IC_AnesMar30_2011F_อ.สุสันณ์

Risk for Contamination ?



Recommendations for Preventing and Monitoring CAUTI Indications for the use of indwelling urethral catheters 1. Perioperative use for selected surgical procedures 2. Urine output monitoring in critically ill patients 3. Management of acute urinary retention and  urinary obstruction 4. Assistance in pressure ulcer healing for  incontinent residents 5. As an exception, at patient request to improve   comfort Daily review of catheter necessity with prompt removal of unnecessary catheter

Recommendations for Preventing and Monitoring CAUTI Appropriate technique for catheter insertion  • Ensure that only trained, dedicated personnel insert catheters  • Consider other methods for management, including condom  catheters or in‐and‐out catheterization • Practice hand hygiene immediately before insertion of the  catheter and before and after any manipulation of the catheter  site • Insert catheters by use of aseptic technique and sterile  equipment • Use gloves, a drape, and sponges; a sterile or antiseptic  solution for cleaning the urethral meatus; and a single‐use  packet of sterile lubricant jelly for insertion • Use as small a catheter as possible that is consistent with  proper drainage, to minimize urethral trauma

Recommendations for Preventing and Monitoring CAUTIAppropriate management of indwelling catheters • Maintain unobstructed urine flow • Keep the collecting bag below the level of  the bladder at all times • Cleaning the meatal area with antiseptic  solutions is unnecessary • Maintain a sterile, continuously closed  drainage system 

Educate Patients & Their Families about CAUTI What is CAUTI? What is a urinary catheter? How do I get a CA‐UTI? What are the symptoms of a UTI? Can UTI be treated? What are some of the things that  hospitals are doing to prevent CAUTI ? What can I do to help prevent CAUTI if I  have a catheter? What do I need to do when I go home  from the hospital?

Incidence of Device-related HAIs Because of All Pathogens in 3 Adult ICUs, 2003-2006 Am J Infect Control 2008;36:461‐3

Device-related MRSA Infections in 3 Adult ICUs, 2003-2006 Total Am J Infect Control 2008;36:461‐3



Recommendations for Preventing and Monitoring SSII. Antimicrobial Prophylaxis• Select antimicrobial prophylaxis in accordance with  evidence‐based guidelines • Administer prophylaxis within 1 hour before incision  (2 hours for vancomycin and fluoroquinolones); redose if  prolonged surgery• Discontinue prophylaxis within 24 hours after surgery for  most procedures; discontinue within 48 hours for cardiac  procedures

Recommendations for Preventing and Monitoring SSIII. Hair Removal • Do not remove hair at the operative site unless the  presence of hair will interfere with the operation • If hair removal is necessary, remove it by clipping



Recommendations for Preventing and Monitoring SSIIII. Blood Glucose Level • Maintain the postoperative blood glucose  level at less than 200 mg/dL (D1, D2) for  patients undergoing cardiac surgery

Recommendations for Preventing and Monitoring SSIIV. Monitoring and Feedback• Routinely provide feedback on SSI rates and process  measures to individual surgeons and hospital leadership ‐ For each type of procedure performed, provide risk‐adjusted rates of SSI ‐ Anonymously benchmark procedure‐specific risk‐adjusted rates of SSI  among peer surgeons• Confidentially provide data to individual surgeons, the surgical division, and/or department chiefs

SSIRate : Mastectomy September 2007- August 200820 81 NNIS Rate=2.20 NNIS Rate= 3.42 509 3 3.70 3015 Risk Risk index index10 9 category 1 NNIS Rate=1.74 category 2,3 5 1.77 0 Risk index category 0N(Total Case) No. of Infection SSI Rate(per 100 operations)Risk Index for SSI surveillance • Wound class III or IV (1)• ASA score 3,4,5 (1)• Duration of surgery >75th (1) 

Recommendations for Preventing and Monitoring SSIV. Other Issues • Reducing modifiable patient risk factors • Optimal cleaning and disinfection of equipment and the  environment • Optimal preparation and disinfection of the operative  site and the hands of the surgical team members  • OR characteristics e.g. ventilation and traffic control • Adherence to standard principles of OR asepsis • Surgeon skill/technique

Patient Related Risk Factors (Modifiable) for SSIGlucose Control (DM) Reduce HbA1c levels to <7% before surgeryObesity Increase dosing of prophylacticSmoking Cessation antimicrobial agent for morbidly obese patients Encourage smoking cessation within 30 days before procedureImmunosuppressive Avoid immunosuppressiveDrugs drugs in perioperative period

Change Agent SkillsKnowledge Change Facilitation Tools Politics of Result changeprocesses skills Radical improvement Minor improvement with little bottom-line impact Wrong solution for situation Mediocre ideas with little consensus or passion Lots of talk, little progress Good ideas that never get implemented Ken Miller

Steps in Guideline Implementation1. Formulate guidelines according to hospital needs 2. Categorize recommendations 3. Obtain necessary resources 4. Conduct research for staff resistance practices 5. Measure baseline rate for demonstrating change 6. Formulate and execute education program 7. Evaluate and monitor progress with staff  feedback  Seto WH, Hong Kong

Important Keys to Implementation1. Choose your projects carefully Strength of the evidence Relative advantage Compatibility with culture, work process, and technical competency Complexity2. Do your homework Create a team with real power Develop a concrete plan Communicate your plan3. Start small, then build momentum4. Address local custom and culture Edward Kim, MD



การใชย าปฏิชีวนะการชว ยชีวิตผูปวย VS การทําลายสงิ่ แวดลอมทางชีวภาพ

Robert P. Rapp, Pharm.D., FCCP

รายงานผลความไวตอ ยาตานจุลชพี ประจําป 2550• 82% ของ Acinetobacter baumanii ดอื้ ตอ ยา Imipenem• 47% ของ Staphylococcus aureus เปน MRSA• 47% ของ E. coli ดื้อตอ ยา Ceftriaxone• 47% ของ Klebsiella pneumoniae ด้ือตอ ยา Ceftriaxone• 32% ของ Pseudomonas aeruginosa ดอ้ื ตอ ยา Ceftazidime

Bacterial Resistance Rate in Thailand            2000‐2009 (NARST)70 IMP‐R Acinetobacter60 SUL‐R Acinetobacter50 IMP‐R P. aeruginosa40 CTR‐R E. coli  30 CTZ‐R E. coli2010 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009





Proportion of MRSA isolates in 2009http://ecdc.europa.eu/en/activities/surveillance/EARS‐Net/database/Pages/map_reports.aspx

MRSA in the Netherlands • 0.03‐ 0.06 % asymptomatic MRSA‐nasal carriage• 1‐2% of all hospital S.aureus is MRSA• 1% of blood isolations of S.aureus is MRSALow prevalence due to• Low use of human antibiotics (Lowest in Europe)• Search‐and‐destroy policy (since end 80th): measures  for patients and staff based on risk categories http://www.infection‐prevention.eu/Nutzerdaten/File/meetings/2010_April_Berlin_MrsaInTheNetherlands.pdf

Why antimicrobial resistance cannot be  solved with single intervention alone?

Factors that influence the acquisition of a      nosocomial antibiotic‐resistant bacterial infection Clinical Infectious Diseases 2008; 46:686–8

S aureus carriage rates per body site in adults Lancet Infect Dis 2005; 5: 751–62

Search and Destroy StrategiesEarly detection:  samples should be cultured from:  • nose  • throat  • feces (rectal swab) or perineum  • sputum, if coughed up  • urine (if a urinary catheter is present)  • skin lesions and woundsEarly identification and containment of the reservoir  (patients, HCWs, environment) http://mrsaactionuk.net/pdfs/netherlands.pdf http://www.wip.nl/UK/free_content/Richtlijnen/MRSA%20hospital.pdf

Patients risk category of the presence of MRSA  Category 1: proven MRSA carrier  • MRSA carriers. Category 2 : high risk of being a carrier  • Patients who were cared for in a foreign hospital for more than 24 hours less than 2  months ago  • Foreign patients in the dialysis department  • Patients who have stayed in the same room with an unexpected MRSA carrier. Category 3 : moderately elevated risk of being a carrier  • Patients during the first year following treatment for carrying MRSA, with negative  control cultures.  • Patients cared for in a foreign hospital more than 2 months ago, who still have persistent  skin lesions and/or risk factors, such as chronic respiratory or urinary tract infections. Category 4 : no elevated risk of being a carrier  • Patients cared for in a foreign hospital more than 2 months ago, who have no persistent  skin lesions and/or risk factors, such as chronic respiratory or urinary tract infections. 

Search and Destroy StrategiesHOW:• isolation of patients proven AND at risk• screening of asymptomatic carriers• cohorting of patients and personnel• eradication of carriership• education of personnel• disinfection http://mrsaactionuk.net/pdfs/netherlands.pdf http://www.wip.nl/UK/free_content/Richtlijnen/MRSA%20hospital.pdf

Infection Control Strategies for MDR Bacteria in Hospitals1. Education & Feedback2. Antimicrobial stewardship3. Alert system & Active surveillance testing4. Hand hygiene5. Strict contact precautions (including dedicated  equipment) for infected &colonized persons 6. Decolonization therapy/ Decontamination of patients7. Decontamination of the environment or equipment8. Device‐associated bundles9. Quality of care e.g. time to appropriate ATB  administration

Contact Precautions• Single‐patient room > Cohorting• Hand hygiene• Gown and gloves• Do not share devices/instruments between patients without  disinfection or sterilization

Your 5 Moments for Hand Hygiene www.who.int/gpsc/5may/en/

Antimicrobial activity of antiseptics used in hand hygiene Pittet D, Allegranzi B, Sax H. Hand  hygiene. Bennet & Brachman’s Hospital Infection, 5th ed. 2007: 31‐44.

Which Hand Hygiene Method is Best at Killing Bacteria? 0.6‐1.1 (15s) 1.8‐2.8 (30s) 3.4‐5.8 (30s) Total bacterial counts on the hands  of medical personnel  3.9 x 104 to 4.6 x 106 CFU/cm2 Lancet Infectious Diseases 2001; April: 9–20

Six‐step hand wash

Time-course of efficacy of unmedicated soap/water and alcohol-based handrub from artificially contaminated handsBacterial contamination (mean log 10 reduction) 0 Handwashing 1 Handrubbing 2 3 4 ↓ 4.02 – 5.53 log10 CFU/cm2 5 6 1 min 2 min 3 min 4 min 0 15sec 30sec Pittet and Boyce. Lancet Infectious Diseases 2001

Advantages of Alcohol-Based Hand RubsCompared With Washing With Soap and Water Mayo Clin Proc. 2004;79:109-116

Indications for Antimicrobial Soap and  Water During Patient Care• hands are visibly soiled or contaminated with proteinaceous material• caring for patients with C. difficile, norovirus, rotavirus, or prion (with glove)• exposure to Bacillus anthracis is suspected or proven• before eating• after using the restroom• after cleaning your hands 5 to 10 times with an alcohol-based handrub - “build-up” of emollients Curr Opin Infect Dis 16:327–335

Indications for Gloving1. Before a sterile procedure: Gloves may reduce the volume of blood on the external surface of a sharp by 46% to 86%2. Standard precautions: Potential for touching blood, body fluids, secretions, excretions and items visibly soiled by body fluids3. Contact precautions: Contact with a patient and immediate surroundings Modified from MMWR 2002; vol. 51, no. RR-16.

Gloves do not provide complete protection  against hand contamination• Small defects in gloves• Contamination of the hands during glove  removal How to Remove Non‐sterile Gloves

Isolation Gowns• protect the HCW’s arms and exposed body  areas and prevent contamination of clothing  with blood, body fluids, and other potentially  infectious material

Skin flora of patients in Thailand Am J Infect Control 2003;31:80‐4

Clonal Spread of Carbapenem Resistant Acinetobacterbaumannii at BMA  Medical College and Vajira Hospital J Med Assoc Thai 2009; 92 (Suppl 7): S173‐80

Frequency of Environmental Contamination of Surfaces in the Rooms of Patients with MRSA Bed Linen Patient Gown Overbed Table BP Cuff Side Rails Bath Door Handle IV Pump ButtonRoom Door Handle 0 10 20 30 40 50 60Percent of Surfaces Contaminated www.handhygiene.org