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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


– 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


– 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


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


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.

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

http://www.learnwell.org/handhygiene.htm