PENCEGAHAN DAN PENGENDALIAN INFEKSI RUMAH SAKIT

Hendro Wahjono BAGIAN/SMF MIKROBIOLOGI KLINIK FK UNDIP/RSUP DR KARIADI

PENCEGAHAN INFEKSI RUMAH 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 Infections

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 is replaced by healthcare-associated infections (HAIs) to reflect the changing patterns in healthcare delivery (2004)

Healthcare-associated infections (HAIs)

An infection occurring in a patient during the process of care in a hospital 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 staff of the facility

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 system Cardiovascular system Gastrointestinal system Eye, ENT, or Mouth Systemic infection Reproductive tract Skin and soft tissue infection Lower respiratory tract infection (other than pneumonia) HIS ICNA HCAI Prevalence Survey 2006

Information required to identify HAI

Information must satisfy the criteria for HAI before an infection is reported:
Clinical Laboratory

Other diagnostic information

HIS ICNA HCAI Prevalence Survey 2006 8

Cuci tangan
Sarung tangan Masker,pelindung mata & wajah Gaun/apron

Pengendalian lingkungan

Penanganan Linen
Penanganan Limbah Kesehatan karyawan Penempatan pasien

Peralatan perawatan Pasien

Selection Vs Spread

SPREAD
SELECTION
Antibiotics Hygien Hygien Hygien Hygien

Hospital Infection Control Program (Hospital Hygiene)

INFECTION CONTROL

INFRA STRUCTURE OF 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
INFECTION AGENT

MODES OF TRANSMISSION
DIRECT CONTACT INGESTION FAMILIES AIRBORNE

INFEKSI
JUMLAH KUMAN X VIRULENSI
--------------------------------------------------MEKANISME DAYA TAHAN TUBUH

PENGENDALIAN INFEKSI DI BAGIAN BEDAH

INFEKSI LUKA OPERASI

TEORI ANTISEPSIS JOSEPH LISTER 1860

TEORI GERM PASTEUR 1890

INFEKSI DITEMPAT PEMBEDAHAN (SSI)

METODE STERILISASI INSTRUMEN

TEKNIK PENCEGAHAN INFEKSI

TEKNIK BEDAH
(ALVARADO 2000)

KONSEP PENCEGAHAN INFEKSI

PARE

HALSTED

LISTER

Luka Pembedahan, pasien yang dibedah dapat dibuat sekecil mungkin terinfeksi

Bakteri yang Bakteri dapat mengkontaminasi dicegah dapat dibunuh masuk pada sekitar kedalam luka tempat operasi dengan alat2 steril sehingga membatasi kontaminasi bakteri

INFEKSI DI TEMPAT PEMBEDAHAN (SSI)

INSISIONAL
(YANG HANYA MELIBATKAN KULIT DAN JARINGAN SUBKUTIS)

ORGAN/RUANG
BAGIAN TUBUH SELAIN BAGIAN DINDING TUBUH YANG DIINSISI YANG TERBUKA ATAU DITANGANI SELAMA SUATU OPERASI

INSISIONAL SUPERFISAL

(YANG MELIBATKAN JARINGAN LUNAK LEBIH DALAM, TERMASUK FASIA DAN OTOT)

INSISIONAL DALAM

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 smoking 13. 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 TECHNIQUE 19. LESS DURATION OF SURGERY 20. APPROPRIATE USE OF SURGICAL DRAINS 21. ASEPTIC DRESSINGS 22. 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 VAP in 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 VAP

Non-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 VAP

Pharmacologic strategies

Stress-ulcer prophylaxis Combination antibiotic therapy Prophylactic antibiotic therapy Chlorhexidine oral rinse Prophylactic treatment of neutropenic pt 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 patients 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