masalah transmisi penyakit infeksi di rs

Dewi MurniatiRS Penyakit Infeksi Prof DR Sulianti Saroso

Jakarta27 April 2013

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Infeksi di RS Infeksi Nosokomial: Infeksi yg terjadi di sarana pelayanan

kesehatan setelah >48 jam hari rawat

HAIs (Health Care Associated Infections) menggantikan istilah infeksi nosokomial(CDC dan HICPAC Juni tahun 2007)

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Dampak HAIs Hari rawat memanjang pemanfaat tempat tidur

berkurang Tindakan pengobatan, perawatan, diagnostik

meningkat Menguras sumber daya dan sumber dana Meningkatkan angka kematian Dampak hukum tuntutan pengadilan,

kerugian material dan immaterial Citra buruk untuk RS pelanggan menurun

Healthcare Associated Infections ( HAIs )

5 -10% pasien dirawat di RS

32 % dapat dicegah

Sekitar 5-10% dipengaruhi lingkungan

90-95% dipengaruhi perilaku

HAIs

TRANSMISI

RESERVOIR

ABresistenMIKROOR

GANISME

MANUSIA

PENGENDALIAN

PROSEDUR TERAPI

Komensal/ patogen

Komunitas/

RS

Sumber HAIs

ENDOGEN: kulit, hidung, mulut, salurancerna, alat kelamin

EKSOGEN: pasien, petugas kesehatan, pengunjung, alat-alat medis, alatperawatan pasien dan lingkunganperawatan

RESERVOIR MIKROORGANISME

MANUSIA HEWAN AIR ALAT KESEHATAN /BENDA LINGKUNGAN

3 CARA TRANSMISI MIKROORGANISME

KONTAK DROPLET >5µ AIRBORNE <5µ

TAK LANGSUNG

ALKES/LINGKUNGAN

TANGAN

DITELAN

SUNTIK

HUBUNGANSEX

TRANSPLASENTA

SERANGGA/HEWAN

LANGSUNG

TRANSIEN RESIDEN

Transmisi Jumlah droplet yg Droplet mengandung

mikrobaberbicara 10 batuk 100bersin keras 10 000

Droplet besar-cepat jatuh!Droplet kecil - melayang disekitar..pelahan berkurang….”crystallize” membentuk suatu bahaninfeksius dg nucleus didalamnya

1.0 micron droplet nuclei akan jatuh setelahjarak 3 m dalam 24 jam!

Manusia

Pasien• Faktor risiko• Diagnosis dini• Kuman

penyebab• Terapi adekuat• Aturan• Informasi

Petugas• Pengetahuan• Ketrampilan• Kepatuhan• Status

kesehatan• vaksinasi

Pengunjung/ keluarga• Status

kesehatan• Aturan• Informasi• Pengawasan

Luka tusuk jarum

300 luka tusuk/100 TT/tahun 21.5% selama tindakan78.5% setelah tindakan

RecappingMelepas jarum / scalpel

Yunihastuti, et al. Health Care Workers’ Behaviour during HIV Occupational Exposure Reported to Pokdisus AIDS Jakarta 2004-2006

PROSEDUR TERAPI Suntik Pemasangan infus

perifer atau sentral Penghisapan lendir Pemasangan NGT Inhalasi Intubasi, ETT Ventilator Kateter urin Kateterisasi jantung

Hemodialisa Penanganan luka Pemotongan tali

pusat Penanganan luka

bakar Trakheostomi Bronkhoskopi Pembedahan

Mengatasinya

KEBIJAKAN PROGRAM

UNIT KERJAORGANISASI

Program Pencegahan danPengendalian Infeksi (PPI)

Pencegahan dan Pengendalian Infeksi RS (PPIRS) :○ Pencegahan HAIs○ Surveilans HAIs○ Penanggulangan KLB○ Pengembangan kebijakan dan prosedur kerja

PPI○ Pendidikan dan Pelatihan

Isolation precautionsKewaspadaan Isolasi

Standard Precautions / Kewaspadaan Standar : (UP +BSI)

Transmission-based precautions / Kewaspadaanberdasarkan transmisi : kontak / droplet / airborne

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Kewaspadaan standar1. Kebersihan tangan2. Sarung tangan3. Masker,goggle, face shield4. Gaun5. Peralatan perawatan pasien6. Pengendalian lingkungan7. Penatalaksanaan Linen8. Perlindungan & Kesehatan karyawan..pengelolaan limbah tajam9. Penempatan pasien10. Hygiene respirasi / Etika batuk11. Praktek menyuntik aman12. Praktek pencegahan infeksi unt prosedur lumbal pungsi

1.Kebersihan tangan

Handwashing …an action of the past(except when hands are visibly soiled)

Alcohol-based hand rub is standard of care

Kebersihan tangan mutlak dijalankan di area POINT of Care

Presenter

Presentation Notes

Point of care - refers to the place where three elements occur together: the patient, the health-care worker, and care or treatment involving patient contact. The concept refers to a hand hygiene product (e.g. alcohol-based handrub) which should be easily accessible to health-care workers by being as close as possible, e.g. within an arm’s reach (as resources permit) to where patient contact is taking place. Point of care products should be accessible without leaving the zone of care/treatment. This enables health-care workers to quickly and easily fulfill the 5 Moments for hand hygiene. The product must be capable of being used at the required moment, without leaving the zone of activity.

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2. Sarung tangan Bersih,tidak steril

darah,cairan tubuh, sekresi, ekskresi, benda terkontaminasi

Steril mukosa membran,kulit tidak utuh

Pilih ukuran sesuai dg tangan

Pasang sp menutup pergelangan gaun

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3. Masker, goggle, face shield,eye visor,face visor

Melindungi mukosa membran mata, hidung,mulut dari

kemungkinan percikan / semprotan darah/cairan tubuh selama prosedur tindakan/perawatan

pasien

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4. Gaun/apronBersih,non sterilSteril

Tergantung risiko jumlah cairan (percikan/semburan ) ygakan dihadapi dan area jaringan yang akan dilakukantindakan ( kulit utuh atau operatif )

Penutup kakilindungi dr tumpahan /percikan bahan infeksius

5.Peralatan perawatan pasien

Kriteria SpauldingNon kritikalSemikritikalKritikal

Dekontaminasiprecleaning-cleaning dengan APD memadaidisinfeksiDTT/Sterilisasi

Presenter

Presentation Notes

After use, instruments and other items should be decontaminated by soaking them in a 0.5% bleach solution for 10 minutes. Decontamination will help protect the person who is cleaning the instruments. Then, physically wash the items until they are visibly clean. Finally, either sterilize or high-level disinfect the instruments. For a step-by-step description of this process, see the document “Instrument Processing” on the Resources page.

Dekontaminasi

Proses fisika / kimia yang digunakan untukmenurunkan/menghilangkan mikroorganisme pada bendamati sehingga aman untuk dipakai kembali3 TAHAP :1. Pencucian & Pembersihan ( Cleaning )2. Disinfeksi

tidak semua mikroorganisme mati (endospora)

3. Sterilisasipembunuhan semua mikroorganisme termasuk endospora

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6. Pengendalian lingkungan

Disinfektan untuk pembersihan harus standar1. Pembersihan permukaan horizontal ruang rawat pasien: lantai tanpa karpet,

permukaan datar lain, meja pasien harus dibersihkan secara teratur dan bila tampak kotor/kena kotoran /cairan tubuh,termasuk keyboard komputer

2. Pembersihan dinding,tirai,jendela bila tampak kotor/kena kotoran

3. Fogging dengan disinfektan seharusnya tidak dikerjakan

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7. Penanganan LinenPenanganan & transport• Cegah terpaparnya mukosa membran dan kontaminasi mikroba

terhadap pasien lain serta lingkunganpakaiAPD

• Penyimpananjaga kebersihan

• Transportasi dengan troley bersih dan kotor terpisah (warna berbeda ? tulisan identifikasi), tertutup

Presenter

Presentation Notes

Other items you need to process are linens, including scrubs from surgery or sheets and towels from patient care. You want to handle them in a manner that prevents skin and mucous membrane exposure. When handling soiled linens, wear gloves, hold linens away from your body, and do not shake them. Wash linens in hot, soapy water and dry them. The procedures for handling linens are the same both in the hospital and at home.

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Kuning:sampah InfeksiusHitam:non infeksius/ domestikMerah:RadioaktifUngu :CytotoksikCoklat: beracun

Tahan bocor dan tusukanDibuang setelah terisi 2/3 bagian

Wadah

Penanganan limbah

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Penanganan benda tajamJangan recapping jarum bekas pakai (kategori IB), Dilarang mematahkan jarum, melepaskan, membengkokkan jarum bekas pakai.

Gunakan cara yang aman bila memberikan benda tajam

Presenter

Presentation Notes

Standard precautions recommend that when handling needles and sharps, health care workers should: Discuss or agree on a plan for handling sharps before surgery begins; Use a safe or neutral zone for passing sharps; Know that even saying “pass” or “sharps” when passing sharps during surgery can prevent injuries. This is communicating effectively as a team.

8.Kesehatan petugas Vaksinasi MCU teratur terutama petugas yg menangani

kasus dengan penularan melalui airborne Penanganan paska pajanan yang memadai (ada

alur pajanan, sebelum 4 jam sudah ditentukan penata laksanaan) petugas yang dihubungi? Pem Lab,laporan ke?

Konseling petugas yang sakit ,berapa lama diliburkan? Batasi kontak langsung dengan pasien

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9.Penempatan pasien

Pasien infeksius di ruang terpisah,beri jarak>1 m

Kohorting bila tidak memungkinkan bila ke2nya tidak memungkinkan

konsultasi dg petugas PPIRSkewaspadaan sesuai cara transmisipenyebab infeksi

10.Higiene sal nafas/Etika batuk

Komponen baru (juni 2007)Target: pasien,keluarga ,teman pasien dg infeksi sal nafas yg dapat

ditransmisikan1. edukasi pasien,keluarga,pengunjung2. beri gambar dg bahasa mudah difahami3. menutup mulut/hidung dg tisu saat batuk,pakai masker4. Jika tidak memiliki tissue, tutuplah dengan lengan kemeja

bagian atas, bukan dengan tangan5. cuci tangan setelah kontak dg sekresi sal nafas6. beri jarak >3 feet bagi pasien infeksi sal nafas di Ruang tunggu bila

perlu pakaikan masker

11.Praktek menyuntik yang aman

Cegah KLB akibat Pemakaian ulang jarum steril

untuk peralatan suntik IV beberapa pasien

jarum pakai ulang obat/cairanmultidose

12.Pencegahan infeksi prosedur LP

Masker harus dipakai klinisi saat melakukan lumbal pungsi,anaestesi spinal /epidural/pasang kateter vena sentral

Cegah droplet flora orofaring,dapat menimbulkan meningitis bakterial

Kewaspadaan Standar

Diberlakukan terhadap Setiap pasien,terinfeksi /kolonisasiSetiap waktu Di Semua fasilitas pelayanan kesehatan

Disusun untuk cegah kontaminasi silang sebelum diagnosis diketahui

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Kewaspadaan berdasar transmisi

3 kewaspadaan - kewaspadaan kontak- kewaspadaan droplet- kewaspadaan airborne

Dapat terjadi kombinasi transmisi Pemilihan APD :

selalu ukur risiko sebelum melakukan tindakan/pelayanan


Kapan harus diterapkan?

• saat pasien pertama datang /pasien barumasuk atau hadirnya infeksi baru !

• Diputuskan dengan dasar kriteria klinis danepidemiologis sebelum hasil pemeriksaanlaboratorium dapat mengkonfirmasi diagnosis

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Diterapkan pada pasien dg gejala/dicurigai terinfeksi ataukolonisasi kuman patogensebagai tambahan Kewaspadaan Standard

Tujuan : memutus rantai penularan dengan mewaspadai cara transmisi patogen penyebab dari infeksi yang ditemui

Kunci kewaspadaan berbasis transmisi

Tambahan Kewaspadaan Standard Tergantung tampilan gejala klinis dan epidemiologis

Kontak : sarung tangan & gaunDroplet : pelindung mata & masker wajahAirborne : respirator N95,pengaturan ventilasi udara

Cuci tangan sebelum dan setelah merawat pasien

Resistant StrainsRare

Resistant Strains Dominant

Antimicrobial Exposure

Resistensi ABSeleksi

Presenter

Presentation Notes

Once resistant strains of bacteria are present in a population, exposure to antimicrobial drugs favors their survival. Reducing antimicrobial selection pressure is one key to preventing antimicrobial resistance and preserving the utility of available drugs for as long as possible.

New Resistant Bacteria

Resistensi AntibiotikaSusceptible Bacteria

Resistant Bacteria

Resistance Gene Transfer

Presenter

Presentation Notes

Bacteria have evolved numerous mechanisms to evade antimicrobial drugs. Chromosomal mutations are an important source of resistance to some antimicrobials. Acquisition of resistance genes or gene clusters, via conjugation, transposition, or transformation, accounts for most antimicrobial resistance among bacterial pathogens. These mechanisms also enhance the possibility of multi-drug resistance.

Inappropriate Antimicrobial Therapy: Impact on Mortality

Source: Kollef M,et al: Chest 1999;115:462-74

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Inappropriate AppropriateTherapy Therapy

42.0% mortality

17.7% mortality Relative Risk = 2.37(95% C.I. 1.83-3.08; p < .001)

# Deaths

# Survivors

Presenter

Presentation Notes

This study demonstrates the strong association of inappropriate therapy and mortality. 42% of those who received inappropriate antimicrobial therapy died, compared to 17.7% of those who received appropriate therapy. In other words, the relative risk of mortality among those who received inappropriate therapy was 2.37. The difference in mortality rate was statistically significant even after adjustment for potential confounding by other factors.

S. aureus

Penicillin

[1950s]Penicillin-resistant

S. aureus

Evolusi resistensi pada S. aureus

Link to: CDC Facts about VISA Link to: CDC Facts about VRE

Methicillin

[1970s]Methicillin-resistant

S. aureus (MRSA)

Vancomycin-resistantenterococci (VRE)

Vancomycin

[1990s]

[1997]

Vancomycinintermediate-

resistantS. aureus(VISA)

[ 2002 ]Vancomycin-

resistantS. aureus

Link to: MMWR on VRSA

Presenter

Presentation Notes

Introduction of every new class of antimicrobial drug is followed by emergence of resistance. By the 1950s, penicillin-resistant S. aureus were a major threat in hospitals and nurseries. By the 1970s, methicillin-resistant S. aureus had emerged and spread, a phenomenon that encouraged widespread use of vancomycin. In the 1990s, vancomycin-resistant enterococci emerged and rapidly spread; most of these organisms are resistant to other traditional first-line antimicrobial drugs. At the end of the century, the first S. aureus strains with reduced susceptibility to vancomycin were documented, prompting concerns that S. aureus fully resistant to vancomycin may be on the horizon. In June 2002 the first case of vancomycin-resistant S. aureus was detected.

http://www.cdc.gov/ncidod/hip/vanco/vanco.htm�

http://www.cdc.gov/ncidod/hip/Aresist/vre.htm�

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5126a1.htm�

Source: National Nosocomial Infections Surveillance (NNIS) System

MRSA among ICU patients, 1995-2004

VRE among Intensive Care Unit Patients,1995-2004

010203040506070

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Presenter

Presentation Notes

The proportion of hospital-onset infections that are due to a resistant organism has increased at an alarming rate. The next four slides show trends in antimicrobial resistance among pathogens causing infections in ICU patients. These trends are based on data from the CDC’s National Nosocomial Infections Surveillance (NNIS) system. Shown on this slide are trends in the proportion of Staphylococcus aureus infections caused by methicillin-resistant strains. From 1995 through 2004, the percent of S. aureus infections caused by methicillin-resistant strains increased from approximately 40% to 60%.

3rd Generation Cephalosporin-Resistant Klebsiella pneumoniaeAmong ICU Patients, 1995-2004

Fluoroquinolone-Resistant Pseudomonas aeruginosaAmong ICU Patients, 1995-2004

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Resistensi Trimethoprim/sulfamethoxazole(TMP/SMX)

San Francisco General HospitalMartin JN, et al: J Infect Dis 1999;180:1809-18

* 30,886 patient-isolatesStaphylococcus aureusEscherichia coliEnterobacter spp.Klebsiella pneumoniaeMorganella spp.Proteus spp.Serratia spp.Citrobacter spp.

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Non-HIV units (n = 28,966 patient-isolates)HIV units (n = 1,920 patient-isolates) Prevalence of TMP/SMX use among AIDS patients

Presenter

Presentation Notes

In this example, the proportion of more than 30,000 bacterial patient-isolates evaluated at San Francisco General Hospital that were resistant to trimethoprim/sulfamethoxazole (TMP/SMX) steadily increased over an 8 year period. When the antibiogram was stratified by HIV versus non-HIV patient unit, major differences in the proportion of resistance were noted. This observation was attributed to the increasing use of TMP/SMX for prevention of opportunistic infections among HIV-infected patients during this same time interval.

Strategi pencegahan resistensi AB

Pencegahaninfeksi

Diagnosis dan terapi

infeksi

PenggunaanAB secara

bijakPencegahan

transmisi

12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults

12 Break the chain11 Isolate the pathogen

10 Stop treatment when cured9 Know when to say “no” to vanco

8 Treat infection, not colonization7 Treat infection, not contamination

6 Use local data5 Practice antimicrobial control

4 Access the experts3 Target the pathogen

2 Get the catheters out1 Vaccinate

Prevent Transmission

Use Antimicrobials Wisely

Diagnose & Treat Effectively

Prevent Infections

Presenter

Presentation Notes

The “12 Steps to Prevent Antimicrobial Resistance: Hospitalized Adults” intervention program is the first “12 Steps” to be launched because hospital patients are at especially high risk for serious antimicrobial-resistant infections. Each year nearly 2 million patients in the United States get an infection in a hospital. Of those patients, about 90,000 die as a result of their infection. More than 70% of the bacteria that cause hospital-acquired infections are resistant to at least one of the drugs most commonly used to treat them. Persons infected with antimicrobial-resistant organisms are more likely to have longer hospital stays and require treatment with second-or third-choice drugs that may be less effective, more toxic, and/or more expensive.

AB rasional

INFEKSI? BAKTERIAL? SEMBUH SENDIRI/ PERLU AB? PENCEGAHAN/TERAPI? EMPIRIS/ DEFINITIF?

KESIMPULAN

Mengetahui cara transmisi penyakitinfeksi dan upaya memutus rantaipenularannya merupakan carapencegahan perluasan penyakit sertaupaya eliminasinya

Peran petugas kesehatan sangatpenting dalam keberhasilanPengendalian penyakit infeksi di saranakesehatan

masalah transmisi penyakit infeksi di rs

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