骨髓移植病房院內血流感染Enterobacter Cloacae之調查及處理

Investigation and Management of an Outbreak of Nosocomial Bloodstream Infections Associated with Enterobacter Cloacae in a Bone Marrow Transplantation Unit

鄧碧(Bi Den) ； 蘇玲慧(Lin-Hui Su) ； 呂學重(Hsieh-Shong Leu) ； 朱宗藍(Tsung-Lan Chu) ； 蘇淑芳(Shu-Fang Su) ； 邱月璧(Yueh-Pi Chiu) ； 暨感染管制小組(Infection Control Group)

《院內感染控制雜誌》 12卷1期 (2002/02) Pp. 22-30

摘要

某醫學中心骨髓移植病房同一病室分別於89年8月31日、10月8日及11月20 日發生3件由Enterobacter cloacae引起之院內血流感染。三位個案之感染菌株以分子生物分型低頻切位聚合酵素鏈鎖反應( infrequent-restriction-site polymerase chain reaction ; IRS-PCR）的方法確定為同型，有交互傳染的情形，遂展開調查。根據病房資料，第一位個案轉出後，病室環境經過消毒滅菌至少四日的前置作業，第二、三位個案才得以轉入，且該病房近五年均未曾有同一病室前後病患感染相同菌株之記錄。本次感染的個案都是骨髓移植患者，分別為22歲、5歲、41歲，皆使用免疫抑制藥物、化學及放射治療之低抵抗力宿主。在環境採檢，其中電動洗牙機、坐浴盆、洗牙盆、抽口服藥水空針筒，分離出E. cloacae皆為病人使用後醫療物品。其他菌種包括多種革蘭氏陽性桿菌及球菌，則由多處環境中培養得到。以上結果，推測感染的途徑，是由第一位個案轉出後，某些污染的相關用品或環境消毒不完全，將此菌交叉傳染給第二、三位個案。為遏止類似情況，建議該單位對口服藥水空針筒由原24小時更換時間改為用後即棄，坐浴及洗牙盆由一週更換改為每日更換，電動洗牙機原僅擦拭外部現改為增加內部浸泡消毒液30分鐘，人員確實遵循無菌技術操作，每日及終期的環境清潔及消毒確實執行及督導，以防範因殘留已污染環境或物品導致類似交互傳染的事件再度發生。

關鍵字

血流感染 ； 骨髓移植 ； 低頻切位聚合酵素鏈鎖反應

並列摘要

Three patients hospitalized in the same isolation room of a bone marrow transplantation (BMT) unit in a tertiary teaching hospital developed nosocomial Enterobacter cloacae bacteremia, on August 31, October 8, and November 20, 2000, respectively. All of the 3 bacteremic isolates were found to be of the same genotype using the infrequent-restriction-site polymerase chain reaction (IRS-PCR) method. Therefore, the investigation for successive cross- infections between patients began. Unit staff records showed that there has been no similar event of nosocomial infections of patients by same organisms during the past 5 years. Disinfection and cleaning were routinely performed after patient was discharged from our BMT unit, and the room used by the last patient should be kept empty at least 4 days before the next patient entered. The ages of these 3 BMT recipients were 22, 5 and 41 years old, respectively. They all received immunosuppressive therapy, chemotherapy and radiotherapy. Surveillance and environmental cultures were performed next day after patients’ discharge from the BMT unit. From our first case, E. cloacae was found in his electric toothbrush, sitz bath, tooth-cleaning utensil, and syringe for oral syrup: Also there were gram-positive bacilli and cocci isolated from the environmental cultures. Review of BMT unit disinfection practices revealed that the inadequate disinfection of environment and instruments between patient uses had served’ as reservoirs for this event of bloodstream infection. To prevent the same event, we recommended: discarding the syringe for oral syrup immediately after use instead of discarding the syringe every 24 hours, daily change of the sitz bath and tooth-washing utensil instead of the change once a week, disinfection, of electric toothbrush by immersing in disinfectants for 30 minutes instead of just cleaning its surface, aseptic technique, and adequate environmental cleaning and disinfections between patients to avoid cross-infections due to environmental or equipment contaminations.

並列關鍵字

bloodstream infections (BSIs) ； bone marrow transplantation (BMT) ； infrequent-restriction-site polymerase chain reaction (IRS-PCR)