PENCEGAHAN DAN PENGENDALIAN INFEKSI RUMAH SAKIT
Hendro WahjonoHendro Wahjono
BAGIAN/SMF MIKROBIOLOGI KLINIKBAGIAN/SMF MIKROBIOLOGI KLINIK
FK UNDIP/RSUP DR KARIADIFK UNDIP/RSUP DR KARIADI
PENCEGAHAN INFEKSIRUMAH SAKIT (NOSOKOMIAL)
Infeksi merupakan interaksi antara: Mikroorganisme dengan pejamu yang
rentan melalui cara transmisi tertentu yaitu melalui darah, udara (droplet /
airborne) dan kontak. Kemampuan memutuskan interaksi antara
faktor-faktor tsb memudahkan kita mencegah IN
• Masyarakat yang menerima pelayanan medis di RS/Klinik dihadapkan kepada risiko terinfeksi. Di lain fihak petugas klinis dan petugas pendukung yang melayanani mereka juga berisiko mendapatkan infeksi.
• Infeksi nosokomial dan infeksi akibat pekerjaan merupakan masalah penting di seluruh dunia dan terus meningkat
Healthcare-Associated Healthcare-Associated InfectionsInfections
Horan TC, Gaynes RP.Surveillance of nosocomial infections.
Hospital Epidemiology and Infection Control, 3rd ed.Philadelphia:Lippincott
Williams & Wilkins, 2004:1659-1702
What is new ?
The term “nosocomial infections“nosocomial infections“ “ is replaced by
““healthcare-associated infections” (HAIs)healthcare-associated infections” (HAIs) to reflect the changing patterns in
healthcare delivery
(2004)
“Healthcare-associated infections” (HAIs)
An infection occurring in a patienta patient during the process of care in a hospital or other healthcare facilityhospital or other healthcare facility which was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staffoccupational infections among staff of the facility
HIS ICNA HCAI Prevalence Survey 2006 7
Infection sites • 13 major sites of infection– Emphasis on four main system infections:• Bloodstream infection• Pneumonia• Urinary tract infection• Surgical site infection
– 9 other healthcare-associated infections:Bone and joint Central nervous systemCardiovascular system Gastrointestinal system
Eye, ENT, or Mouth Systemic infectionReproductive tract Skin and soft tissue infectionLower respiratory tract infection (other than pneumonia)
HIS ICNA HCAI Prevalence Survey 2006 8
Information requiredto identify HAI
Information must satisfy the criteria for HAI before an infection is reported:
• Clinical
• Laboratory
• Other diagnostic information
Cuci tangan
Sarung tangan
Masker,pelindung mata & wajah
Gaun/apron
Peralatan perawatan Pasien
Pengendalian lingkungan
Penanganan Linen
Penanganan Limbah
Kesehatan karyawan
Penempatan pasien
Ant
ibio
tics
HygienHygien
Hygien
Hygien
SELE
CTI
ON
SPREAD
Selection Vs Spread
Hospital Infection Control Program
(Hospital Hygiene)
•INFRA STRUCTUREOF INFECTION CONTROL
INFECTION CONTROL
•KNOWLEDGE, ATTITUDE AND BEHAVIOUR
•SURVEILLANCE
Program ini akan terlaksana apabila:
• Ada organisasi• Ada peraturannya• Ada komitment untuk melaksanakannya Surveilans
• Ada kegiatan– penyempurnaan
Umpan balik
RANTAI INFEKSI
INFECTIONAGENT
MODES OFTRANSMISSION
DIRECT CONTACT FAMILIESINGESTION AIRBORNE
SUSCEPTIBLE
HOST
RESERVOIRSPEOPLE
EQUIPMENTWATER
PORTAL OF EXIT
EKSKRESI, SEKRESI
KULIT, D
ROPLET
PORTAL OF ENTRY
MUCOUS MEMBRANE,
GI TRACT, RESP. TRACT
BROKEN SKIN
INFEKSI
JUMLAH KUMAN X VIRULENSI ---------------------------------------------------
MEKANISME DAYA TAHAN TUBUH
PENGENDALIAN INFEKSI DI BAGIAN BEDAH
INFEKSI LUKA OPERASI
TEORI ANTISEPSISJOSEPH LISTER
1860
TEORI GERMPASTEUR
1890
INFEKSI DITEMPAT PEMBEDAHAN (SSI)
METODE STERILISASIINSTRUMEN
TEKNIK BEDAH
TEKNIK PENCEGAHANINFEKSI
(ALVARADO 2000)
KONSEP PENCEGAHAN INFEKSI
PARE LISTERHALSTED
Luka Pembedahan,pasien yang
dibedahdapat dibuat
sekecil mungkin terinfeksi
Bakteri dapat dicegah masukkedalam luka dengan alat2
sterilsehingga
membatasi kontaminasi
bakteri
Bakteri yang mengkontaminasi
dapat dibunuhpada sekitar
tempat operasi
INFEKSI DI TEMPAT PEMBEDAHAN (SSI)
INSISIONAL ORGAN/RUANG
INSISIONAL SUPERFISAL(YANG HANYA MELIBATKAN
KULIT DAN JARINGAN SUBKUTIS)
INSISIONAL DALAM(YANG MELIBATKAN
JARINGAN LUNAK LEBIH DALAM, TERMASUK FASIA DAN
OTOT)
BAGIAN TUBUH SELAIN BAGIAN DINDING TUBUH YANG DIINSISI YANG TERBUKA ATAU
DITANGANI SELAMA SUATU OPERASI
INFEKSI LUKA OPERASI
– ILO Superfisial
- ILO terjadi < 30 hari
-ILO dari Jaringan diatas fascia
-Gejala:* tanda-tanda radang lokal dan
umum* pus keluar dari luka
operasi/drain diatas fascia
INFEKSI LUKA OPERASI
– ILO Profunda* ILO yang terjadi setelah 30 hari
s/d 1 tahun paska operasi* ILO meliputi jaringan dibawah fascia* Dengan salah satu gejala:
-Tanda radang umum/lokal-Pus dari luka dibawah fascia-Dehisensi luka/luka dibuka karena
adanya tanda infeksi -Biakannya (+)
PREOPERATIVE PREVENTION OF SWI - 1
Environmental Factors 1. Ultraviolet Light 2. Laminar flow ventilation systems 3. Limit operation theater traffic 4. Pre-operative preparations 5. Avoid antibiotic use except for surgical antibiotic
prophylaxis
PREOPERATIVE PREVENTION OF SWI - 2
6. Eliminate basal colonization with S.aureus 7. Pre-operative antimicrobial shower 8. Treat distant site infections before elective
procedures 9. Hair removal Avoid shaving / hair clipping is
recommended as near to the site of surgery as possible
10. Skin preparation Scrubbing for 5 to 7 minutes
PREOPERATIVE PREVENTION OF SWI - 3
11. Resolve malnutrition and obesity 12. Discontinue cigarette smoking13. Optimize diabetic control 14. Antibiotic prophylaxis 15. Choice, timing and duration are critical 16. OT team discipline 17. Vigilance for breaks in aseptic techniques
INTRAOPERATIVE PREVENTION
18. GOOD SURGICAL TECHNIQUE19. LESS DURATION OF SURGERY20. APPROPRIATE USE OF SURGICAL DRAINS21. ASEPTIC DRESSINGS22. FEEDBACK OF SURGEON SPECIFIC
INFECTION RATES TO OTHER SURGEONS TO ADOPT THE SAME TECHNIQUES AND TO REDUCE SWI
PREVENTION BY ANTIBIOTIC PROPHYLAXIS IN SURGERY
• ESSENTIAL PREVENTIVE MEASURE TO PREVENT SWI
• MAY BE EXPENSIVE FOR HOSPITAL BUT • COST BENEFIT ANALYSIS OF PROPHYLACTIC
ANTIBIOTICS?• WHAT IS THE COST OF WOUND INFECTION? IN
MONEY? IN SUFFERING?• HOW EFFECTIVE IS PROPHYLAXIS• HOW MUCH WE CAN SPEND TO PREVENT A CASE
OF SWI?
HAP and VAPin Infection Control
Definition
• Hospital Acquired Pneumonia/HAP:
Occurring at least 48 hours after admission and not incubating at the time of hospitalization
Pathogenesis
• For pneumonia to occur, at least one of the following three conditions must occur: 1. Significant impairment of host defenses 2. Introduction of a sufficient-size inoculum to overwhelm the host's lower respiratory tract defenses 3. The introduction of highly virulent organisms into the lower respiratory tract
• Most common is microaspiration of oropharyngeal secretions colonized with pathogenic bacteria.
Pathogenesis
• For pneumonia to occur, at least one of the following three conditions must occur: 1. Significant impairment of host defenses 2. Introduction of a sufficient-size inoculum to overwhelm the host's lower respiratory tract defenses 3. The introduction of highly virulent organisms into the lower respiratory tract
• Most common is microaspiration of oropharyngeal secretions colonized with pathogenic bacteria.
Classification
• Early-onset nosocomial pneumonia: Occurs during the first 4 days Usually is due to S. pneumoniae, MSSA, H. Influenza, or anaerobes.
• Late-onset nosocomial pneumonia: More than 4 days More commonly by G(-) organisms, esp. P. aeruginosa, Acinetobacter, Enterobacteriaceae (klebsiella, Enterobacter, Serratia) or MRSA.
Ventilator-associated Pneumonia (VAP)
• Definition: Hospital-Acquired Pneumonia has developed in patient
who are receiving mechanical ventilation
• Classification: Early-onset: within 48-72 hours after tracheal
intubation, which complicates the intubation process
Late-onset: after 72 hours
Preventions for VAPNon-pharmacologic strategies
• Effective hand washing and use of protective gowns and gloves
• Semirecumbent positioning• Avoidance of large gastric volume• Oral (non-nasal) intubation• Continuous subglottic suctioning• Humidification with heat and moisture exchanger• Posture change
--- The Prevention of Ventilator-Associated Pneumonia Vol.340 Feb 25, 1999 NEJM
Preventions for VAPPharmacologic strategies
• Stress-ulcer prophylaxis• Combination antibiotic therapy• Prophylactic antibiotic therapy• Chlorhexidine oral rinse• Prophylactic treatment of neutropenic p’t• Vaccines
--- The Prevention of Ventilator-Associated Pneumonia Vol.340 Feb 25, 1999 NEJM
Basic VAP Prevention Elements
•Hand hygiene
•Ventilator bundle
• Oral care
Hand Hygiene Campaign
JCAHO Patient Safety Goal CDC posters in visitor lounge and in ICU http://www.cdc.gov/handhygiene/Education
for patients and visitors
Patient and family educational brochures “How to Prevent Infections During your Hospital Stay” Infection Control info in Visiting Information brochure
“Foam-In and Foam-Out” Campaign Alcohol-based foam usage reports Observation audits were impractical
Signage at entrance to patient’s room
Oral Care
Developed and implemented protocol in end of year 2002 Teeth brushing Q 8-12 hours
Oral care with swabs Q 2-4 hours Sub-glottic suctioning Q 6-8 hours
Reinforced in the ICU Standards of Practice Included on pre-printed ventilator orders
Products Non-alcohol based antiseptic solution or toothpaste (i.e.,
Perox-A-Mint) Oral suction swabs with mouth moisturizer
Suction toothbrushes Sub-glottic suction catheters
Covered Yankeur
Y - Connection
Use a separate suction tubing for oral care/oral suctioning; and ETT suctioning
Prevents contamination between areas suctioned
Keeps system closed
Use Y connector on top of suction canister
Sub-glottic Suctioning
To ensure that secretions are cleared from above the tube cuff: Before deflating the cuff of an ETT in preparation for removal
Before repositioning the tube Routinely every six hours
This includes surgical patients (i.e., CABGs, “vented overnight”, etc.)
Physician interest in the Hi-Lo Evac tubes
Current Practice Compared to CDC Guidelines
Suctioning Use only 5 ml saline bullets
Education on suctioning Assure use of 72-hr Ballard product
Document in-line suction changes q 72 hr Limit saline instillation, if possible
Audits New device for condensation removal in vent tubing
Evidence-based care ICU Journal Club articles
Suctioning Education
Do hand hygiene before and after Use new clean gloves
Closed in-line system – preferable Change catheter every 72 hours
NO routine suctioning Review CXR or talk to RT
Auscultate
CDC Recommended Procedure for Condensate Removal
Decontaminate hands before and after procedure Wear new clean gloves
Periodically drain and discard any condensate that collects in the tubing of mechanical ventilator
Use sterile trap without opening system DO NOT allow condensate to drain toward the patient
Feeding Tubes
Routinely verify appropriate placement of feeding tube Post-pyloric placement best for patients with:
Gastric problems High residuals
High-risk for aspiration Pre-printed order set for post-pyloric placement
Assess for continuing need at extubation