PRINSIP PENCEGAHAN INFEKSI

UNIVERSAL PRECAUTIONFithri kurniatiINFEKSI :Berkembang biaknya penyakit pada hospes disertai timbulnya respon imunologik dengan gejala klinik atau tanpa gejala klinikManusiahost / penjamuPenyakitagentTransmisi kuman adalah :Proses masuknya kuman ke dalam penjamu sehingga timbul radang / penyakit

Health Care-Associated Infections (HAI)According to WHO:HAI is also called nosocomial.HAI is defined as: an infection acquired in hospital by a patient who was admitted for a reason other than that infection. an infection occurring in a patient in a hospital or other health-care facility in whom the infection was not present or incubating at the time of admission.

WHO [12] defines a health care-associated infection (also called nosocomial) as:An infection acquired in hospital by a patient who was admitted for a reason other than that infection. An infection occurring in a patient in a hospital or other health-care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.3Definisi Infeksi NosokomialInfeksi nosokomial adalah suatu infeksi yang diperoleh atau dialami oleh pasien selama dia dirawat di rumah sakit dan menunjukkan gejala infeksi baru setelah 72 jam pasien berada di rumah sakit serta infeksi itu tidak ditemukan atau diderita pada saat pasien masuk ke rumah sakit (Olmsted RN, 1996, Ducel, G, 2002). Batasan Atau Kriteriai. Pada waktu penderita mulai dirawat di rumah sakit tidak didapatkan tanda-tanda klinik dari infeksi tersebut. ii. Pada waktu penderita mulai dirawat tidak dalam masa inkubasi dari infeksi tersebut. iii. Tanda-tanda infeksi tersebut baru timbul sekurang-kurangnya 3 24 jam sejak mulai dirawat. iv. Infeksi tersebut bukan merupakan sisa (residual) dari infeksi sebelumnya (Hasbullah T, 1992).

Types of HAIBloodborne pathogens (including HIV/AIDS, Hepatitis B & C)MRSA (Methicillin-Resistant Staphylococcus Aureus)PneumoniaInfluenzaNorovirusVaricella (chickenpox), mumps, Clostridium difficile (C. diff), TB, & a host of others. If you would like to see a more complete list, visit the CDC at http://www.cdc.gov/ncidod/dhqp/id.html.

Transmission of HAIDirect physical contact including touching & sexual meansIndirect contact via an inanimate object (fomite)Vector recipient is bitten by an insect or animal (the vector)Fecal-oral from contaminated food or drinkDroplet expelled through coughing, sneezing, talkingAirborne pathogen hitches a ride on dust or evaporated dropletsNote that bloodborne pathogens (those in blood or other bodily fluids) may be transmitted by sexual or direct contact or through fomites (e.g., surgical instruments or dried blood on an object)Impacts of Health Care-Associated Infections (HAI)HAI can: Increase patients suffering.Lead to permanent disability.Lead to death.Prolong hospital stay. Increase need for a higher level of care.Increase the costs to patients and hospitals.In the United States, 1 out of every 136 hospital patients becomes seriously ill as a result of acquiring an infection in hospital; this is equivalent to two million cases and about 80 000 deaths a year.In England, more than 100 000 cases of health care-associated infection lead to over 5000 deaths directly attributed to infection each year.In Mexico, an estimated 450 000 cases of health care-associated infection cause 32 deaths per 100 000 inhabitants each year. Health care-associated infections in England are estimated to cost 1 billion a year. In the United States, the estimate is between US$ 4.5 billion and US$ 5.7 billion per year. In Mexico, the annual cost approaches US$ 1.5 billion.

8Risk stratificationRisk of InfectionType of PatientsType of Procedures1MinimalNot immunocomrpomisedNo significant underlying diseaseNon-invasiveNo exposure to biological fluids2MediumInfected Patients or patients with some risk factorsExposure to biological fluids or invasive non-surgical procedure3HighSeverely immunocompromised patient, multiple trauma, severe burns, organ transplant patientsSurgery or high-risk invasive proceduresPreventing infectionsRequires health care providers who have: Knowledge of common infections and their vectorsAn attitude of cooperation and commitment Skills necessary to provide safe care10Required KnowledgeKnowledge of the extent of the problem;Knowledge of the main causes, modes of transmission, and types of infections.

What students need to know (knowledge requirements): know the extent of the problem; know the main causes and types of infections.11Required AttitudesBeing an effective team player.

Commitment to preventing HAIs

12Required SkillsApply universal precautions*Use personal protection methodsKnow what to do if exposedEncourage others to use universal precautionsReport breaks in technique that increase patient risksObserve patients for signs and symptoms of infectionUniversal precautions: "Universal precautions," as defined by CDC, are a set of precautions designed to prevent transmission of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and other bloodborne pathogens when providing first aid or health care. Under universal precautions, blood and certain body fluids of all patients are considered potentially infectious for HIV, HBV and other bloodborne pathogens. Retrieved from CDC web site http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html

13Main Sources of InfectionPerson to person via hands of health-care providers, patients, and visitorsPersonal clothing and equipment (e.g. Stethoscopes, flashlights etc.)Environmental contaminationAirborne transmissionHospital staff who are carriers Rare common-source outbreaks

Health care-associated infectionsInfections are caused by bacteria, fungi or viruses entering the body through one or more of the following routes. person-person via hands of health-care providers patients and visitors; personal equipment (e.g. stethoscopes, computers) and clothing; environmental contamination; airborne transmission; carriers on the hospital staff; rare common-source outbreaks.

Epidemiological evidence suggests that multidrug-resistant organisms are carried from person-to-person by health-care professionals.

Carriers are individuals who harbor disease organisms in their body without visible symptoms and may pass the infection to another person. It is possible to carry an organism without being aware of it for example, Typhoid Mary a woman who carried the typhoid bacillus and unknowingly started an epidemic in the US in the 1880s .

Outbreak is a term used in epidemiology to describe an occurrence of disease greater than would otherwise be expected in a particular time and place. It may be small and localized group or impact upon thousands of people across an entire continent. Two linked cases of a rare infectious disease may be sufficient to constitute an outbreak. Outbreaks may also refer to epidemics, which affect a region in a country or a group of countries, or pandemics, which describe global disease outbreaks.

Common source outbreak Some diseases arise from a single definable source, such as a common water supply. The basic idea is that common source outbreaks are not propagated from individual-to-individual (e.g., person-to-person). Instead, sick individuals typically are propagation dead ends. Yet the disease continues to be endemic and perhaps epidemic as a consequence of contact with some typically geographically well-defined disease reservoir.

14Main Routes for infectionsUrinary tract infections (UTI)Catheter-associated UTIs are the most frequent, accounting for about 35% of all HAI.Surgical infections: about 20% of all HAIBloodstream infections associated with the use of an intravascular device: about 15% of all HAIPneumonia associated with ventilators: about15% of HAI

The following four types of infections account for more than 80% of all health care-associated infections: urinary tract infections usually associated with catheters: - catheter-associated urinary tract infections are the most frequent, accounting for about 35% health care-associated infections; surgical infections: - these are second in frequency, about 20%; bloodstream infections associated with the use of an intravascular device: - about 15%; pneumonia associated with ventilators: - about 15%.15

Burke J Infection control-a problem for patient safety New Eng Journal of Medicine (February 13, 2003)Types of Infections16Reference:Burke, J. P. (2003). Infection control A problem for patient safety. The New England Journal of Medicine, 348, p. 651-656. Pengertian prinsip pencegahan infeksi :Suatu usaha yang dilakukan untuk mencegah terjadinya resiko penularan infeksi mikro organisme dari lingkungan klien dan tenaga kesehatan ( Nakes )Tujuan :Mengurangi terjadinya infeksiMemberikan perlindungan terhadap klien, nakes6 komponen proses terjadinya penyakit :ReservoirPenyebab penyakitJalan masukCara keluarnya penyebab penyakit dari host5.Kepekaan penjamuTindakan pencegahan penyakit :Cuci tanganMemakai sarung tanganMemakai perlengkapan pelindungMenggunakan tehnik aseptikMemproses alat bekas pakaiMenangani peralatan tajam dengan amanMenjaga kebersihan dan kerapihan lingkungan serta pembuangan sampah secara benar

CUCI TANGAN : aspek yang paling pentingAda 2 kategori organisme yang ada di Organisme residen ( flora normal )S. aureus, diphteroids ( tidak hilang secara permanen )Organisme transienKarena kontak, contoh : E. Colli (mudah dihilangkan dengan cuci tangan efektif)

Mengapa kita perlu mencuci tangan :Penanganan pasien dengan kontak tangan

Kontaminasi flora normal pasien kontak perubahan flora normal patogen

Apa yang harus digunakan untuk mencuci tangan :Dekontaminasi tangan rutin dengan sabun dan air mengalirDesinfeksi kulit ( hibiscrub, handyclean )

Hand hygiene: Three optionsThe Guideline for Hand Hygiene in Health-Care Settings CDC document at http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf will answer virtually any question you might have on the topic. Hand hygiene includes the following practices:

Hand washing with plain soap & waterThe choice for visibly dirty handsLittle to no antimicrobial activity

Hand washing with antimicrobial soap (soap with antiseptic agent) & waterSee table of antiseptic agents on next slide

Using an antiseptic hand rubWaterless, typically alcohol-based solutionsSee table of antiseptic agents on next slide

Not all of these are interchangeable, meaning that there are some situations in which one method is preferred over the other. An individual must also consider any history of allergic reaction to various products & the potential for contact dermatitis resulting from chronic use of a product.Hand hygiene: Antiseptic agents

Table excerpted from the CDCs Guidelines for Hand Hygiene in Health-Care Settings , p. 45 retrieved 12/1/09 at http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf. Your 5 moments for HAND HYGIENE

PELINDUNG DIRICuci tanganPemakaian sarung tanganSarung tangan sterilSarung tangan DTTSarung tangan bersihSarung tangan rumah tangga3. Pemakaian maskerPemakaian gaunSterilkamar bedahNon SterilICU, kamr bayi, KBSkortCelemek plastik5.Pemakaian kacamata pelindung6.Pemakaian sepatu boot / sepatu tertutup7.Kap8.Duk

Protective Barriers (PPE)Personal protective equipment (PPE) or personal protective attire (PPA) are selected and worn based upon the nature of the patient interaction* and the likely mode of pathogen transmission.** PPE include:

GlovesMasksGowns & other apparelEye, face, mouth, & inhalation protection

*Naturally the CDC has recommendations on when to use PPE. The Yale-New Haven Hospital (http://www.med.yale.edu/ynhh/infection/precautions/intro.html) offers more on the use of PPE along with instruction on how to don (put on) the equipment & remove the equipment. This is presented in the following slides.**A presentation of Transmission-Based Precautions follows the PPE information.PPE: When to use

PPE: GlovesGloves are worn to prevent the health care worker's hands from becoming contaminated with blood or body substances. Gloves should be worn for:

Procedures involving direct contact with the blood and body substances of any patient. Procedures where contact with blood and body substances might be expected to occur.Procedures involving direct or potential contact with the mucous membranes of any patient. Procedures involving direct or potential contact with the non-intact skin of any patient. Non-intact skin is skin that is cut, chapped, abraded, cracked, afflicted with weeping or exudative lesions, or is otherwise broken. Touching or handling any instruments, equipment, or surfaces that have been, or may have been, in contact with blood or body substances. In addition, gloves should be worn in providing care to a patient or in managing equipment when the health care worker has cuts, scratches, or other breaks in the skin on his/her hands. PPE: GlovesSterile gloves should be used for all sterile procedures and for activities that involve contact with areas of the body that are normally sterile.

There should be an adequate supply of clean disposable gloves on the standard precautions stations or in other locations that are convenient to each patient's room.

Gloves used in patient's care should be worn only for contact with the patient. Once used, gloves must be discarded before leaving the patient's room.PPE: GlovesProcedure for donning sterile gloves: Remove all jewelry, including rings. Wash hands using an antimicrobial cleansing agent. Dry hands thoroughly with a paper towel. Use the towel to turn off the faucet.Remove the packet of gloves from the outer wrapper. Place this packet on a clean, dry, flat surface.Unfold the packet as if opening a book. Position the packet so that the cuffed ends of the gloves are nearest to you.Grasp the center flaps and open. Both gloves must have folded cuffs. Position the packaging so that it lies flat.Use one hand to glove the other. Grasp the edge of the right glove cuff with the fingers of the left hand, and slip the right hand into this glove. Pull it on by holding onto the cuff, but do not touch the outside of the glove.Adjust both gloves so they fit properly. Make sure there are no gaps between the fingertips and the ends of the gloves.Inspect the gloves for nicks and tears before and during the procedure. Obtain a new pair of sterile gloves if there is a break in aseptic technique or if a nick or tear occurs.

PPE: Gowns

PPE: Gowns

PPE: Eye, face, mouth, & inhalation protection

PPE: Eye, face, mouth, & inhalation protection

PPE: Eye, face, mouth, & inhalation protection

PPE: Eye, face, mouth, & inhalation protection

Transmission-Based PrecautionsThe three categories of Transmission-Based Precautions come into effect when Standard Precautions are insufficient to interrupt the route(s) of transmission. (This means that Standard Precautions AND the indicated Transmission-Based Precautions should be in effect.) The categories are:

Contact precautionsApply when excessive wound drainage, fecal incontinence, or other dischargesIdeally entails single room or spatial arrangements to protect others in shared roomCaregiver wears gown & glovesDroplet precautionsApply with respiratory illnesses spread through relatively close approximation to othersIdeally entails single room or spatial arrangements & curtain to protect others in shared roomCaregiver wears maskAirborne precautionsApply when infectious agents may be suspended in the air over long distancesPreferred placement for patient in airborne infection isolation roomCaregiver wears mask or respirator as indicated by disease-specific recommendationsTransmission-Based PrecautionsOne example

CDC: 2007 Guidelines for Isolation Precautions, p. 121, retrieved 12/1/09 from http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Precautions for Specific Conditions

The CDCs 2007 Guidelines for Isolation Precautions contains a 23 page Appendix listing precautions for selected infections & conditions. A sample of this (retrieved 12/1/09 from page 94 of that document at http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf) is displayed below.Additional Precautions: Sharps

Additional Precautions: Sharps.

ASEPSIS dan TEKHNIK ASEPTIKIstilah umum yang digunakan untuk menggambarkan upaya kombinasi untuk mencegah masuknya mikroorganisme ke dalam area tubuh manapun yang sering menyebabkan infeksiTujuan asepsis adalah : membasmi jumlah mikroorganisme pada permukaan hidup (kulit dan jaringan) dan obyek mati (alat-alat bedah dan barang-barang yang lain)ANTISEPSISProses menurunkan jumlah mikroorganisme pada kulit, selaput lendir atau jaringan tubuh lainnya dengan menggunakan bahan antimikrobial (antiseptik)

KRITERIA PEMILIHAN ANTISEPTIK :Aksi yang luas (menghambat mikroorganisme secara luas gram positif. Negatif, Tb, fungi, endospora)EfektivitasKecepatan aktivitas awalEfek residuAksi yang lama setelah pemakaian untuk meredam pertumbuhan5.Tidak mengakibatkan iritasi kulit6.Tidak menyebabkan alergi7.Efektif sekali pakai, tidak perlu diulang.Contoh larutan antiseptik :Alkohol (60%- 90%)Setrimid/klorheksidin Glukonat (2-4%)contoh : Hibiscrub, Hibitane Klorheksidin Glukonat (2%)Contoh : SavlonHeksaklorofen (3%)Contoh : pHisoHextidak boleh digunakan pada selaput lendir seperti mukosa vaginaKloroksilenol (Para-kloro-metaksilenol atau PCMX)Contoh : Dettoltidak bisa digunakan untuk antisepsis vagina karena dapat membuat iritasi pada selaput lendir yang akan mempercepat pertumbuhan mikroorganisme dan tidak boleh digunakan pada bayi baru lahirIodofor (7,5-10%)Contoh : BetadineLarutan yang berbahan dasar alkohol (tingtur) seperti iodin Contoh : Yodium tinkturTriklosan (0,2-2%)

Mikroorganisme :Agen penyebab infeksiTermasuk didalamnya :bakteri, virus, fungi, parasitUntuk tujuan pencegahan infeksi bakteri dibagi menjadi 3 kategori :Vegetatif contoh : stafilokokusMikobakteria, contoh : tuberkolosisEndospora, contoh : tetanusEndospora paling sulit dibunuh disebabkan oleh lapisan pelindungnya

SterilisasiTindakan yang dilakukan untuk menghilangkan semua mikroorganisme (bakteri, jamur, parasit dan virus) termasuk endospora bakteri pada benda mati atau instrumen dengan cara uap air panas tekanan tinggi (otoklaf), panas kering (oven), sterilan kimia atau radiasi

DESINFEKSI TINGKAT TINGGI (DTT) :Tindakan yang dilakukan untuk menghilangkan semua mikroorganisme kecuali endospora bakteri pada benda mati dengan cara merebus, mengukus atau penggunaan desinfektan kimiawi

DESINFEKTAN :Adalah bahan kimia yang membunuh atau menginaktivasi mikroorganismeContoh larutan desinfektan :Klorin pemutih 0,5%untuk dekontaminasi permukaan yang lebar Klorin 0,1%Untuk DTT kimiaGlutaraldehida 2%mahal harganya biasa digunakan untuk DTT kimia atau sterilisasi kimiaFenol, klorin tidak digunakan untuk peralatan/bahan yang akan dipakaikan pada bayi baru lahir

DEKONTAMINASI :Proses yang membuat objek mati lebih aman ditangani staf sebelum dibersihkan (menginaktifasi serta menurunkan HBV, HIV tetapi tidak membasmi)Peralatan medis dan permukaan harus di dekontaminasi segera setelah terpapar darah atau cairan tubuh

PEMBERSIHAN (Mencuci dan membilas) :Tindakan yang dilakukan untuk menghilangkan semua darah, cairan, tubuh, benda asing dari kulit atau instrumen.

DEKONTAMINASIRendam dalam larutan klorin 0,5 % selama 10 menit

CUCI DAN BILASGunakan deterjen dan sikatPakai sarung tangan tebal untuk menjaga agar tidak terluka oleh benda tajam

Metode yang dipilih Metode alternatif Sterilisasi DESINFEKSI TINGKAT TINGGI

OTOKLAF PANAS KERING KIMIAWI REBUS / KUKUS KIMIAWI106 kPa170 C Rendam Panci tertutup Rendam121 C60 menit 10-24 jam 20 menit 20 menit30 menit jikaTerbungkus20 menit jika Tidak terbungkus

DINGINKAN DAN KEMUDIAN SIAP DIGUNAKANPeralatan yang sudah diproses bisa disimpan dalam wadah tertutup yang didisinfeksi tingkat tinggiSampai satu minggu jika wadahnya tidak dibuka

STERILISASI :STERILISASI UAP121 C , tekanan pada 106 kPa20 ' untuk alat tidak terbungkus30 ' untuk alat yang dibungkus2. STERILISASI PANAS KERING (OVEN)170 C selama 1 jam. Waktu penghitungan dimulai setelah suhu yang diinginkan tercapai160 C untuk alat tajam (gunting, jarum) selama 2 jam3. STERILISASI KIMIAGlutaraldehid 2-4 %(cydex), Direndam sekurang-kurangnya 10 jamFormaldehid 8 %, direndam 24 jamBilas dengan air steril sebelum digunakan kembali atau sebelum disimpan

DESINFEKSI TINGKAT TINGGI (DTT) :DTT dengan merebusMulai menghitung waktu saat air mulai mendidihMerebus 20 dalam panci tertutupSeluruh alat harus terendamJangan menambah alat apapun ke air mendidihPakai alat sesegera mungkin atau simpan wadah tertutup dan kering yang telah di DTT, maksimal 1 mingguDTT dengan mengukusSelalu kukus 20 dalam kukusanKecilkan api sehingga air tetap mendidihWaktu dihitung mulai saat keluarnya uapJangan pakai lebih dari 3 panci uapKeringkan dalam kontainer DTT

3. DTT dengan kimia :Desinfektan kimia untuk DTT klorin 0,1%, Formaldehid 8%, Glutaraldehid 2%Langkah-langkah DTT Kimia :DEkontaminasi Cuci+bilas keringkanRendam semua alat dalam larutan desinfektan selama 20Bilas dengan air yang telah direbus dan dikeringkan di udara Segera dipakai atau disimpan dalam kontainer yang kering dan telah di DTTCARA MEMBUAT LARUTAN KLORIN :Jumlah bagian (JB) air = % larutan konsentrat 1 % larutan yang diinginkan

JB air = 5,0% - 1 = 10 1 = 9 0,5%

Jadi tambahkan 9 bagian air (air tidak perlu dimasak) kedalam 1 bagian larutan klorin konsentratTerdapat rumus 9 : 1 Air : KlorinContoh soal :Buat larutan klorin 0,5% sebanyak 500 ccBuat larutan klorin 0,5% sebanyak 1 literJawab :Air = 9 x 500 cc = 450 cc 10Klorin = 1 x 500 cc = 50 cc 10 500 cc

1 liter = 1000 ccAir= 9 x 1000 cc = 900 cc 10Klorin= 1 x 1000 cc = 100 cc 10 1000 cc PENANGANAN SAMPAH / LIMBAHTujuan :Melindungi petugas pembuangan sampah dari perlukaanMelindungi penyebaran infeksi terhadap para petugas kesehatanMencegah penularan infeksi terhadap para petugas kesehatanMencegah penularan infeksi pada masyarakat sekitarnyaMembuang bahanbahan berbahaya (bahan toksik dan radioaktif) dengan amanSampah medis terbagi 2 :Tidak terkontaminasiTidak memberikan resiko infeksiContoh : kertas, kardus, botol, wadah plastik yang digunakan didalam klinikDapat dibuang ditempat sampah umumTerkontaminasiMembawa mikroorganisme yang mempunyai potensi menularkan infeksi kepada orang yang kontak baik nakes maupun masyarakatContoh : bekas pembalut luka, sampah dari kamar operasi (jaringan, darah, nanah,kasa, kapas,dll), dari laboratorium (darah, tinja, nanah, dahak, dll), alat-alat yang dapat melukai (jarum suntik, pisau)

Sampah lain yang tidak mengandung bahan infeksius tetapi digolongkan berbahaya karena mempunyai potensi berbahaya pada lingkunganBahan kimia atau farmasi (misal kaleng atau botol yang mengandung obat kadaluwarsa, vaksin, reagen desinfektan)Sampah sitotoksik (misal obat-obat untuk kemoterapi)Sampah yang mengandung logam berat (misal air raksa dari termometer yang pecah, bahan bekas gigi,dll)Wadah bekas berisi gas dan tidak dapat didaur ulang (misal kaleng penyembur) yang dapat meledak bila dibakar.

SAMPAH KERINGSAMPAH BASAHJarum, kapas, kasa, pembalut Darah, duh tubuh lain, Pisau skapel, botol obat, dll jaringan plasenta, bagian janin

DIBAKAR DALAM Dirumah sakit INSINERATOR dikumpulkan dalam wadah terpisah

Abunya (berisi gelas / bendaDibuang dalam lubang Yang tidak terbakar) ditanamyang dalam dan tertutupDalam lubang tertutupPENGGUNAAN PERAALATAN TAJAM SECARA AMANHati-hati saat melakukan penjahitan agar tidak tertusuk jarum secara tidak sengajaJangan menutup kembali, memelengkungkan, mematahkan atau melepaskan jarum yang akan dibuangBuang benda-benda tajam dalam wadah anti bocor dan segel dengan perekat jika sudah dua pertiga penuh wadah benda tajam tadi harus dibakar dalam insineratorJika tidak dapat dibakar dalam insinerator maka jarum harus dibilas 3x dengan larutan klorin 0,5% untuk dekontaminasi. Tutup lagi ujung jarum dengan penutupnya menggunakan tehnik satu tangan (one hand tehnik) lalu ditanam dalam tanah.Tempat sampah hitamsampah tidak kontaminasiTempat sampah kuningsampah terkontaminasiTerima kasih