3/12/2017. Nozokomijalne infekcije. Nozokomijalna infekcija. nosus -bolest. komeion - brinuti se
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1 Nozokomijalne infekcije Kurs 3: Intenzivno lečenje, urgentna medicina i transfuzija Naziv teme: Nozokomijalne infekcije Datum: Jezik: Srpski Grad: Kopaonik Zemlja: Srbija Predavač: prof Radmilo Janković Radmilo J. Janković Medicinski fakultet, Univerzitet u Nišu Nozokomijalna infekcija Nozokomijalna infekcija nosus -bolest komeion - brinuti se 1. svaka infekcija nastala unutar 48 h od hospitalizacije, koja se ispoljava kao lokalno ili sistemsko oboljenje koje je rezultat reakcije organizma na prisustvo jednog ili više infektivnih agenasa ili njihovih toksina, a koje nije bilo manifestno klinički i/ili laboratorijski i /ili mikrobiološki, niti je pacijent bio u inkubaciji prilikom prijema u bolnicu ili neku drugu zdravstvenu ustanovu; 2. do 3 dana nakon otpuštanja iz bolnice 3. asimptomatski pacijent kome je patogeni mikroorganizam izolovan iz telesnih tečnosti ili dela tela koji normalno je sterilan(krv, cerebrospinalna tečnost) CHIKERE CB, OMONI VT, CHIKERE BO. Distribution of potential nosocomial pathogens in a hospital environment. Afr J Biotechnol 2008; 7: European Centre for Disease Prevention and Control definition 1
2 Nozokomijalne infekcije - Evropa -prevalenca nozokomijalnih infekcija 7,1% bolesnika godišnje u Evropi ima neku nozokomijalnu infekciju ( podaci Evropskog Centra za prevenciju i kontrolu bolesti) - Južna Amerika, Afrika, Azija >40% hospitalizovanih sa nozokomijalnim infekcijama - U JIL prevalenca nozokomijalnih infekcija 20,6% (European Prevalence of Infection in Intensive Care EPIC study, 1999) Rahmqvist et al.direct health care costs and length of hospital stay related to health care-acquiredinfections in adult patients based on point prevalence measurements. Am J Infect Contr.2016;44(5): World Health OrganizationPrevention of hospital-acquired infections: a practical guide World Health Organization, Geneva (2002) - Visoka stopa morbiditeta i mortaliteta! - Produženo bolničko lečenje i veliki bolnički troškovi! Više od 70% bakterija je multirezisteno! Nozokomijalne infekcije- faktori predispozicije Podela nozokomijalnih infekcija prema poreklu uzročnika, izvori infekcije Endogene: -Izazvane uzročnicima koji su deo stalne ili prolazne flore domaćina Egzogene: 1. Izazvane uzročnicima koji se prenose sa bolesnika na bolesnika( izvor infekcije: bolesnik) 2.Izazvane uzročnicima koji lako preživljavaju u bolničkoj sredini( izvorbolnička sredina: voda, vazduh, rastvori, kateteri, aparati za mehaničku ventilaciju, bolničko rublje, hrana...) 2
3 Vektori transmisije uzročnika Kontaktom: 1. Direktno- sa osobe na osobu - Najčešći i najznačajniji put transmisije uzročnika Direktni kontaktni put Vektori transmisije uzročnika Kontaktom: 2. Indirektno: kontaminirani :instrumenti, igle,posteljina, rastvori, rukavice, kateteri,hrana, voda... Kapljičnim putem: - čestice <5 μ se duže zadržavaju u vazduhu i kao nosioci mikroorganizma mogu se dispergovati vazdušnim strujama, na udaljenosti daleko većoj od samog izvora 3
4 Uzročnici nozokomijalnih infekcija - Bakterije (90%) - Virusi - Gljivice - Paraziti Bakterije-najčešći uzročnici Gram pozititivne: -Staphilococcus aureus -Streptococcus sp. - Klebsiella Gram negativne: -Acinetobacter sp. - P.aeruginosa - E.coli - Proteus Multi rezistentne bakterije: -MRSA - VRE -Vankomicin rezistentni S. aureus - Klebsiella ESBL - Pseodomonas ( od 1980.) - Acinetobacter( od 1980.) BEREKET, W., et al. Update on bacterial nosocomial infections. Eur Rev Med Pharmacol Sci, 2012, 16.8:
5 Prevalence of ESBL+ Isolates by Years (IAI and UTI) SMART (STUDY FOR MONITORING ANTMICROBIAL RESISTANCE TRENDS) STUDYDATA SERBIA 2011 (EUCAST 2012 BREAKPOINTS) Escherichia coli ESBL+ Klebsiella pneumoniae ESBL + Proteus mirabilis ESBL+ DATA EXTRACTED: ANALYSIS DATE:
6 6
7 DBD 120.7% 59.9% 7
8 Virusi: -influenza A,B -SRV - parainfluenza - HBV, HCV -adenovirusi - rota virusi, - entero virusi... Gljivice: Vancomycin resistant S. aureus and vancomycin-resistant enterococci were not detected - Candida sp. -Aspergillus sp. - Mucorales sp. - Fusarium sp. Nozokomijalne infekcije- podela From: Overview of Nosocomial Infections Caused by Gram-Negative Bacilli Clin Infect Dis. 2005;41(6): doi: / Infekcije urinarnog trakta - Infekcije hirurške rane - Pneumonije - Infekcije krvi Results of intensive care unit surveillance revealing percentages of gram-positive (Gram Pos) and gram-negative (Gram Neg) pathogens associated with pneumonia, urinary tract infection (UTI), surgical site infection (SSI), and bloodstream infection (BSI) National Nosocomial Infections Surveillance system,
9 From: Overview of Nosocomial Infections Caused by Gram-Negative Bacilli Clin Infect Dis. 2005;41(6): doi: / From: Overview of Nosocomial Infections Caused by Gram-Negative Bacilli Clin Infect Dis. 2005;41(6): doi: / Results of intensive care unit surveillance for the proportion of selected gram-negative organisms reported for pneumonia from the National Nosocomial Infections Surveillance system, The proportion of Acinetobacter species was significantly higher in 2003, compared with 1986 (P <.001, by the Cochran-Armitage χ 2 test for trend). Date of download: 3/8/2017 Nozokomijalne infekcije urinarnog trakta - >40% svih nozokomijalnih infekcija! - Najčešći uzročnici: E. coli, Klebsiella, Proteus, Pseudomonas, Enterococcus, Enterobacter, Serratia -76% infekcija udruženo sa urinarnim kateterom Tenke P, Jackel M, Nagy E. Prevention and Treatment of Catheter-Associated Infections: Myths orreality? EAU update series 2004; 2: Najčeši put prenosa mikroorganizama je ascendentni: 1. Preko lumena katetera 2. Preko mukoznog filma između katetera i uretera 9
10 Nozokomijalne pneumonije Uročnici: Acinetobacter, Klebsiella pneumoniae, Enterobacter sp, Streptococcus pneumoniae, H. Inflenzae, MRSA... Poseban značaj- VAP From: Overview of Nosocomial Infections Caused by Gram-Negative Bacilli Results of intensive care unit surveillance revealing the proportions of Acinetobacter isolates that were resistant to amikacin, imipenem, and ceftazidime National Nosocomial Infections Surveillance system, In all instances, results of Cochran-Armitage χ 2 tests for trend were significant (P <.001). 10
11 Nozokomijalne pneumonije VAP- terapija Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of Americaand the American Thoracic Society Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 Clinical Practice Guidelines by the Infectious Diseases Society of America and the American Thoracic Society Infekcije hirurške rane Infekcije hirurške rane-terapija Uzročnici Staphilococcus aureus E.Coli Streptococcus fecalis MRSA 11
12 Infekcije krvi Uzročnici: MRSA Klebsiella ESBL, S.aureus, P.aeuriginosa... Izvor infekcije: CVK, arterijske linije, Swan Ganz... Staphylococcus aureus Staphylococcus epidermidis Patofiziološka osnova Kasne infekcije vaskularnih katetera razvijaju se nakon dana od implantacije i uglavnom su rezultat kolonizacije sintetskog implantiranog materijala Staphylococcus Epidermidisom koji prouzrokujre infekciju niskog intenziteta praćenu formiranjem biofilma na površini grafta. Bakterijski biofilm je specifično zažtitno okruženje koje bakterijama pruža izuzetno povoljno mikrookruženje uključujući i zaštitu od odbrambenih mehanizama domaćina i dejstva antibiotika. 12
13 Prevencija nozokomijalnih infekcija 1. Praćenje Prevencija nozokomijalnih infekcija 2. Izolacija U proseku 5 do 15 % zdravih osoba imaju nastanjen Staphylococcus aureus u svojim nozdrvama. Ova prevalenca raste kod pacijenta sa terminalnom fazom bubrežne bolesti, infekcijama kože, i različitim vidovima imunodeficijencije. Kliconoštvo Staphylococcus aureus-a pokazalo se je kao jedan od najizraženijih faktora rizika za nastanak infekcija kod pacijenta, uvećavajući mogućnost nastanka infekcije za četiri do osam puta. Sa druge strane, preoperativna MRSA kolonizacija nozdrva kod vaskularnih pacijenta povećava mogućnost nastanka nozokomijalnih infekcija uz prosečno produženje bolničkog boravka za četiri dana 13
14 4.Sterilizacija 5.Higijena ruku- kada... Hemijska Fizička... i kako? 6. Nositi rukavice - protektivna barijera i prevencija kontaminacije ruku.- prevencija kontaminacije pacjenta tokom neinvazivnih i invazivnih procedura 14
15 7. Dezinfekcija 15
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