HEALTH CARE ASSOCIATED

INFECTIONS
CAUTI-CLABSI-SSI
KOMITE PPI
RSUD DR. SOETOMO SURABAYA
 Rantai Penularan Penyakit
Cara Transmisi:
Agen Infeksius • Kontak langsung
(Kuman, Virus, dll) • Air dan Udara
• Makanan
Reservoir: • Lingkungan
Host • Kursi-Meja, Bed
• Manusia/ Binatang
Potong • Peralatan / Lingkungan
• Bangunan: lantai, wastafel
• Sampah
Rantai
• Linen
Penularan • Peralatan
Pintu masuk: Pintu keluar:
• Stetoskop, Thermo,
• saluran napas, sal. • saluran napas, sal. Tensimeter
kencing, kulit dll. kencing, kulit dll.
• Infus set, jarum & alat tajam
Mode yang terkontaminasi
transmisi
 Mode Transmisi Infeksi

Infeksi Infeksi Infeksi dari

mandiri Silang lingkungan Udara

Makanan Debu

Disinfektan, Infus/ IV
air, dll. Kateter

Respirator Bedpan/
dan alat tempat
pasien Tenaga
pasien bantu napas
kesehatan/pa cuci
sien lain
Endoscope
Definisi HAIs
Healthcare-associated Infection

Dulu dikenal dengan Hospital-acquired/nosocomial infections, juga disebut infeksi

nosokomial. Sekarang disebut: Healthcare-associated infection

“Sebuah infeksi yang terjadi pada pasien selama proses perawatan di rumah
sakit atau pelayanan kesehatan lainnya dimana infeksi tersebut belum terjadi
atau tidak dalam masa inkubasi ketika pasien MRS, dan/atau infeksi muncul
setelah pasien pulang, serta infeksi yang dialami oleh petugas kesehatan akibat
pekerjaannya.”

Kriteria
Sebelum MRS Di RS tidak Tanda klinis
tanda klinik dalam masa positif > 2 x
negatif inkubasi 24 jam
 HAIs Prevalence Rate
No Parameter HAIs 2016 2017 2018 Target

Ventilator Associated Pneumoniae (VAP)

1 IRNA Anak 10,05‰, GRIU 6,25‰, 5,31‰ 6,03‰ ↑ 3,71‰ ↓ 5,8‰
IGD 2,02‰, IRIR 5,47‰
Catether Associated UTI (CAUTI)
2 IRIR 1,86‰, Graha Amerta 0,50‰, IRNA 2,99‰ 0,90‰ ↓ 0,33‰ ↓ 6,5‰
Bedah 0,56‰, IGD 0,62‰
Central Line Associated BSI (CLABSI)
3 IRIR 1,90‰, GRIU 0,66‰, IRNA Bedah 1,51‰ 0,85‰ ↓ 0,40‰ ↓ 3,5‰
0,23‰, IGD 0,51‰
Surgical Site Infection (SSI) – Operasi Bersih
4 0,41% 0,08% ↓ 0,08% - 1,5%
IRIR/IBP 6,90%
Hijau: Biru :
Merah :
ditemukan di tahun Tidak prominen di tahun
Melebihi ambang batas/ target
sebelumnya & turun di 2018 sebelumnya, meningkat di 2018
Cathether Associated
Urinary Tract Infection
CAUTI
Background: Pathogenesis of CAUTI

* Source of microorganisms may be endogenous (meatal, rectal,

or vaginal colonization) or exogenous, usually via contaminated
hands of healthcare personnel during catheter insertion or
manipulation of the collecting system

Figure from: Maki DG, Tambyah PA. Emerg Infect Dis 2001;7:1-6 7
 Background: Pathogenesis of CAUTI

• Formation of biofilms by urinary pathogens common on the surfaces

of catheters and collecting systems
• Bacteria within biofilms resistant to antimicrobials and host defenses
• Some novel strategies in CAUTI prevention have targeted biofilms

Scanning electron micrograph of S. aureus bacteria

on the luminal surface of an indwelling catheter with
interwoven complex matrix of extracellular
polymeric substances known as a biofilm

Photograph from CDC Public Health Image Library: http://phil.cdc.gov/phil/details.asp 8

 Patogenesis

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Sumber : Nat Rev Microbiol. 2015 May ; 13(3):269-284
Etiologi

Gambar . Etiologi dari Infeksi Saluran Kemih

10
Sumber : Nat Rev Microbiol. 2015 May ; 13(3):269-284
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Urinary Tract Infection
Urinary tract infections (UTI) are defined using
• Symptomatic Urinary Tract Infection (SUTI) criteria
• Asymptomatic Bacteremic UTI (ABUTI)
• Urinary System Infection (USI) criteria.
CAUTI
• Catheter-associated UTI (CAUTI):
• A UTI where an indwelling urinary catheter was in place for more than 2
consecutive days in an inpatient location on the date of event
• with day of device placement being Day 1*
• AND
• an indwelling urinary catheter was in place on the date of event or the day
before.
• If an indwelling urinary catheter was in place for more than 2 consecutive
days in an inpatient location and then removed, the date of event for the UTI
must be the day of device discontinuation or the next day for the UTI to be
catheter-associated.
Kriteria Diagnosis UTI
CDC, January 2020
Kriteria Diagnosis UTI

CDC, January 2020

Kriteria Diagnosis UTI

CDC, January 2020

Kriteria Diagnosis UTI

CDC, January 2020

Kriteria Diagnosis UTI

CDC, January 2020

Ringkasan

• Terpasang kateter
• Klinis
SUTI 1a CAUTI • Kultur urin tdk > 2 spesies , 105

• Px telah lepas kateter

SUTI 1 b Non- • Klinis
CAUTI • Kultur urin tdk >2 spesies, 105

SUTI 2 a • Usia < 1 tahun

• Klinis
• Kultur urin tdk lbh > 2 spesies, 105
CAUTI-Non CAUTI
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 ABUTI • Klinis -
• Kultur urin tdk > 2 spesies , 105

CAUTI-Non • Kultur darah = kultur urin

CAUTI
• Infeksi pada ginjal, ureter, kandung
kemih, uretra, jaringan retroperineal

USI atau jaringan perinefron

• Organisma teridentifikasi dari cairan kec
urine atau jaringan sekitarnya
• Demam >38 atau localized tenderness
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APLIKASI BUNDLE
ISK

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TUJUAN BUNDLES
• Bundles merupakan sekumpulan langkah, secara
seragam ditujukan untuk mencapai hasil perawatan
pasien yang optimal harus dilaksanakan oleh petugas
yang melaksanakan tindakan untuk mencegah ISK,
IDO, VAP, IAD
• SPO dan item dalam cek list borang kepatuhan dalam
audit

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KOMPONEN BUNDLE UTI

1. Kaji Kebutuhan
2. Hand hygiene
3. Insertion Technique
4. Catheter Maintenance
5. Catheter Care
6. Catheter Removal

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1. Kaji Kebutuhan:

§ Hati – hati dalam menentukan pemasangan kateter

§ Pertimbangkan untuk pemakaian kondom atau pemasangan
intermitten
§ Pemasangan kateter hanya jika betul- betul diperlukan seperti pada
retensi urine, obstruksi kemih, kandung kemih neurogenik, pasca
bedah urologi, untuk memonitor output yang ketat
Segera lepas kateter jika sudah tidak diperlukan

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2. Hand hygiene

¨Segera lakukan kebersihan tangan sebelum dan

sesudah pemasangan kateter serta setelah
memanipulasi kateter

¨Pakailah sarung tangan jika memanipulasi kateter

atau pengosongan urine bag

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3.Insertion Technique:
¨Gunakan teknik aseptik saat pemasangan kateter, (
sarung tangan steril, tirai, cairan antiseptik yang
tepat, dan membersihkan bagian meatus uretra).
¨ Kembangkan Balon dengan jumlah air yang
direkomendasikan pabrik.

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Set steril

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4. Catheter Maintenance
¨Fiksasi Kateter untuk mencegah gerakan dan trauma pada
meatus.
¨Selalu meletakan urine bag lebih rendah dari kandung kemih.
¨Tidak meletakan urine bag dilantai
¨Periksa slang sesering mungkin jangan sampai terlipat (
kingking).
¨Menjaga sistem drainase tertutup.
¨Gunakan penampung pembuangan urine untuk satu pasien
satu alat
¨Gunakan teknik aseptik untuk mendapatkan spesimen.

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Pemeliharaan
Pertahankan indwelling kateter sistem drainage tertutup

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Pemeliharan

Letakkan urine bag > rendah dari kandung kemih dan

buang
tiap 8 jam (per shift)/ bila penuh

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Cara Pengambilan Spesimen.

¨ Pengambilan spesimen steril dari kateter

¨ Clamp tubing di bawah port kateter
¨ Swab port dengan alkohol
¨ Ambil spesimen dengan menusukan jarum suntik kebagian port kateter.
¨ Dengan menggunakan teknik steril masukkan spesimen ke dalam tempat
yang steril dan kirim ke lab
¨ Buka clamp, biarkan urine mengalir

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5. Catheter Care
• Lakukan perawatan perineal sehari-hari dan setiap selesai
buang air besar.
• Gunakan kateter terkecil yang mencapai drainase
• Tidak ada penggunaan krim atau serbuk di daerah perineum
• Irigasi kandung kemih & pemakaian antibiotika tidak dapat
mencegah infeksi saluran kemih

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6. Catheter Removal
¨Kateter segera lepas jika tidak diperlukan. Lepas
atau ganti semua kateter dalam waktu 24 jam masuk
ke rumah sakit.

¨Lepas atau ganti kateter jika pasien timbul gejala

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Central Line Associated
Bloodstream Infection

CLABSI
Sites of possible contamination of intravascular
infusions

December 1, 2013 35
 Sources and Routes of
Transmission - 1
• Sources of contamination intrinsic or extrinsic
• Most microorganisms from the patient’s skin flora
• Contamination of device hub also a source of
infection
• S. aureus - 60 to 90% of infections

December 1, 2013 36
 Sources and Routes of
Transmission - 2
Hands of staff Flora del
paciente

Contamination of fluids Skin flora

Contamination of
insertion site

Injections ports

Contaminación de las
conexiones
December 1, 2013
Seed from 37
distant site
Kriteria Diagnosis
CLABSI
• CDC, 2020
• Primary bloodstream infection (BSI): A Laboratory Confirmed
Bloodstream Infection (LCBI) that is not secondary to an infection at
another body site
• Secondary BSI: A BSI that is thought to be seeded from a site-specific
infection at another body site
Kriteria Diagnosis
CLABSI
CDC 2020
Kriteria Diagnosis
CLABSI
CDC 2020
Kriteria Diagnosis
CLABSI
CDC 2020
Kriteria Diagnosis
CLABSI
CDC 2020
Kriteria Diagnosis
CLABSI
CDC 2020
Prevention of Infections - 1
Main source of Prevention
infection
Infusion fluids Monitor sterilisation
Ensure fluid is pyrogen free.
Avoid damage to containers
Inspect containers
Addition of Aseptic technique
medications Sterile medications
Carry out procedures in the pharmacy.
Sterile device for accessing the system.
Single-dose vials
If multi-dose vials have to be used:
Refrigerate after opening
Wipe diaphragm with 70% isopropanol
Warming- Ensure no contamination
container Dry warming systems are preferred.
December 1, 2013 45
 Prevention of Infections - 2
Main source of Prevention
infection
Insertion of Thorough hand disinfection and sterile gloves
catheter Thoroughly disinfect the skin insertion site.
Catheter site Cover with sterile dressing
Remove catheter if signs of infection occur.
Inspect site every 24 hours.
Change dressing only when necessary.
Do not use antimicrobial ointments.
Injection ports Clean with 70% isopropanol and allow to dry
Close ports that are not needed with sterile stopcocks.
Changing of Replace no more frequently than 72 hours (blood and lipids
infusion set every 24 hours).
Thorough hand disinfection
Use good aseptic technique.

December 1, 2013 46
General Comments - 1
• Routine changes of peripheral IV catheters not required
• In adults recommendation to change every 72-96
hours to reduce phlebitis
• In children should not be replaced routinely
• Routine replacement of central catheters not necessary
• Central catheters used only when indicated
• Non-essential catheters removed
• Risk of infection increases with length of catheterisation

December 1, 2013 47
General Comments - 2
• Teflon or polyurethane catheters associated with
fewer infections
• Steel needles same rate of infection as Teflon
catheters
• Steel needles complicated by infiltration of IV
fluids
• Well-trained staff to set up and maintain infusions
• Masks, caps, and gowns not necessary for insertion
of peripheral IV lines
• Use of non-sterile barriers will protect the operator if
blood exposure likely

December 1, 2013 48
Protocol for peripheral infusions - 1
• Place arm on a clean sheet or towel
• Hand hygiene (alcohol hand rub or antiseptic soap)
• Dry hands on a paper or unused linen towel
• Hand hygiene (gloves does not replace it)
• Not remove hair (if necessary clip, avoid shaving)
• Disinfect skin site, apply for 30 seconds and allow drying
• 0.5% chlorhexidine-alcohol, 2% tincture of iodine, 10% alcoholic povidone-
iodine, or isopropanol).
• Chlorhexidine products should not be used in children younger than 2
months

December 1, 2013 49
Protocol for peripheral infusions - 2
• Cannula preferably in an upper limb
• Secure sterile dressing
• Transparent dressings allow inspection of the site
• Secure cannula, label with insertion date
• Assess need for catheter every 24 hours
• Inspect catheter daily
• Avoid cut downs, especially in the leg
• Cannulae and sets must be sterile

December 1, 2013 50
Additional guidelines for central catheters
• Selection of site
• Higher infections for jugular and femoral
• Maximum barriers
• Disinfect skin with 2% chlorhexidine/alcohol
• Change transparent dressings once a week or if soiled,
loose, or damp, gauze every two days
• Replace sets not for blood or lipids no more than 72 hours

December 1, 2013 51
 Measures that should not be considered
as part of a general prevention policy:

• Systemic antibiotic prophylaxis

• Topical use of antimicrobial ointments
• Routine replacement of central venous catheters
• Routine use of antibiotic locks for central venous
catheters
• Routine use of in-line filters

December 1, 2013 52
Surgical Site Infections
(SSI)
 Surgical Site Infection

• Refers to an infection that

• occurs after surgery
• in the part of the body
• Where the surgery took place

United States Centers for Disease Control and Prevention

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 Surgical site infection is also defined as :
• An infection that occurs within 30 days after the
operation
• involves the skin and subcutaneous tissue of the
incision (superficial incisional) and/or
• the deep soft tissue (for example, fascia, muscle)
of the incision (deep incisional) and/or any part
• of the anatomy (for example, organs and spaces)
other than the incision that was opened or
manipulated during an operation (organ/space).

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European Centre for Disease Prevention and Control
Factors that influence
transmission of infection
1. Patient risk factors
2. Types of surgical procedures
(Operative risk factors)
3. Operating room environment

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Basic Recommendations for Prevention –
Preoperative - 1
• Identify and treat all infections
• Good control of diabetes (normoglycemia)
• Minimum hospital stay
• Do not remove hair unless interfere with surgery
• If essential, use a non-invasive procedure, e.g., clipper
• Skin preparation with antiseptic
• Bathing preop

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Surgical clippers vs Razzor
Basic Recommendations for Prevention –
Preoperative - 2
• Surgical scrub with antiseptic (can be water-less);
nail cleaner
• No brushes
• Exclude personnel with infections
• Prophylactic antibiotics
• Determine the level of experience required for
surgeons in complex surgeries

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Surgical hand scrub/hand rub

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Basic Recommendations for Prevention –
Intraoperative - 1
• Surgical checklist
• Limit the duration of the procedure
• Validate Sterilisation
• No flash sterilisation routinely
• Sterile gloves
• Water-repellent gowns and drapes, mask, cap
• Positive pressure ventilation (20 changes per hour)
• Filter air
• Doors closed
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December 1, 2013 64
Basic Recommendations for Prevention –
Intraoperative - 2
• Restrict entrance to the operating room to
necessary personnel only and restrict their
movement
• Asepsis in interventions and invasive procedures
• Handle of tissue gently
• Drains only if is necessary
• Remove as soon as possible
• Normothermia
• Normoglycaemia

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Maintenance of the Sterile Field
• Do not violate sterile pathway once created
Sterile field

Do not allow sterile personnel to reach across

unsterile areas or to touch unsterile items, or vice
versa
Basic Recommendations for Prevention –
Intraoperative - 3
• Avoid artificial nails among surgical team
• Screening and decolonisation of carriers of S.
aureus in high-risk patients

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Basic Recommendations for Prevention -
Postoperative
• Don’t touch the wound unless necessary
• Review daily the necessity of continuing drains
and take out when not necessary
• Surveillance system for SSI with risk
classifications
• Post-discharge surveillance for ambulatory
surgery or short hospital stay

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Surveillance
• Shown to reduce SSI risk
• Post-discharge surveillance essential
• Should include
• Standard definitions
• Risk stratification

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Risk stratification
• Based on a specific surgery
• Specific risk of patients
• Type of surgery (Surgery Wound Classification)
• Clean, clean-contaminated, contaminated, or dirty
• Compare the clean wound SSI rates among
different surgeons
• Patient index
• Standardised infection ratios

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Summary
• SSI development is multifactorial
• There are strategies like surgical techniques, skin preparation, and the
timing and method of wound closure that influence it
• The surgical team must know them and follow in general
practice
• Antibiotic prophylaxis may have a positive impact in certain types of
surgery

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