dr hadi yusuf - management moi
DESCRIPTION
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MANAGEMENT OF MULTIRESISTANT
NOSOCOMIAL INFECTION
Infectious Diseases Unit
Internal Medicine Department
Hasan Sadikin General Hospital / Faculty of Medicine
Padjadjaran University
DEFINISI
• Infeksi nosokomial• Bakteri multiresisten
PROBLEM
• Lokal
Nasional
global
• Klinisi
Farmasi
Pengelola
POINTS
• Faktor Resiko• Pencegahan• Terapi
Kolonisasi
Infeksi
Terjadinya
Penyebaran
● CCU
INANIMATE ENVIRONMENT
PATIENTSHCW
● Critically ILL patients
Ecosystem of microorganism
Endogenous flora
Less pathogen Resistant pathogen fungi
Selective pressureOf Antibiotic
- Chromosom- plasmid
Faktor Resiko
• Inappropriate antibiotic therapy
• Prolong antibiotic therapy
• Wrong combination antibiotic therapy
• Infeksi sulit / multipel
• Terapi kolonisasi
• Standar / peraturan / policy ( - )
Manardi 1998Cunha 1998,2002
Pencegahan timbulnya kuman multi resisten• Batasi antibiotik yang potensial terjadi
resistensi
• Usahakan antibiotik yang kurang potensial terjadinya resistensi
• Rotaring formulary (cycling) ?
• Monoterapi > kombinasi
• Pengenalan antibiotik failure
• Indikasi tepat untuk antibiotik tertentu
Spreading of Resistant pathogen
• Invasive diagnostic
• Invasive therapeutic
• Devices,clothe, linen
• HCW
Frequency
intencityRisk of noso. inf
Pencegahan penyebaran kuman multi resisten• Surveilance
• Universal precaution, droplet precaution, contac precaution, air borne precaution
• Empiric precaution
• Isolation (BSI, single room, cohort)
• Peraturan antara lain transportasi
Hand washing
DIAGNOSTIK MDR
• Reliable laboratorium
• Regular report
• Early detection
Antibiotic policies / noso. control program
• Guidelines
• Education, out break investigation, surveilance• Committee/ :- clinician
team - microbiologist - pharmacist - administration, epidemiologist - nurse
• Antibiotic – resistance pattern report & routine feedback.• Restriction : (indication)
- high potential to resistance- broad spectrum
National & local
Control the emergence of resistant strains
KAKKILAYA (2005)
We must exercise considerable restraint in prescribing antibacterials. Restrict a.b use to only certain definite indications
Definitivetherapy
Empiricaltherapy
Prophylactictherapy
Cost-effective : Narrower spectrum; SE
Cheaper; easy adm; resistency
• 50 % A. B. use in CCU : unjustification/ documented (-)• Review → report : Antibiotic pattern• Reliable culture results ↔ clinical entity• Modification / reassesment
– Change– Superinfection– Non infection– Drug fever
Combination
• Monoterapi is preffered
• Certain indication
- anti TBC
- anti pseudomonas
- mix infection → spectrum ↑
• Combination resistant m.o?
Rotation (cycling)
• Controversi
• Resistance to both agents
still emerge
• Alternative to restriction
Vancomycin use (avoid VRE)
acceptable Discouraged
1. Betalactame resistance m.o
2. Gram + infection but betalactam allergy
3. Antibiotic – associated colitis + fails to metronidazol
1. MSSA
2. Skin contamination with Staphyloccocus is likely
3. Continued empiric use, while culture ( - ) for betalactam resistant gram positive
4. MRSA colony eradication
5. Topical use
Hand washing / Antiseptic
• Simple, education!• Studies : - Sampling of physician hand : gram (-) rod, S. aureus
- Routine washing → skin bact. Carriege → noso. Infection
• “before and after contact” (patient/procedure/source/gloves)• Antiseptic soap/solution : e.g chlorhexidine
water/plain soap → Heavy contamination?• Gloves → Physical barrier
Surveillance
• Most important of inf. Control program• Baseline Rate; infection rate
recognition of potential outbreaks
early identification : - special patients
- resistant m.o
- outbreaks• Collecting, analyzing
• Re-usable device : - disinfection - sterilization
• Physical plant/Engineering- facilitate inf. controle- limit infection spread
• Isolation precaution (private,cohort)• Droplet precaution (e.g meningococus, MRSA)• Airborne precaution ( e.g TBC)• Contact precaution ( e.g MRSA, VRE)
MDR Noso. Infection
• Easy to be transmitted :
VRE
MRSA
• Others :
- ESBL-gram negative (e.g pseudomonas)
- MDR TB
- GISA
Pengobatan MDR Pathogin
• Sulit
• Jenis kuman? Pola resistensi?
• MRSA
VREMudah menyebar
MRSA (Methicillin-resistant Staph. Aureus)
• Resistant to : betalactam, and usually (occassionally) other antibiotics
• Special lab test
• Readily & easily transmitted
• Difficult & expensive to control and to treat
(1)
MRSA
• Good colonizers • Transmission : hand of HCW, equipment, clothing,
air.• Screening : admission, staff• Notify it transferred• Isolation for patients and treat (single or cohort
room?)• Treatment infected patients :
- Vancomycin- Vancomycin + gentamycin /
rimfampycin / cotrimmoxazole
(2)
MRSA
• Sampling sites : 2/3 negative results
(patients, room)
clearance
• MRSA control
- Surveillance → early detection
- Isolation & treatMupirocin topical 2% chlorhexidine 1% neomycinbacitracin
Nasal (local) 1 week
(3)
MRSA
• Bathing (shower) 1 week
• Prophylactic : during outbreaks• Droplet precaution• Hand washing + disinfection• Gloves, apron, gown when handling
patients• Disinfecting before opening
Chlorhexidine 2% triclosan
(4)
VRE = glycopeptide resistant Enteroccocus
• Resistance to vanco and other agents (aminoglycoside, ampicillin)
Difficult to treat• Risk factors : - broad spectrum A.
- vancomycin - prolonged hospitalization - others
• Measures to limit the spreadeg.: - strict limitation of vancomycin
- precautions• Treatment : - linezolid; quinepristin/dalfopristin
- UTI : Nitrofurantoin, Fluoroquinolon
Strep. Pneumoniae
• Resistance to : Penicillin cephalosporin
a.l macrolide, tetra, chloramph.• Pattern ~ lokalisasi• Th/: - mic < 2 mg/L to penicillin dosis / cefotaxime,
ceftriaxone
- high level of resistance: imipenem,glycopeptides
- pnemococcal menginitis : ceftriaxone + vanco.
Pseudomonas Aeruginosa
• The most adaptable m.o
• Resistance to ceftazidine
to : amikacin
cipofloxacin
imipenem
PROBLEM
• Kasus : multiresistant klebsiella
♂, 70 th, strokeurine culture : K. pneumoni yang resistensi semua A.B kecuali imipenem
• Marin Kollef (2003) : Gr-(e.g Kleb.Pn; E. Coli often produce ESBLs
• Reese (1996) multidrug resistant outbreak of klebsiella spp have been reported.They are still susceptible to imipenem.
• LEVLY :
To deal with MDR m.o
all of us: physician, patient, microbiologist
pharmacist, P.H/epidemiologist, infection control practitioner.
• Some MDR pathogen untreatable
• Closely monitor individual (local) antibiogram
• Preventing MDR - m.o most logical approach
• Surveillance : a.b – m.o - infection
KESIMPULAN
1. Waspadai terjadinya dan penyebaran kuman multiresisten di rumah sakit
2. Kenali faktor resiko
3. Pencegahan terjadinya kuman tsb.
4. Deteksi dini - cegah penyebaran
- pengobatan