pencegahan dan kontrol infeksi
DESCRIPTION
Kontrol InfeksiTRANSCRIPT
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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
D W
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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)
D W
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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
D W
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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
D W
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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
D W
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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