呼吸加護病房泛抗藥性Acinetobacter baumannii群突發的調查及處理

Epidemiologic Study and Control of an Outbreak of Pandrug-resistant Acinetobacter baumannii at a Respiratory Intensive Care Unit in a Medical Center

張雅雯(Ya-Wen Chang) ； 湯雅芬(Ya-Fen Tang) ； 林孟志(Meng-Chih Lin) ； 蘇玲慧(Lin-Hui Su) ； 劉建衛(Jien-Wei Liu)

《感染控制雜誌》 15卷1期 (2005/02) Pp. 1-15

https://doi.org/10.6526/ICJ.200502_15(1).0001

摘要

某醫學中心呼吸加護病房於2004年7月19曰至8月5日之間發生泛抗藥性鮑氏不動桿菌(pandrug-resistant Acinetobacter baumannii；RDRAB)感染造成的呼吸道感染群突發。四個感染病患中，其中有一人發生續發性PDRAB血流感染。感染的個案都屬重症患者，皆有氣管內管插管及使用呼吸器，並接受多種侵入性導管留置，曾接受多種抗生素治療感染症。環境檢體共採檢54件，其中7件長出PDRAB，分別是採自床欄（2件）、呼吸監視器表面、抽痰壓力表表面、集尿桶放置架與洗手台（2件）等。在醫護人員手部採檢共37件，僅有清潔人員雙手所採之檢體長出非泛抗藥性A. baumannii。以脈衝電泳將所收集到的A. baumannii作基因分型，發現在本呼吸加護病房有六種不同基因型，其中一種基因型的PDRAB感染造成此次群突發。此基因型的PDRAB菌株也有自呼吸加護病房環境檢體中驗出。環境污染是導致PDRAB群突發的重要因素。而此菌特殊的生物特性，容易散布在環境與病患間，只要工作人員稍為鬆懈，未確實執行接觸防護措施，易在環境中散佈造成流行。此外環境清潔人員的傳播角色容易被忽略，本次調查發現清潔人員用同一組用具清潔不同病室中之床欄、治療櫃、洗手台等。病患間未確實脫除手套洗手，易導致環境污染，細菌散佈，進而造成院內交互傳播。而對清潔人員限於其教育背景，對於院內環境清潔的嚴格要求，不易瞭解及徹底執行，故針對清潔人員的教育訓練，更應反覆示教及模擬訓練為之。針對具抗藥性之細菌應建立監視系統，集中照護及隔離感染或移生病患，確實的洗手、嚴謹執行隔離措施，徹底清潔消毒工作場所的表面及多重的環境監控是有效控制傳播的方法，因此在八月下旬終止這次的群突發。

關鍵字

泛抗藥性鮑氏不動桿菌 ； 院內呼吸道感染 ； 群突發 ； 呼吸加護病房

並列摘要

An outbreak of nosocomial pneumonia caused by pandrug-resistant Acinetobacter baumannii (PDRAB) occurred between July 19 and August 5, 2004 at a respiratory intensive care unit (RICU) in a medical center in Taiwan. A total of 4 critically ill patients were involved; all were endotracheally intubated for mechanical ventilatory support and inserted with central venous catheter, nasogastric tube and Foley catheter. One of these patients developed secondary A. baumannii bacteremia. To identify the distribution of the culprit pathogen in this RICU, specimens collected from environmental sources and both hands of hospital workers including clinicians, nurses, respiratory therapists and a ward environment cleaner were sent for bacterial cultures. Among 54 environmental specimens, 7 grew PDRAB. PDRAB contaminated environmental sources included surfaces of bed rails, ventilator screen, sputum-suctioning device, shelves where urine containers were placed, and the sinks. Among the 37 specimens from both hands of hospital workers, only the one from those of the ward cleaner grew nonpandrug-resistant A. baumannii. Fingerprint-typing of all isolated A. baumannii generated by pulsed-field gel electrophoresis disclosed that there were 6 A. baumannii genotypes at this RICU. PDRAB (A. baumannii strain with fingerprint type A2) was responsible for this nosocomial pneumonia outbreak, and were also isolated from seven environmental specimens. One isolate of A. baumannii type B (non-PDRAB) was found from the hands of the ward cleaner. All involved patients in this outbreak were vulnerable to infections because they were critically ill mandating mechanical ventilatory support, frequent sputum-suction and intensive care in the crowded RICU. As a result, failure to stick to the strict contact precautions by any staff member would potentially spark a nosocomial-infection outbreak. After implementing fortified infection control measures, including strict hand-washing policy and contact precautions, educating the ward cleaner on the importance of infection control and alerting her to the possible distractions from infection principles that easily made while cleaning the environment, daily environment disinfecting by hypochlorite and cohorting affected patients. This nosocomial outbreak was eventually terminated in late August 2004.

並列關鍵字

pandrug-resistant Acinetobacter baumannii ； nodocomial pneumonia ； outbreak ； respiratory intensive care unit