ICU医院感染控制进展

单击此处编辑母版标题样式,编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,1,大家好,2,1,ICU,医院感染控制进展,复旦大学附属中山医院,胡必杰,2008-10-3,Dr.HU Bijie,3,2,2008,年,7,月某医院会诊病例,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,2008-10-3,Dr.HU Bijie,4,3,临床医生必须关注感染预防！,正确认识感染预防的,重要性；,要摒弃形式化感控；,国外感控理念和方,法，变化巨大；,中国感控期待与国际,接轨；,只有临床医生参与，,感控才能有突破,2008-10-3,Dr.HU Bijie,5,4,美国,ICU,床位在增加, 8% hospital beds in USA are ICU beds in 1991, Between 1985 and 2000, CCM beds increased (69,300 to 87,400, 26.1%),especially in small (27%) and medium (44.2%) hospitals, non-CCM beds decreased (820,300 to 566,900, -,30.9%), most prominently in large (-44.2%) and extra-,large (-46.1%) hospitals., proportion of total hospital beds assigned to CCM,increased (71.8%), most markedly in large (93.5%) and,extra-large (85.7%) hospitals.,2008-10-3,Dr.HU Bijie,Critical care medicine 2006, 34:2105-2112,6,5,欧美已经将,ICU,感染列为重点,2008-10-3,Dr.HU Bijie,7,6,Hospitals in Europe Link,for Infection Control,through Surveillance,HELICS IV,Euro database,National/regional summaries,ICU,surveillance,2008-10-3,SSI,surveillance,Dr.HU Bijie,Prevalence,surveys,8,7,卫生部,医院管理评价指南（,2008,年版）,12,医院感染管理与持续改进,（,1,）根据国家有关的法律、法规，按照,医院感染管理办法,要求，制定并落,实医院感染管理的各项规章制度。,（,2,）根据,医院感染管理办法,要求和医院功能任务，建立完善的医院感染管,理组织体系。,（,3,）医院感染管理部门实行目标管理责任制，职责明确。,（,4,）医院的建筑布局、设施和工作流程符合医院感染控制要求。,（,5,）落实医院感染的病例监测、消毒灭菌监测、必要的环境卫生学监测和医院,感染报告制度。,（,6,）加强对医院感染控制重点部门的管理，包括感染性疾病科、口腔科、手术,室、重症监护室、新生儿病房、产房、内窥镜室、血液透析室、导管室、临床,检验部门和消毒供应室等。,（,7,）加强对医院感染控制重点项目的管理，包括呼吸机相关性肺炎、血管内导,管所致血行感染、留置导尿管所致尿路感染、手术部位感染、透析相关感染等。,（,8,）医务人员严格执行无菌技术操作、消毒隔离工作制度、手卫生规范、职业,暴露防护制度。,（,9,）对消毒药械和一次性使用医疗器械、器具相关证明进行审核，按规定可以,重复使用的医疗器械，实施严格的清洗、消毒或者灭菌，并进行效果监测。,（,10,）开展耐药菌株监测，指导合理选用抗菌药物。协助抗菌药物临床应用监,测与管理。,（,11,）加强卫生安全防护工作，保障职工安全。,2008-10-3,Dr.HU Bijie,9,8,常见,ICU,感染问题,侵入性操作相关感染问题,导管相关血流感染,呼吸机相关肺炎,导尿管相关尿路感染,多重耐药菌感染问题,MRSA,，,VRE,PDR-,不动杆菌，,ESBLs,艰难梭菌，真菌感染,免疫抑制患者感染问题,医院感染暴发问题,2008-10-3,Dr.HU Bijie,10,9,美国医院拯救十万生命运动,始于,2004,年,12,月,14,日,目的是改善操作规程，在,2006,年,6,月前避免,100,000,住院病人不必要的死亡,发起创议的医院超过,2000,所,预防三种主要的医院感染,SSI,VAP,CA-BSI,2008-10-3,Dr.HU Bijie,11,10,2008-10-3 Dr.HU Bijie,新起点：五百万生命运动,增 加：预防耐药菌传播和加强手卫生,Institute of Healthcare Improvement (IHI) and several,organizations,Seven changes that save lives,Prevent catheter related BSI,Prevent SSI,Prevent VAP,Prevent adverse drug events,Deploy rapid response teams,Deliver reliable, evidence based care for acute MI,Hand hygiene,As of 3,000 hospitals have joined the campaign,5,000,000 lives campaign,Prevent transmission of MRSA, VRE and C. difficile,(),12,11,我国医院感染管理模式需要调整,多做干预,感控目的：降低危险因素，减少发病,没有干预（新技术、新方法、新流程），就没有改变,科学的干预方法：循证感控,少做监测,已经了解本底发病率和危险因素,“完美”的监测永无止境，少做或不做意义不大的监测,转向目标性监测,强调过程监测比结果监测更重要,2008-10-3,Dr.HU Bijie,13,Mortality Reduction 2004-2007,2008-10-3,Dr.HU Bijie,Missouri Baptist Medical Center,12,BJC HealthCare St. Louis, Missouri,14,1,2,3,4,5,Dr.HU Bijie,13,The organization ensures appropriate practices,to prevent nosocomial infection,Monitor & evaluate,Program,Strategies to reduce,infection risk,Standard Precaution,Clean/disinfect/sterilize,Infectious waste,Hand hygiene,design,Building structure,Environment control ventilation,hand washing facilities,Management,Working area with,unique concerns,Minimize risk of,certain infection,OR, LR, ICU, laundry,CSSD, kitchen, PT,postmortem,SSI, VAP, CAUTI, IV,infection, BSI, sepsis,Minimum,infection,Blood-borne infected,Care of,complex case,low immune, resistant,bacteria, & emerging,infection,2008-10-3,Resources,15,14,进入,ICU,，究竟是否要更换衣服、,鞋子和戴口罩？,2008-10-3,Dr.HU Bijie,16,15,医院感染的科学预防方法,预防感染的一揽子方法（,bundle,）,医院感染预防指南中第,I,类建议的组合,经循证医学证明有效,容易操作，花费低,2008-10-3,Dr.HU Bijie,17,16,导管相关血流感染,CLA-BSI,2008-10-3,Dr.HU Bijie,18,1.,3.,4.,5.,6.,17,Evidence-Based Strategies,Selected to Reduce CLA-BSIs,Central line-associated BSI bundle,2.,Hand hygiene,Maximal sterile barriers,Chlorhexidine for skin asepsis,Avoid femoral lines,Avoid/remove unnecessary lines,2008-10-3,Dr.HU Bijie,19,18,Efficacy of Hand Hygiene,Preparations in Killing Bacteria,Good,Plain Soap,2008-10-3,Better,Antimicrobial,soap,Dr.HU Bijie,Best,Alcohol-based,handrub,20,19,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 酒精类手消毒液是,卫生保健的标准,2008-10-3,Dr.HU Bijie,21,公,共,卫,前,崇,黄,眼,耳,海,武,精,员,警,神,肿,中,鼻,医,医,卫,瘤,明,心,喉,院,院,生,医,10,名,生,中,市心,儿,中,长心,海,医,市院,中,西,儿医,科,医,建院,工,市医,儿院,童,医,中院,山,医,华院,山,医,院,长,中,心,后,10,名,金,中,心,静,中,奉心,贤,中,心,院,14,20,酒精擦手液消耗量（,ml/,天,.,床）,排名前,10,位的医院,排名后,10,位的医院,12,10,8,6,4,2,0,国外文献报告：,24,75ml/d.,床,2008-10-3,Dr.HU Bijie,22,Dr.HU Bijie 21,Maximal Sterile Barriers, Maximal sterile barriers improve,sterile technique during catheter,insertion, The person inserting the central,line wears a head cap, face mask,sterile body gown, and sterile,gloves, and uses a full size drape to,cover the patient from head to toe, One study found a 6-fold higher,rate of catheter-related septicemia,when minimal sterile barriers,(sterile gloves and small drape),were used instead of maximal,sterile barriers,2008-10-3,Raad II, et al. Prevention of central venous catheter-related,infections by using maximal sterile barrier precautions during,insertion.,Infect Control Hosp Epidemiol.,1994;15:231238.,23,22,Benefits of CHG,2% CHG in tincture of isopropyl alcohol has rapid,bactericidal activity and is effective within 30 seconds,after application versus 2-minute period for povidone,iodine,CHG provides persistent bactericidal activity on the,skin and maintains its activity in the presence of other,organic material,Minimal systemic absorption,Back and forth, up and down motion,Motion promotes penetration of the cleanser within,multiple layers of the epidermis,Clear solution,Orange tinted solution now available,2008-10-3,Dr.HU Bijie,24,23,Chlorhexidine for Skin Asepsis, Studies have compared chlorhexidine,gluconate (CHG) versus povidone iodine as a,skin antiseptic for catheter insertion and,routine insertion site care, Recent meta-analysis, the use of CHG rather than,povidone iodine was found to reduce the risk of,CLA-BSIs by approximately 50% in hospitalized,patients who required short term catheterization,Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine,compared with povidone-iodine solution for vascular catheter-site care: a,meta-analysis.,Ann Intern Med.,2002;136:792801.,2008-10-3,Dr.HU Bijie,25,24,Site Selection: Avoid Femoral Lines, Insertion of CVCs can lead to serious and,sometimes life-threatening complications, whether,of mechanical, infectious, or thrombotic origin, Higher rate of infectious complications in study,comparing femoral lines versus subclavian lines, 19.8% vs 4.5%,2008-10-3,Dr.HU Bijie,26,25,Empowerment of Nursing, One of the most important steps in,preventing CLA-BSIs is to empower the,nursing staff to stop the central line,insertion procedure if the guidelines were,not followed,2008-10-3,Dr.HU Bijie,27,26,Avoid and Remove Unnecessary Lines, Once placed, there should be periodic, if not,daily assessment, of its continued need,with emphasis on prompt removal,2008-10-3,Dr.HU Bijie,28,Casesper1000catheterdays,May-99,Mar-99,Jan-99,Nov-99,Sep-99,May-00,Jul-99,Mar-00,Jan-00,Nov-00,Sep-00,May-01,Jul-00,Mar-01,Jan-01,Nov-01,Sep-01,May-02,Jul-01,Mar-02,Jan-02,Nov-02,Sep-02,Jul-02,Mar-03,Jan-03,8,27,导管相关,BSI,干预流行病学,/,操作改进,39 month period 237 cath.-rel. bloodstream infections avoided BUMC,Estimated annual cost savings in cost avoidance = $2.5 - 4 x 106,Fig 5. CVC-Related Bloodstream Infections, 1999-2003, Brookdale University Medical Center,22,20,18,16,Silver-Chlorhexidine Catheters Used Since 1997,Jan 01: Silver-Platinum Catheters Introduced,Dec 99: Awareness and Education Program Started,14,Mean Rate,12,Oct 01: Sterile Barrier Kits Introduced,10,Jan 02: 2% CHG-70% isopropyl alcohol,Skin Prep introduced,6,4,2,0,Monthly Rate,Mean Rate,2008-10-3,Dr.HU Bijie,Garcia R, et.al. Abstract, APIC- Used with Permission,29,28,呼吸机相关肺炎,VAP,2008-10-3,Dr.HU Bijie,30,上海市呼吸机相关肺炎与,NNIS,比较,感染率,ICU,类型,CCU,心胸,ICU,内科,ICU,混合,ICU,神经外科,ICU,儿科,ICU,外科,ICU,创伤,ICU,2005,年,20.55,17.77,28.86,24.74,24.05,15.53,25.34,40.32,2006,年,20.82,14.84,32.41,25.34,25.11,13.05,24.72,27.51,呼吸,ICU,2008-10-3,19.01,27.08,Dr.HU Bijie,29,31,30, Dr.HU,预防医院内肺炎的有效方法,降低口咽部和上消化道定植,经常口腔卫生,选择性消化道脱污染,(SDD),通气时间较长的病人避免鼻腔插管,防止口咽部分泌物吸入,半卧位,经常校正鼻饲管位子，调整进食速度和量以避免反流,使用超过幽门的鼻饲管如鼻十二指肠、空肠管,使用,ETT,管，能进行声门下吸引,保护胃粘膜的特性,尽可能肠内营养,使用硫糖铝，胃粘膜保护剂,治疗休克和低氧血症,减少外源性污染,合适的手卫生,气管腔内吸引时保持远端无菌,密闭气管腔内吸引系统,2008-10-3,使用湿鼻替代加热的湿化器,Bijie,减少回路管道的更换频率,32,31,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,2,6,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（？）,2008-10-3,Dr.HU Bijie,33,32,VAP,预防措施的证据,预防与胃管给食有关的吸入如果无反指征，,将头部的床摇高形成,30,45,度角（,IB,）,仰卧位与半卧位,VAP,发病率,仰卧,23,半卧,5,Lancet,1999; 354:1851-58,2008-10-3,Dr.HU Bijie,34,33,2008-10-3 online 26,Meta-analysis of RCT investigating,the relationship between ventilator-circuit-change,frequency and the risk of VAP,呼吸机回路管道更换,systematic review and meta-analysis pneumonia in mechanically ventilated adults: Oral decontamination for,prevention of 2007;334;889-; originally publishedDr.HU Bijie Mar 2007;,BMJ,35,34,VAP,预防措施方面新的证据与进展,使用气囊上方带侧,腔的气管插管，有,利于积存于声门下,气囊上方分泌物的,引流,气囊放气或拔除气,管插管前应确认气,囊上方的分泌物已,被清除,2008-10-3,Dr.HU Bijie,36,Rate/1000vent.days,Ja,n-,0,M4,ar,-0,M4,ay,-0,4,Ju,l-0,Se4,p-,0,N4,ov,-0,Ja4,n-,0,M5,ar,-0,M5,ay,-0,5,Ju,l-0,Se5,p-,0,N5,ov,-0,Ja5,n-,0,M6,ar,-0,M6,ay,-0,6,Ju,l-0,Se6,p-,0,N6,ov,-0,Ja6,n-,0,M7,ar,-0,M7,ay,-0,7,12.0,35,Ventilator Associated Pneumonia Rates Combined,2004-2007,14.0,Preintervention Mean 3.8,10.0,8.0,6.0,4.0,2.0,Oral,Care,Post Intervention Mean 0.9,p0.01,NNIS 5.1,0.0,Month/Year,Rate,Mean,NNIS,2008-10-3,Dr.HU Bijie,37,36,导尿管相关尿路感染,CR-UTI,2008-10-3,Dr.HU Bijie,38,37,多重耐药菌感染,MDROs,2008-10-3,Dr.HU Bijie,39,Dr.HU Bijie,38,Campaign to Prevent Antimicrobial Resistance in Healthcare Settings,耐药菌愈演愈烈，,感染预防的价值越来越大！,12,遏制医务工作者传播,11,隔离患者,10,与时停用抗菌药物,9,严格掌握万古霉素应用指证,8,治疗感染，而非寄殖,7,治疗感染，而非污染,6,专家会诊,5,应用当地资料,4,控制抗菌药物应用,3,针对性病原治疗,2,拔除导管,预防传播,合理应用抗菌药物,有效的诊断和治疗,预防感染,1,接种疫苗,2008-10-3,预防抗菌药物耐药的,12,项措施,40,R,R,39,ICU,内出现了,PDR-,鲍曼不动杆菌,怎么办？,阿米卡星,庆大霉素,氨苄西林,+,舒巴坦,哌拉西林,+,他唑巴坦,R,R,2008-10-3,头孢吡肟,头孢他啶,亚胺培南,环丙沙星,TMPco,Dr.HU Bijie,R,R,R,R,R,41,40,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,2008-10-3,Dr.HU Bijie,42,41,哪些病原体感染需要隔离？,耐药菌,MRSA,，不动杆菌,艰难梭菌，,VRE,ESBL,？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！,2008-10-3,Dr.HU Bijie,耐药菌隔离的警告标识,43,42,2008-10-3,Dr.HU Bijie,44,numberofreports,43,C. difficile,voluntary reporting 1991 2005:,England, Wales and Northern Ireland,50000,45000,40000,35000,30000,25000,20000,15000,10000,5000,0,1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005,2008-10-3,year,Dr.HU Bijie,45,Percentpositive,44,Percentage of,C. difficile-positive,cultures,n=9 rooms,80,70,60,50,40,30,20,10,0,Bedrail,Bedside table,Phone,Call button,Toilet,Door handle,Before cleaning,After,After,*Similar results found after ES,cleaning following,housekeeping disinfection by,cleaning research team*,interventions,2008-10-3,Dr.HU Bijie,Eckstein et al, BMC Infect Dis. 2007 Jun 21;7:61.,46,45,医院感染暴发,Outbreak,2008-10-3,Dr.HU Bijie,47,46,上海,ICU,内感染暴发举例,2001,年上海某医院儿,科心脏术后,18,例肺炎,克雷白杆菌血流感染,暴发,1999,年上海某医院心,脏手术后,5,例鲍曼不,动杆菌血流感染暴发,2008-10-3,Dr.HU Bijie,48,47,医院感染暴发流行,外源性,可预防性,感染控制环节漏洞,社会影响严重性,2008-10-3,Dr.HU Bijie,49,48,调整医疗费用的支付模式,现状：医院感染的预防成本远低于治疗,成本，但预防没有回报，感染诊断和治,疗费用高额回报,改革：像商业运作一样进行感染预防：,Costs of Infection Prevention,，,Benefits of,Infection Prevention,2008-10-3,Dr.HU Bijie,50,美国计划停止支付部分医院感染诊疗费用,SSIs following total knee replacement,Legionnaires disease,Ventilator-associated pneumonias,Staph aureus,septicemia,Clostridium difficile,-Associated Disease,2008-10-3,Dr.HU Bijie,49,49,51,Dr.HU Bijie 50,2008,年,2,月,18,日：卫生部与法国生物梅里埃,公司共同签署了,医院感染项目计划,实施步骤,确定监测指标,本底调查,制定,SOP,教育培训,实施,SOP,复查与评估,样板医院,协和、北医、人民、中日,中山、瑞金,湘雅、中国医大一院、南方,让,医院感染控制手册（,SOP,）,2008-10-3,成为我国医院感染规范化管理的基础！,52,51,中华预防医学会医院感染控制分会,ICU,医院感染管理指南（,2008,版）,（意见征求稿）,工作人员管理,病人管理,访客管理,建筑布局和相关设施的,管理,医疗操作流程管理,物品管理,环境管理,抗菌药物管理,废物与排泄物管理,监测与监督,2008-10-3,Dr.HU Bijie,53,52,欢迎浏览,上海国际医院感染控制网上论坛,（我国最大的医院感染控制交流平台）,2008-10-3,Dr.HU Bijie,