11 醫院常見多重抗藥菌叢護理照護重點 鍾惠君 1* 李茹萍 2 1 佛教慈濟綜合醫院護理部副主任 2 慈濟大學護理學系教授 摘要 : 抗藥性菌種伴隨而來的高死亡率及高醫療成本支出已成為全球矚目的健康照護議題, 台灣在 2010 年甚至出現無藥可治的超級細菌, 引發媒體的大 幅報導和民眾的恐慌! 要避免這樣的多重抗藥性 菌種的感染, 最重要的即是照護團隊落實感染管 制措施 從感染鏈的概念而言, 現今的臨床照護 實務因人口老化及慢性病 各種醫療措施的介 入 免疫製劑 抗微生物制劑的使用 及人工 植入物的增加 等, 使得與醫療照護相關感染的 易感受宿主人口日益增多 然而, 最有效的感染 管制措施如手部衛生, 在醫療照護人員的執行 率偏低, 僅占 30~70% 之間, 因環境及醫護人員 手部交叉汙染而引起的感染群突發事件亦時有所 聞 因此, 本文依據臨床常見之多重抗藥菌種的 特性及照護問題, 綜整文獻與實務經驗之建議, 以做為護理人員在臨床照護實務上的參考 關鍵詞 : 多重抗藥菌種 護理 感染控制 Enterococcus faecium Staphylococcus aureus Klebsiella pneumoniae Acinetobacter baumannii Pseudomonas aeruginosa Enterobacter species ESKAPE 2010 1% 5% 45 57 Haley, White, Culver, & Hughes, 1987 Diagnosis Related Group DRG 95% Haley et al., 1987 1929 Alexander Fleming Penicillin 2002 Vancomycin Jean & Hsueh, 2011 2010 Antimicrobial Availability Task Force, AATF multidrug-resistant Acinetobacter baumannii, MDRAB Acinetobacter baumannii 2002 imipenem 5% 2004 16% -lactams aminoglycosides fluoriquinolones carbapenems MDRAB MDRAB MDRAB 100 7 6 * 97002 707 038 561825 2220
12 Nursing Care and Multidrug-Resistant Bacteria MDRAB 2011 methicillinresistant S. aureus; MRSA MRSA methicillin methicillin-resistant Staphylococcus aureus MRSA methicillin 1990 MRSA S. aureus 60% S. aureus MRSA 2011 Vanconmycin-resistant entrococci, VRE VRE 1988 vancomycin VRE 2009 extendedspectrum -lactamase, ESBL-klebsiella pneumoniae 1980 ESBL cephalosporin ESBL Klebsiella pneumoniae Escherichia coli ESBL Salmonella enteric Proteus spp. cephalosporin ESBL Jean & Hsueh, 2011-1 New Delhi metallo- -lactamase-1, NDM-1 2010 NDM-1 NDM-1 Enterobacteriaceae Klebsiella pneumoniae Escherichia coli carbapenemndm-1 carbapenemcarbapenem-resistant Enterobacteriaceae, CRE 2008 1 2010 8 NDM-1 2011 2011 2011
13 2008 colonization
14 Nursing Care and Multidrug-Resistant Bacteria 2008 4 2011 5 10 http://www.cdc.gov.tw/content.asp?mp=1& CuItem=13383 [Centers for Disease Control, Taiwan, ROC. (2008, April). Guidelines for the prevention and control of infection by multidrug-resistant microorganisms. Retrieved May 10, 2011, from http://www.cdc.gov.tw/content.asp?mp=1&cuitem=13383] 2011 2 22 NDM-1 2011 5 10 http://www.cdc.gov.tw/ct.asp?xitem=30626&ctnode=1733&mp=1 [Centers for Disease Control, Taiwan, ROC. (2011, February 22). New Delhi metallo-β-lactamase -1 enterobacteriaceae. Retrieved May 10, 2011, from http://www.cdc.gov.tw/ct.asp? xitem=30626&ctnode=1733&mp=1] 2011 21 2 73 82 [Huang, T. F., Chan M. C., Chang, C. M., Qiu, Y. H., Chang, S. M., Xie1, Y. J., et al. (2010). Analysis of healthcare-associated staphylococcus aureus infections in general wards and intensive care units in a medical center. Infection Control Journal, 21 (2), 73 82.] 2010 21(1) 38 43 [Sun, J. R., & Chan, M. C. (2010). Eradication of antibiotic-resistant agents: ES- KAPE. Infection Control Journal, 21(1), 38 43.] 2011 9 3 146 159 [Teng, P. C., Jang, T. N., Lee, S. H., Lee, C. L., Huang, C. S., Lee, T. Y., et al. (2011). Investigation and management of an outbreak of multiple drug-resistant Acinetobacter baumannii in a medical intensive care unit in Northern Taiwan. Infection Control Journal, 21(1), 12 24.] 2011 21 2 83 94 [Chao, L. H., Su, L. H., Tang, Y. F., Chen, I. L., Hwang, K. P., & Liu, J. W. (2011). Reducing healthcare-associated infections caused by multidrug-resistant Acinetobacter baumannii by implementing hospital-wide environmental cleaning measures. Infection Control Journal, 21(2), 83 94.] 2009 19 4 229 239 [Hsieh, L. C., Lin, C. M., Lee, W. S., Lin, Y. H., Hsieh, Y. C., Hsu, C. H., et al. (2009). Outbreak of vancomycin-resistant entrococci in a medical intensive care unit of medical center in Northern Taiwan. Infection Control Journal, 19(4), 229 239.] Haley, R. W., White, J. W., Culver, D. H., & Hughes, J. M. (1987). The financial incentive for hospitals to prevent nosocomial infections under the prospective payment system: An empirical determination from a nationally representative sample. JAMA: The Journal of the American Medical Association, 257(12), 1611 1614. Jean, S. S., & Hsueh, P. R. (2011). Antimicrobial drug resistance in Taiwan. Journal of the Formosan Medical Association, 110(1), 4 13.
15 Multidrug-Resistant Bacteria in the Hospital: The Focus of Nursing Care Hui-Chun Chung 1 * Ru-Ping Lee 2 1 RN, MSN, Deputy Director, Department of Nursing, Buddhist Tzu Chi General Hospital; 2 RN, PhD, Professor, Department of Nursing, Tzu Chi University. Abstract: Antimicrobial resistance is a major global health threat associated with high mortality rates and high medical costs. In Taiwan, numerous news reports on threats from super-bacteria have caused intermittent public panics since 2010. Improving the adherence of medical team members to infection control precaution policies is the most effective and immediate way to prevent antimicrobial resistance. In line with the infection chain concept, the modern clinical practice faces increases in susceptible hosts in the form of various immune-compromised patients, aging populations, rising numbers of chronically ill patients, various medical interventions, and increased antimicrobial agent use. Such has significantly increased opportunities for hospital-acquired infections. Medical staffs have also widely failed to comply with infection control measures. The compliance rate for hand hygiene, for example, has been reported as only 30~70 %. Many reports have been published on hospital-acquired multidrugresistant bacteria outbreaks traced to the hospital environment and medical staff cross-contamination. This article provides insight into the problem and facilitates clinical staff decision-making regarding the prevention and control of multidrug-resistant bacterial infections. Key Words: multidrug-resistant bacteria, nursing care, infection control. Accepted for publication: July 6, 2011 *Address correspondence to: Hui-Chun Chung, No. 707, Chung-Yang Rd. Sec. 3, Hualien City 97002, Taiwan, ROC. Tel: +886 (3) 856-1825 ext. 2220; E-mail: Hc_chung@tzuchi.com.tw