MANAJEMEN HAIs

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DR. BAMBANG ARIANTO Sp. B.

KOMITE PPI

RSU HAJI SURABAYA


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Manajemen Infeksi Luka Operasi

Antibiotik oral/iv

Kultur bakteri, bakteri resisten?

Reeksplorasi luka insisi, drenasepus? Evakuasi hematoma?

Plate/screw, bila infeksi berat,perlu dilepas

Terapi suportif, cairan/medikasi

Masuk rumah sakit? Lapor PPI/Surveilance


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SurveilanceLaporan

Infeksi paskaoperasi

PPI

ReaksiCepat

Alur Monitoring Infeksi

KLB

Non KLB


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Konsep manajemeninfeksi paska operasiPengendalian Infeksi Paska Operasi

Patient savety Infeksi Paska Operasi

Pasien

SDM

AB Profilaksis

Sterilisasi alat/linen

Ruang Operasi

Prosedur Tetap

Pasien?

SDM?

AB Profilaksis?

Sterilisasi alat/linen?

Ruang Operasi?

Prosedur Tetap?

Prosedur operasi Prosedur operasi?


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Epidemiology of Postoperative

Infection 18 million surgical procedures yearly

486,000 nosocomial infections

20% in intensive care unit, with SICU highest risk

Patients have longer and costlier hospitalization Twice as likely to die

Mortality rate up to 44% in ICU patients

60% more likely to spend time in ICU

Five times more likely to be re-admitted Excess direct cost $5,038/infected patient

Kirkland et al. Infect Control Hosp Epidemiol1999;20:725-730Wallace et al. Am Surg1999;65:987-989


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Transmission cycle in OT


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Strategi mencegah SSI

Objektif Menurunkan jumlah bakteri pada tempat insisi

Surgical Site Preparation Antibiotik Profilaksis

Optimmalisasi lingkungan mikro area operasi Meningkatkan fisiologi pertahanan tubuh

Berkaitan dengan faktor resiko, bisadikelompokkan : Faktor intrinsik pasien Pre-operative Operative


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Faktor Pasien- Age

- Nutritional status

- Diabetes- Smoking

- Obesity

- Coexistent infections at a remote body site

- Colonization with microorganisms

- Altered immune response

- Length of preoperative stay


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Faktor prosedur operasi

Hair removal technique

Preoperative infections

Surgical scrub

Skin preparation

Antimicrobial prophylaxis

Surgeon skill/technique

Asepsis

Operative time

Operating room characteristics


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Type of Procedure Risk of SSI

Clean < 2 %Clean-Contaminated 5 -15 %

Contaminated 15 - 30 %

Dirty* > 30 %

Nichols RL. Am J Surg 1996;172: 68-74.

Traditional Classification of

Operative Procedures and Risk of Surgical Site

Infection (SSI)

* Dirty wounds infection - antibiotics indicated as therapy


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Risk Factors

Surgical Site Infection

NNIS Study-CDC

Wound classification

(Contaminated/dirty)

ASA Class > 3

Prolonged operative time(> 75th percentile)


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Surgical Site Infections Stratified ByPatient Risk-CDC 1991

0

2

4

6

8

10

12

14

0 Risk

Factors

1 Risk Factor 2 Risk

Factors

3 Risk

Factors

SSI/ 100 Operations


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Major Pathogens in

Surgical Site Infection

0%

5%

10%

15%

20%

%o

finf

ections

S.aureu

s

CN

S

Enterococ

ci

E.coli

P.aeru

ginos

a

Enteroba

ctersp

p.

NNIS, 1990-1996.

For the VAST majority of procedures,antibiotic prophylaxis should be directedhere

Elective colon surgery(plus anaerobic coverage)


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Relative Distribution of Bacteria

from Superficial to Deep Infections

Staphylococcus

Streptococcus

Gram-negative

bacilliAnaerobes

Superficialinfection

Deep

infection


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Antibiotik Profilaksis

1. Antibiotik profilaksis diberikan dalam satu jam sebelum insisioperasi

Tujuannya agar antibiotik telah mencapai level bakteriosid di jaringan danserum ketika dilakukan insisi.

Dasar pemikirannya adalah menurunkan jumlah kontaminasi mikroorganismeintraoperasi pada level tidak melebihi kemampuan pertahananan tubuh.

2. Antibiotik profilaksis selektif pada setiap pasien operasi.Pasien operasi yang mendapatkan antibiotik profilaksis harus konsisten dengan

paduan antibiotik yang dibuat untuk menurunkan infeksi luka operasi.(spesifik pada tiap prosedur operasi).

*CDC Guideline for Prevention of Surgical Site Infections, 1999


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Antibiotik Profilaksis

3. Antibiotik profilaksis maksimal digunakan dalam 24 jampaskaoperasi.

Dasar pemikirannya : penggunaan antibiotik yang pendek efektif mencegahinfeksi dibanding penggunaan antibiotik yang lama. Penggunaan antibiotik

yang lama sering menyebabkan berkembangnya bakteri resisten.

4. Antibiotik profilaksis tidak boleh sebagai antibiotikterapi


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Relation Between Timing

and Surgical Wound Rate

0%

1%

2%

3%

4%

5%

6%

>2 2 1 1 2 3 4 5 6 7 8 9 10 >10

InfectionRa

te(%)

Hoursbefore Incision

Hours after incision

Classen et al. N Engl J Med1992;326:281-285.

D f A tibi ti d Ri k f


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Days of Antibiotics and Risk of

MRSA-Pooled Odds Ratios

Asensio et al. ICHE 1996;17:20-28

0

2

4

6

8

10

12

0 1 to 2 3 to 7 8 to 14 15 or

more

Odds Ratios

Days of Antibiotic Administration


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Infeksi Luka Operasi


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Perioperative Hypothermia and

the Risk of SSIKurz et al. N Engl J Med 1996;334:1209-1215.

200 patients-colorectal surgery

Standardized anesthesia and antibiotics

Randomized to routine care (34.7o

C) or activewarming (36.6oC) during surgery

SSI: Culture-positive drainage of pus

Hypothermia group:

More infections (19 vs. 6%, p


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Perioperative Supplemental

Oxygen and the Risk of SSIGreif et al. N Engl J Med 2000;342:161-167.

500 patients-colorectal surgery

Standardized anesthesia and antibiotics

Randomized 30% vs. 80% O2 during surgery and for 2 hours

afterward

SSI: Culture-positive drainage of pus

Hypothermia group: More infections (11.2 vs. 5.2%, p=0.01)


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Early Enteral Nutrition in Trauma

Meta-AnalysisMarik and Zaloga. Crit Care Med 2001;29:2264-2270

15 randomized trials

All postoperative, trauma, or burn studies

Reduced infections RR 0.45 (0.30-0.66)

Reduced hospital stay

Mean, 2.2 days (0.81-3.63 days)

No effect on mortality

No effect on non-infectious complications


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Early Postoperative Glucose Control Predicts Nosocomial

Infection Rate in Diabetic Patients

Pomposelli et al. JPEN 1998;22:77-81

100 consecutive diabetic patients initially free ofinfection

All patients received antibiotic prophylaxis

Glucose control per attending surgeon + 220 mg/dL POD 1

Poor glucose control and infection

All infections: RR 2.7 (31.3% vs 11.5%)

Non-UTI: RR 5.7


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Diabetes Control and Surgical Site Infections-

Cardiac Surgery

Latham et al. Infect Control Hosp Epidemiol2001;22:604-606.

1000 consecutive patients, 7.2%

infectionsRisk factors for infection:

Odds ratio

Diabetes 2.76

Postoperative hyperglycemia 2.02

Chronic poor glycemic control was not a risk factor


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Regulate the Operating Room Environment

Ventilation = positive pressure.

Variable air systems (positivepressure only)

Air introduced at the ceiling andexhausted near the floor

Humidity


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Regulate the Operating Room Environment

Minimize personnel

traffic duringoperations


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Cleaning and Disinfecting

Environmental Surfaces

Medical equipment surfaces

knobs, handles on equipment such as x-ray machines, instrument carts

Housekeeping surfaces

floors, walls, chairs, and tabletops


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Design of operation room with

zonal ventilation


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Sterilisasi


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SURVEILLANCE

Tem PPI


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Surveillance

Planning,

Implementation,Evaluation of practice

Timely dissemination of data

Ongoing, systematic

collection,analysisinterpretation

Tem PPI

Costi P

Infection Control and Quality Healthcare in the New Millenium


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Q y

Multidisciplinary team approach

1847

1958

1970

1980

1990

2000

1863

Pittet D,Am J Infect Control2005, 33:258


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SAVELIVES

WHO PatientSafety

WHOCollaboratingCentres

Countrycampaigns &activities

Facilitycampaigns &

activities includingevaluation andfeedback


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TERIMA KASIH

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