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1、1,1,多重耐药菌感染的预防与控制,1,11多重耐药菌感染的预防与控制1,2,2,对于超级细菌/多重耐药菌，要防被忽悠，更要防止麻木！,3,对于超级细菌/多重耐药菌，要防被忽悠，更要防止麻木！3,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,4,耐药菌的难题，远不止NDM-1！MRSA4,什么是多重耐药菌？,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
2、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。,5,什么是多重耐药菌？多重耐药菌（Multidrug-Resis,2022/12/16,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
3、月死亡花费：10万元？,2008年7月某医院会诊病例,6,2022/10/2Dr.HU Bijie6临床情景2008年,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,7,医院感染越来越险恶！案例7,2005-2009年上海XX医院鲍曼不动杆菌对亚胺培南耐药率变化,2005年,8,2005-2009年上海XX医院鲍曼不动杆菌对亚胺培南耐药,正确认识接触预防有效控制多重耐药菌MDRO,9,正确认识接触预防有效控制多重耐药菌MDRO
4、9,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,10,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,Antimicrobial Resistance恶性循环,Susceptible pathogen,11,Antimicrobial Resistance恶性循环耐药,2022/12/16,Dr.HU Bijie,12,预防传播合理应用抗菌药物有效的诊
5、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！,12,2022/10/2Dr.HU Bijie12,2010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,T9,13,2010年上海某医院ICU中22例病人痰培养检出多
6、重耐药菌,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)
7、7e. Prevent surgical site infections (SSI)13a. Patient involvement in their care: respiratory & hand hygiene on day of admission pt. & family,14,National Patient Safety Goals,美国National Patient Safety Goal,NPSG.07.03.01-Implement evidence-based practices to prevent health care-associated infections
8、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,15,美国National Patient Safety Goal,Spread of MDROs Can Be Controlled By:,Good infection control pr
9、acticesMeticulous 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,16,Spread of MDROs Can Be
10、Control,FIGHTS,Follow isolation practicesIn-service training for staff Gauging disinfectant efficacyHand hygieneTesting environmental surfacesStandardized cleaning procedures,17,FIGHTSFollow isolation practic,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
11、）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,18,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（,19,19,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,20,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,最新MDR
12、O 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
13、必泰洗浴Antimicrobial stewardship 抗菌药物管理,21,最新MDRO BundleHand Hygiene 手卫生2,ANTIBIOTIC RESISTANT PATHOGENSON / INPATIENTS,ENVIRONMENTAL SURFACES,HCWHANDS,SUSCEPTABLE PATIENTS,ISOLATION,HAND HYGENE,DISINFECTION CLEANING,22,ANTIBIOTIC RESISTANT PATHOGENS,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
14、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,23,超级细菌出现/MDRO泛滥，我们需要改变什么呢？接触传播的,2022/12/16,Dr.HU Bijie,24,手卫生,24,2022/10/2Dr.HU Bijie24手卫生24,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!,25,酒精擦手的优点比洗手有更高的依从性感染控制，不仅仅是手卫生!,2022/12/16,Dr.HU Bijie,26,接触隔离,26,202
15、2/10/2Dr.HU Bijie26接触隔离26,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,27,接触隔离的要求隔离：尽量将患者安置于单间27,2022/12/16,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
16、标识,28,2022/10/2Dr.HU Bijie28哪些病原体感染需,多重耐药菌进行专门标记（德国某医院）,29,多重耐药菌进行专门标记（德国某医院）29,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。,30,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,2022/12/16,Dr.HU Bijie,31,减少设备共用,31,2022/10/2Dr.HU Bijie31减少设
17、备共用31,ICU减少共用物品,听诊器血压计体温表微量输液泵,32,ICU减少共用物品听诊器32,2022/12/16,Dr.HU Bijie,33,环境清洁,33,2022/10/2Dr.HU Bijie33环境清洁33,2022/12/16,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！,34,2022/10/2Dr.HU Bijie34 环境微生,Pathogen Survival in the En
18、vironment,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.,35,Pathogen Survival in the Envir,Decontamination,Risk of infection by used items in healthcare1968 Earle H Spaulding Cr
19、itical 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,36,DecontaminationRisk of infect,手频繁接触的物体表面，是高度危险的！,37,手频繁接触的物体表面，是高度危险的！37,38,38,High-t
20、ouch 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 th
21、e 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
22、, 2009,39,High-touch equals high-risk:,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,40,ICU中，容易被污染的物表温度计呼叫按钮40,ICU环境中耐药鲍曼不动杆菌污染严重,41,ICU环境中耐药鲍曼不动杆菌污染严重41,Removes organic soil / visible soil Removes potentially infectious micro organisms Removes soi
23、l which protects m.o. during disinfectionCareful cleaning Mechanical energy- friction, flushing, scrubbingChemical products - detergents or enzymesRight Method- manual & machinal,Manual Cleaning,42,Removes organic soil / visibl,Manual Cleaning,NO SAFE Products!,43,Manual CleaningNO SAFE Product,Ever
24、ybody is an “EXPERT” Difficult to monitor Responsibilities not clear Health-risk,Manual Cleaning,NO SAFE Procedure!,44,Manual CleaningNO SAFE Procedu,Common in Households Not Common in Healthcare settings Easy to use Standardization & Validation Better Result Saves Nursing Time Monitoring Thermal Di
25、sinfection,Machinal Cleaning,Machinal Cleaning is Safer,45,Common in Households Machinal,病区的基本配置：清洗消毒机,46,病区的基本配置：清洗消毒机46,日本尿壶与便盆的消毒,47,日本尿壶与便盆的消毒47,关注频繁手接触物体表面的去污染,48,关注频繁手接触物体表面的去污染48,MICRO FIBER The “cleaner” cleaning system,49,MICRO FIBER The “cleaner,关东病院设备科-保养与维修,50,关东病院设备科-保养与维修50,How Can We
26、Evaluate Environmental Cleaning,Direct observationCulture the environmentATP bioluminescence ToolFluorescent marking tool,03/26/2010,TSICP,51,51,How Can We Evaluate Environmen,TESTING OF SURFACES,52,TESTING OF SURFACES52,ATP bioluminescence,Swab surface luciferase tagging of ATP Hand held luminomete
27、r,Used in the commercial food preparation industry to evaluate surface cleaning before reuse and as an educational tool for more than 30 years.,53,ATP bioluminescence Swab surf,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。,54,ATP is present in blood,
28、skin,Dazo Solution(Initially called “GOO”),55,Dazo Solution(Initially calle,56,56,Baseline Environmental Evaluation of 36 Acute Care Hospitals,% of Objects Cleaned,Hospitals,Mean = 48.5 %,(20,056 Objects),57,Baseline Environmental Evaluat,PROPORTION OF OBJECTS CLEANED AS PART OF TERMINAL ROOM CLEANI
29、NG IN 20 ACUTE CARE HOSPITALS,%,58,PROPORTION OF OBJECTS CLEANED,17 HOSPITALS,10 HOSPITALS,8 HOSPITALS,Terminal Room Cleaning Project Three Programmatic Responses,59,17 HOSPITALS10 HOSPITALS8 HOSP,Hospitals Environmental Hygiene Study Group36 Hospital Results,% of Objects Cleaned,PRE INTERVENTION,PO
30、ST INTERVENTION,P = .0001,Resource Neutral,60,Hospitals Environmental Hygien,TERMINAL ROOM CLEANING INFECTION PREVENTION TARGETS Sink and FaucetsToilet SurfacesToilet Flush HandleBedpan CleanerToilet Area HandholdsToilet Area Door Knobs or Push PlatesBedside TableTray TablePatient ChairSide RailsRoo
31、m Door KnobsCall BoxTelephoneBathroom Light Switches,Specific Opportunities for Improvement,61,TERMINAL ROOM CLEANING S,Evaluating Patient Zone Environmental Hygiene,62,Evaluating Patient Zone Enviro,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,63,如何选择表面消毒剂杀菌谱和杀菌速度63,Low and Intermediate
32、 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 sporesIntermediate-level disinfectant: agent
33、 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.,64,Low and Intermediate Level Di,Examples of Low & Intermediate Level Disinfec
34、tants,Quaternary ammonium germicidal detergent solution (quat)Sodium hypochlorite 5.25-6.15% household bleach diluted 1:500 provides 100 ppm available chlorinePhenolic germicidal detergent solutionIodophor germicidal detergent solutionEthyl or isopropyl alcohol (70-90%) Hydrogen peroxide solutions,6
35、5,Examples of Low & Intermediate,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-criti
36、cal Items,66,Clean/disinfect:Cleaning & Dis,2022/12/16,Dr.HU Bijie,67,主动监测培养,67,2022/10/2Dr.HU Bijie67主动监测培养67,Reservoir for Spread of Antibiotic Resistant Pathogens,Clinical Infections,Colonized (Asymptomatic) Patients,68,Reservoir for Spread of Antibi,2022/12/16,Dr.HU Bijie,69,对超级细菌MRSA感染的“零宽容”,主动
37、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,69,2022/10/2Dr.HU Bijie69对超级细菌MRS,Outcomes: Active Surveillance Controls MRSA BSIs,Huang et al., CID 2006;43:971-8,70,Outcomes: Active Surveillance,美国20个州立法：住院病人主动筛查、隔离MRSA和VRE,71,美国20个州立法：住院病人主动筛查、隔离MRSA和VRE7,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？
38、,72,进行主动筛查的人群全部新入住ICU的病人？72,2022/12/16,73,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,73,2022/10/273ICU病人MDROs主动监测培养鼻拭子,2022/12/16,Dr.HU Bijie,74,医院感染的组合预防,74,2022/10/2Dr.HU Bijie74医院感染的组合预,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,75,ICU需要重点防范的医院感染呼吸机相关肺炎VAP
39、75,2022/12/16,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（？）,76,2022/10/2Dr.HU Bijie76美国目前推行的预,2022/12/16,
40、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,77,2022/10/2Dr.HU Bijie77预防CR-BSI,2022/12/16,Dr.HU Bij
41、ie,78,洗必泰洗浴,78,2022/10/2Dr.HU Bijie78洗必泰洗浴78,洗必泰对于鲍曼不动杆菌的控制,79,洗必泰对于鲍曼不动杆菌的控制79,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 admissi
42、on, 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,8
43、0,Impact of 4% Chlorhexidine (CH,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,81,洗必泰全身擦浴显著降低病原菌皮肤的定植（MRSA、VRE、鲍,2022/12/16,Dr.HU Bijie,82,抗菌药物管理,82,2022/10/2Dr.HU Bijie82抗菌药物管理82,Antibiotic Stewardship,ID DivisionInfectious Diseases SpecialistDepartment of PharmacyClinical PharmacistH
44、ealth administrationAntibiotic Utilization Review Subcommittee Electronic antibiotic stewardshipcomputerized antimicrobial approval system in a hospital setting Education and interactionInfection control professional,83,Antibiotic StewardshipID Divis,抗菌治疗策略(Antibiotic Therapy Strategies) 降阶梯治疗策略（De-
45、Escalation Therapy 短程治疗策略(short-course therapy) 联合治疗（combination therapy） 优化药动学/药效学原则（Optimizing PK/PD principles） 消除定植策略（Antimicrobial Decolonization Strategies） 抗菌药物管理策略(Antibiotic Management Strategies) 指南（Guidelines） 限制处方（formulary restriction） 抗生素轮换(Antibiotic Cycling) 抗生素替换/干预策略(substitution/i
46、ntervention）,优化抗感染治疗策略 Optimizing antimicrobial therapy,84,抗菌治疗策略(Antibiotic Therapy Stra,85,85,86,86,卫生部将采取一系列措施，进一步加强抗菌药物临床应用管理,制定抗菌药物临床应用管理办法，严格落实抗菌药物分级管理和处方点评制度；加强抗菌药物临床应用和细菌耐药监测网建设，对医疗机构抗菌药物临床应用和细菌耐药情况进行动态监测和预警；开展全国抗菌药物临床应用专项整治行动，引入社会监督机制，加大抗菌药物不合理应用行为的监督和处理力度；继续开展医务人员培训和公众宣传教育工作，提高抗菌药物临床合理应用水平
47、，强化公众合理使用抗菌药物意识。,87,卫生部将采取一系列措施，进一步加强抗菌药物临床应用管理制定抗,2011年上海市医院感染质控管理的工作重点,抗菌药物管理进一步规范围术期抗菌药物使用提高血培养的送检率多重耐药菌控制推广ICU多重耐药菌的主动培养加强ICU环境消毒CRBSI和VAP的预防引入几种新的干预措施,抵御耐药性今天不采取行动，明天就无药可用！,88,2011年上海市医院感染质控管理的工作重点抗菌药物管理抵御耐,卫生行业科研专项项目临床多重耐药菌医院感染预防及控制研究,主要研究内容研究不同感染控制方法，包括提高手卫生依从性、环境清洁、医疗设备和手高频接触物品的表面消毒、隔离、耐药菌的主动筛查和清除、抗菌药物干预，对降低几种重要多重耐药菌在医院内尤其是ICU内定植、感染和暴发的效果研究抗菌药物干预策略（如轮换策略、替代策略），对降低ICU内多重耐药菌感染的作用研究不同的单一干预技术和组合干预技术，对预防耐药菌引起的导管相关血流感染（CR-BSI）和呼吸机相关肺炎（VAP）的作用制定我国多重耐药菌医院感染控制操作规程、ICU环境清洁、消毒操作规程和评价指标，研究其在不同地区和不同等级医院的可行性和有效性,89,卫生行业科研专项项目临床多重耐药菌医院感染预防及控制研究主,
