• Dr. Agung Dwi Wahyu Widodo, dr, M.

Si
• Departemen Mikrobiologi Kedokteran/ Klinik
• Fakultas Kedokteran FK Unair/ RSUD Dr
Soetomo Surabaya
Curriculum Vitae
• Training :
• Infection and Immunity, Osaka Univ, Japan
(2009)
• Tropical Infection and Molecular Biology,
Gottingen Univ, Germany (2010)
• Infection and Immunity, The Univ of Tokyo,
Japan (2010)
• Infection and Immunity, Osaka Univ, Japan
(2012)
• Molecular Biology of Infection, RSPTI Unair-
The Univ of Tokyo (2012)
• Antimicrobial Resistance, Siriraj Hosp, Mahidol
Univ, Bangkok (2013)
• Research Fellow on Molecular Viral Infection
and Immunity, RIMD, Osaka Univ Japan (2013)
• Emerging and Re-Emerging Infectious Disease,
Mahidol Univ, Bangkok (2014)

• Current Position: IPCO Dr Soetomo Hospital

and Lecturer Faculty of Medicine
 Dasar HAIs-IV Line:
Diagnosis dan Pencegahan BSI
Agung Dwi Wahyu Widodo
Departemen Mikrobiologi Klinik Fakultas Kedokteran
Universitas Airlangga / RSUD Dr Soetomo Surabaya
 Subject
• Pengantar
• HAIs Definition: BSI
• Source and Route of
Transmission
• Strategies to Prevent and
Control
 Pengantar
• Intravenous (IV) infus merupakan prosedur
invasif tersering yg banyak di lakukan (peripheral
atau central)
• IV central catheter merupakan sumber utama
bloodstream infection (CLABSI)
• Infeksi dapat terjadi:
• Cellulitis, abscess, thrombophlebitis, bacteraemia,
endocarditis
• Prinsip pencegahan infeksi sama untuk kateter
central dan peripheral

December 1, 2013 4
 Definition of BSI
• CDC (2017), Blood Stream Infection,
devide into:
– LC-BSI (Laboratory Confirm-BSI)
• LC-BSI Defined with 3 Criteria:
• Criteria 1: Any age
• Criteria 2: Any age
• Criteria 3: only patients < 1years
 CA-BSI
Cath associated Bloodstream Infection
• CA-BSI
• Primary bloodstream infections (BSI ):
Laboratory - confirmed bloodstream infections
(LCBI) that are not secondary to an infection
at another body site
• Terdiri atas:
– LCBI-1
– LCBI-2
– LCBI-3
 LCBI-1
• Patient has a recognized pathogen identified
from one or more blood specimens by a culture
or non-culture based microbiologic testing
method which is performed for purposes of
clinical diagnosis or treatment (e.g., not Active
Surveillance Culture/Testing (ASC/AST).
• AND
• Organism(s) identified in blood is not related to
an infection at another site
 LCBI-2
• Patient has at least one of the following signs or symptoms: fever
(>38.0oC), chills, or hypotension
• AND
• Organism(s) identified from blood is not related to an infection at
another site
• AND
• the same common commensal (i.e., diphtheroids [Corynebacterium
spp. not C. diphtheriae], Bacillus spp. [not B. anthracis],
Propionibacterium spp., coagulase-negative staphylococci [including
S. epidermidis], viridans group streptococci, Aerococcus spp., and
Micrococcus spp.) is identified from two or more blood specimens
drawn on separate occasions, by a culture or non-culture based
microbiologic testing method which is performed for purposes of
clinical diagnosis or treatment (e.g., not Active Surveillance
Culture/Testing (ASC/AST).
 LCBI-3
• Patient ≤ 1 year of age has at least one of the following signs or
symptoms: fever (>38.0oC), hypothermia (<36.0oC), apnea, or
bradycardia
• AND
• Organism(s) identified from blood is not related to an infection at
another site
• AND
• the same common commensal (i.e., diphtheroids [Corynebacterium
spp. not C. diphtheriae], Bacillus spp. [not B. anthracis],
Propionibacterium spp., coagulase-negative staphylococci [including
S. epidermidis], viridans group streptococci, Aerococcus spp., and
Micrococcus spp.) is identified from two or more blood specimens
drawn on separate occasions, by a culture or non-culture based
microbiologic testing method which is performed for purposes of
clinical diagnosis or treatment (e.g., not Active Surveillance
Culture/Testing (ASC/AST).
 Sites of possible contamination of
intravascular infusions

December 1, 2013 10
 Sumber dan Rute Transmisi - 1
• Sumber kontaminasi dapat intrinsic or extrinsic
• Sebagian besar mikroorganisme berasal dari
flora kulit pasien
• Kontaminasi pada ujung alat (kolonisasi) juga
merupakan sumber infeksi
• S. aureus - 60 - 90% dari infeksi

December 1, 2013 11
 Sumber dan Rute Penularan - 2
Hands of staff Flora del
paciente

Contamination of fluids Skin flora

Contamination of
insertion site

Injections ports

Contaminación de las
conexiones
December 1, 2013
Seed from 12
distant site
 Pencegahan Infeksi- 1
Sumber utama Pencegahan
infeksi
Infusion fluids Monitor sterilisation
Ensure fluid is pyrogen free.
Avoid damage to containers
Inspect containers
Addition of Aseptic technique
medications Sterile medications
Carry out procedures in the pharmacy.
Sterile device for accessing the system.
Single-dose vials
If multi-dose vials have to be used:
Refrigerate after opening
Wipe diaphragm with 70% isopropanol
Warming- Ensure no contamination
container Dry warming systems are preferred.
December 1, 2013 13
 Pencegahan Infeksi - 2
Main source of Prevention
infection
Insertion of Thorough hand disinfection and sterile gloves
catheter Thoroughly disinfect the skin insertion site.
Catheter site Cover with sterile dressing
Remove catheter if signs of infection occur.
Inspect site every 24 hours.
Change dressing only when necessary.
Do not use antimicrobial ointments.
Injection ports Clean with 70% isopropanol and allow to dry
Close ports that are not needed with sterile stopcocks.
Changing of Replace no more frequently than 72 hours (blood and lipids
infusion set every 24 hours).
Thorough hand disinfection
Use good aseptic technique.

December 1, 2013 14
 General Comments - 1
• Penggantian kateter perifer secara rutin tidak anjurkan
– Pada Dewasa rekomendasi penggantian tiap 72-96
jam untuk menghindari phlebitis
– Pada Anak tidak di anjurkan di ganti secara rutin
• Lepas central catheters jika tidak dibutuhkan
• Central catheters digunakan bila ada indikasi
– Non-essential catheters removed
• Risk of infection meningkat dengan lama pemasangan
kateter

December 1, 2013 15
 General Comments - 2
• Teflon atau polyurethane catheters berhubungan
dengan minimnya infeksi
• Steel needles memiliki kesamaan rate of infection
seperti Teflon catheters
• Well-trained staff to set up and maintain infusions
• Masks, caps, and gowns not necessary for insertion
of peripheral IV lines
• Use of non-sterile barriers will protect the operator if
blood exposure likely

December 1, 2013 16
Protocol for peripheral infusions - 1
• Place arm on a clean sheet or towel
• Hand hygiene (alcohol hand rub or antiseptic soap)
• Dry hands on a paper or unused linen towel
• Hand hygiene (gloves does not replace it)
• Not remove hair (if necessary clip, avoid shaving)
– Disinfect skin site, apply for 30 seconds and allow drying
– 0.5% chlorhexidine-alcohol, 2% tincture of iodine,
10% alcoholic povidone-iodine, or isopropanol).
• Chlorhexidine products should not be used in children
younger than 2 months

December 1, 2013 17
Protocol for peripheral infusions - 2
– Cannula preferably in an upper limb
– Secure sterile dressing
• Transparent dressings allow inspection of the site
– Secure cannula, label with insertion date
– Assess need for catheter every 24 hours
– Inspect catheter daily
– Avoid cut downs, especially in the leg
– Cannulae and sets must be sterile

December 1, 2013 18
 Additional guidelines for central
catheters
• Selection of site
– Higher infections for jugular and femoral
• Maximum barriers
• Disinfect skin with 2% chlorhexidine/alcohol
• Change transparent dressings once a week or if soiled,
loose, or damp, gauze every two days
• Replace sets not for blood or lipids no more than 72 hours

December 1, 2013 19
 Measures that should not be
considered as part of a general
prevention policy:

• Systemic antibiotic prophylaxis

• Topical use of antimicrobial ointments
• Routine replacement of central venous catheters
• Routine use of antibiotic locks for central venous
catheters
• Routine use of in-line filters

December 1, 2013 20
 Key points for Preventon from BSI
• Strict asepsis for insertion and maintenance of
catheters
• Insertion site dry and protected with a sterile dressing
• No touch technique
• IV line secure without movements
• Closed system
• Inspection of the insertion site daily
• Remove the catheters as soon as possible
• No reuse of catheters intended for single use
• Healthcare personnel educated and their knowledge
assessed
• Alternative routes for hydration or parenteral therapy

December 1, 2013 21
Arigato-gozaimasu