手衛生在遏制抗微生物藥物耐藥性中的作用

喬 甫(

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

·專家論壇·

手衛生在遏制抗微生物藥物耐藥性中的作用

喬 甫(

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

手衛生； 世界衛生組織； 5月5日； 醫院感染； 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)在全球范圍內飛速增長[1]。據歐洲疾病預防與控制中心估計，歐洲范圍內AMR相關感染每年將導致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。

醫務人員污染的手在醫院感染的傳播過程中起著重要作用[4]，醫療機構內防控醫院感染和遏制AMR的傳播，手衛生扮演著關鍵的角色。2000年Lancet上發表了第一篇通過多策略模式改進全院手衛生依從性的研究[5]，證實手衛生在防控AMR中的作用，手衛生依從性從1994年的47.6%上升至1997年的66.2%，相應的醫院感染發生率從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生多策略模式得到了醫院管理者、人力資源部門、藥房、臨床主任、護士長以及全院醫務人員的大力支持，核心內容包括：鼓勵所有醫務人員使用小包裝的速干手消毒劑(alcohol-based hand rub，ABHR)消毒雙手，全院范圍內使用色彩繽紛的海報宣傳手衛生的重要性，培訓教育醫務人員，以及監測和反饋手衛生的依從性。后來，上述策略演變成世界衛生組織(World Health Organization，WHO)手衛生多模式改進策略[4]，包括：系統改變(工作中更傾向于使用ABHR消毒雙手而不是洗手)、培訓和教育、監測和反饋手衛生依從性、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療機構降低醫院感染，而且能降低醫療費用。在日內瓦，手衛生項目的花費僅占醫院感染相關費用的1%[6]；臺灣地區在手衛生方面每花費1美元，可以節約23.7美元[7]。過去幾年中，手衛生在防控醫院感染中核心作用的研究非常多[8]，WHO也發表了一篇關于手衛生降低AMR的系統綜述[9]。因此，有足夠的循證醫學證據支持我們在醫院內推動手衛生項目。

另外，為幫助醫療機構推動手衛生，WHO還發布了《世界衛生組織手衛生指南》[4]、《WHO多模式改進手衛生策略實施指南》[10]、《手衛生技術參考手冊》等指南，在WHO的網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/)。中國衛生部于2009年頒布了《醫務人員手衛生規范》(http://www.nhfpc.gov.cn/zwgkzt/s9496/200904/40118.shtml)，為中國醫院推動手衛生項目提供了制度保障。現在，中國大多數的感控工作者和醫務人員都已知道手衛生在感染預防和控制中的重要作用，并已經開始改進手衛生行為。一項中國14個省份200多所醫院參與的調查結果顯示，醫務人員手衛生依從性已達到70%[11]。作為2012年“亞太手衛生杰出大獎”的獲得者——四川大學華西醫院也為其他醫院推動手衛生樹立了榜樣[12]。

現在，是開展2017年世界手衛生日活動的時候，截至2017年2月，已經有來自177個國家的19 217所醫療機構在網上注冊參與年度手衛生活動。請立即行動起來，注冊參與今年的手衛生活動(注冊網址：http://www.who.int/gpsc/5may/register/en/)，你可以從WHO的官方網站(http://www.who.int/gpsc/5may/en/)上下載相關的宣傳海報、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, 李衛光，等.中國醫院手衛生知識知曉及依從性現狀調查[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，主要從事手衛生和多重耐藥菌醫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