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呼吸道感染之預防與管制

呼吸道感染之預防與管制. 台大醫院感染科王振泰醫師. Load of Nosocomial Pneumonia. 國外的資料 15% of all nosocomial infections (NIs) 27%, 24% of NIs in MICU, CCU 國內的資料 (1999 ~ 2002) 10.6 ~ 13.7 % （醫學中心） and 24.9 ~ 25.3% （區域醫院） of all NIs 14.7 ~ 20.3 % （醫學中心） and 32.2 ~ 35.3% （區域醫院） of NIs in ICUs.

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呼吸道感染之預防與管制

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  1. 呼吸道感染之預防與管制 台大醫院感染科王振泰醫師

  2. Load of Nosocomial Pneumonia • 國外的資料 • 15% of all nosocomial infections (NIs) • 27%, 24% of NIs in MICU, CCU • 國內的資料 (1999 ~ 2002) • 10.6 ~ 13.7 %（醫學中心）and 24.9 ~ 25.3%（區域醫院）of all NIs • 14.7 ~ 20.3 %（醫學中心）and 32.2 ~ 35.3%（區域醫院）of NIs in ICUs

  3. Risk Factors for Nosocomial Pneumonia • 增加於上消化道移生的細菌菌落數 • Administration of Abx • Admission to ICUs • Presence of underlying chronic lung diseases • 增加吸入或胃食道逆流的因素 • Endotracheal intubation, insertion of NG tube • Supine position, Coma, immobilization • Surgical procedures involving head, neck, thorax, upper abdomen

  4. Risk Factors for Nosocomial Pneumonia • 長時間使用呼吸器造成病患暴露於被污染的器材、醫護人員的雙手 • Transmission is the major problem! • 宿主本身的因素 • Extreme of age, malnutrition, severe underlying diseases, immunosuppression

  5. Prevention of Nosocomial Pneumonia: general considerations • Staff Education and involvement in infection prevention: • Infection and microbiologic surveillance: • Surveillance for the incidence and trends of nosocomial pneumonia • Identification of outbreak • No routine culture surveillance

  6. Prevention of Nosocomial Pneumonia: general considerations • Oropharyngeal and tracheal colonization: • Local bacterial interference: • Alpha-hemolytic streptococci • Efficacy for general use has not been evaluated • Aerosolization of antimicrobial agents • Decreasing the incidence of GNB infections • No effect on mortality • Superinfection with resistant pathogens

  7. Oropharyngeal, and Tracheal Colonization • Selective oropharyngeal decontamination with Abx: • Topical preparation decrease the incidence of VAP and colonizers • No effect on mortality, ICU stay, and duration of mechanic ventilation（不建議routine使用） • Oropharyngeal cleaning and decontamination with an antiseptic agents • Toothbrushing, mouth-swabbing with an antiseptic agent, and suction of the mouth and subglottic area • Should be implemented, but needing randomized clinical trial

  8. Oropharyngeal, and Tracheal Colonization • Oral chlorhexidine rinse in adult patients undergoing cardiac surgery: • The benefit has been demonstrated （建議使用在此類病人） • However, still no study to confirm its benefit for patients of other clinical settings（unresolved issue）

  9. Oropharyngeal and gastric colonization • Selective decontamination of the digestive tract (SDD): • One of most studied strategy • Decrease Candida spp. and GNB, without altering anaerobic flora • Probably cost-effective for use of critical surgical patients • Antimicrobial resistance • Superinfection with MDR pathogens • 不建議routine使用

  10. Oropharyngeal and gastric colonization: gastric acidity • Sucralfate v.s. H2 blockers, antacids, and stress-bleeding prophylaxis: • no evidence to determine which is better • Acidified enteral feeding: • Effect on the incidence of pneumonia has not been evaluated • Continuous v.s. intermittent enteral feeding: • No evidence to determine which is better

  11. Aspiration of oropharyngeal and gastric flora • Risk factors: • Impaired consciousness, dysphagia, ET tube, tracheostomy, NG tube • Naso-tracheal is more risky than oro-tracheal tube • Prevention: • Semi-upright position • 是否使用較小管徑之胃管、連續或間歇灌食、置放Naso-duodenal tube，仍為unresolved issues

  12. Mechanically Assisted Ventilation and Endotracheal Intubation • Reasons: • Passage of the oropharyngeal bacteria to the trachea via intubation • Depressed host defense • Aggregation of bacteria on the surface of tube and dislodge into the lower respiratory tract

  13. Mechanically Assisted Ventilation and Endotracheal Intubation • Drainage of subglottic secretions: • 可以減少VAP的發生，並且是cost-effectiveness（建議使用） • 但對overall mortality, ICU stay, duration of ventilator等並無幫忙。 • Non-invasive ventilation: • 減少插管及重複插管的必要 • 可以減少肺炎的發生 • 應考慮使用其為weaning process之一部分

  14. Mechanically Assisted Ventilation and Endotracheal Intubation • Contamination of devices used on the respiratory tract: • Semi-critical, high-level disinfection • After disinfection, rinsed with sterile water • 若使用tap water或filtered water（0.2 mm）, 沖淨後再用酒精rinse，並用forced-air吹乾 • Mechanical ventilators: • 不需要對機器內部進行高層次消毒

  15. Contamination of devices used on the respiratory tract: • Breathing circuits: • 當有可見的或已知的污染存在、或dysfunction時，才需要更換 • Humidifier: • 使用sterile water填充 • 對於是否需要使用closed, continuous-feed humidifcation system：仍無結論 • 當有可見的污染或dysfunction時，才更換管路

  16. Contamination of devices used on the respiratory tract: • Condensate in the circuits: • 很容易形成被細菌污染的污染源 • 定期引流、清除 • 減少condensate的方法：但仍無證據顯示對預防VAP有一定的功效 • Heated wire in the tubing: dry sputum • Heat-moisture exchanger: increased dead space, resistance • 不要routine的、少於每48小時就更換連接的管路 • 當有可見的污染或dysfunction時，才更換HME

  17. Contamination of devices used on the respiratory tract: • Nebulizers: 小心使用，避免污染 • 在兩次使用間，應清潔、消毒，並用sterile water來rinse • 應使sterile water用來進行nebulization • Mist-tent: • 使用後應滅菌或高層次消毒 • 用在同一個病人身上時，mist-tent nebulizer, reservoirs, and tubing，目前並不清楚該多久更換；但應每日進行低層次消毒

  18. Suction Catheters • Closed multi-use catheter system v.s. open single-use catheter system: • 可以長期不更換抽痰管v.s.每次更換抽痰管 • 可以減少來自外在環境的污染 • 是否可減少VAP之發生：unresolved issue • 清潔手套v.s.無菌手套：unresolved issue • 使用sterile fluid來進行抽痰

  19. Standard Precautions (標準防護) • Hand washing (洗手) • Gloves (戴手套) • Mask, eye protection, face shield (面罩) • Gown (隔離衣) • Patient-care equipment (醫療器械) • Environmental control (減少環境污染) • Linen (治療巾、床套、被褥) • Occupational health and blood-borne pathogens (血液、體液、痰液等感染檢體處理) • Patient placement (病患之隔離及安置)

  20. Resuscitation Bags, Ventilator Spirometers, Temperature Probes • 必須要高層次消毒或sterile • 這些雖然多為可重複使用的部分，但清洗及消毒十分不容易，很容易成為污染的來源 • 必須反覆教育臨床醫師，呼吸治療師，護士等，該如何確實做好

  21. Post-operative State • Preoperative risk index: • Type of surgery (AAA repair, thoracic surgery, emergency surgery), use of general anesthesia, age 60 years; totally dependent functional status, weight loss greater than 10%, steroid use; recent alcohol use, COPD, • Incentive spirometry and deep breathing • routine使用chest physiotherapy, unresolved issue

  22. Other Prophylactic Measures • Immunomodulation: • Pneumococcal vaccination • Cost-effective, 但功用有限 • Use of IVIG or G-CSF：無證據顯示其效果 • Use of glutamine-enriched enteral feeding: • Lymphocyte and enterocyte function • Decreased incidence of VAP and bacteremia in multiple-trauma patients • Otherwise, no evidence

  23. Other Prophylactic Measures • Administration of antimicrobial agents: • Prophylactic systemic ABx: • Conflicting results & resistant pathogens • ABx cycling for empiric therapy: • 在2003年美國CDC的guideline中認為是仍待評估；但2006年CID的文章中認為效果不彰 • Turning or rotation therapy

  24. Specific Prevention: Legionnaires Diseases (LD) • Staff education • Infection and environmental surveillance: • High index of clinical suspicion • 定期瞭解LD診斷工具的利用率與庫存狀況 • Routine culturing of water system: • 對沒有patient-care的地方：unresolved issue • 對於有進行器官移植的機構，建議使用 • 何種方法最好？Unresolved issue

  25. Use and care of medical devices, equipment, and environment • Nebulizer and other devices: • Don’t use large-volume room-air humidifiers製造大量的aerosol • 在免疫力不足的病人區中，一旦自水中分離出Legionell spp.，就必須更換faucet aerators直到culture negative • Cooling tower • 新建構的cooling tower應避免產生之漂流物回留置至中央空調的進氣口 • 應定期使用biocides來加以維護

  26. Water-distribution System • 對於免疫力不全病患的區域，應控制飲用水的出水溫度51℃為或20℃ • 是否使用二氧化氯、重金屬離子、臭氧、或紫外線來消毒：unresolved issue • 對於移植病患的供水若培養出Legionella: • Decontaminate the water supply • 避免淋浴 • 使用無菌水

  27. Prevention of Influenza and SARS Respiratory Diseases with Threatening to Both Patients and Health Care Workers

  28. 感染和疾病的時間關係 Inoculum Latent period Infectiousness 具傳染性時期 不具傳染性時期移除、死亡、復原 Susceptible Host 傳染動力學 No clinical symptoms Incubation period Clinical symptoms Susceptible Host 疾病動力學 SARS Avian Flu

  29. 傳染病的預防：基本概念 • 基礎再生數(R0)決定疾病的持續流行與否 • 一個可傳染宿主在其可傳染期間於一個完全易感受的族群中預期可產生的新感染宿主個數 • <1: 流行將不繼續 每次接觸的 傳播機率 每單位時間 接觸次數 可傳染期間 X R0 = X 疫苗 防護裝備 預防性用藥 隔離 治療

  30. Early Detection of SARS

  31. Early Detection of SARS

  32. Comparison of Sequential Symptoms SARS Patients Others Viral Infection Chen SY, et al. Ann Emerg Med. 2004;43:1-5

  33. Predictive Model of Diagnosis Clinical Score = A + B + C + D + E + F < 1 Symptom Score = A + B + C + D < 0 Chen SY, et al. Ann Emerg Med. 2004;43:1-5

  34. Definite Diagnosis of SARS • Confirmed positive PCR for SARS-CoV • At least two different clinical specimens • The same clinical specimen collected 2 more days apart during the disease course • 2 different assays or repeated PCR using the same clinical sample on each occasion of testing

  35. Definite Diagnosis of SARS • Seroconversion by ELISA or IFA • Negative on acute serum, positive on convalescent serum • Four fold rising between acute and convalescent serum • Virus culture • Confirmed by PCR

  36. Early Diagnosis of N.I.

  37. Definite Diagnosis of N.I. • Immunofluorescence assay: • Monoclonal antibody detect A/H5 Ag • Clinical specimen, viral culture • Virus isolation: • Gold standard, time-consuming (2 ~ 8 days) • Culture line: Madin-Darby canine kidney cells • Confirmed by method 1 and 3 • Throat swab is more adequate than nasopharyngeal swab

  38. Definite Diagnosis of N.I. • Reverse-transcriptase PCR: • Estimated products: 219 base-pairs • Primer: • H5-1: GCC ATT CCA CAA CAT ACA CCC • H5-3: CTC CCC TGC TCA TTG CTA TG • Day 2 ~ 15 throat swab, 10 time viral load than usual human influenza • Specific Ab response: • 2 ~ 4 weeks is needed for diagnosis: 4-time elevation • Fluchip Diagnostic Microarray: H1N1, H3N2, H5N1

  39. 傳染病的預防：基本概念 • 隔離（isolation） • 在病毒沒有有效的人傳人能力前 • 人和人之間的隔離：是否需要？ • 人和禽畜類的隔離：必須 • 倘若病毒以可以有效的在人與人之間傳遞 • 人和人之間的隔離：必要 • 人和禽畜類的隔離：必要

  40. 傳染病的預防：基本概念 • 隔離時，應進行何種措施？ • 傳播途徑：飛沫傳染、接觸傳染 • 應採用可以有效防止飛沫傳染、接觸傳染的措施 • 當醫療、社會資源充足時，考慮禽流感的高致死率，可以使用更高階的、防止空氣傳染的預防措施 • 何時啟用： • 暴露後及應啟用，不是等到發病再啟用 • 隔離的效果，流感一定較SARS來得差

  41. 傳染病的預防：基本概念 • Personal protect equipment (PPE): • 採用有效防止飛沫傳染、接觸傳染的PPE • 當醫療、社會資源充足時，考慮禽流感的高致死率，可以使用更高階的、防止空氣傳染的PPE • 隔離與PPE必須使用多久？ • 暴露後未發病：[新型流感：暴露後10至14天]，[SARS：7到10天] • 暴露後發病： • 新型流感：成年人，退燒後7天；小孩：發病後21天 • SARS：退燒後14天

  42. Principles of Isolation & PPE • 標準防護措施（standard precautions） • 飛沫傳染防護措施（droplet precautions） • 接觸傳染防護措施（contact precautions） • 空氣傳染防護措施（airborne precautions）

  43. Standard Precautions (標準防護) • Hand washing (洗手) • Gloves (戴手套) • Mask, eye protection, face shield (面罩) • Gown (隔離衣) • Patient-care equipment (醫療器械) • Environmental control (減少環境污染) • Linen (治療巾、床套、被褥) • Occupational health and blood-borne pathogens (血液、體液、痰液等感染檢體處理) • Patient placement (病患之隔離及安置)

  44. Betts FR, Douglas RG, Mandell G.L., Douglas R. G., Bennett J.E., Principles and practice of infectious diseases, 3rd ed., 1990;39:1306-25

  45. 呼吸道衛生與咳嗽禮節 • 海報宣導 • 咳嗽、打噴嚏時要摀住口鼻 • 使用衛生紙來包覆呼吸道分泌物，並將之丟棄在最近的垃圾桶內 • 接觸呼吸道分泌物後要洗手

  46. 標準防護 (Standard precautions) • 洗手 • 接觸病患體液、血液、排泄物或污染衣物前後需洗手 • 手套移除後馬上洗手 • 使用一般肥皂洗手即可 • 如有院內抗藥菌流行時,可使用抗菌性肥皂洗手 • 手套 • 接觸病患及其體液時須戴手套 • 手套在照顧病患後需立刻移除 • 口罩/面罩/護目鏡 • 口鼻黏膜可能接觸病患體液時(如CPR)需佩戴 • 隔離衣、被單 • 環境消毒

  47. 洗手

  48. 洗手標準程序 手沾濕 執行治療或 接觸病人前後 取洗手液 一般洗手用清潔劑 侵入性治療時用消毒劑 雙手搓揉 （注意指尖、指縫） 沖淨後擦乾 搓揉起泡 10-15秒

  49. 空氣傳染之病原(顆粒<5µm) • 麻疹 • 水痘 • 天花 • 開放性肺結核

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