手卫生在遏制抗微生物药物耐药性中的作用

2017-01-14乔甫(

中国感染控制杂志 2017年4期

关键词：里斯本耐药性医务人员

乔甫(

(1 四川大学华西医院，四川成都 610041; 2 日内瓦大学医院感染控制服务部，WHO病人安全与感染控制合作中心，日内瓦瑞士，1211； 3 里斯本大学北里斯本中心医院/医学院感染性疾病科，里斯本葡萄牙，1649-023)

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手卫生在遏制抗微生物药物耐药性中的作用

乔甫(

手卫生；世界卫生组织； 5月5日；医院感染；抗微生物药物耐药性

Antimicrobial resistance (AMR) is increasing rapidly worldwide[1]. The European Centre for Disease Prevention and Control (ECDC) estimates that 25 000 deaths, 2.5 million extra hospital days, and 1.5 billion extra Euros are associated with AMR infection in Europe each year[2]. In the United States, according to the Centers for Disease Control and Prevention(CDC), healthcare-associated infections (HAIs) caused by carbapenem-resistant Enterobacteriaceae are responsible for 610 deaths annually[3]. Therefore, it’s urgent to prevent and control the spread of AMR.

Health care workers’ (HCWs) contaminated hands play an important role in the spread of HAIs[4]. Hand hygiene should be implemented for all patients at all times: this is key to prevent HAI and the spread of AMR in healthcare setting. The first study that showed an improvement in hand hygiene compliance with a hospital-wide multimodal strategy also demonstrated a reduction in HAI and AMR spread[5]， the increase in hand hygiene compliance from 47.6% in 1994 to 66.2% in 1997 was associated with a reduction in the prevalence of HAIs from 16.9% in 1994 to 9.9% in 1998 as well as with the overall decrease in incidence of methicillin-resistantStaphylococcusaureus(MRSA) infections from 2.16 to 0.93 episodes per 10 000 patient-days. The multimodal hand hygiene improvement programme had a strong support from hospital administrator, the human resources department, pharmacy, chief executive, medical and nursing directors, as well as all health care workers(HCWs) in the hospital. The most prominent component of this strategy was the change from hand washing to the use of alcohol-based hand rub (ABHR): individual bottles of ABHR were distributed to all HCWs and they were encouraged to carry it in their pockets and used it to clean their hands. Additionally, colourful posters that emphasized the importance of hand hygiene were displayed all over the hospital, educational sessions were performed to teach HCWs, and monitoring of hand hygiene and feedback of results to HCWs were frequently performed. This programme later became the WHO hand hygiene multimodal improvement strategy[4], which is constituted by five elements: system change with the preferred use of ABHR rather than handwashing with soap and water, HCWs’ education, compliance monitoring of the “five moments for hand hygiene” and performance feedback, reminders in the workplace and institutional safety climate. Importantly, this strategy not only helped to decrease HAI but also reduce cost. In Geneva, the hand hygiene program contribute to less than 1% of the costs associated with HAIs[6]. A study conducted in Taiwan showed that for every U.S. $ 1 spent on hand hygiene promotion, U.S. $ 23.7 were saved[7]. Many other studies published in the past years provided evidence on the central role of hand hygiene in the prevention and control of HAI[8]. Additionally, a review about the role of hand hygiene in controlling AMR in healthcare settings has been published by WHO[9]. The evidence for promoting hand hygiene is very strong.

WHO published several guidelines and documents to help healthcare settings to promote hand hygiene, includingWHOGuidelinesonHandHygieneinHealthCare[4],AGuidetoImplementationoftheWHOMultimodalHandHygieneImprovementStrategy[10],HandHygieneTechnicalReferenceManual, etc. The Chinese versions of these guidelines and tools are available free of charge (http://www.who.int/gpsc/5may/tools/zh/). Additionally, the Ministry of Health of China has published a national hand hygiene guideline in 2009 (http://www.nhfpc.gov. cn/ zwgkzt/s9496/200904/40118.shtml). These documents show the strong commitment from the Chinese authorities towards improving hand hygiene and open another door for infection control practitioners (ICPs) to promote hand hygiene in their hospitals. Most ICPs and HCWs in China have understood the importance of hand hygiene in infection control and have started to improve hand hygiene with encouraging results. A recently published study conducted in more than 200 hospitals in 14 provinces of China revealed that the compliance with hand hygiene was up to 70%[11]. As a winner of ‘TheAsiaPacificHandHygieneExcellenceAwardandInnovationAward’ in 2012[12], the West China Hospital of Sichuan University is also a model to inspire other hospitals in China.

Now, it’s time to celebrate the WHO hand hygiene day in 2017. By the end of February 19, 2017, 217 health care facilities across 177 countries have registered to support the annual hand hygiene campaign and have committed to action to improve hand hygiene (you can also register your facility at: http://www.who.int/gpsc /5may/ register/en/). You can get posters, videos and other materials for free in theCleanCareisSaferCarewebsite to promote hand hygiene and the 5thof May at your hospital (http://www.who.int/gpsc/5may/en/).

Fight antimicrobial resistance—it’s in your hands !

近年来，抗微生物药物耐药性(antimicrobial resistance，AMR)在全球范围内飞速增长[1]。据欧洲疾病预防与控制中心估计，欧洲范围内AMR相关感染每年将导致2.5万例患者死亡，额外增加250万住院日以及15亿欧元花费[2]。美国的情况同样严重，据美国疾病控制与预防中心(CDC)估计，美国每年仅耐碳青霉烯类肠杆菌科细菌引起的感染就会导致610例患者死亡[3]。因此，预防和控制AMR的传播已迫在眉睫。

医务人员污染的手在医院感染的传播过程中起着重要作用[4]，医疗机构内防控医院感染和遏制AMR的传播，手卫生扮演着关键的角色。2000年Lancet上发表了第一篇通过多策略模式改进全院手卫生依从性的研究[5]，证实手卫生在防控AMR中的作用，手卫生依从性从1994年的47.6%上升至1997年的66.2%，相应的医院感染发生率从1994年的16.9%下降至1998年的9.9%，耐甲氧西林金黄色葡萄球菌(methicillin-resistantStaphylococcusaureus，MRSA)感染的发生率从2.16 例/万患者日降低至0.93例/万患者日。该研究中使用的手卫生多策略模式得到了医院管理者、人力资源部门、药房、临床主任、护士长以及全院医务人员的大力支持，核心内容包括：鼓励所有医务人员使用小包装的速干手消毒剂(alcohol-based hand rub，ABHR)消毒双手，全院范围内使用色彩缤纷的海报宣传手卫生的重要性，培训教育医务人员，以及监测和反馈手卫生的依从性。后来，上述策略演变成世界卫生组织(World Health Organization，WHO)手卫生多模式改进策略[4]，包括：系统改变(工作中更倾向于使用ABHR消毒双手而不是洗手)、培训和教育、监测和反馈手卫生依从性、工作场所提醒以及建立安全的文化5大策略。这些措施不仅能帮助医疗机构降低医院感染，而且能降低医疗费用。在日内瓦，手卫生项目的花费仅占医院感染相关费用的1%[6]；台湾地区在手卫生方面每花费1美元，可以节约23.7美元[7]。过去几年中，手卫生在防控医院感染中核心作用的研究非常多[8]，WHO也发表了一篇关于手卫生降低AMR的系统综述[9]。因此，有足够的循证医学证据支持我们在医院内推动手卫生项目。

另外，为帮助医疗机构推动手卫生，WHO还发布了《世界卫生组织手卫生指南》[4]、《WHO多模式改进手卫生策略实施指南》[10]、《手卫生技术参考手册》等指南，在WHO的网站上也可以免费获得部分指南的中文版本(http://www.who.int/gpsc/5may/tools/zh/)。中国卫生部于2009年颁布了《医务人员手卫生规范》(http://www.nhfpc.gov.cn/zwgkzt/s9496/200904/40118.shtml)，为中国医院推动手卫生项目提供了制度保障。现在，中国大多数的感控工作者和医务人员都已知道手卫生在感染预防和控制中的重要作用，并已经开始改进手卫生行为。一项中国14个省份200多所医院参与的调查结果显示，医务人员手卫生依从性已达到70%[11]。作为2012年“亚太手卫生杰出大奖”的获得者——四川大学华西医院也为其他医院推动手卫生树立了榜样[12]。

现在，是开展2017年世界手卫生日活动的时候，截至2017年2月，已经有来自177个国家的19 217所医疗机构在网上注册参与年度手卫生活动。请立即行动起来，注册参与今年的手卫生活动(注册网址：http://www.who.int/gpsc/5may/register/en/)，你可以从WHO的官方网站(http://www.who.int/gpsc/5may/en/)上下载相关的宣传海报、视频等资料。

遏制抗微生物药物耐药性，就在你的手中。

[1] World Health Organization. Antimicrobial resistance: global report on surveillance [M]. WHO, 2014.

[2] European Centre for Disease Prevention and Control. The bacterial challenge, time to react[M]. Stockholm, ECDC, 2009.

[3] Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States[R]. CDC, 2013.

[4] World Health Organization. Guidelines on hand hygiene in health care: first global patient safety challenge: clean care is safer care[S].WHO, 2009.

[5] Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene[J]. Lancet, 2000, 356(9238): 1307-1312.

[6] Pittet D, Sax H, Hugonnet S, et al. Cost implications of successful hand hygiene promotion[J]. Infect Control Hosp Epidemiol, 2004, 25(3): 264-266.

[7] Chen YC, Sheng WH, Wang JT, et al. Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections[J]. PloS One, 2011, 6(11): e27163.

[8] Luangasanatip N, Hongsuwan M, Limmathurotsakul D, et al. Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis[J]. BMJ, 2015, 351: h3728.

[9] World Health Organization. Evidence of hand hygiene to reduce transmission and infections by multi-drug resistant organisms in health-care settings [EB/OL]. (2014-11)[2016-12]. http://www.who.int/gpsc/ 5may / MDRO _literature-review.pdf.

[10] World Health Organization. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy[S]. WHO, 2009.

[11] 徐丹慧, 侯铁英, 李卫光，等.中国医院手卫生知识知晓及依从性现状调查[J]. 中国感染控制杂志,2016, 15(9): 654-658.

[12] HHEA. Hand hygiene excellence award and innovation award [EB / OL].(2016)[2017-1]. http://www.hhea.info.

(本文编辑：左双燕)

Combat antimicrobial resistance: the role of hand hygiene

QIAO Fu)1, Daniela Pires2,3, Didier Pittet2

(1 West China Hospital, Sichuan University, Chengdu 610041, China; 2 Infection Control Programme and WHO Collaborating Centre on Patient Safety-Infection Control & Improving Practice, University of Geneva Hospital and Faculty of Medicine, Geneva 1211, Switzerland; 3 Department of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon 1649-023, Portugal)

hand hygiene; World Health Organization； 5thof May; healthcare-associated infection; antimicrobial resistance

2017-04-05

乔甫(1982-),男(汉族) , 四川省成都市人，主管技师，主要从事手卫生和多重耐药菌医院感染的预防与控制研究。

Didier Pittet E-mail:didier.pittet@hcuge.ch

10.3969/j.issn.1671-9638.2017.04.001

R197.323.4

1671-9638(2017)04-0293-03