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Transcript
Purpose to lectures This lecture is dedicated to particularity to epydemiology, hygenic base of the preventive maintenance, the main trends of the control and checking внутрибольничной to infections (VBI), questions to desinfections and sterilisations in medical-preventive institutions, problem VICH infections, as well as on organizing and methodical bases to activity сестринской services on preventive maintenance внутрибольничных infection. EPYDEMIOLOGY VNUTRIBOLINICHNYH INFECTION Gospitalinaya infection (внутрибольничная infection VBI) presents itself one of the the most actual problems of the public health of all countries of the world. Inflicted by her social-economic damage enormous and it is difficult yields to определе нию. Paradoxical, but, in spite of stupendous achievements in the field of medical-diagnostic technology and, in particular, technology of the stationary treatment, problem VBI remains in modern condition one of the most sharp, gaining all greater medical and social value. The Growing of the frequency VBI in modern condition induced ком плексом factor, the main from which are: 1. Creation large hospital complex with своеобраз ной ecology, which define: многочисленность кон тингента sick (mainly weakened) and медицин ского of the personnel, constantly and closely communicating with sick; the intensive миграционные processes; lock-in окружаю щей ambiences (the chambers for sick, cabinets for diagnostics and medical procedures): своеобразие микробиологической харак теристики (the circulation of the row штаммов conditionallypathogenic мик роорганизмов). 2. Shaping powerful artificial (the артифициального) of the mechanism of the issue of the incitants infection, connected with invalid's interference, medical and диагностичес кими medical procedure, use медицин ской equipments. 3. The Activation natural mechanism issues возбуди телей infectious diseases, particularly air-капельного and contact-home, in condition of the close-fitting contact sick, medical personnel in medical institutions. 4. Presence of the constant big array of the sources воз будителей infection in the manner of patient, enterring in стацио нар with нераспознанными infectious disease, persons, beside ко торых VBI accumulates on the main disease in permanent establishment. and medical personnel (the carriers, sick стертыми by forms to infections). 5. Broad, sometimes uncontrolled using antibiotic; not always it is enough thought-out strategy and tactics of the using in medical and preventive purpose antibiotic and химиопрепаратов promote the appearance to medicinal stability microorganism. 6. Shaping beside many microorganism внутригоспитальных штаммов, характеризующихся plural medicinal stability, possessing селективными advantage, high stability to disadvantage factor surrounding ambiences (the ultraviolet irradiation, высушиванию, action disinfecting preparation); ed внутрибольничные штаммы golden and эпидермального стафилококков, синегнойной of the stick, протея, клебсиелл, энтеробактера, row сероваров salmonellas and others 7. Increase the contingent of the risk patient, выхаживаемых and cured due to achievements of modern medicine. In past these person were considered doomed. 8. Increasing the share very heavy sick, beside which condition неспецифических defensive power of the organism is reduced. Increase the specific gravity elderly sick reflects change the age structure of the population, growth life expectancy. Presence in permanent establishment of the large number детей early age is bound, on the one hand, with reduction 9. The Reduction неспецифических defensive power of the organism beside populations of the globe as a whole on the strength of his(its) эволюционной неподготовленности to rapidly changing condition to lifes in connection with tempestuous research progress (contamination surrounding ambiences, ecological crisis, гиподинамия, stress, disadvantage influence on organism of the noise, vibrations, magnetic flap and other negative factor). 10. All are a more broad use for diagnostics and treatments of the complex technology, needing for person method to sterilisations. Using instrumental medical and диагнос слизистых shell and skin cover, shaping "winch" for incitants infection. 11. The Slow psychological realignment of a part клиницистов, which as before consider many VBI (pneumonia, пиелонефрит, inflammatory diseases of the skin, subdermal cellulose and others) as неинфекционную pathology and at an incorrect time realize or not at all conduct necessary preventive and противоэпидемические of the action. In extensive list of the incitants VBI enter the представи тели of the different taxonomic groups, referring to bacteria, virus, the most simplest and mushroom. VBI possible to split into: infectious diseases, caused obligate пато генными a microorganism of the person; infectious diseases, caused conditionally-pathogenic микрофлорой. The Epidemic process under festering-septic infection has a following particularities: he runs long, is infected large number sick and representatives of the medical personnel; he is realized in closed (hospital) space; exists probability of the shaping in one centre several mechanisms of the issue: аэрозольного, contacthome and others; as reservoir of the incitants to infections alongside with больны ми and carrier emerges the external ambience. 2. MAIN TREND of the CONTROL And CHECKING VNUTRIBOLINICHNOY INFECTIONS The Difficulty of the fight with госпитальной infection is defined that that her(its) level, structure and track record are conditioned действи ем and interaction many factor. This dictates необходи мость complex approach to her(its) preventive maintenance. Regardless of profile of the medical permanent establishment must be executed three важ нейших requirements: information to minimum possibility snowdrift to infections; exception внутригоспитального contamination; exception stand;bear infections for limits of the medical institution. Epide miologicheskiy control for VBI this system of the monitoring for track record of the epidemic process внутрибольничных ин фекций (the disease, носительство, летальность), фактора ми and condition, influencing upon their spreading, analysis and generalization to got information for development scientifically motivated systems of the measures of the fight and preventive maintenances. The Purposes of the epydemiological control: give the objective conclusion about epydemiological ситуа ции on VBI in medical-preventive institution and his(its) subdivisions and on this base to develop scientifically обосно ванные recommendations on checking VBI; in good time install the trends of the epidemic process, change этиологии VBI, connection factor risk for operative contributing correction in established system of the measures of the fight and preventive maintenances; promote the optimization preventive and противо эпидемических action. Discovery sick VBI promote the following методи ческие acceptance: participation (seasonly) in pass-by of the physicianклинициста; interview with physician and nurses; regular observation for warm-up graph; familiarization with given antibiotic about using for вы явления patient, getting course антибиотикотерапии (information from drugstore, from branch, applications for antibiotics, reception their); предоперационное shaving. The Component part of control is a spying for sanitary-hygenic and противоэпидемическим cut in LPU. In USA, the country of the Europe and Asia work on preventive maintenance VBI name infectious checking. Checking for VBI осуще ствляют the different specialists, including physicians of the medical profile, эпидемиологи, pharmacists while in many country infectious checking is entrusted exactly on высоко квалифицированный сестринский personnel. The Component part of control is a spying for sanitary-hygenic and противоэпидемическим cut in LPU. In USA, the country of the Europe and Asia work on preventive maintenance VBI name infectious checking. Checking for VBI осуще ствляют the different specialists, including physicians of the medical profile, эпидемиологи, pharmacists while in many country infectious checking is entrusted exactly on высоко квалифицированный сестринский personnel. The General approaches of the preventive maintenance VBI beside persons with иммунодефицитами discovery possible factor risk of the development VBI before begin main treatment; absolute observance of the general measures of the preventive maintenance; the reinforcement of defensive power of the organism of the master, for what are conducted following measures: вакцинация patient with observance corresponding to schemes of the inoculations and evidences: vaccines against Rzeiyotopaz aegi to5a are shown Ozhegovym sick; вакцинация against hepetitis In sick, residing on treatment in branch гемодиализа; passive immunization with use иммуноглобулина at contact with sick hepetitis А or measles; purpose corresponding to diets; use эубиотиков, бактериофагов; антигеннеспецифическая иммунопрофилактика (иммуномодуляторы). 3. HYGENIC BASE of the PREVENTIVE MAINTENANCE VNUTRIBOLINICHNYH INFECTION The Preventive maintenance внутрибольничных infection (VBI) in лечеб но-preventive institution (LPU) depends on many factor, the most significant of them is observance ги гиенических requirements, which are presented both to проведе нию different manipulate, and to LPU as a whole. The Questions of the origin and spreading VBI indissoluble are connected with hygenic problem. So successfully осуществ лять preventive maintenance VBI possible only by decisions both эпи демиологических, and hygenic problems, costing before medical-preventive institution. Sanitary-epydemiological control for VBI be conditionally divided: on эпиде миологический and hygenic blocks, mutually complementing each other (refer to scheme). PREVENTIVE INSTITUTIONS Protivoepidemicheskie actions in medical-профилак тических institutions (LPU), directed on preventive maintenance внутрибольничной to infections, provide the desinfection an object surrounding ambiences, counting for распро странения infectious diseases, and sterilisation изде лий medical purpose. Under desinfection understand destruction pathogenic and ус ловно-pathogenic microorganism on surface in помеще ниях (the floor, wall, handles of the doors, breakers, windowsill and etc), on hard furniture, surface device, instrument, equipment, midair premiseses, on the dishes, linen, product of the medical purpose and subject of the care for sick, sanitary-technical equipment, in separations sick, био логических liquid and etc. The Sterilisation provides destruction all type microorganism, including their dispute, on product and in product of the medical purpose. The Hydrogen peroxide (PV) and preparations on her(its) base have a row attractive quality absence of the scent, ecological purity, possibility of the using for desinfection not only, but also for предстерилизационной peelings and sterilisations изде лий medical purpose. However ингаляционное воздей ствие PV on person is characterized 2-m class to dangers; The Disinfecting facilities on base альдегидов, представ ляющие itself ready solutions to using or fluid concoctions ("Glutaral" and "Glutaral N" Russia, "Saydeks" USA, "Steranios 20% concentrated" France and others), use for desinfection and sterilisations product медицин ского of the purpose, since they possess the high activity in respect of all type bacteria, virus, mushroom and dispute мик роорганизмов and do not change the functional characteristic обраба тываемых object. Because of ability альдегидов to fix organic contamination necessary before desinfection уда лять with surfaces product blood and other organic суб страты. More are broadly used facility, containing, кро ме альдегидов, четвертичные ammonium join (the HOUR), гуанидины, неионогенные SUNG and the other components, снижаю щие toxicity дезинфектантов and adding him washing свой ства ("Alaminol", "Bianol" Russia, "Lizoformin 3000" Germany, "Dekoneks 50ФФ" Switzerland). ISSUE, CLINIC, PREVENTIVE MAINTENANCE VICH-infection viral disease, caused one of the representatives family ретровирусов. It can проте кать and бессимптомно, and with development of the heavy complications. THE AIDS DISEASE (the syndrome gained иммунодефицита) is a terminal phase VICHinfections and is characterized выра женным by reduction иммунитета that brings about development оп портунистических infection, malignant новообразова ний, defeats CNS, кахексии. Begin epoches of the spreading VICH-infections possible от нести to 1981, when american centre on checking заболе ваемости has registered the unusual growing of the consumption препа рата for treatment pneumonia, caused пневмоцистой. Such pneumonia it is enough rare disease, usually she встре чается beside people with иммуносупрессией. Then, was installed that basically disease strikes the mans-гомосексуалис тов, drug addict, sick hemophilia. Consequently, возбуди тель infections can be in any liquid and экссуда тах, in composition which enter the plasma shelters and лимфоциты, this blood, семенная liquid, влагалищный secret, breast milk. The incitant disease was discovered In 1983 virus, назван ный virus иммунодефицита person (VICH). VICH RNA-containing virus, which particularity is presence in him ferment inverse транскриптазы, allowing on base RNA virus to synthesize DNK-copy, which then внедряет ся in gene Т-хелперов and макрофагов key hutches, from кото рых depends protection of the organism from чужеродных microorganism. The Mechanisms of this process before the end not clear, however установле но that gradual disappearance Т-хелперов and макрофагов brings about destruction whole иммунной systems and development mortal оппортунистических infection and tumors. For issue VICH-infections particularly great importance of the inflammation слизистых shell. So, was proved that on фо не different infection, sending sexual by way (сифи лиса, герпеса and etc), probability of the contamination VICH-infection sharply increases. Modern epydemiological иссле дованиями is installed that under casual prick by needle зараже ние VICH occurs in 0,5% events, but risk sharply increases under deep prick. Specifically follows to note extremely low ве роятность contamination VICHinfection under home contact. In modern scientific literature no nor one proved event инфицирования VICH in family, which members пользова лись same home subject and the dishes, as sick, helped sick under одевании, bathing, receiving the food and etc. CLINIC In Russia acts the clinical categorization VICH-инфек ции, offered by V. I. Pokrovskim (1989). In accordance with her, I stage of the disease this инкубационный period i.e. ла тентная phase, when some clinical manifestations отсутст вуют moreover no and laboratory sign инфицирования (the ан тител). Length to this stage from several months before several years. All this time virus multiplies so медлен но that does not recognize the иммунной system, find him(it) on this stage possible only by means of полимеразной chain ре акции (PCR). In some cases during 2 4 ned. after зара жения develops 3 14-days sharp, мононуклеозоподобный syndrome, being accompanied fever, malaise, rash, артралгиями and quickly appearing полилимфоаденопатией; in this case already through 1 3 knead i.e. much early, происхо дит сероконверсия, all manifestations will grow still (except полилимфо-аденопатии). Such a image disease reveals itself beside 15% VICH- инфицированных and, since clinical picture gangplank with such at mononucleosis, all sick, перенесшим this ин фекцию, regardless of age necessary through 3 knead after begin diseases to fix the examination on antibodies to VICH. r' II stage продромальная, or stage primary проявле ний. The Disease runs wave-like bright clinical signs are replaced full their disappearance. In this stage can appear the so-called AIDS DISEASE-associated complex set constant симптомов developing beside VICH инфицированных; typical of AIDS DISEASE оппортунис тические to infections and tumors are absent. In list these ти пичных for AIDS DISEASE cliniclaboratory sign enter: infections V.I.POKROVSKIY, 1989 International categorizations, 1994 I stage incubation Primary VICH-infection. The Incubation (before appearance antibody), clinical бессимптомная in 80% events. Mononukleozopodobnyy syndrome in 15% sluchaev. II stage primary manifestations Phase А quiping infection (мононуклеозоподобный syndrome) phase B бессимптомная (latent) Phase V генерализованная лимфаденопатия Chronic VICH-infection III stage secondary diseases Subdivision on phase on the grounds of clinical симптомокомплекса phase A phase B phaseV VICH-infection on stage of the unrolled AIDS DISEASE. Antibodies cease be worked out IV stage terminal LABORATORY DIAGNOSTICS Finding beside patient one of enumerated вы ше clinical manifestations or instructions on contact with VICH инфицированным allow заподозрить VICHinfection. Exact her(its) diagnostics possible at determination in shelters most virus or his(its) antigen. But these methods in consequence of сво ей дороговизны have not got while spreading though their ис пользование and could help discovery VICH инфицированных already in latent phase of the disease. The Determination antibody to VICH is sensitive and не дорогим method that promotes his(its) broad using. Two tests are Used on antibodies to VICH. One of them твердофазный иммуноферментный analysis IFA (EYZA-test), dousing high sensitivity and specificity, од нако possible and ложноположительные results, in connection with than at the reception positive result analysis необ ходимо their additional acknowledgement by means of специфи ческого of the method Vestern-блот. Vestern-блот иммуноэлектрофоретическая reaction, allowing reveal the antibodies, working out in organism to squirrel VICH only. Under по лучении positive result in IFA these tests shelters are checked back by method вестерн-блот i.e. they are confirmed, and only after this patient consider инфицированным VICH. Use EYZA-test for obligatory examination донорской shelters has sharply reduced the risk of the contamination under перелива нии shelters, but not has quite excluded him(it) so, in accordance with recommendation carry, blood transfusion and her(its) дериватов must be produced on life evidences only. TREATMENT While drastic remedies of the fight with VICH no. The Majority противовирусных preparation, using in different combination, only reduces the amount of the viral particles in ор ганизме sick and slows the development a disease. The Special значе ние has a well-timed discovery оппортунистических ин фекций and tumors that possible only in specialized centre. PREVENTIVE MAINTENANCE In Republic Uzbekistan legal base of the fight with VICH- infection is a law About warning распростране ния in Republic Uzbekistan diseases, caused виру сом иммунодефицита person (VICH-infection) , establishing confidentiality in work with VICH инфицированными by persons and sick AIDS DISEASE. Without fall под лежат the examination on antibodies to VICH donors shelters, semens and organ, pregnant, patients with diseases, передающи мися the sexual by way. All are a foreign people, arriving in Uzbekistan more then on 3 knead, are obliged to present the certificates about checking for VICH at registration of the exit visa. Protivoepidemicheskiy mode in medical учреждени ях is provided integer beside order, directed on provision of safety medical manipulate, обез вреживание biological liquids, organ and fabric. Lich naya preventive maintenance медперсонала is concluded in using disposable toolbox, keeping used ма териала in special container with толстыми wall. In no event it is impossible put on the cap on disposable needles по сле their use. The Careful desinfection in accordance with instruction subjects to the toolbox an многоразового дейст вия (the surgical instruments, эндоскопы and etc), necessary also use the systems of the safe fence shelters. ORGANIZING And METHODICAL BASE to ACTIVITY SESTRINSKOY SERVICES ON PREVENTIVE MAINTENANCE VNUTRIBOLINICHNYH INFECTION The Particularities of the development of the epidemic process in condition of the permanent establishment and value of the problem VBI for public health have brought about making the new branch of medicine госпитальной to epydemiology. Foreign and domestic experience on fight with VBI witnesses: for making efficient профилак тических programs necessary to use scientifically обоснован ные methods and use the knowledges and facility of all services and под разделений LPU.