Pencegahan Dan Kontrol Infeksi

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Sudirman Katu Divisi Penyakit Tropik dan Infeksi Ilmu Penyakit Dalam FKUH/RSWS Makassar STRATEGI PENGENDALIAN DAN PENCEGAHAN INFEKSI DI RUMAH SAKIT

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Kontrol Infeksi

Transcript of Pencegahan Dan Kontrol Infeksi

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Sudirman Katu

Divisi Penyakit Tropik dan Infeksi Ilmu Penyakit Dalam FKUH/RSWS Makassar

STRATEGI PENGENDALIAN DAN PENCEGAHAN INFEKSI

DI RUMAH SAKIT

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Risk of Fatal Outcome per Exposure

10 -2 10 -3 10 -4 10 -5 10 -6 10 -7 10 -8

Dangerous Acceptable Risk Safe Ultra-safe

2

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Environment

Patient

Antimicrobials Hands

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Rantai kejadian infeksi

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PENDAHULUAN

• Health Care Associated Infection ;

• dalam 48 jam perawatan di rumah sakit

• setelah 3 hari keluar dari rumah sakit

• 30 hari setelah tindakan operasi.

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Pasien sebagai sumber infeksi

Kontak Langsung Pasien - Pasien Pengunjung

Kontak Langsung Pasien – Petugas

Daya Tahan Pasien Rendah

Umur, Terapi Steroid / Imuno Supresi, Imuno Defisiensi,DM / Sirosis Hati / Operasi, dsb

Tindakan invasif

Kontaminasi Peralatan Medik

SUMBER INFEKSI HAI/HCAI

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MODES OF TRANSMISSION

• Parenteral Transmission – the spread of an agent through intact skin by a sharp e.g., needle stick injury.

• Common Vehicle Transmission – the spread of an agent through a common contaminated source e.g., multi-dose vials.

• Vector Transmission – occurs when a host is bitten by an animal or insect carrying the infectious agent e.g., mosquito transmitting and West Nile virus.

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MODES OF TRANSMISSION OF HAI PATHOGENS(1)

Mode of transmission Reservoir/source Examples of pathogensContactPatients/health care Staphylococcus aureus

workers, fomites, Enterococcus spp.medical devices Enterobacteriaceae

Clostridium difficileRespiratory syncytial virusRotavirusAdenovirusCandida spp.

Droplet spread Health care workers, Staphylococcus aureuspatients Respiratory syncytial virus

Influenza virusDevice-related Water/respiratory Pseudomonas aeruginosa

equipment, Acinetobacter spp.endoscopes Stenotrophomonas maltophilia

Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 2010

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MODES OF TRANSMISSION OF HAI PATHOGENS(2)

Mode of transmission Reservoir/source Examples of pathogensMedication-related Water/iv fluids Burkholderia cepacia

disinfectants Acinetobacter spp.Serratia marcescens

Transfusion, Patients/blood Hepatitis B virus, hepatitis Cneedlestick virus, HIV, etc.

Transplantation Patients/donor tissue CytomegalovirusToxoplasma gondiiCreutzfeld-Jacob agent

Airborne Patients Mycobacterium tuberculosisHot water/showers Legionella spp.Soil/dust Aspergillus spp.

Foodborne Animals/food products Salmonella spp.Water/enteral feeding Enterobacter spp.

Pseudomonas aeruginosa

Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 2010

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BEBERAPA LOKASI/TEMPAT YANG MERUPAKAN SUMBER INFEKSI DI RUMAH SAKIT

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RISK FACTOR FOR HAI / HCAI IN ICU

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URINARY CATHETERURINARY INVASIVE PROCEDURESADVANCED AGESEVERE UNDERLYING DISEASEUROLITIASISPREGNANCYDIABETES

URINARY TACT INFECTION

VASCULAR CATHETERNEONATAL OR ADVANCED AGE

SEVERE UNDERLYING DISEASENEUTROPENIA

IMMUNODEFICIENCYNEW INVASIVE TECHNOLOGY

CRITICAL CARELACK OF TRAINING & SUPERVISION

BLOOD INFECTIONS

MECHANICAL VENTILATIONSASPIRATION

USE OF ANTI-DEPRESANTSANTIBIOTICS & ANTACIDS

PROLONGED HOSPITAL STAYMALNUTRITION

ADVANCED AGENASOGASTRIC TUBE

SURGERYIMMUNODEFICIENCY

LUNG INFECTIONS

INADEQUATE ANTIBIOTICS PROPHYLAXISINCORRECT SURGICAL SKIN PREPARATIONSURGICAL INTERVENTION DURATIONTYPE OF WOUNDINAPPROPRIATE WOUND CAREPOOR SURGICAL ASEPSISDIABETESNUTRITIONAL STATEIMMUNODEFICIENCYLACK OF TRAINING & SUPERVISION

SURGICAL-SITE INFECTIONS

COMMON SITES AND

RISK FACTORS

THE MOST COMMON SITES OF HEALTH CARE-ASSOCIATED INFECTION AND SOME

SPECIFIC RISK FACTORS UNDERLYING THE OCCURANCE OF THESE INFECTIONS

WHO Global Patient Safety Challenge,

2007

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HOST FACTORS PREDISPOSING TO HOSPITAL INFECTION

Factor ExampleAge Neonates, elderly patientsUnderlying disease System of organ failure (e.g. liver cirrhosis, diabetes, mellitus, chronic obstructive pulmonary disease, renal failure), cancer, neutropeniaImmunodeficiency Congenital, or acquired, (e.g. AIDS, immunosuppressive therapy, malnutrition)Specific immunity Susceptibility to viral infectionsBreach of Mucocutaneous Trauma, burns, surgery, endoscopy, indwelling devices barriers

Mucosal and skin diseasesAnesthesia, sedation Suppression of cough and peristalsis, hypoventilationAntibiotics, antacids Alterations of resident microflora and decrease of resistance to colonization by hospital flora

Selection of antibiotic-resistant mutants and naturally resistant bacteria and yeasts

Colonizing flora Carriage of opportunistic bacteria and fungiLatent infection Latent infection with intracellular pathogens reactivated by immunosuppression

Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 2010

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Infections Associated with Invasive Devices and Procedures

Device/procedure Type of infectionIntravascular catheter Bacteremia; catheter site infectionBladder catheter Urinary tract infectionMechanical ventilation Pneumonia; sinusitisStents Pyelonephritis; chongalitis;

meningitisSurgery Surgical site infection; pneumoniaEndoscopy Bacteremia; pneumonia;

gastroenteritis and cholangitisBlood transfusion Bacteremia fungemia; viral infections

Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 2010

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KUMAN PENYEBAB HAI/HCAI

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HAI Pathogens

Organism Carriage site Methode of spread

Staphylococcus aureus Nose, Groin Hairline Hands, skin scalesskin lesions, wounds, droplet spreadurinary catheters

Group A streptoccoci Anterior nares throat, Hands, skinSkin lesions, wounds

Gram-negative bacilli : Stool, urine, moist Hands, urinary, Multiply antibiotic skin lesions catheter, non- resistent clinical equipment, Pseudomonas ventilators, aeruginosa disinfectants, moist area in the environment

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TIPE INFEKSI HAI/HCAI

One in 10 of hospitalised patients

Urinary Tract Infection 30-40%Surgical Wound Infection 17-19%Lower Resp. Tract Infection16-18%Skin and Soft Tissue Infection 6%Bacteraemia 8%

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INFECTIONS SPREAD BY HEALTH CARE WORKERS TO PATIENTS OR OTHER HEALTH CARE WORKERS

Infection Comment

Hepatitis B virus e-Antigen positivity and high level of viremia associated with transmissionHepatitis C virus Surgeon resumed work following medical control of his hepatitis c infectionMethicillin-resistant ‘Cloud adult’ and chronic sinusits may facilitateStaphylococcus aureus spread Group A streptococci Carriers may harbor the organism in throat, vagina, rectum, or skinSalmonella Routine surveillance for dietary workers of unproven benefitTuberculosis Health care workers may spread disease through hospitalsMeasles, rubella Unvaccinated medical students are source of many outbreaks

Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 2010

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MICROORGANISM WITH DRUG RESISTANCE THAT ARE MAJOR PROBLEMS IN HOSPITALS

Gram-positive organism Gram-negative organism

MRSA Klebsiella species

MRSA (HRV) VRSA Enterobacter species

VRE Pseudomonas aeruginosa

Acinetobacter baumannii

NOTE : HRV, heterogeneous resitance to vancomycin;

MRSA, methicillin-resistant Staphylococcus aerus;

VRE, vancomycin-resistant enterococci; VRSA

vancomycin-resistant S.aureus

Levy, S. B. ; CID 2001:33

(Suppl 3)

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DAMPAK HAI / HCAI

Peningkatan Morbiditas / Mortalitas

Lama Perawatan

Biaya

Timbulnya MIkroorganisme yang Resisten

Citra Profesi / Rumah Sakit

Mediko – Legal

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Hospital Associated Infection Control Programme to Ensure the Improvement of Health

Service Quality

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INFRASTRUCTURE OF AN INFECTION CONTROL PROGRAMME

Surveillance data

Laboratory base Ward base

ICO + ICN

Infection Control Committee

Isolation & treatment of infection

Focused epidemiological studies

Containment 1)Influencing

PCPs

2) Care of environment & equipment

3) Prophylaxis for the health-care workers

4) Writing of policies

Control usage of antibiotic & disinfection

Staff health & education

Input

Analysis & interpretation

Action & enforcement

Control measures ICN ICO

Administration & hospital staff

Seto Wing Hong 2004D W

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AIMS OF HOSPITAL INFECTION SURVEILLANCE

To identify high-risk patients and procedures and assign infection control priorities To monitor trends over time of incidence and patterns

of infection To detect outbreaks of hospital infection To evaluate the efficacy of prevention and control

interventions To evaluate quality assurance programs To educate and motivate health care providers and

decision makers

A number of aims can be assigned to hospital epidemiologic surveillance systems

Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 1999

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The Awareness of HAI/HCAI Infection Control

• Over the past 30 years, nosocomial infection surveillance, prevention and control programs have been integrated into hospitals

• The goal is to ensure the well being of patients, staff, visitor and others in the healthcare environment

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The Critical Importance of HAI/HCAI Infections 1

• In 1976 the Joint Commission on Accreditation of Health Care Organizations (JCAHO) highlighted the nosocomial infection as preventable & controllable adverse hospital outcomes

Scheckler WE et al Am J Infect Contr 1998;26:47 D W

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The Critical Importance of HAI/HCAI Infections 2

JCAHO published standards for :– Organization Surveillance– Reporting Evaluation– Record maintenance – & other requirements

For infection prevention & control activities as a condition for hospital accreditation

Scheckler WE et al Am J Infect Contr 1998;26:47

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The Benefit of HAI/HCAI Infection Control Programme

• Subsequent analyses have demonstrated that nosocomial infection prevention and control programs are:

– Clinically effective – Cost effective

SENIC (Wenzel 1995)

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Goals for Infection Control

3 principal goals for hospital infection control programs :

• Protect the patient;• Protect the healthcare worker; visitors, and others in the healthcare environment;• Accomplish the previous two goals in

a cost-effective manner

Scheckler WE et al Am J Infect Contr 1998;26:47 D W

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Monitoring the Achievement of Infection Control Goals 1

• Every healthcare institution must developed specific objectives & outcome measures to determine whether they have achieved their infection control goals

JCAHO

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Monitoring the Achievement of Infection Control Goals 2

• The outcome measures should relate directly to the specific goals of the infection control program, namely:

– To measure the effectiveness of procedures, policies, or programs to protect patients & healthcare providers

– To determine the cost effectiveness of these activities

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The Essential of Hospital Infection Control Program

Hospital infection control is a quality improvement activity that focuses on improving the care of patients and protecting the health of staff

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Paradigm in Infection Control= Quality improvement

programs

• Ongoing data collection & analyses• Problem identification and definition• Intervention to improve outcomes• Reassessment to ensure that the

intervention has led to the desired result

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HAI/HCAI INFECTION CONTROL PROGRAM

Target for HCWThe save delivery of health care

Promote HCW awareness - Of NI as a problem- That NI can (in part) be prevented

HospitalsShould do the sick no harm

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ORGANIZATION OF HOSPITAL INFECTION CONTROL

Structure & Function

INFECTION CONTROL COMMITEE

- Powerfull chairman

- Representatives of all

clinical & service

departments

INFECTION CONTROL TEAM

- Infected control officer

- Infected control nurse

- Policies &

major decisions

- Monitors I. C. T.

All day to day

duties

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A RATIONAL CLASSIFICATION OF HOSPITAL INFECTION PREVENTION STRATEGIES(1)

Target Objective Example of strategyEndogenous To prevent or Antibiotic prophylaxis in surgeryInfection neutralize the Skin antisepsis before surgery

translocation of Antiseptic-bound iv cathetercommensal flora Intestinal decontamination of

neutropenic patients Pneumococcal immunization before splepectomy

Exogenous To prevent cross- Hand hygiene for patient care proceduresInfection infection Isolation and decolonization of carriers of

transmissible pathogens Sterilization or disinfection of invasive devices Cleaning and disinfection of fomites Outbreak detection and molecular

epidemiologic studies to determine the mode and vehicles of spread

Bennett & Brachman's Hospital Infections, 5th Ed, 2007 Lippincott Williams & Wilkins

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A RATIONAL CLASSIFICATION OF HOSPITAL INFECTION PREVENTION STRATEGIES(2)

Target Objective Example of strategy

Antimicrobial To prevent the Restricted usage of broad-spectrum resistance emergence, and antimicrobial agents

spread of Optimized anti-infectious therapy (agents,

resistance genes dosage and duration)

To prevent the Detection, monitoring and timely reporting

spread of of antimicrobial resistanceresistant strains Isolation precautions and

treatment of of micro- carriers of transmissible resistant

strains organisms Molecular epidemiologic studies to distinguish between mutant selection, gene or clone dissemination

A classification of strategies to prevent hospital infection and control antimicrobial resistance

Bennett & Brachman's Hospital Infections, 5th Ed, 2007 Lippincott Williams & Wilkins

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1. Kebersihan tangan

2. Alat Pelindung Diri (APD)

3. Peralatan perawatan pasien(non kritikal, semi kritikal dan kritikal )

4. Pengendalian Lingkungan

5. Pemrosesan peralatan pasien dan penatalaksanaan linen

6.Kesehatan karyawan/perlindungan petugas kesehatan

7.Penempatan pasien sesuai sumber transmisi

8. Hygiene respirasi/Etika batuk

9. Praktek penyuntikan yang aman

10. Praktek lumbal fungsi

10 Kewaspadaan standar terdiri dari

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Transmisi

1. Kontak spt : MRSA kewaspadaan standar : Kebersihan tangan dan penggunaan APD

2. Dropplet Pneumonia kewaspadaan standar : Kebersihan tangan, masker dan goggle

3. Air bone Kewaspadaan standar• Tekanan negatif atau natural ventilation• Masker N 95• Pintu kamar harus selalu tertutup

Kewaspadaan berdasarkan Transmisi

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Resume 1

• HAI/HCAI is a preventable & controllable adverse hospital outcomes

• Hospital infection control is a quality improvement activity that focuses on improving the care of patients and protecting the health of staff

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Resume 2

• HAI/HCAI control program is clinically effective & cost-effective

• Specific objectives & outcome measures must be developed to determine whether they have achieved their infection control goals

D W

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TERIMA KASIH