手衛(wèi)生在遏制抗微生物藥物耐藥性中的作用

喬 甫(

(1 四川大學華西醫(yī)院，四川 成都 610041; 2 日內(nèi)瓦大學醫(yī)院感染控制服務部，WHO病人安全與感染控制合作中心，日內(nèi)瓦 瑞士，1211； 3 里斯本大學北里斯本中心醫(yī)院/醫(yī)學院感染性疾病科，里斯本 葡萄牙，1649-023)

·專家論壇·

手衛(wèi)生在遏制抗微生物藥物耐藥性中的作用

喬 甫(

(1 四川大學華西醫(yī)院，四川 成都 610041; 2 日內(nèi)瓦大學醫(yī)院感染控制服務部，WHO病人安全與感染控制合作中心，日內(nèi)瓦 瑞士，1211； 3 里斯本大學北里斯本中心醫(yī)院/醫(yī)學院感染性疾病科，里斯本 葡萄牙，1649-023)

手衛(wèi)生； 世界衛(wèi)生組織； 5月5日； 醫(yī)院感染； 抗微生物藥物耐藥性

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 !

近年來，抗微生物藥物耐藥性(antimicrobial resistance，AMR)在全球范圍內(nèi)飛速增長[1]。據(jù)歐洲疾病預防與控制中心估計，歐洲范圍內(nèi)AMR相關(guān)感染每年將導致2.5萬例患者死亡，額外增加250萬住院日以及15億歐元花費[2]。美國的情況同樣嚴重，據(jù)美國疾病控制與預防中心(CDC)估計，美國每年僅耐碳青霉烯類腸桿菌科細菌引起的感染就會導致610例患者死亡[3]。因此，預防和控制AMR的傳播已迫在眉睫。

醫(yī)務人員污染的手在醫(yī)院感染的傳播過程中起著重要作用[4]，醫(yī)療機構(gòu)內(nèi)防控醫(yī)院感染和遏制AMR的傳播，手衛(wèi)生扮演著關(guān)鍵的角色。2000年Lancet上發(fā)表了第一篇通過多策略模式改進全院手衛(wèi)生依從性的研究[5]，證實手衛(wèi)生在防控AMR中的作用，手衛(wèi)生依從性從1994年的47.6%上升至1997年的66.2%，相應的醫(yī)院感染發(fā)生率從1994年的16.9%下降至1998年的9.9%，耐甲氧西林金黃色葡萄球菌(methicillin-resistantStaphylococcusaureus，MRSA)感染的發(fā)生率從2.16 例/萬患者日降低至0.93例/萬患者日。該研究中使用的手衛(wèi)生多策略模式得到了醫(yī)院管理者、人力資源部門、藥房、臨床主任、護士長以及全院醫(yī)務人員的大力支持，核心內(nèi)容包括：鼓勵所有醫(yī)務人員使用小包裝的速干手消毒劑(alcohol-based hand rub，ABHR)消毒雙手，全院范圍內(nèi)使用色彩繽紛的海報宣傳手衛(wèi)生的重要性，培訓教育醫(yī)務人員，以及監(jiān)測和反饋手衛(wèi)生的依從性。后來，上述策略演變成世界衛(wèi)生組織(World Health Organization，WHO)手衛(wèi)生多模式改進策略[4]，包括：系統(tǒng)改變(工作中更傾向于使用ABHR消毒雙手而不是洗手)、培訓和教育、監(jiān)測和反饋手衛(wèi)生依從性、工作場所提醒以及建立安全的文化5大策略。這些措施不僅能幫助醫(yī)療機構(gòu)降低醫(yī)院感染，而且能降低醫(yī)療費用。在日內(nèi)瓦，手衛(wèi)生項目的花費僅占醫(yī)院感染相關(guān)費用的1%[6]；臺灣地區(qū)在手衛(wèi)生方面每花費1美元，可以節(jié)約23.7美元[7]。過去幾年中，手衛(wèi)生在防控醫(yī)院感染中核心作用的研究非常多[8]，WHO也發(fā)表了一篇關(guān)于手衛(wèi)生降低AMR的系統(tǒng)綜述[9]。因此，有足夠的循證醫(yī)學證據(jù)支持我們在醫(yī)院內(nèi)推動手衛(wèi)生項目。

另外，為幫助醫(yī)療機構(gòu)推動手衛(wèi)生，WHO還發(fā)布了《世界衛(wèi)生組織手衛(wèi)生指南》[4]、《WHO多模式改進手衛(wèi)生策略實施指南》[10]、《手衛(wèi)生技術(shù)參考手冊》等指南，在WHO的網(wǎng)站上也可以免費獲得部分指南的中文版本(http://www.who.int/gpsc/5may/tools/zh/)。中國衛(wèi)生部于2009年頒布了《醫(yī)務人員手衛(wèi)生規(guī)范》(http://www.nhfpc.gov.cn/zwgkzt/s9496/200904/40118.shtml)，為中國醫(yī)院推動手衛(wèi)生項目提供了制度保障。現(xiàn)在，中國大多數(shù)的感控工作者和醫(yī)務人員都已知道手衛(wèi)生在感染預防和控制中的重要作用，并已經(jīng)開始改進手衛(wèi)生行為。一項中國14個省份200多所醫(yī)院參與的調(diào)查結(jié)果顯示，醫(yī)務人員手衛(wèi)生依從性已達到70%[11]。作為2012年“亞太手衛(wèi)生杰出大獎”的獲得者——四川大學華西醫(yī)院也為其他醫(yī)院推動手衛(wèi)生樹立了榜樣[12]。

現(xiàn)在，是開展2017年世界手衛(wèi)生日活動的時候，截至2017年2月，已經(jīng)有來自177個國家的19 217所醫(yī)療機構(gòu)在網(wǎng)上注冊參與年度手衛(wèi)生活動。請立即行動起來，注冊參與今年的手衛(wèi)生活動(注冊網(wǎng)址：http://www.who.int/gpsc/5may/register/en/)，你可以從WHO的官方網(wǎng)站(http://www.who.int/gpsc/5may/en/)上下載相關(guān)的宣傳海報、視頻等資料。

遏制抗微生物藥物耐藥性，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, 侯鐵英, 李衛(wèi)光，等.中國醫(yī)院手衛(wèi)生知識知曉及依從性現(xiàn)狀調(diào)查[J]. 中國感染控制雜志,2016, 15(9): 654-658.

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

(本文編輯：左雙燕)

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

喬甫(1982-),男(漢族) , 四川省成都市人，主管技師，主要從事手衛(wèi)生和多重耐藥菌醫(yī)院感染的預防與控制研究。

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

10.3969/j.issn.1671-9638.2017.04.001

R197.323.4

A

1671-9638(2017)04-0293-03