課前預習定義病人在醫(yī)療機構因其他疾病接受治療的過程中所感染

Healthcare-associatedInfections醫(yī)療相Definition:Infectionsthatpatientsacquireduringthecourseofreceivingtreatmentforotherconditionswithinahealthcaresetting Settings:hospitals(IntensiveCareUnits,SpecialCareUnits,otherhospitalsettings),long-termcarefacilities(LTCFs),outpatientfacilitiessuchasambulatorysurgicalclinics,dialysiscenters機構：醫(yī)院（重癥監(jiān)護 ，特殊護理，其他）長期護理機構，門診如門診手術 ，透析Inhospitalsalone(annually)每年僅在醫(yī)1.7million1outof20patients(5%)acquirean99,000deathsassociatedwith$26-33billioninexcesshealthcare

170萬醫(yī)療相5%病例發(fā)生醫(yī)療相 死于醫(yī)療相260-330億額外醫(yī)療開EstimatesofHealthcare-associatedInfectionsinUSHospitalsAnnually每年在醫(yī)院中的醫(yī)數(shù)

National損失（十

器械相UrinarytractinfectionsBloodstreaminfections血流

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Procedure-relatedinfections操作相Surgicalsite 手術部 3- Healthcare-associatedInfectionsinNon-hospitalSettings非醫(yī)院內的醫(yī)療相Long-termcare長期護1.7millionbedswith2.5millionresidents/yearnationally nsHealthcareSystem:133LTCFs,11,475退 醫(yī)療系統(tǒng)：133個長期護理機構，11475名患√HAIprevalence:醫(yī)療相 患病率√Indwellingmedicaldevice:25%ofall內置醫(yī)療器械：25%NCHS,Tsan,AJIC,Klevens,SeminDialysis,MMWRMay16,2008;Healthcare-associatedInfectionsinNon-hospitalSettings非醫(yī)院內的醫(yī)療相Ambulatorysurgicalcenters:5,175門診手術中心：5175DataonHAIsfromoutbreaks;nonational爆發(fā)數(shù)據(jù)，無監(jiān)測Example:hepatitisCoutbreakassociatedwithsyringereuseresultedinlettersto>40,000endoscopycenter例如：重復使用針頭導致肝爆，手室因需要向萬出 件告知其 可能性NCHS,Tsan,AJIC,Klevens,SeminDialysis,MMWRMay16,2008;Healthcare-associatedInfectionsinNon-hospitalSettings非醫(yī)院內的醫(yī)療相Dialysiscenters:4,950透析中心：4950家機Catheter-relatedbloodstreaminfections:4.2per100patientmonths導管相關血流 Incidenceofmethicillin-resistantStaphylococcusaureus(MRSA)bloodstreaminfection:100xgreaterthaninnondialysispopulation耐甲氧西林金黃色葡萄球菌 NCHS,Tsan,AJIC,Klevens,SeminDialysis,MMWRMay16,2008;MRSAInfectionsAreaPatientSafetyChallengeLimitedtoAcuteCareHospitalSetting ~ s“ial” 60%ntifiedbeforeonfirst2daysofhospitalizationbutwithcntactstohealtharesettings)60%的最初兩天發(fā)現(xiàn)（存在與醫(yī)療相關的接觸） 15%在醫(yī)院獲得，在社區(qū)發(fā)EmergingThreatsinHealthcareEstimateofClostridiumdifficileCases,bySetting醫(yī)療領域的 ：艱難梭Hospital-acquired,hospital-onset165,000,$1.3billioninexcesscosts,0

ClostridiumdifficileAnylisted1997199819992000200120022003200420052006

9,000deaths (upto450,000,$0.3billioninexcesscosts,3,000deaths /每Nursinghome-onset263,000,$2.2billioninexcesscosts,16,500deaths Campbell,InfectControlHospEpidemiol.2009Dubberke,ClinInfectDis.2008

Dubberke,EmergInfectDis.Elixhauseretal.HCUPStatisticalBrief#50.%GramNegativeBacteriaResistanttoKeyDrugsbyHealthcare-associatedInfectionTypeSource:NationalHealthcareSafetyNetwork耐藥革蘭 菌百分比（ 類別分類）數(shù)據(jù)來源：國 菌

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UrinaryCarbapenemresistantKlebsiella Cef/CtrresistantCarbapenemresistant

Hidronetal.ICHEStateofPreventionHICPAC/CDCEvidence-basedPreventionGuidelinesaredevelopedforeachtypeofinfectionandbasedonsystematicreviewsofthemedicalli ture在系統(tǒng)綜述醫(yī)學文 Categoriesof 類Category1A1AStrongmendation/strongormoderatequalityof強烈建議/高質量或中等質量的文Category1B1BStrongmendation/weakqualityofevidenceor強烈建議/稍弱 或已被接受的操StateofPreventionHICPAC/CDCEvidence-basedPreventionCategory1C1CStrongmendationrequiredbystateorfederal國家 要求的，強烈建Category22Weakmendationsupportedbylimited非強烈建議 有Nomendation/unresolved無建議/未解決的問Insufficientevidencetosupporta不足，無法支持建StateofPreventionSuboptimalAdherencetoHICPAC/CDC對HICPAC/CDC的建議執(zhí)行差強Handhygieneadherence手衛(wèi)生規(guī)范執(zhí)5%81overallaverage405-81%按照標準（總體平均Surgicalantimicrobialprophylaxis手術抗生素預<50%adherencetomendations執(zhí)行小于FullcompliancewithmajorHAIguidelines全面執(zhí)行HAI指南Among1,256UShospitals—30.7%to在1256家醫(yī)院中-30.7%到Central-linebloodstreaminfectionsprevention—中心靜脈血 預防-ArchSurg StateofPreventionSuccessfulPreventionofBloodstreamInfectionsMichigan&Pennsylvania密西根州和賓夕法尼亞州成功預防中心靜脈血ImplementationofCDC/HICPACInfectionPreventionGuideline執(zhí)行CDC/HICPAC中心靜脈 Forinsertionandremovalofintravascularcatheters介入和移除血液導Intensivecareunits重癥監(jiān)SWPennsylvania(66),Michigan(103)Interventionstoincreasedadherencetomendationsweresimilar Educationofstaff人員教育Creationofacentral-linecart中心靜脈介入操作車Data/feedbackonadherencetopracticesand數(shù)據(jù)反MutoetalMMWROt45rttJl6ryrounds每日多部門巡Strategiestoimprovesafetyculture營造安全醫(yī)的人文環(huán)StateofpreventionPreventsBloodstreamInfections Pennsylvania賓 Michigan密西根108103ICUsat67 hospitals,1820 18

PronovostP.NewEnglJMed2006;355:2725-TrendsinMRSABloodstreamInfectionsbyICUNationalHealthcareSafetyNetworkHospitals,1997-根據(jù)不同ICU類別對MRSA血 趨勢的分析，國 網(wǎng)，1997-Estimated據(jù)估計PooledMeanAnnualCLABSIRatePooledMeanAnnualCLABSIRateper1,000CentralLine 防止7000例血 的發(fā) 1,800lives 挽救了1800患者的生 $50-180Minaverted43避免了0.5-1.8 的經(jīng)3損21 PreliminaryEstimatesofPreventableInfections,Deaths&BasedonPublished 可防止 和經(jīng)濟損失，基 文獻的初步估Typeof

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避免的經(jīng)濟損失（十億美金PUrinarytractSurgicalsiteUmschied,C.UniversityofPennsylvania.PresentationatHICPAC,MarchKeysfortheEliminationofHealthcare-associatedInfections Datafor行動Improvedimplementationofexistingbest強化對現(xiàn)有措施的Recognizeexcellencein認可和Addressgapsin填補Identifyandrespondtoemerging發(fā)現(xiàn)并應對新DataforAction行動StateInitiatives:PublicReportingofHAIs,全美倡議：醫(yī)療相 的公開報告DisclosuresofratesHHS nforHAINational5Year健康與公眾服務部的醫(yī)療相 指來National5-Year協(xié)作Bloodstreaminfections50%依從靜脈導管的操100%Clostridiumdifficile(hospitalizations)艱難梭菌（住院30%Clostridiumdifficileinfections艱難梭30%Urinarytractinfections25%MRSAinvasiveinfectionsMRSA侵入（人群50%MRSAbacteremia(hospital)MRSA菌血癥（醫(yī)院25%25%SurgicalCareImprovementProject手術護理改善項目95%NHSN=NationalHealthcareSafetyNetwork NHDS=NationalHospitalDischargeSurveyHCUP=HealthcareCostandUtilizationProject EIPs=EmergingInfectionsProgramSCIP=SurgicalCareImprovementProjectRecognizeExcellencein認可和激 國會：醫(yī)Healthreformbillsproposemandatorynationalpublic醫(yī) 法案要求公開報告醫(yī)療相 數(shù)HAIpreventionwouldbetiedtoMedicare/Medicaid醫(yī)療相 與醫(yī) 關CentersforMedicareandMedicaidServices 醫(yī)Reducedpaymentforhospital-acquiredconditions(HACs)healthcare-associated 降低對醫(yī)療相 的費用支EffectiveOctober 2008年生Includeshospital-associatedbloodstreaminfections,urinaryinfections,andselectedsurgicalsite 包括血 ，部份手術切Payforreporting/performance對報告和良好表現(xiàn)進TopCDCmendationstopreventhealthcareassociatedinfections StateofPreventionHICPAC/CDCEvidence-basedPreventionGuidelinesaredevelopedforeachtypeofinfectionandbasedonsystematicreviewsofthemedicalli ture在系統(tǒng)綜述醫(yī)學文 Categoriesof 類Category1A1AStrongmendation/strongormoderatequalityof強烈建議/高質量或中等質量的文Category1B1BStrongmendation/weakqualityofevidenceor強烈建議/稍弱 或已被接受的操Topreventcatheterassociatedurinarytract預防 插管相Insertcathetersonlyforappropriate 必要時再進行Leavecatheters ceonlyaslongas 置管時間要合Ensurethatonlyproperly sinsertand 僅接受過專業(yè)培訓的人員才能進行插管Insertcathetersusingaseptictechniqueandsterileequipmentcare 進行必要的清Followasepticinsertion,maintainacloseddrainagesystem Maintainunobstructedurine 保持ComplywithCDChandhygienemendationsandStandard Topreventsurgicalsite預防手Before 手術Administerantimicrobialprophylaxisinaccordancewithbasedstandardsand生

根據(jù)相關標準和指南Treatremoteinfections-wheneverpossiblebefore 在擇期手術前對其 進行治Avoidhairremovalattheoperativesiteunlessitwillinterferetheoperation;donotuse進行備皮；避免使用剃

如果對手術無干擾，不采用剃毛Useappropriateantisepticagentandtechniqueforskin Topreventsurgicalsite預防手During KeepORdoorsclosedduringsurgeryexceptasneededpassageof nel,andthe閉，除非必要的設AfterSurgery手術Maintainimmediatepostoperative正

保持手術室保持患者術后Protectprimaryclosureincisionswithsteriledressing保持傷口清Controlbloodglucoselevelduringtheimmediatepost-operativeperiod(cardiac)保持血糖正常水平Discontinueantibioticsaccordingtoevidence-basedand 根據(jù)基于循證醫(yī)學制Topreventcentrallineassociatedbloodstream預防中心靜脈插管相關血RemoveunnecessarycentrallinesFollowproperinsertionpracticesFacilitateproperinsertionpracticesComplywithCDChandhygienemendationsUseappropriateagentforskinantisepsis采用合理的皮膚 ChoosepropercentrallineinsertionsitesPerformadequatehub/accessportdisinfection對插管部件進行消ProvidestaffeducationoncentrallinemaintenanceandTopreventClostridiumdifficileinfections預防艱ContactPrecautionsfordurationof ComplywithCDChandhygieneAdequatecleaninganddisinfectionofequipmentandLaboratory-basedalertsystemforimmediatenot