Download Pre-antibiotic era - 강동성심병원 진단검사의학과 홈페이지

병원 감염 실태 및 대책
한림대 성심병원
감염 내과
정
두 련
1
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16 세기 병원
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Puerperal fever
Urban maternity hospitals in the 18th and 19th centuries
, caring for the poor
 notoriously high mortality rates
Thomas Lightfoot, “the gates which lead (women) to death”
(London Medical Times, 1850)
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6
1846, Massachusetts General Hospital, Boston
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8
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Antimicrobial Resistance : Return to Pre-antibiotic era?
• Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
• Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
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Antimicrobial Resistance : Return to Pre-antibiotic era?
• Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
• Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
– Emergence of penicillinase secreting S. aureus, 1944
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Antimicrobial Resistance : Return to Pre-antibiotic era?
• Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
• Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
– Emergence of penicillinase secreting S. aureus, 1944
– Penicillinase-resistant semisynthetic penicillins, 1959
– Cephalosporins, Aminoglycosides, ……
12
Antimicrobial Resistance : Return to Pre-antibiotic era?
• Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
• Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
– Emergence of penicillinase secreting S. aureus, 1944
– Penicillinase-resistant semisynthetic penicillins, 1959
– Cephalosporins, Aminoglycosides
– Emergence of methicillin-resistant S. aureus (MRSA), 1961
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Epidemiology of MRSA in U.S.A.
[National Nosocomial Infections Surveillance (NNIS) system]
100
Inpatients
90
내성률 (%)
80
ICUs
70
60
35%
50
50.5%
Non-ICU
39.9%
29%
OPD
40
24.1%
30
20
10
2.4%
0
1975
1991
1996
1998 - 2001
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메티실린 내성률(%)
Epidemiology of MRSA in Korea
100
서울대학병원
90
80
세브란스병원
84%,
3차 병원
70
79%,
한림대 성심
(2001)
43%,
1-2차 병원
(1997-8)
60
50
40
30
20
10
0
1969
1976
1981
1982
1983
1990
1996
15
Epidemiology of MRSA in Korea
Community-acquired S. aureus bacteremia
Methicillin 내성률
• 11.0 %
(정경해 등. 감염(29):39, 1997)
• 18.8 %
(김의석 등. 감염 (31):325, 1999)
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Antimicrobial Resistance : Return to Pre-antibiotic era?
• Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
• Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
– Emergence of penicillinase secreting S. aureus, 1944
– Penicillinase-resistant semisynthetic penicillins, 1959
– Cephalosporins, Aminoglycosides
– Emergence of methicillin-resistant S. aureus (MRSA), 1961
– Use of vancomycin, teicoplanin
17
Antimicrobial Resistance : Return to Pre-antibiotic era?
• Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
• Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
– Emergence of penicillinase secreting S. aureus, 1944
– Penicillinase-resistant semisynthetic penicillins, 1959
– Cephalosporins, Aminoglycosides
– Emergence of methicillin-resistant S. aureus (MRSA), 1961
– Use of vancomycin, teicoplanin
– Emergence of vancomycin-resistant enterococci(VRE), 1986
and vancomycin intermediate-resistant S. aureus, 1996
18
Vancomycin-resistant enterococci
Europe
• First report in the UK and France in 1986
• Incidence remains low : generally < 2%
USA (North America)
• Major nosocomial pathogens in the U.S. hospitals
0.3% (1989) 
21.2% (1998) in general wards
0.4% (1989) 
26.3% (2000) in ICU patients
•
•
•
•
Outbreaks of infection in the ICUs of large hospitals
Intra-hospital or Inter-hospital spread of clonal strains
Patient-to-patient transmission
Established endemicity in large hospitals
19
Estimated Prevalence of VRE in Korea
(김우주. 2002년 대한감염학회 연수강좌)
30
내성률 (%)
25
20
15
?
10
5
0
1990
1992
1994
1996
1998
2000
2002
First report
20
Enterococci
• 인체의 정상적인 장내 상재균 중 하나
• E. faecalis (80-90%), E. faecium (5-15%)
• UTI, Intraabdominal infection, Bacteremia
• 균이 임상검체에서 분리될 때 임상적 의미?
• 미국에서 병원감염 원인균 중 2-3위의 빈도
• 한림대성심병원 (2001년)
중환자실 병원감염의 원인균 중 3위 (12.8%)
 이 중 35.2%가 VRE
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VRE 의 임상적 중요성
•
Limited therapeutic options
- VRE 는 대개 다른 항균제에도 내성을 보임
Intrinsic resistance to cephalosporins, aminoglycosides
Acquired resistance :
ampicillin, teicoplanin
High-level resistance to aminoglycosides
(Loss of synergic effect)
•
High mortality in immunocompromized patients
- Esp. Bacteremia, endocarditis, meningitis
•
Threat of transfer of vancomycin-resistance genes
to more virulent Staphylococcus aureus (i.e. VRSA)
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병원내 내성균 확산 – VRE
항균제 : vancomycin, 3rd cepha., aminoglycosides
aztreonam, imipenem, quinolones
Patient
hand
비의료진
VRE infected
or colonized patient
Stool, urine, wound discharge, sputum
비의료진
stool
주위 환경
Patient
hand
hand
의료진
청진기,체온계
의료진
hand
stool
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Antimicrobial Resistance : Return to Pre-antibiotic era?
Pre-antibiotic era :
– Mortality rate of S. aureus bacteremia ;
82%
Antimicrobial era (1940 - ) :
– Discovery of penicillin “Miracle drug”, 1940
– Emergence of penicillinase secreting S. aureus, 1944
– Penicillinase-resistant semisynthetic penicillins, 1959
– Emergence of methicillin-resistant S. aureus (MRSA), 1961
– Use of vancomycin, teicoplanin
– Emergence of vancomycin-resistant enterococci(VRE), 1986
and vancomycin intermediate-resistant S. aureus, 1996
– Synercid, linezolid
– Resistance to Synercid, linezolid
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Antimicrobial Resistance : Return to Pre-antibiotic era?
• Resistant Microorganisms
– MRSA, VISA
– VRE
– Penicillin-resistant Streptococcus pneumoniae
– Extended spectrum b-lactamase producing
Escherichia coli & Klebsiella pneumoniae
– Imipenem-resistant Pseudomonas aeruginosa
– All-resistant Acinetobacter baumannii
– Multidrug-resistant Mycobacterium tuberculosis
– Candida resistant to fluconazole
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Antimicrobial Resistant pathogens in ICU (NNIS, USA)
Vancomycin / enterococci
% Increase
in Resistance
26.3%
31%
Methicillin / S. aureus
55.3%
Methicillin / CNS
29%
1%
87.5%
3rd Ceph / E. coli
15%
3.4%
3rd Ceph / K. pneumoniae
5%
11.2%
Imipenem / P. aeruginosa
23%
17.7%
Quinolone / P. aeruginosa
3rd Ceph / P. aeruginosa
27.3%
53%
26.4%
24%
34.9%
3rd Ceph / Enterobacter
0
10
20
30
40
50
60
- 1%
70
80
90
% Resistance
Jan. – Dec., 2000
1995-1999 (SD)
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DEFINITIVE THERAPY
antimicrobial susceptibility test
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DEFINITIVE THERAPY
antimicrobial susceptibility test
28
환자는 불안하다
병 고치러 갔다 병 걸린다
병원은 病原인가
‘병원 감염’ 첫 집단손배 소송…슈퍼박테리아 감염 4명 병원에
서 환자 10여명이 일반 항생제가 듣지 않는 세균인 '슈퍼 박테
리아'에 집단 감염돼 이 중 2명이 숨지는 사고가 발생, 환자들이
국가와 병원을 상대로 거액의 손해배상 청구소송을 제기했다.
(2002. 5. 16)
병원 감염'으로 인한 의료분쟁 증가
2002-03-07
SBS 그것이 알고 싶다
병원감염 막을 수 없나 - 내성박테리아 MRSA
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병원감염 (Nosocomial infection)의 정의
Infection
which was not present or incubating
at the time of admission to the hospital
(48 hours after admission)
30
Nosocomial infections, USA
approx. 5 to 6 hospital-acquired infections per 100 admissions
Year Admissions
(X106)
Patient
Length
Nosocomial Nosocomial
days
of stay
infection
(X106)
(days)
(X106)
infection
( /1000
patient days)
1975
38
299
7.9
2.1
7.2
1995
36
190
5.3
1.9
9.8
(Weinstein RA. Emerging Infectious Diseases 1998)
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국내 병원감염 발생빈도
• 입원 환자 중 병원감염률 (%) :
5.8 – 15.5 %
• ICU 환자 중 병원감염률 (%) :
10.8 – 39.7%
• 수술 후 창상감염 (%) :
5.6 – 9.8 %
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항암요법, 면역억제제  면역기능저하 환자의 증가
침습적 처치 (invasive procedure)
병원감염의 증가
효율적인 감염관리 시스템의 부재
항균제 오남용 및 항균제 내성균의 증가
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병원감염 증례 (1)
• 62/F, Neurosurgery, post-op day 19, fever developed.
• Prophylactic antibiotics:
D0-D14; ampicillin-sulbactam + ceftriaxone
D15-19; cefaclor (경구)
• Wound clear, post-op
• Neutrophil count < 100 /mm3
• Septic shock, respiratory failure
 Broad-spectrum antimicrobial Tx.
 Expired 3 days later
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병원감염 증례 (2)
•
10/M, Ventilator care & anticonvulsant Tx
due to Ischemic brain injury after inhalational burn accident
•
Total parenteral nutrition via central venous catheter
•
D1-D13 : ampicillin-sulbactam + amikacin
•
D14-D34 : amoxicillin-clavulanate + cefotaxime
• Skin rash persistent, fever not resolved
• Antibiotics were discontinued
•
D37-D41 : CXR showed multiple nodular infiltration, progressive
• vancomycin + aztreonam + amikacin
• C-line removal
•
D42-D79 : Blood culture grew MRSA
• vancomycin (6 weeks in total)
• Subcutaneous abscess (grows MRSA) on chest on D45
I&D
35
Multiple septic pulmonary embolism in a
patient
with C-line associated S. aureus bacteremia
36
미국 (NNIS) 병원감염 조사
(1990-1996, National Nosocomial Infection Surveillance, NNIS)
21%
34%
기타
UTI
14%
Bloodstream
Infection
Pneumonia
Surgical Site
Infection
13%
17%
37
국내 병원감염 조사
(대한병원감염관리학회 1996)
6.4%
8.0%
Skin/
기타
Soft tissue
8.4%
30.2%
UTI
GI
Bloodstream
Infection
Pneumonia
14.5%
Surgical Site
Infection
17.1%
15.5%
38
국내 병원감염의 흔한 원인균
(대한병원감염관리학회, 1996)
Pathogens
S. aureus
All sites (UTI / PN / SSI / BSI)
17.2 %
MRSA
(14.4)
P. aeruginosa
13.8
E. coli
12.3
K. pneumoniae
7.7
Enterococcus
7.6
Candida
7.6
39
중환자실 감염의 흔한 원인균 (한림대 성심병원)
(2001. 1 – 2001. 12)
Pathogens
S. aureus
All sites (UTI / PN / SSI / BSI)
23.0 %
MRSA
(17.1)
A. baumannii
18.5
Enterococcus
12.8
VRE
(4.5)
P. aeruginosa
11.5
K. pneumoniae
10.1
E. coli
8.2
Candida
6.6
40
Changing pattern of etiologic organisms
in Nosocomial infections
• 19 세기:
Group A Streptococcus
• 1950년대 이전까지:
Streptococci, Staphylococcus aureus
• 1960 – 1970 년대:
Gram negative bacilli
Enterobacteriaceae
Pseudomonas aeruginosa
• 1980 – 1990 년대:
S. aureus (MRSA)
Coagulase-negative staphylococci
Enterococci (VRE)
E. coli, P. aeruginosa
Enterobacter spp., K. pneumoniae
41
병원 감염의 결과
• Morbidity & Mortality
• 환자 진료의 질 저하
• 환자 의료비 상승 및 병원의 재정적 손실
• 재원 일수 증가
• 의료 소송
• 윤리적 사회적 문제
42
항암요법, 면역억제제  면역기능저하 환자의 증가
침습적 처치 (invasive procedure)
병원감염의 증가
효율적인 감염관리 시스템의 부재
항균제 오남용 및 항균제 내성균의 증가
43
Antimicrobial resistance
•
Natural biological phenomenon
•
Selection of drug-resistant subpopulations of microorganisms
•
Widespread use of antimicrobials  resistance to each drug
•
Inappropriate use of antimicrobial agents  resistance 
•
Development of new families of antimicrobials throughout the
1950s and 1960s
•
Modifications of these through 1970s and 1980s
•
The pipeline of new drugs is running dry.
•
The incentives to develop new antimicrobials is weak.
44
45
46
병원 내 항균제 내성 증가의 요인
• Greater severity of illness of hospitalized patients
• More severely immunocompromised patients
• Newer devices and procedures in use
• Increased introduction of resistant organisms from the
community
• Increased use of antimicrobial prophylaxis
• Increased empiric polymicrobial antimicrobial therapy
• High antimicrobial usage per geographic area per unit time
• Ineffective infection control and isolation practices and
compliance
47
병원 내 항균제 내성 증가의 요인
Use of Antibiotics
• Overuse & abuse
• 병원에 입원한 환자의 23 - 53%에서 항균제가 사용됨 (미국).
• 이 중 50% 이상은 부적절한 사용임.
(Wenzel RP. Prevention and Control of Nosocomial Infections.
1997. 3rd ed. Williams & Wilkins)
한림대 성심병원 (2001년 1월  12월)
• 항균제비 / 총의약품대비: 34.6%
• 3세대 cephalosporin 혹은 제한 항균제 / 총 항균제비 : 31.6%
48
Appropriate Use of Antimicrobials
Cost-effective use of antimicrobials
which maximizes clinical therapeutic effect
while minimizing both drug-related toxicity
and the development of antimicrobial resistance
49
부적절한 항균제 사용에 따르는 문제점
•
Emergence of Resistance
– Selective pressure of antibiotics
• Community-acquired
• Nosocomial
•
Superinfection
– Infection caused by resistant organisms during or after antimicrobial
therapy
•
Untoward side effects
– Neutropenia, nephrotoxicity, skin rash
– Diarrhea (Clostridium difficile colitis)
•
Treatment failure
•
환자의 의료비 부담 상승
•
보험삭감과 감염관리 비용에 따르는 병원 재정 손실
•
의료소송
50
Inappropriate Use of Antimicrobials
Prescribers
•
항균요법의 전문화 및 지식의 부족
(감염병, 미생물학, 감별진단, 항균제)
•
제약회사 영업사원의 홍보 및 상업성을 갖는 발행지에서 얻는 정보
•
인쇄물을 통한 교육
•
강의, 세미나
•
감염전문가에 의한 의사 개개인과의 만남을 통한 일대일 교육
•
증례 해결 방식의 interactive 교육
•
항균제 사용의 제한 : 원내 항균제 종류 최소화, 지침
처방의 제한 – 종류, 사용일수
51
Inappropriate Use of Antimicrobials
Hospitals
• Highly susceptible patients
• Intensive and prolonged antimicrobial use
• Cross-infection
Nosocomial infections with highly resistant
bacterial pathogens
Horizontal
Transmission
Within hospitals
Spread outside the hospital
causing infections in the community
52
항균제 내성균 증가에 대한 대처
•
Prudent use of antibiotics
•
Establish a system for monitoring bacterial resistance and
antibiotic usage
•
Establish practice guidelines and other institutional policies to
control the use of antibiotics, and respond to data from the
monitoring system
•
CDC “Guidelines for Isolation Precautions in Hospitals” :
colonized or infected with resistant microorganisms
•
Hospital committees to develop local policies and to evaluate and
adopt, as appropriate, guidelines from national societies
53
Prudent Use of Antibiotics
• Fever = Infection
• Narrowest spectrum antibiotics
• Combination therapy의 자제
• Adequate agent and short duration for surgical prophylaxis
• Consultation to Expert
54
20
2002, 5
2002, 4
2002, 3
2002, 2
2002, 1
2001, 12
45
2001, 11
3세대 세파 및 제한 항균제/
항균제 (%)
2001, 10
2001, 9
2001, 8
2001, 7
2001, 6
2001, 5
2001, 4
50
2001, 3
2001, 2
2001, 1
분율 (%)
항균제 사용 패턴 변화 (한림대 성심병원)
항균제/총의약품(%)
제한항균제
규정 적용
감염내과
40
35
30
25
55
20
2002, 4
2002, 3
2002, 2
2002, 1
2001, 12
2001, 11
2001, 10
2001, 9
2001, 8
2001, 7
2001, 6
2001, 5
2001, 4
2001, 3
2001, 2
2001, 1
2000, 12
2000, 11
2000, 10
2000, 9
2000, 8
2000, 7
2000, 6
2000, 5
분율 (%)
항균제 사용 패턴 변화 (강동성심)
50
항균제/총의약품(%)
45
3세대 세파 및 제한 항균
제/항균제 (%)
40
35
30
25
56
항암요법, 면역억제제  면역기능저하 환자의 증가
침습적 처치 (invasive procedure)
병원감염의 증가
효율적인 감염관리 시스템의 부재
항균제 오남용 및 항균제 내성균의 증가
57
병원 감염관리 (Hospital Infection Control)
• 병원 감염 발생 감시 (Surveillance)
• 집단 감염 조사 (Outbreak investigation)
• 감염관리 정책 및 규칙의 수립
- 환자 격리 방침 및 방법
- 각 부서별 감염관리 방침 및 방법
- 감염 위험성이 높은 수기나 시술에 대한 감염예방 지침
- 병원 내 환경 소독 및 청소 지침
• 교육
• 병원 직원 건강 관리
• 항균제 사용 관리
• 항균제 내성균 패턴의 감시
58
항균제 관리
• 항균제 사용 교육
• 항균제 사용 지침
• 제한 항균제 시스템
• 항균제 사용 현황의 감시
• 항균제 감수성 결과 보고의 제한
• 항균제 관리 전산 프로그램
• 원내 항균제 종류의 축소
• 제약회사 마케팅의 영향력 차단
59
항균제 사용 모니터링
• 장기적, 지속적 모니터링, 피드백
– 항균제 사용 양상의 변화 (경험적, 예방적)
– 항균제 사용의 질적 적정성
– 항균제 감수성 양상의 변화
– 항균제 사용량 및 금액 변화
– 보험 삭감 변화
• 즉각적 모니터링
– 잘못된 항균제 처방에 대한 즉각적 피드백
60
CDC Study on Efficacy of Nosocomial Infections (SENIC) project
(Data in 1970s)
• Nosocomial infection rates fell by 32% in hospitals
that established such programs:
- An organized hospital-wide surveillance system
- At least one infection-control practitioner per 250 beds
- Program reporting infection rates back to surgeon
and those clinically involved with the infection
- An effective infection control physician
• Rates in hospitals without effective programs increased by 18%.
(Harey RW, et al. Am J Epidemiol 1985)
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Infection Control in USA
• 1983: Adoption of a fixed price prospective payment system
based on diagnostic-related groups (DRGs)

• 56% of DRGs did not allow for any complication or
comorbidity.
(Wenzel RP. Am J Med 1985)
• Only 5% of the costs to treat nosocomial infections would be
reeimbursed to hospitals. (Haley RW, et al. JAMA 1987)
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ISOLATION
Other patients
Infected or colonized patients
Health Care Workers (HCW)
Hospital visitors
63
Colonized Patients?
• Important reservoir for transmission to other patients or HCWs
• When possible, patients colonized with resistant organisms,
whether they have been recognized through a surveillance
effort or by chance, should be treated in the same manner as
patients clinically infected.
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Guidelines for Isolation
(1996 revised, CDC & HICPAC)
• Standard Precautions
• Transmission-based Precautions
65
Standard Precautions
•
(1996 revised, CDC & HICPAC)
Gloves should be worn to touch any of the following: blood; all
body fluids, secretions, and excretions except sweat,
regardless of whether they contain visible blood, nonintact skin,
and mucous membranes
•
Hand should be washed immediately after gloves are removed and
between patients.
•
•
For procedures that are likely to generate splashes or sprays of
body fluid, a mask with eye protection or a face shield and a gown
should be worn.
Needles should not be recapped, bent, or broken but should be
disposed of in puncture-resistant containers.
66
Hand Washing
• Hand-washing compliance by HCW in ICUs :
< 50%
• Increase in hand-washing compliance by 1.5 to twofold
 25 to 50% decrease in the incidence of nosocomial infections
67
Microorganisms on the hand
• Resident flora :
Coagulase-negative staphylococci
Micrococcus
Corynebacterium ………..
• Transient flora :
important cause of nosocomial infections
68
Hand Washing
• Before and after contact with patients and
immediately after the removal of gloves
• Chlorhexidine and isopropyl alcohol
--- superior to soap and water
in the removal of VRE &
multiply-resistant Gram-negative organisms
69
Gloves
• to prevent contamination of the hands with microorganisms
• to prevent exposure of the HCW to blood-borne pathogens
• to reduce the risk of transmission of microorganisms
from the hands of the HCW to the patient
Adjunctive protective barrier
but not as a substitute for hand washing
70
Transmission-based Precautions
(1996 revised, CDC & HICPAC)
• Airborne Precautions
• Droplet Precautions
• Contact Precautions
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Contact Precautions (1)
• Direct contact : touching the patient
• Indirect contact : touching contaminated objects or surfaces
• Multidrug resistant organisms, such as MRSA and VRE
contaminate the environment in the vicinity of the infected or
colonized patient.
• Indications:
Patients infected or colonized with multidrug-resistant
bacteria (MRSA, VRE, Glycopeptide-resistant S. aureus)
Clostridium difficile colitis
Shigellosis, Rotavirus, Hepatitis A
Varicella / Disseminated zoster
72
Transmission of antimicrobial-resistant strains
Patient
Hospital personnel
Environment
Patient
73
Highly susceptible patients
Intensive and prolonged antimicrobial use
Cross-infection
Nosocomial infections
with highly resistant bacterial pathogens such as
multi-resistant Gram-negative rods,
vancomycin-resistant enterococci (VRE),
MRSA, &
resistant fungal infections
74
Contact Precautions (2)
• Barrier precautions to prevent the contamination of exposed
skin and clothing
• Gloves / Hand washing
• Gowns
• Do not share patient care equipments (stethoscopes, blood
pressure cuffs) with other patients.
• Transport of the patient from the room should be kept minimal.
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Colonization & Infection by S. aureus
• Humans are a natural reservoir of S. aureus.
• 30% of healthy adults are colonized (anterior nares).
• Persons colonized with S. aureus are at increased risk for
subsequent infections.
• Risk factors for staphylococcal infections
–
–
–
–
Diabetes mellitus
Intravenous drug users
Hemodialysis
Surgical patients
AIDS
Intravascular catheters
Qualitative or quantitative defects in leukocyte function
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Transmission of S. aureus
• Nosocomial infections :
Acquired through exposure to the hands of
health care workers after they have been
transiently colonized with staphylococci
from their own reservoir or
from contact with an infected patient
77
How resistance develops in S. aureus?
• Genetic mutation
• Take up of a resistance-conferring plasmid
or DNA fragment from the environment
Selective Pressure
by antibiotics
Resistance
78
Methicillin resistance in S. aureus
Replacement of nasal MSSA by MRSA
Cessation of
antibiotics
Reversion of antibiotic-selected MRSA
to heterotypic MSSA (~30 days)
79
Methicillin resistance in S. aureus
Selective antibiotic pressure
continued use of
antibiotics
MRSA sustained in any environment
80
병원 감염 관리 - MRSA
• Isolation & Barrier Precautions
- Place patients colonized or infected with MRSA in a private room.
- Until three consecutive cultures (from anterior nares and other
known positive body sites) are negative for MRSA
- Cohorting
- Handwashing
- Gloves / Gowns / Masks
• Environmental Control
• Eradication of Carrier state
- Mupirocin ointment, intranasal for 5 days
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병원 감염 관리 - VRE
• Notify appropriate hospital staff promptly when VRE are detected.
• Inform clinical staff of the hospital’s policies regarding VRE-infected
or colonized patients.
• Establish system for monitoring appropriate process and outcome measures.
• Isolation precautions to prevent patient-to-patient transmission:
- Place patients colonized or infected with VRE in a private room.
- Cohorting
- Gloves / Gown / Handwashing
- Do not share stethoscope, blood pressure cuff, thermometer.
- Obtain a stool culture or rectal swab from roommates of patients
newly found to be infected or colonized with VRE.
- Isolation until three consecutive cultures (from rectal swab or stool,
and other known positive body sites) are negative for VRE
• Environmental Control
82
병원내 내성균 확산 방지 - VRE
Antibiotic therapy : vancomycin, 3rd cepha., aminoglycosides
aztreonam, imipenem, quinolones
X
X
Patient
X
hand
X
비의료진
VRE infected
or colonized patient
Stool, urine, wound discharge, sputum
X
X
Patient
X
hand
의료진
청진기,체온계
X
X
X
stool
주위 환경
의료진
비의료진
hand
hand
stool
83
If a hospital were to have an outbreak of infection with
the Ebola virus, the compliance rate for infectioncontrol measures would soar.
All patients deserve the best possible medical care,
which includes simple efforts to prevent the spread of
resistant organisms to patients who are not already
colonized.
84