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Severely ill patients often have organ failure or are in a more critical state after surgery; at the same time, there are often damage to the skin and mucosal barriers after the operation, including damage to the respiratory tract barrier caused by tracheal intubation, and damage to the gastrointestinal mucosal barrier leading to gastrointestinal bleeding.
Therefore, this Patients in this category are at high risk of infection.
Once a patient develops an infection, the treatment time is urgent and the precision requirements are higher.
Therefore, the rational application of antibacterial drugs is particularly important for critically ill patients.
What is the status of ICU infection prevention and control? What are the new requirements for infection prevention and control in the Department of Critical Care Medicine due to the severe situation of microbial resistance, increasingly standardized management of antimicrobial drugs, and changes in medical insurance policies? "Physician Daily" specially invited Professor Qiu Haibo, Deputy Secretary of the Party Committee and Secretary of the Disciplinary Committee of Zhongda Hospital Affiliated to Southeast University, to give a detailed interpretation.
Prevention is the first to effectively carry out the standardization of infection control and various operations "Infection prevention and control is one of the most important tasks in the ICU, which mainly includes how to prevent infection and how to accurately diagnose and treat patients who have already been infected.
" Professor Qiu Said that the prevention of catheter-related infections, ventilator-associated pneumonia (VAP) and urinary tract infections is still the top priority, and it is particularly important to control the infection.
Therefore, sensory control measures such as hand hygiene and bedside isolation of patients are getting more and more attention.
"Our department requires a handwashing rate of more than 90% before and after contact with patients to reduce the spread of pathogenic microorganisms between patients or between patients and medical staff.
" At the same time, every high-risk operation that may cause infection has management practices, such as VAP.
Bundle management (VAPBundle) includes the management of a series of items that require patients in a semi-recumbent position, oral cleaning, disinfectant treatment, balloon pressure measurement, reasonable airway management, and appropriate anticoagulation.The prevention of catheter-related infections begins when the catheter is inserted, including the indication of deep venous catheter placement; the catheter placement site can be given priority to the subclavian internal jugular vein and femoral vein; standard disinfection before catheter insertion, and the whole body drape, Try to intubate the catheter under ultrasound guidance to avoid damage to the blood vessel.
After the catheter is placed, you must use imaging to locate the catheter; manage each catheter and its interface to avoid future contamination.
At the same time, evaluate the catheter removal every day.
There is also a corresponding Bundle for urinary tract infections.
"In recent years, with the implementation of these infection control measures and preventive measures, we can see from the national quality control data that the overall infection rate of VAP, catheter-related infections and urinary tract infections has gradually decreased, but it is still biased compared with international ones.
High.
"The ICU is the window for the results of the prevention and control of drug resistance in the hospital and the whole society.
To accurately understand the epidemic situation of infectious etiology in the intensive care department, we must first pay attention to the source of specimens.
Professor Qiu said that in the early years, the relevant specimens were more from the lower respiratory tract or sputum, but it is often difficult to distinguish infection and colonization from the lower respiratory tract and sputum specimens.
"In recent years, the proportion of blood culture specimens has increased, and respiratory tract specimens have dropped from about 70% in the past to less than 50% today.
" From the current drug resistance data, the main positive bacteria in the ICU in the past 10 years-golden yellow grapes The cocci significantly decreased, reflecting the effectiveness of hospital feeling control.
On the other hand, the proportion of negative bacteria increased, mainly including Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and some Enterobacteriaceae bacteria, such as Escherichia coli.
In particular, the drug-resistant Klebsiella pneumoniae has gradually become the most important pathogenic bacteria for bloodstream infections, abdominal cavity infections, and even lung infections, requiring vigilance.
"From the national monitoring data, the proportion of carbapenem-resistant Klebsiella pneumoniae has declined.
ICU patients come from all departments of the whole hospital, so it also reflects the use of antibacterial drugs in the whole hospital and whether the control of hospital feeling is in place or not.
The result.
"Professor Qiu said that the ICU is like a window, a window to display drug-resistant bacteria in the whole hospital.
If there are more and more drug-resistant bacteria in the ICU, the reasons should be analyzed. Professor Qiu's team conducted a study to screen all patients entering the ICU regardless of emergency department, surgery, tumor, etc.
for drug-resistant bacteria.
It was found that 20% to 30% of patients were carrying multi-drug resistant bacteria when they entered the ICU.
For example, some patients with hematological tumors may have infections, longer use of antibacterial drugs, and longer hospital stays.
20% of patients may carry carbapenem-resistant Klebsiella pneumoniae, which may later become bloodstream infections and systemic infection.
"In the past, hospital feelings focused more on hand hygiene, but now it is discovered that after hand hygiene is done, the pressure of the whole society on the use of antibacterial drugs and the results of the use of antibacterial drugs and the infection control measures in the whole hospital will eventually be reflected in the patients.
Some direct Severely ill patients from the community, when they entered the ICU, the drug-resistant bacteria were screened and found to carry multidrug-resistant bacteria, which may be related to the use of antimicrobial drugs in other industries (such as animal feed addition), and the previous unreasonable use of antimicrobial drugs caused pressure on antimicrobial drugs.
It is worthwhile The entire hospital and the entire society attach great importance to it.
"Multidisciplinary collaboration and the development of pathogen detection technology promote the transformation of empirical treatment to target treatment.
The rational application of antimicrobials is an important measure to effectively treat patients and curb drug resistance.
Professor Qiu said that the management of antibacterial drugs in the entire hospital needs to be undertaken by a main department.
The "Notice on Further Strengthening the Management of Antimicrobial Drugs to Contain Drug Resistance" issued by the National Health Commission on April 7 emphasized the strengthening of the construction of related disciplines, especially the construction of main departments, such as the Department of Infectious Diseases, which is responsible for the rationalization of antimicrobial drugs in hospitals.
The main responsibility of the use.
For intensive care doctors, it is extremely important to improve their anti-infective medical capabilities, but at the same time, intensive care doctors have their own work priorities and discipline characteristics.
Therefore, in anti-infectives, while standardizing diagnosis and treatment, it is necessary to pay attention to multidisciplinary cooperation and promptly request Multidisciplinary consultations such as the Department of Infectious Diseases and clinical pharmacy are very important to improve the timeliness, rationality and standardization of the entire treatment of severe infections.
"In addition, the notice also calls for strengthening the construction of clinical microbiology.
For severe infections, early diagnosis of pathogenic microorganisms and accurate drug sensitivity reports are very important.
The progress of microbiology will also drive the improvement of the ability of severely ill patients to resist infection. "Professor Qiu said that due to the high proportion of severely infected Gram-negative bacteria, carbapenems are clinically important antibacterial drugs.
The
rational application of carbapenems can reduce the occurrence of drug resistance.
On the one hand, it is necessary to treat pathogenic microorganisms.
Make an early and appropriate judgment.
In
the case of no etiological results, it is necessary to emphasize the strict implementation of the management system of special-level antibacterial drugs when using empirically, and there must be a chief physician or deputy chief physician, or a corresponding consultation team.
Medication Indications, especially in empirical medication, the patient’s site of infection, severity of infection, and host factors should be considered.
If it is considered to be a gram-negative bacteria and the infection is very serious, carbon blue will be considered only when it is likely to be resistant to enzyme preparations.
Mycodins.
And send the microorganisms to culture immediately before use, shorten the time of empirical medication as much as possible, and turn empirical treatment into targeted treatment.
"Nowadays, some new technologies, such as MALDI-TOF technology and metagenomic sequencing technology, Let us know what microorganisms are and what antibacterial drugs are resistant to earlier, and provide important support for shortening the time of empirical treatment and reducing resistance.
"Quality first, low prices, but more emphasis on rational application.
The centralized procurement of drugs with volume is a major national measure to reduce patient medical expenditures, reflecting the advanced nature and superiority of the system design.
Professor Qiu said that this is a real move.
It reduces the medical burden of patients and reflects the country’s purpose for the people.
At the same time, there are several aspects that need to be paid attention to in the specific implementation process.
"In some places, in addition to the price factor, the brand and quality also need to be adequate.
consider.
Antibacterial drugs, especially those used by severely infected patients, are often life-saving, so they must be quality first and must be effective.
The state should strengthen evaluation and supervision in this regard.
At present, it is still not enough to carry out the consistency evaluation, that is, the evaluation of pharmacokinetics.
"On the other hand, Professor Qiu told reporters that due to the decline in prices of antibacterial drugs after the collection of antibacterial drugs, some primary hospitals have used some antibacterial drugs, such as enzyme inhibitor complex preparations and carbapenem drugs, to a certain extent.
This will lead to an increase in the drug resistance of hospital patients.
“The price drop does not mean that we can use these drugs on more patients, but it also requires strict indications, whether from clinical norms or from the health authorities.
Both are very important from a regulatory perspective.
Typesetting: Huang Lingling, Qiu Jia Editor: Qiu Jia Review: Xu Fengyan For more content, please click: Stop drug resistance, you and me ①｜Zhuo Chao: Stop drug resistance, starting from getting to know it, currently 1130000+ doctors have joined us
Therefore, this Patients in this category are at high risk of infection.
Once a patient develops an infection, the treatment time is urgent and the precision requirements are higher.
Therefore, the rational application of antibacterial drugs is particularly important for critically ill patients.
What is the status of ICU infection prevention and control? What are the new requirements for infection prevention and control in the Department of Critical Care Medicine due to the severe situation of microbial resistance, increasingly standardized management of antimicrobial drugs, and changes in medical insurance policies? "Physician Daily" specially invited Professor Qiu Haibo, Deputy Secretary of the Party Committee and Secretary of the Disciplinary Committee of Zhongda Hospital Affiliated to Southeast University, to give a detailed interpretation.
Prevention is the first to effectively carry out the standardization of infection control and various operations "Infection prevention and control is one of the most important tasks in the ICU, which mainly includes how to prevent infection and how to accurately diagnose and treat patients who have already been infected.
" Professor Qiu Said that the prevention of catheter-related infections, ventilator-associated pneumonia (VAP) and urinary tract infections is still the top priority, and it is particularly important to control the infection.
Therefore, sensory control measures such as hand hygiene and bedside isolation of patients are getting more and more attention.
"Our department requires a handwashing rate of more than 90% before and after contact with patients to reduce the spread of pathogenic microorganisms between patients or between patients and medical staff.
" At the same time, every high-risk operation that may cause infection has management practices, such as VAP.
Bundle management (VAPBundle) includes the management of a series of items that require patients in a semi-recumbent position, oral cleaning, disinfectant treatment, balloon pressure measurement, reasonable airway management, and appropriate anticoagulation.The prevention of catheter-related infections begins when the catheter is inserted, including the indication of deep venous catheter placement; the catheter placement site can be given priority to the subclavian internal jugular vein and femoral vein; standard disinfection before catheter insertion, and the whole body drape, Try to intubate the catheter under ultrasound guidance to avoid damage to the blood vessel.
After the catheter is placed, you must use imaging to locate the catheter; manage each catheter and its interface to avoid future contamination.
At the same time, evaluate the catheter removal every day.
There is also a corresponding Bundle for urinary tract infections.
"In recent years, with the implementation of these infection control measures and preventive measures, we can see from the national quality control data that the overall infection rate of VAP, catheter-related infections and urinary tract infections has gradually decreased, but it is still biased compared with international ones.
High.
"The ICU is the window for the results of the prevention and control of drug resistance in the hospital and the whole society.
To accurately understand the epidemic situation of infectious etiology in the intensive care department, we must first pay attention to the source of specimens.
Professor Qiu said that in the early years, the relevant specimens were more from the lower respiratory tract or sputum, but it is often difficult to distinguish infection and colonization from the lower respiratory tract and sputum specimens.
"In recent years, the proportion of blood culture specimens has increased, and respiratory tract specimens have dropped from about 70% in the past to less than 50% today.
" From the current drug resistance data, the main positive bacteria in the ICU in the past 10 years-golden yellow grapes The cocci significantly decreased, reflecting the effectiveness of hospital feeling control.
On the other hand, the proportion of negative bacteria increased, mainly including Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and some Enterobacteriaceae bacteria, such as Escherichia coli.
In particular, the drug-resistant Klebsiella pneumoniae has gradually become the most important pathogenic bacteria for bloodstream infections, abdominal cavity infections, and even lung infections, requiring vigilance.
"From the national monitoring data, the proportion of carbapenem-resistant Klebsiella pneumoniae has declined.
ICU patients come from all departments of the whole hospital, so it also reflects the use of antibacterial drugs in the whole hospital and whether the control of hospital feeling is in place or not.
The result.
"Professor Qiu said that the ICU is like a window, a window to display drug-resistant bacteria in the whole hospital.
If there are more and more drug-resistant bacteria in the ICU, the reasons should be analyzed. Professor Qiu's team conducted a study to screen all patients entering the ICU regardless of emergency department, surgery, tumor, etc.
for drug-resistant bacteria.
It was found that 20% to 30% of patients were carrying multi-drug resistant bacteria when they entered the ICU.
For example, some patients with hematological tumors may have infections, longer use of antibacterial drugs, and longer hospital stays.
20% of patients may carry carbapenem-resistant Klebsiella pneumoniae, which may later become bloodstream infections and systemic infection.
"In the past, hospital feelings focused more on hand hygiene, but now it is discovered that after hand hygiene is done, the pressure of the whole society on the use of antibacterial drugs and the results of the use of antibacterial drugs and the infection control measures in the whole hospital will eventually be reflected in the patients.
Some direct Severely ill patients from the community, when they entered the ICU, the drug-resistant bacteria were screened and found to carry multidrug-resistant bacteria, which may be related to the use of antimicrobial drugs in other industries (such as animal feed addition), and the previous unreasonable use of antimicrobial drugs caused pressure on antimicrobial drugs.
It is worthwhile The entire hospital and the entire society attach great importance to it.
"Multidisciplinary collaboration and the development of pathogen detection technology promote the transformation of empirical treatment to target treatment.
The rational application of antimicrobials is an important measure to effectively treat patients and curb drug resistance.
Professor Qiu said that the management of antibacterial drugs in the entire hospital needs to be undertaken by a main department.
The "Notice on Further Strengthening the Management of Antimicrobial Drugs to Contain Drug Resistance" issued by the National Health Commission on April 7 emphasized the strengthening of the construction of related disciplines, especially the construction of main departments, such as the Department of Infectious Diseases, which is responsible for the rationalization of antimicrobial drugs in hospitals.
The main responsibility of the use.
For intensive care doctors, it is extremely important to improve their anti-infective medical capabilities, but at the same time, intensive care doctors have their own work priorities and discipline characteristics.
Therefore, in anti-infectives, while standardizing diagnosis and treatment, it is necessary to pay attention to multidisciplinary cooperation and promptly request Multidisciplinary consultations such as the Department of Infectious Diseases and clinical pharmacy are very important to improve the timeliness, rationality and standardization of the entire treatment of severe infections.
"In addition, the notice also calls for strengthening the construction of clinical microbiology.
For severe infections, early diagnosis of pathogenic microorganisms and accurate drug sensitivity reports are very important.
The progress of microbiology will also drive the improvement of the ability of severely ill patients to resist infection. "Professor Qiu said that due to the high proportion of severely infected Gram-negative bacteria, carbapenems are clinically important antibacterial drugs.
The
rational application of carbapenems can reduce the occurrence of drug resistance.
On the one hand, it is necessary to treat pathogenic microorganisms.
Make an early and appropriate judgment.
In
the case of no etiological results, it is necessary to emphasize the strict implementation of the management system of special-level antibacterial drugs when using empirically, and there must be a chief physician or deputy chief physician, or a corresponding consultation team.
Medication Indications, especially in empirical medication, the patient’s site of infection, severity of infection, and host factors should be considered.
If it is considered to be a gram-negative bacteria and the infection is very serious, carbon blue will be considered only when it is likely to be resistant to enzyme preparations.
Mycodins.
And send the microorganisms to culture immediately before use, shorten the time of empirical medication as much as possible, and turn empirical treatment into targeted treatment.
"Nowadays, some new technologies, such as MALDI-TOF technology and metagenomic sequencing technology, Let us know what microorganisms are and what antibacterial drugs are resistant to earlier, and provide important support for shortening the time of empirical treatment and reducing resistance.
"Quality first, low prices, but more emphasis on rational application.
The centralized procurement of drugs with volume is a major national measure to reduce patient medical expenditures, reflecting the advanced nature and superiority of the system design.
Professor Qiu said that this is a real move.
It reduces the medical burden of patients and reflects the country’s purpose for the people.
At the same time, there are several aspects that need to be paid attention to in the specific implementation process.
"In some places, in addition to the price factor, the brand and quality also need to be adequate.
consider.
Antibacterial drugs, especially those used by severely infected patients, are often life-saving, so they must be quality first and must be effective.
The state should strengthen evaluation and supervision in this regard.
At present, it is still not enough to carry out the consistency evaluation, that is, the evaluation of pharmacokinetics.
"On the other hand, Professor Qiu told reporters that due to the decline in prices of antibacterial drugs after the collection of antibacterial drugs, some primary hospitals have used some antibacterial drugs, such as enzyme inhibitor complex preparations and carbapenem drugs, to a certain extent.
This will lead to an increase in the drug resistance of hospital patients.
“The price drop does not mean that we can use these drugs on more patients, but it also requires strict indications, whether from clinical norms or from the health authorities.
Both are very important from a regulatory perspective.
Typesetting: Huang Lingling, Qiu Jia Editor: Qiu Jia Review: Xu Fengyan For more content, please click: Stop drug resistance, you and me ①｜Zhuo Chao: Stop drug resistance, starting from getting to know it, currently 1130000+ doctors have joined us
