Pola Transmisi & Faktor Risiko Infeksi Nosokomial

Masalah infeksi nosokomial

Mortalitas: 88000/tahun 1 tiap 6 menit Ekonomi: US$4,5 Milyar

Bola salju Morbiditas: 9,8/1000 pasien RS 2 juta pasien RS/thn 50% komplikasi

PENDAHULUAN Pelayanan Kesehatan

efficacious safety

quality

FAKTOR DAN AKTOR

Prosedur medik

Alat medik

Kondisi pasien

Hospital environment

Inappropriate Antimicrobial Therapy: Impact on Mortality

Number of patients 600 500 400 300 200 100 0

17.7% mortality

(95% C.I. 1.83-3.08; p < .001)

Relative Risk = 2.37

42.0% mortality

# Survivors # Deaths

Inappropriate Therapy

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

Being alert
Infeksi nosokomial: 2 juta pasien/tahun Sekitar 10% pasien rawat inap Dampak 44,000 - 98,000 kematian (IOM) Biaya: $17-$29 milyar per tahun Rata-rata extra hospital days 4 Rata-rata additional charge > $2,000

NI prevalence rate (% )

D en m ar k
12 10 14 2 0 8 6 4

Nosocomial Infection National Prevalence Surveys in Europe

79 Ita ) ly Be (1 98 lg iu 3) C m ze (1 ch 98 S. 4) R. (1 98 Sp 8) ai n G (1 er 99 m 0) an y( 19 94 UK Sw ) itz (1 er 99 la 5) nd (1 Fr 99 an 6) ce (1 No rw 996 ay ) (1 99 7)

(1 9

Serious infections testing positive for MRSA isolates among hospitalised patients (1997 SENTRY data)
Patients (%) 50 40 30 20 10 0 Pneumonia UTI Wound Infection type Bloodstream

UTI = urinary tract infection

Jones. Chest 2001;119:397S404S

Risk factors for colonisation or infection with MRSA in hospitals

Prior antibiotic exposure Admission to an ICU Surgery Exposure to an MRSA-colonised patient
Chambers. Emerg Infect Dis 2001;7:178 182

Gram-negative organisms with resistance to ciprofloxacin (1997 SENTRY data)

Organisms (%)

50 40 30 20 10 0

All patients (USA) Lower RTI (USA and Canada)

Acinetobacter spp. P. aeruginosa Stenotrophomonas Escherichia maltophilia coli

Organism type

Jones. Chest 2001;119:397S404S

Nosocomial infection

An infection that was not found to be present prior to hospital admittance

apabila kejadiannya berkaitan dengan suatu prosedur medik, terapi, atau kejadian penyakit setelah pasien masuk ke rumahsakit.

hospital acquired infection

1. Terjadi 48-72 jam setelah pasien masuk rumahsakit dan dalam kurun waktu 10 hari setelah pasien boleh meninggalkan rumahsakit. 2. Tidak disebut sebagai infeksi nosokomial apabila terjadinya pada saat pasien masuk.

Infeksi nosocomial (INOS)

Prolong hospital stay

10% dari pasien rawat inap Lama rawat 2,5 x lebih panjang Rata-2 tambahan hari: 11 hari /kasus Biaya 2,8 kali lebih mahal Rata-2 tambahan biaya: 2917/kasus

Increase cost

Increase morbidity and mortality

5000 kematian inos per tahun (>tinggi dari Lakalantas

National Audit Office, UK (2000)

4 Jenis INOS utama

Urinary tract (44%) Lower respiratory tract (18%) Surgical wound sites (11%) Bloodstream (8%) Risiko tertinggi: ICU dan long-term care patients

Sumber-2 infeksi nosokomial

Unclean hands or gloves Alat medik (endoscope, respiratory equipment, tube feed bags) terkontaminasi bakteri (dari air atau improper sterilization procedure) Area-2 terkontaminasi: inadequately cleaned

Air sebagai Reservoir of Nosocomial Pathogens

Organisme spt Pseudomonas aeruginosa, Serratia marcescens, and Acinetobacter calcoaceticus dapat mereplikasi dalam air yang relatif murni Ditemukan pula di air minum yang telah memenuhi limit of safety (<1 coliform bacterium/100 mL)

Burn Infections

Tap water has been cited as the source for serious wound and sepsis
Kolmos HJ, Thuesen B, et al. Outbreak of infection in a burn unit due to Pseudomonas aeruginosa originating from contaminated tubing used for irrigation of patients.

Eksposur patien terhadap air di rumah sakit

Handwashing (crosscontamination) Enteral feedings Respiratory equipment Drinking Showering Bed bathing

DECUBITUS-Pressure ulcer
1.6 juta kasus per tahun di acute care Area:
bangsal Bedah dan ruang operasi intensive care units rehabilitation centers long term and home care

Prevalensi Decubitus
Reported rates Two large studies

3% s/d 11%

9.2% (148 hospitals) 1 7% (116 hospitals) 2

1. Meehan M. Multisite pressure ulcer prevalence survey. Decubitus 1990;3:4-14. 2. Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000;27:209-15.

Faktor-faktor pencetus lain

Transplantasi organ Transfusi darah Extensive, invasive surgery Renovasi infrastruktur dan fasilitas rumah sakit

Modes of spread of infection

STAFF

OTHER PATIENTS

PATIENT

(endogenous)

EQUIPMENT

ENVIRONMENT

causative organisms
The predominant organisms: Gram negative bacilli
- Pseudomonas aeruginosa, Acinetobacter, Klebsiella

Staphylococcus aureus Coagulase-negative staphylococci Candida Enterococci

causative organisms Increasing trends towards more Gram-positive and resistant microorganisms Fungal infections are on the increase and require high index of suspicion

Common bacteria and their most likely sources and modes of spread
Bacteria
Staph. aureus including MRSA Coagulasenegative staphylococci Enterococci E.coli and Klebsiella Pseudomonas aeruginosa

Possible sources
Endogenous, other infected pts, staff or environment Pts own skin flora, possibly skin flora of staff Endogenous part of GI and genital flora Endogenous part of GI flora Environmental, esp. moist areas

Modes of spread
Hands, airborne Ass. with intravascular catheters Hands Hands Hands, contaminated equipment

Nosocomial infections in ICU

Nosocomial infections in ICU

Nosocomial infections in ICU

5 10X more likely to acquire nosocomial infections ICU is an "epidemiological jungle" because of the abundance of organisms that proliferate in these units.

BMJ 1998;317:6524

Proportion of S aureus isolates resistant to methicillin recovered from clinical specimens of inpatients in selected European countries. Data for hospitals are derived from Voss et al,4 and data for intensive care units from Vincent et al5

Risk factors

Patient factors

Factors related to diagnostic/ therapeutic interventions

Environmental factors

Patient factors
Age Immune status Severity of illness Malnutrition Underlying or chronic disease Prolonged ICU stay

interventional factors
Poor compliance with handwashing, aseptic technique : understaffing, less skilled workers,
emergency situations

Invasive devices e.g tracheal tubes, intravascular and urinary catheters Parenteral feeding Indiscriminate use of antibiotics and the development of resistant organisms

Environmental factors
Space limitations causing crowding Lack of isolation for colonised or infected patients Inadequate demarcation of clean and dirty areas Unsafe handling of infectious wastes Recirculation of unfiltered air Decreased environmental hygiene

common sites
ICU
Respiratory system (31%) Urinary tract (24%) Bloodstream (16%)

Hospital
Urinary tract (44%) Respiratory system (18%) Surgical wound (11%) Bloodstream (8%)

Principles of infection control

Asepsis Food hygiene Specimen handling Sharps safety Linen Body fluid spilage GENERAL PRINCIPLES Protective clothing Hand hygiene Waste Cleaning, disinfection, sterilization