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STRATEGI PENGENDALIAN

DAN PENCEGAHAN INFEKSI


DI RUMAH SAKIT

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

Risk of Fatal Outcome per Exposure

10 -2

10 -3

Dangerous

10 -4

10 -5

Acceptable Risk

10 -6

10 -7

Safe

10 -8

Ultra-safe

Environment

Patient

Antimicrobials

Hands

Rantai kejadian infeksi

PENDAHULUAN
Health Care Associated Infection ;
dalam 48 jam perawatan di rumah sakit
setelah 3 hari keluar dari rumah sakit
30 hari setelah tindakan operasi.

SUMBER INFEKSI HAI/HCAI


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

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.

MODES OF TRANSMISSION OF HAI


PATHOGENS(1)
Mode of transmission Reservoir/sourceExamples of pathogens
Contact Patients/health care Staphylococcus aureus
workers, fomites,Enterococcus spp.
medical devices Enterobacteriaceae
Clostridium difficile
Respiratory syncytial virus
Rotavirus
Adenovirus
Candida spp.
Droplet spread Health care workers, Staphylococcus aureus
patients
Respiratory syncytial virus
Influenza virus
Device-related Water/respiratory
Pseudomonas aeruginosa
equipment,
Acinetobacter spp.
endoscopes
Stenotrophomonas maltophilia
Struelens MJ : Hosp. Infec. Control, in Amstrong & Cohen : Infect. Dis, 2010

MODES OF TRANSMISSION OF HAI


PATHOGENS(2)
Mode of transmission
Medication-related

Reservoir/source
Water/iv fluids
disinfectants

Examples of pathogens
Burkholderia cepacia
Acinetobacter spp.
Serratia marcescens

Transfusion,
needlestick

Patients/blood

Hepatitis B virus, hepatitis C


virus, HIV, etc.

Transplantation

Patients/donor tissue

Cytomegalovirus
Toxoplasma gondii
Creutzfeld-Jacob agent

Airborne

Patients
Hot water/showers
Soil/dust

Mycobacterium tuberculosis
Legionella spp.
Aspergillus spp.

Foodborne

Animals/food products
Water/enteral feeding

Salmonella spp.
Enterobacter spp.
Pseudomonas aeruginosa

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

BEBERAPA LOKASI/TEMPAT YANG MERUPAKAN SUMBER INFEKSI DI RUMAH SAKIT

RISK FACTOR FOR HAI / HCAI IN


ICU

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


SPECIFIC RISK FACTORS UNDERLYING THE OCCURANCE OF THESE INFECTIONS
URINARY CATHETER
URINARY INVASIVE PROCEDURES
ADVANCED AGE
SEVERE UNDERLYING DISEASE
UROLITIASIS
PREGNANCY
DIABETES

URINARY TACT
INFECTION
SURGICAL-SITE
INFECTIONS
INADEQUATE ANTIBIOTICS
PROPHYLAXIS
INCORRECT SURGICAL SKIN
PREPARATION
SURGICAL INTERVENTION DURATION
TYPE OF WOUND
INAPPROPRIATE WOUND CARE
POOR SURGICAL ASEPSIS
DIABETES
NUTRITIONAL STATE
IMMUNODEFICIENCY
LACK OF TRAINING & SUPERVISION

COMMON
SITES AND
RISK
FACTORS

MECHANICAL VENTILATIONS
ASPIRATION
USE OF ANTI-DEPRESANTS
ANTIBIOTICS & ANTACIDS
PROLONGED HOSPITAL STAY
MALNUTRITION
ADVANCED AGE
NASOGASTRIC TUBE
SURGERY
IMMUNODEFICIENCY

LUNG
INFECTIONS
BLOOD
INFECTIONS

WHO Global Patient


Safety Challenge,
2007

VASCULAR CATHETER
NEONATAL OR ADVANCED AGE
SEVERE UNDERLYING DISEASE
NEUTROPENIA
IMMUNODEFICIENCY
NEW INVASIVE TECHNOLOGY
CRITICAL CARE
LACK OF TRAINING & SUPERVISION

HOST FACTORS PREDISPOSING TO HOSPITAL INFECTION


Factor
Example
Age
Neonates, elderly patients
Underlying disease
System of organ failure (e.g. liver cirrhosis, diabetes,
mellitus, chronic obstructive pulmonary disease, renal
failure), cancer,
neutropenia
Immunodeficiency
Congenital, or acquired, (e.g. AIDS, immunosuppressive
therapy, malnutrition)
Specific immunity
Susceptibility to viral infections
Breach of Mucocutaneous
Trauma, burns, surgery, endoscopy, indwelling devices
barriers
Mucosal and skin diseases
Anesthesia, sedation
Suppression of cough and peristalsis, hypoventilation
Antibiotics, 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 fungi
Latent infection
Latent infection with intracellular pathogens reactivated by
immunosuppression

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

Infections Associated with Invasive


Devices and Procedures
Device/procedure
Type of infection
Intravascular catheter
Bacteremia; catheter site infection
Bladder catheter
Urinary tract infection
Mechanical ventilation Pneumonia; sinusitis
Stents
Pyelonephritis; chongalitis;
meningitis
Surgery
Surgical site infection; pneumonia
Endoscopy
Bacteremia; pneumonia;
gastroenteritis and cholangitis
Blood transfusion
Bacteremia fungemia; viral infections

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

KUMAN PENYEBAB HAI/HCAI

HAI Pathogens
Organism Carriage site Methode of spread
Staphylococcus aureus Nose, Groin Hairline Hands, skin scales
skin lesions, wounds, droplet spread
urinary catheters
Group A streptoccoci
Anterior nares throat, Hands, skin
Skin lesions, wounds
Gram-negative bacilli : Stool, urine, moist
Hands, urinary,
Multiply antibiotic skin lesions
catheter, nonresistent
clinical equipment,
Pseudomonas
ventilators,
aeruginosa
disinfectants,
moist area in the
environment

TIPE INFEKSI HAI/HCAI


One in 10 of hospitalised
patients
Urinary Tract Infection 30-40%
Surgical Wound Infection 1719%
Lower Resp. Tract Infection1618%
Skin and Soft Tissue Infection

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 transmission
Hepatitis C virus Surgeon resumed work following medical
control of his
hepatitis c infection
Methicillin-resistant Cloud adult and chronic sinusits may facilitate
Staphylococcus aureus
spread
Group A streptococci Carriers may harbor the organism in throat, vagina,
rectum, or skin
Salmonella Routine surveillance for dietary workers of unproven benefit
Tuberculosis Health care workers may spread disease through
hospitals
Measles, rubella Unvaccinated medical students are source of many outbreaks

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

MICROORGANISM WITH DRUG RESISTANCE THAT ARE MAJOR


PROBLEMS IN HOSPITALS

Gram-positive organism
MRSA

Klebsiella species

MRSA (HRV) VRSA


VRE

Gram-negative organism

Enterobacter species

Pseudomonas aeruginosa
Acinetobacter baumannii

NOTE : HRV, heterogeneous resitance to vancomycin; MRSA,


methicillin-resistant Staphylococcus aerus; VRE, vancomycinresistant enterococci; VRSA vancomycin-resistant S.aureus
Levy, S. B. ; CID 2001:33 (Suppl 3)

DAMPAK HAI / HCAI


Peningkatan Morbiditas / Mortalitas
Lama Perawatan
Biaya
Timbulnya MIkroorganisme yang Resisten
Citra Profesi / Rumah Sakit
Mediko Legal

Hospital Associated
Infection Control
Programme to Ensure the
Improvement of Health
Service Quality

INFRASTRUCTURE OF AN INFECTION CONTROL


PROGRAMME
Input
Analysis &
interpretation
Action &
enforcement

Surveillance data
Laboratory base
Ward base
ICO + ICN
Infection Control Committee
ICN
ICO

Control measures

Containment
Isolation &
Focused
treatment of epidemiological 1) Influencing
PCPs
infection
studies
2) Care of
environment
& equipment

Administration &
hospital staff
Control usage
of antibiotic &
disinfection

Staff
health &
education

3) Prophylaxis
for the healthcare workers
4) Writing of
policies

Seto Wing Hong 2004


DW

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

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
DW

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

DW

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


DW

The Benefit of HAI/HCAI


Infection Control Programme
SENIC (Wenzel 1995)
Subsequent analyses have
demonstrated that nosocomial
infection prevention and control
programs are:
Clinically effective
Cost effective
DW

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

DW

Monitoring the Achievement


of Infection Control Goals 1

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

DW

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

DW

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
DW

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

DW

HAI/HCAI INFECTION CONTROL


PROGRAM
Target for HCW
The save delivery of health care
Promote HCW awareness
- Of NI as a problem
- That NI can (in part) be prevented
Hospitals
Should do the sick no harm

ORGANIZATION OF HOSPITAL
INFECTION CONTROL
Structure & Function
INFECTION CONTROL COMMITEE
- Powerfull chairman
- Representatives of all
clinical & service

- Policies &
major decisions
- Monitors I. C. T.

departments

INFECTION CONTROL TEAM


- Infected control officer
- Infected control nurse

All day to day


duties

A RATIONAL CLASSIFICATION OF HOSPITAL


INFECTION PREVENTION STRATEGIES(1)
Target Objective Example of strategy
Endogenous To prevent or Antibiotic prophylaxis in surgery
Infection
neutralize the
Skin antisepsis before surgery
translocation of
Antiseptic-bound iv catheter
commensal flora Intestinal decontamination of neutropenic
patients
Pneumococcal immunization before
splepectomy
Exogenous To prevent cross- Hand hygiene for patient care procedures
Infection
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

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 resistance
resistant strains
Isolation precautions and treatment of
of microcarriers 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

10 Kewaspadaan standar terdiri dari


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

45

Kewaspadaan berdasarkan Transmisi


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

46

Resume

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
DW

Resume

HAI/HCAI control program is


clinically effective & costeffective
Specific objectives & outcome
measures must be developed
to determine whether they
have achieved their infection
control goals
DW

TERIMA KASIH

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