Transcript Isolation of patients

透析單位之感染管制
吳丁樹 醫師
感染管制委員會
內科部 感染醫學科
林口長庚紀念醫院
透析病人之免疫功能
• 淋巴球等免疫細胞功能不佳
– 尿毒的影響
– 營養不良
– 透析設備的材質問題
• 視同免疫缺損病患
透析病人的體溫調節
• 基準體溫偏低
– 50%
– 原因
• 不明
• 感染後的體溫反應
– 容易不發燒
– 原因
• 發燒反應並無異常
• 多重其他原因
– 基準體溫偏低
– 營養不良
血液透析與感染
• Vascular access for prolonged periods
• Multiple patients on dialysis concurrently
– Person-to-person transmission
• Directly
• Indirectly
–
–
–
–
Devices & equipment
Supplies
Environmental surfaces
Hands of HCW
• Loading with nosocomial pathogens
– Antimicrobial resistance
血液透析與感染
• 感染頻率高
• 感染嚴重度高
感染管制
• Safety
• 病患安全
• 工作人員安全
Infection Control Components
-Study on the Efficacy of Nosocomial Infection Control (SENIC)
• Surveillance and control activities
• Infection preventionist
• Trained hospital epidemiologist
• A system
Am. J. Epidemiol. 121, 182–205 (1985)
Comprehensive Infection Control
Program in Hemodialysis Unit
• Infection control practices
– Infection control precautions
• Bloodborne viruses
• Pathogenic bacteria
– Routine serologic testing for HBV & HCV
– Vaccination of susceptible patients against hepatitis B.
– Isolation of patients with HBsAg
• Surveillance for infections
• Infection control training and education
CDC MMWR 2001;50:1-41
Dialysis Center Guidelines
• Prevention of vascular access infections
• Environmental disinfection
• Hand hygiene
• Prevention of MDR organisms
• Vaccinations
• Pevention of bloodborne viruses
Isolation strategies
• Airborne precaution
• Droplet precaution
• Contact precaution
透析用水作業標準及發展趨
勢—國內
•2013年血液透析及腹膜透析訪視評量標準說明
「 5.1.3 細菌培養 (僅血液透析) 」
「至少每月檢測一次透析用水(RO水)細菌培養、
每季一次所有機台的透析液細菌培養並做紀
錄。」
2016/4/4
11
透析用水標準
國際發展趨勢
2009
2004
2004
2002
2001
1998
1992
1990
AAMI RD52: 200 (50)
CFU/ml, 2 (1) EU/ml
USP XXVII: 100 CFU/ml, 2 EU/ml
ISO 13959: 100 CFU/ml, 1 - (5) EU/ml
Eur Pharm 4th ed 2002:≤102 CFU/ml,<0.25 IU/ml
EDTNA Guideline: <102 CFU/ml, ≤0.25 IU/ml
ISO 13959: 100 CFU/ml, 5 EU/ml
Eur Pharm 2nd ed 1992: ≤102 CFU/ml, ≤0.25 IU/ml
Sweden LS1990: <102 CFU/ml, <0.25 IU/ml
2016/4/4
1982
ISO 13959:2009:
<100 (50) CFU/ml
<0.25 EU/ml
EDTA Best Practice Guideline:
<100 CFU/ml, <0.25 IU/ml (high flux:<
0.1 CFU/ml, <0.03 IU/ml)
2002
2002
<200 (50) CFU/ml
<2 EU/ml
2013
12
AAMI: 200 CFU/ml,
- EU/ml
Bloodborne Viruses
HEPATITIS B
流行病學
• 盛行率逐漸降低
– 輸血篩檢
– Erythropoietin使得輸血減少
– 台灣全面性的疫苗施打
臨床表現
• 多半無症狀
– 非特異性的疲勞
– 肝臟酵素輕微上升
• GOT/GPT 2-3X
– 少有黃疸
臨床表現
• 慢性B型肝炎
– 50%
– 治療
• Interferon
• Lamivudine 100 MG QD
• Adefovir 10 MG QD
預防
• Routine testing
• Vaccination
• Restricting exposure
• Hepatitis B immune globulin
Routine Testing
Patient Status
All patients
Anti-HBs ( - )
Anti-HBc ( - )
On Admission
Monthly
Semiannual
HBsAg
Anti-HBs, Anti-HBc
Anti-HCV
ALT
HBsAg
Anti-HBs (+)
Anti-HBc ( - )
Anti-HBs (+)
Anti-HBc (+)
Anti-HCV( - )
Annual
Anti-HBs
No additional HBV testing
ALT
Anti-HCV
Vaccination
• Subjects
– All patients on chronic hemodialysis
– The healthcare providers
Vaccination
• anti-HBs Testing
– 1-2 months after last dose
•<10 mIU/mL: susceptible
– Revaccinate with an additional 3 doses
– Retest anti-HBs.
•>10 mIU/mL: immune
– Retest annually.
– Booster dose if anti-HBs <10 mIU/mL
– Continue to retest annually
HBsAg-Positive Patients
• Infection control practices as for all H/D patients
• Dialysis in a separate room with separate machines,
equipment, instruments, and supplies
• Staff members should not care for HBV-susceptible
patients at the same time
– Same shift
– Patient changeover
Outbreaks of HBV Infection
•
Cross-contamination to patients via
–
–
–
–
Environmental surface, supplies ( eg. hemostats, clamps),
or equipment was not routinely disinfected after each use
Multiple dose medication vials and intravenous solution
were not used exclusively for one pt
Medications for injection were prepared in areas adjacent
to areas where blood samples were handled
Staffs simultaneously cared for both HBV-infected and
susceptible pts.
MMWR 2001;50:1-41
Other Measures
• General infection control practices
– Cleaning & disinfecting nondisposable items
– Using gloves when touch patients and equipments
– Between patients
• Changing gloves
• Cleaning & disinfection of equipment & environment
– Adherence
• Hand hygiene
• Safe injection and medication preparation
– Surveillance for HBV infection in susceptible patients
• HBsAg monthly
Bloodborne Viruses
HEPATITIS C
流行病學
• 比一般人要高
• 原因
– Blood transfusions
– Duration of dialysis
– Mode of dialysis
• Lower risk in peritoneal dialysis
– Previous organ transplantation
– Intravenous drug abuse
自然病程
• 仍不十分清楚
• 生化檢查和病理嚴重度關係不密切
• 增加肝硬化和肝癌
– 可能因此死亡率增加
Cross Contamination
• Preparation of multidose medications in the dialysis
treatment station
• Mobile medication/supply cart to deliver supplies
between patient stations
• Failure to clean and disinfect the dialysis station or
dialysis machine
• Shared use of single-dose medication vials for more
than one patient.
Infection Control Technique
• Safe injection practices
• Hand hygiene
• Between patients
– Cleaning & disinfection of equipment &
environment
• Isolation of patients: not recommended
Routine Testing
Patient Status
All patients
Anti-HBs ( - )
Anti-HBc ( - )
On Admission
Monthly
Semiannual
HBsAg
Anti-HBs, Anti-HBc
Anti-HCV
ALT
HBsAg
Anti-HBs (+)
Anti-HBc ( - )
Anti-HBs (+)
Anti-HBc (+)
Anti-HCV( - )
Annual
Anti-HBs
No additional HBV testing
ALT
Anti-HCV
感染管制措施-環境
• 透析機和管路之消毒-機器維修與消毒
–班與班透析機消毒至少有沖水，有感染之虞時
應改採化學消毒模式
–班與班之間透析機外表消毒方式，建議向廠商
要求提供適當方式，以不傷害機器面板而達消
毒目的
–若廠商確認機器有二次水洗功能且有設定完成
即可
– CC肝，BB肝，班與班之消毒方法採沖水；
因為化消班與班間來不及，CB肝；BC肝
消毒方法建議採化學消毒
2016/4/4
資料來源：台灣腎臟醫學會一零二年度血液透析及腹膜透析評量作業說明
31
感染管制措施-環境
• 透析機和管路之消毒-機器維修與消毒
–每日最後一班結束後透析機消毒方式如下：(機
器若未能自動監測者，應檢測消毒劑殘餘量)
–化學消毒模式順序︰
前水洗 → 吸藥 → 藥液浸泡 → 後水洗 → 關閉電源
–醋酸+化消模式順序︰
•前水洗 → 吸酸→ 浸泡 →中水洗 →吸漂白→浸泡→
後水洗 → 關閉電源
2016/4/4
資料來源：台灣腎臟醫學會一零二年度血液透析及腹膜透析評量作業說明
32
Bloodborne Viruses
HIV
Routine Testing
• Not recommanded
• Only for:
– Patients with risk factors of infection
血液曝露的處理程序
• Source patient
– HBsAg (+) or unknown
•Hepatitis B immune globulin
– Test for HIV
•Inform patient; consent required
•Prophylaxis
– RPR for syphilis
•PCN 3M u IM stat
– aHCV Ab
血液曝露的處理程序
• Staff
– HBsAg; HBsAb; HIV Ab; RPR; aHCV Ab
•Time of incident
•6 weeks later
•6 months later
BSI (Blood Stream Infection)
CLA-BSI
(Central Line Associated BSI)
中央靜脈導管感染
• Pathogenesis
– More common
• Pathogen migration along external surface
– Early (< 7days)
• Hub contamination with intraluminal colonization
– Late ( >10 days)
– Less common
• Hematogenous
– Seeding from another source
– Contaminated infusates
中央靜脈導管感染
• Source of Infection
– Contiguous skin flora
– Contamination
• Catheter hub or Lumen
• Infusate
– Hematogenous colonization
• From distant, unrelated sites of infection
中央靜脈導管感染
• Pathogens
–
–
–
–
–
Coagulase-negative staphylococci
S. aureus
Candida spp.
Gram-negative bacilli
Enterococci
Resistance: CLA-BSI Agents
Pathogen
Staph. coag neg – MRSE75%
Staph. aureus – MRSA
Enterococci - Vanco R
Pseudomonas aeruginosa
Fluoroquinolone
Imipenem
Ceftazidime
Piperacillin
Enterobacter 3rd Cef
E. coli 3rd Cef
ICU
Non ICU
65%
50%
12%
40%
12%
26%
20%
15%
17%
36%
36%
25%
12%
8%
12%
5%
5%
中央靜脈導管感染
• Biofilm
– Attachment to intravascular catheters
– Sanctuary from antimicrobial agents
– Extracellular polysaccharide
• esp. Staphyloccoci
– Quorum-sensing" proteins
• Pseudomonas
– Drug resistance
Extraluminal Route of Infection
• Cutaneous microflora
• Migration between
– Catheter
– Cannulated vessel
• Migration to
– First the catheter tip
– Then the bloodstream
Intraluminal Route of Infection
• Contamination
– Catheter hubs
– Ports of needleless systems
• Over longer periods of time
– Surgically implanted catheter
– Cuffed catheters
Intraluminal Route of Infection
• Extrinsic contamination
– Patient's skin
– Immediate environment
– Uncleaned hands of healthcare workers
• Intrinsic contamination
– Hematogenous colonization
– Epidemic infection
• Faulty manufacturing
• Onsite compounding
Healthcare Personnel
Hand Contamination
Hub
Contamination
Contaminated
Infusate
Contamination of
insertion site
Extraluminal
Contamination
Hematogenous
spread
組合式照護(Bundle Care)
• 同時施行所有實證醫學證實有效措施
• 集結這些措施的效果
• 讓介入成效最大化
團結力量大
CLA-BSI Bundle
◦ 確實執行手部衛生
◦ 全覆蓋防護
 最大面積的覆蓋防護
 執行者
 病患
◦ 皮膚消毒
 置放中央導管需徹底進行皮膚消毒
 消毒液採用2% chlorhexidine為佳
◦ 慎選置放中央導管的位置
 避免使用鼠蹊部為置放部位
◦ 每天檢討中央導管是否仍有需要
 不再需要時立即拔除
Clin Infect Dis 2011; 52:1087–99
血液透析單位的相關感控措施
• Universal precautions
– Staff must wear fluid-impermeable garments
– Gloves for potential exposure to blood or body
fluids
– Gloves changed and hands washed between
patients
– Protective eyewear and face shields for potential
splashing of blood
– No recapping of contaminated needles w/ prompt
disposal in appropriate container
– No eating or drinking in dialysis unit
血液透析單位的相關感控措施
• General precautions for staff and patients
– Isolation
•  HBsAg (+)
•  aHCV Ab (+)
•  HIV (+)
– Dialyzer reuse
•  HBsAg (+)
•  aHCV Ab (+)
•  HIV (+)
– Cleansing w/ with 1% bleach
• Dialysis machines
• blood/body fluid contaminated areas
Infection Control Precautions
for All Patients
• Gloves: Wear disposable gloves when caring for the patient or
touching the patient’s equipment at the dialysis station
• Handwashing: Remove gloves and wash hands between
each patient or station
• Items: taken into the dialysis station should
– Either be disposed of, dedicated for use only on a single patient
– Or cleaned and disinfected before being taken to a common clean area or
used on another patient
Infection Control Precautions
for All Patients
• Unused medications (including multiple dose vials containing
diluents) or supplies (e.g., syringes, alcohol swabs) taken to the
patient’s station should be used only for that patient and should not be
returned to a common clean area or used on other patients.
• When multiple dose medication vials are used (including vials
containing diluents), prepare individual patient doses in a clean
(centralized) area away from dialysis stations and deliver separately to
each patient. Do not carry multiple dose medication vials from station to
station.
• Do not use common medication carts to deliver medications
to patients. Do not carry medication vials, syringes, alcohol swabs, or
supplies in pockets. If trays are used to deliver medications to individual
patients, they must be cleaned between patients.
Infection Control Precautions
for All Patients
• Clean areas should be clearly designated for the preparation,
handling, and storage of medications and unused supplies and
equipment. Clean areas should be clearly separated from contaminated
areas where used supplies and equipment are handled. Do not handle
and store medications or clean supplies in the same or an adjacent area
to where used equipment or blood samples are handled.
• Use external venous and arterial pressure transducer
filters/protectors for each patient treatment to prevent blood
contamination of the dialysis machines’ pressure monitors. Change
filters/protectors between each patient treatment, and do not reuse
them. Internal transducer filters do not need to be changed routinely
between patients.
Infection Control Precautions
for All Patients
• Clean and disinfect the dialysis station (e.g., chairs, beds,
tables, machines) between patients.
• Give special attention to cleaning control
panels on the dialysis
machines and other surfaces that are frequently
touched and potentially contaminated with patients’ blood.
• Discard all fluid and clean and disinfect all surfaces and containers
associated with the prime
machines).
waste (including buckets attached to the
• For dialyzers and blood tubing that will be
reprocessed, cap dialyzer ports and clamp tubing. Place all used
dialyzers and tubing in leakproof containers for transport from station to
reprocessing or disposal area.
Infection Control
• Respiratory virus prevention in general
• Hemodialysis center
– Patient identification
• Patient education
– Self reporting
» Before arrival
– Respiratory hygiene and cough etiquette
• Segregation from other patients and staff
– Staff not allowed to work
Acknowledgement
• 黃景泰 主任
• 林鈞穗 專員
Thank You