuān)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2022/8/20Dr.HU Bijie28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？

14、HBV？耐藥菌危害嚴(yán)重，我國(guó)必須制訂政策，進(jìn)行嚴(yán)格隔離！耐藥菌隔離的警告標(biāo)識(shí)多重耐藥菌進(jìn)行專(zhuān)門(mén)標(biāo)記（德國(guó)某醫(yī)院）何時(shí)開(kāi)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。2022/8/20Dr.HU Bijie31減少設(shè)備共用ICU減少共用物品聽(tīng)診器血壓計(jì)體溫表微量輸液泵2022/8/20Dr.HU Bijie33環(huán)境清潔2022/8/20Dr.HU Bijie34 環(huán)境微生物菌落總數(shù)衛(wèi)生標(biāo)準(zhǔn)類(lèi)別 范圍 空氣

15、 物體表面 醫(yī)務(wù)人員手 層流室 10 5 5 普通手術(shù)室等 200 5 5 普通病房等 500 10 10 傳染科及病房 15 15環(huán)境微生物監(jiān)測(cè)要求必須改變！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.OrganismDuratio

16、n 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 monthsDecontaminationRisk of in

17、fection 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手頻繁接觸的物體表面，是高度危險(xiǎn)的！High-touch

18、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

19、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

20、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(tīng)診器電腦鍵盤(pán)、鼠標(biāo)電話呼叫按鈕床頭桌床上托盤(pán)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 Removes organic soil / visible soil Removes potentially infectious micro organisms Removes soil which protects m.o. during disinfectionCareful cleaning Mechanical energy- friction, flush

21、ing, scrubbingChemical products - detergents or enzymesRight Method- manual & machinalManual CleaningManual CleaningNO SAFE Products! Everybody is an “EXPERT” Difficult to monitor Responsibilities not clear Health-risk Manual CleaningNO SAFE Procedure! Common in Households Not Common in Healthcare s

22、ettings Easy to use Standardization & Validation Better Result Saves Nursing Time Monitoring Thermal Disinfection Machinal CleaningMachinal Cleaning is Safer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 MICRO FIBER The “cleaner” cleaning system關(guān)東病院設(shè)備科-保養(yǎng)與維修How Can We Evaluate Environmental CleaningDirect o

23、bservationCulture the environmentATP bioluminescence ToolFluorescent marking tool03/26/2010TSICP51 TESTING OF SURFACESATP 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 e

24、ducational tool for more than 30 years.ATP is present in blood, skin cells, other bodily fluids and microbes.ATP存在于血液，皮膚細(xì)胞，其它體液和微生物中。 Dazo Solution(Initially called “GOO”)Baseline Environmental Evaluation of 36 Acute Care Hospitals% of Objects CleanedHospitalsMean = 48.5 %(20,056 Objects)PROPORTION

25、OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANING IN 20 ACUTE CARE HOSPITALS%17 HOSPITALS10 HOSPITALS8 HOSPITALSTerminal Room Cleaning Project Three Programmatic ResponsesHospitals Environmental Hygiene Study Group36 Hospital Results % of Objects Cleaned PRE INTERVENTION POST INTERVENTIONP = 100

26、ppm available chlorinePhenolic germicidal detergent solutionIodophor germicidal detergent solutionEthyl or isopropyl alcohol (70-90%) Hydrogen peroxide solutionsClean/disinfect:On a regular basis, When spills occur, When visibly soiled Follow manufacturers instructions for proper use:use-dilution, d

27、well time,material compatibility, storage, shelf-life.1:10 Bleach recommended for C. difficileCleaning & Disinfecting Non-critical Items2022/8/20Dr.HU Bijie67主動(dòng)監(jiān)測(cè)培養(yǎng)Reservoir for Spread of Antibiotic Resistant PathogensClinical InfectionsColonized (Asymptomatic) Patients2022/8/20Dr.HU Bijie69對(duì)超級(jí)細(xì)菌MRS

28、A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: Active Surveillance Controls MRSA BSIsHuang et al., CID 2006;43:971-8美國(guó)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？2022/8/2073ICU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2022/8/20Dr.HU Bijie74醫(yī)院感染的組合預(yù)防ICU需要重點(diǎn)防范

29、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)outbreak2022/8/20Dr.HU Bijie76美國(guó)目前推行的預(yù)防VAP bundle床頭抬高至少30度Head of bed - 30 每天一次停用鎮(zhèn)靜劑并評(píng)價(jià)是否可以撤機(jī)Sedation Holiday/weaning盡早停用應(yīng)激性潰瘍預(yù)防藥物Peptic Ulcer Disease (PUD) Prophylaxis口腔護(hù)理：用洗必泰沖洗每26小時(shí)Oral care 深靜脈血栓預(yù)防Deep Vein Thrombosis (DVT) Prophylax

30、is插管氣囊上方分泌物的吸引（？）2022/8/20Dr.HU Bijie77預(yù)防CR-BSI： bundle留置導(dǎo)管術(shù)時(shí)最大無(wú)菌屏障Maximal sterile barriers洗必泰皮膚消毒Chlorhexidine skin antisepsis盡量使用鎖骨下靜脈部位穿刺Site choice嚴(yán)格執(zhí)行手衛(wèi)生規(guī)則HAND HYGIENE每天評(píng)估是否需要繼續(xù)留置導(dǎo)管抗菌導(dǎo)管Antibiotic-coated or antiseptic- impregnated catheter插管后的護(hù)理Post-insertion care2022/8/20Dr.HU Bijie78洗必泰洗浴洗必泰對(duì)于

31、鮑曼不動(dòng)桿菌的控制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 CHGOf 320 patients at admission, 55(17%)ACBA-positive skin swabsPrevalence of ACBA skin colonisation

32、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2022/8/20Dr.HU B

33、ijie82抗菌藥物管理Antibiotic StewardshipID 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抗菌治療策略(Antibiotic Therapy Strategies) 降階梯治療策略（De-E