6-Infeksi Nosocomial.pdf

7/27/2019 6-Infeksi Nosocomial.pdf

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Pola Transmisi & FaktorRisiko InfeksiNosokomial


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Masalah infeksi nosokomial

Morbiditas:9,8/1000 pasien RS2 juta pasien RS/thn50% komplikasi

Mortalitas:88000/tahun

1 tiap 6 menit

Ekonomi:

US$4,5 Milyar

Bola salju


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PENDAHULUAN

efficacious

safety

quality

Pelayanan Kesehatan


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Prosedurmedik

Kondisi pasien

Alat medik

Hospital environment

FAKTOR DAN AKTOR


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Inappropriate Antimicrobial Therapy:Impact on Mortality

Inappropriate AppropriateTherapy Therapy

42.0% mortality

17.7% mortality Relative Risk = 2.37(95% C.I. 1.83-3.08; p < .001)

# Deaths

# Survivors

Number of patients

Kollef M,et al: Chest 1999;115:462-74

0

100

200

300

400

500

600


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Being alert

Infeksi nosokomial: 2 juta pasien/tahun

Sekitar 10% pasien rawat inap

Dampak 44,000 - 98,000 kematian (IOM) Biaya: $17-$29 milyar per tahun

Rata-rata extra hospital days 4 Rata-rata additional charge > $2,000


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Nosocomial Infection National Prevalence

Surveys in Europe

0

2

4

6

8

10

12

14

Denm

ark(

1979)

Italy

(1983

)

Belgi

um(1984

)

CzechS

.R.(1988

)

Spain(

1990)

Germ

any(

1994)

UK(1995

)

S

witze

rland

(1996

)

Fran

ce(1996

)

Norway

(1997

)

NIprevalencerate

(%)


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Serious infections testing positive for MRSA

isolates among hospitalised patients(1997 SENTRY data)

Patients (%)

0

30

50

10

Pneumonia

20

40

UTI Wound Bloodstream

Infection type

Jones. Chest 2001;119:397S404S

UTI

UTI = urinary tract infection


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Risk factors for colonisation or infection

with MRSA in hospitals

Chambers. Emerg Infect Dis 2001;7:178

Admission to an ICU

Surgery

Prior antibiotic exposure

Exposure to an MRSA-colonised patient


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Gram-negative organisms with resistance

to ciprofloxacin (1997 SENTRY data)

Organisms (%)

0

30

50

10

Stenotrophomonasmaltophilia

20

40

Acinetobacterspp.P. aeruginosa Escherichia coli

All patients (USA)Lower RTI (USA and

Canada)

Organism typeJones. Chest 2001;119:397S404S


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An infection that was not found to bepresent prior to hospital admittance

Nosocomial infection

apabila kejadiannya berkaitan dengan suatuprosedur medik, terapi, atau kejadian penyakit

setelah pasien masuk ke rumahsakit.


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1. Terjadi 48-72 jam setelah pasien masukrumahsakit dan dalam kurun waktu 10 harisetelah pasien boleh meninggalkan rumahsakit.

2. Tidak disebut sebagai infeksi nosokomial apabilaterjadinya pada saat pasien masuk.

hospital acquired infection


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Infeksi nosocomial (INOS)

Prolong hospital stay

Increase cost

Increase morbidityand mortality

National Audit Office, UK (2000)

10% dari pasien rawat inap

Lama rawat 2,5 x lebih panjang Rata-2 tambahan hari: 11 hari /kasus

Biaya 2,8 kali lebih mahal Rata-2 tambahan biaya: 2917/kasus

5000 kematian inos per tahun(>tinggi dari Lakalantas


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4 Jenis INOS utama

Risiko tertinggi: ICU dan long-term care patients

Urinary tract (44%)

Lower respiratory tract (18%)

Surgical wound sites (11%)

Bloodstream (8%)


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Unclean hands or gloves Alat medik (endoscope, respiratory

equipment, tube feed bags) terkontaminasi

bakteri (dari air atau improper sterilizationprocedure)

Area-2 terkontaminasi: inadequatelycleaned

Sumber-2 infeksi nosokomial


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Air sebagai Reservoir of Nosocomial

Pathogens

Organisme spt Pseudomonas aeruginosa,Serratia marcescens, and Acinetobacter

calcoaceticusdapat mereplikasi dalam air

yang relatif murni

Ditemukan pula di air minum yang telah

memenuhi limit of safety (


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Burn Infections

Tap water has been cited as thesource for serious wound and

sepsis

Kolmos HJ, Thuesen B, et al. Outbreak of infection in a burnunit due to Pseudomonas aeruginosaoriginating fromcontaminated tubing used for irrigation of patients.


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Eksposur patien terhadap air di

rumah sakit

Handwashing (cross-contamination)

Enteral feedings

Respiratory equipment

Drinking

Showering Bed bathing


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DECUBITUS-Pressure ulcer

1.6 juta kasus per tahun di acute care Area:

bangsal

Bedah dan ruang operasi

intensive care units

rehabilitation centers long term and home care


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Prevalensi Decubitus

1. Meehan M. Multisite pressure ulcer prevalence survey. Decubitus 1990;3:4-14.

2. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and

incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:209-15.

Reported rates

3% s/d 11%

Two large studies

9.2% (148 hospitals)17% (116 hospitals) 2


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Faktor-faktor pencetus lain

Transplantasi organ

Transfusi darah

Extensive, invasive surgery

Renovasi infrastruktur dan fasilitas

rumah sakit


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Modes of spread of infection

ENVIRONMENT

STAFF

PATIENT(endogenous)

EQUIPMENT

OTHER PATIENTS


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causative organisms

The predominant organisms:

Gram negative bacilli

- Pseudomonas aeruginosa, Acinetobacter, Klebsiella

Staphylococcus aureus

Coagulase-negative staphylococci

Candida

Enterococci


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Increasing trends towards moreGram-positive and resistantmicroorganisms

Fungal infections are on the increaseand require high index of suspicion

causative organisms


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Common bacteria and

their most likely sources and modes of spread

Hands, contaminatedequipment

Environmental, esp. moistareas

Pseudomonasaeruginosa

HandsEndogenous part of GIflora

E.coli andKlebsiella

HandsEndogenous part of GIand genital flora

Enterococci

Ass. with intravascular

catheters

Pts own skin flora, possibly

skin flora of staff

Coagulase-

negativestaphylococci

Hands, airborneEndogenous, other infectedpts, staff or environment

Staph. aureusincluding MRSA

Modes of

spread

Possible sourcesBacteria


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Nosocomial infections in ICU


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5 10X more likely to acquire

nosocomial infections

ICU is an "epidemiological jungle"because of the abundance oforganisms that proliferate in theseunits.

BMJ 1998;317:652 4


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Proportion of S aureusisolates resistant to methicillin recovered from clinicalspecimens of inpatients in selected European countries. Data for hospitals are

derived from Voss et al,4 and data for intensive care units from Vincent et al5

BMJ1998;317:6524


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Risk factors

Patient factors Factors related to

diagnostic/ therapeuticinterventions

Environmental

factors


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Age

Immune status

Severity of illness

Malnutrition

Underlying or chronic disease

Prolonged ICU stay

Patient factors


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interventional factors

Poor compliance with handwashing, aseptic

technique : understaffing, less skilled workers,emergency situations

Invasive devices e.g tracheal tubes,

intravascular and urinary catheters

Parenteral feeding

Indiscriminate use of antibiotics and thedevelopment of resistant organisms


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Space limitations causing crowding

Lack of isolation for colonised or infected patients

Inadequate demarcation of clean and dirty

areas

Unsafe handling of infectious wastes

Recirculation of unfiltered air

Decreased environmental hygiene

Environmental

factors


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common sites

Respiratory system(31%)

Urinary tract (24%)

Bloodstream (16%)

Urinary tract (44%)

Respiratory system

(18%)

Surgical wound (11%)

Bloodstream (8%)

ICU Hospital


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Principles of infection control

GENERALPRINCIPLES

Asepsis

Body fluidspilage

Protective clothing

Hand hygiene

Waste

Cleaning,disinfection,sterilization

Specimen handling

Sharps safety

Linen

Food hygiene


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6-Infeksi Nosocomial.pdf

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