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 10 -4 10 -5 10 -6 10 -7 10 -8

Dangerous Acceptable Risk Safe Ultra-safe

2
 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/source Examples 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 Reservoir/source Examples of pathogens
Medication-related Water/iv fluids Burkholderia cepacia
disinfectants Acinetobacter spp.
Serratia marcescens
Transfusion, Patients/blood Hepatitis B virus, hepatitis C
needlestick virus, HIV, etc.
Transplantation Patients/donor tissue Cytomegalovirus
Toxoplasma gondii
Creutzfeld-Jacob agent
Airborne Patients Mycobacterium tuberculosis
Hot water/showers Legionella spp.
Soil/dust Aspergillus spp.
Foodborne Animals/food products Salmonella spp.
Water/enteral feeding 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 MECHANICAL VENTILATIONS

URINARY INVASIVE PROCEDURES ASPIRATION
ADVANCED AGE USE OF ANTI-DEPRESANTS
SEVERE UNDERLYING DISEASE ANTIBIOTICS & ANTACIDS
UROLITIASIS
PROLONGED HOSPITAL STAY
PREGNANCY
DIABETES MALNUTRITION

URINARY TACT
COMMON ADVANCED AGE
NASOGASTRIC TUBE
INFECTION SITES AND SURGERY
IMMUNODEFICIENCY
SURGICAL-SITE
INFECTIONS
RISK LUNG
INFECTIONS
INADEQUATE ANTIBIOTICS
FACTORS
PROPHYLAXIS BLOOD
INCORRECT SURGICAL SKIN INFECTIONS
PREPARATION
SURGICAL INTERVENTION DURATION VASCULAR CATHETER
TYPE OF WOUND NEONATAL OR ADVANCED AGE
INAPPROPRIATE WOUND CARE SEVERE UNDERLYING DISEASE
POOR SURGICAL ASEPSIS NEUTROPENIA
DIABETES IMMUNODEFICIENCY
NUTRITIONAL STATE WHO Global Patient NEW INVASIVE TECHNOLOGY
IMMUNODEFICIENCY Safety Challenge, CRITICAL CARE
LACK OF TRAINING & SUPERVISION LACK OF TRAINING & SUPERVISION
2007
 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, non-
resistent 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 17-19%
Lower Resp. Tract Infection16-18%
Skin and Soft Tissue Infection 6%
Bacteraemia 8%
 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 Gram-negative organism

MRSA Klebsiella species

MRSA (HRV)  VRSA Enterobacter species
VRE Pseudomonas aeruginosa
Acinetobacter baumannii

NOTE : HRV, heterogeneous resitance to vancomycin; MRSA,

methicillin-resistant Staphylococcus aerus; VRE, vancomycin-
resistant 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
Surveillance data
Input
Laboratory base
Analysis &
Ward base
interpretation
ICO + ICN
Action &
enforcement
Infection Control Committee

Control measures ICN Administration &

ICO hospital staff

Isolation & Focused Containment Control usage Staff

1) Influencing of antibiotic & health &
treatment of epidemiological PCPs
infection studies disinfection education
2) Care of
environment
& equipment
3) Prophylaxis
for the health-
care 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 control goals

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 desired result

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 - Policies &
- Representatives of all major decisions

clinical & service - Monitors I. C. T.

departments

INFECTION CONTROL TEAM

All day to day
- Infected control officer
duties
- Infected control nurse
 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 micro- carriers 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 6.Kesehatan

2. Alat Pelindung Diri karyawan/perlindungan
(APD) petugas kesehatan
3. Peralatan perawatan 7.Penempatan pasien sesuai
pasien(non kritikal, semi sumber transmisi
kritikal dan kritikal ) 8. Hygiene respirasi/Etika
4. Pengendalian Lingkungan batuk
5. Pemrosesan peralatan 9. Praktek penyuntikan yang
pasien dan aman
penatalaksanaan linen 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 1

• 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 2

• HAI/HCAI control program is clinically

effective & cost-effective

• Specific objectives & outcome measures

must be developed to determine whether
they have achieved their infection control
goals

DW
TERIMA KASIH