摘要
目的报道一起罕见非耐药鲍曼不动杆菌(AB)致外周静脉导管(PVC)血流感染聚集事件的调查分析与预防控制。方法用描述性研究和现场实验研究结合的方法对此次医院感染聚集事件进行流行病学调查与分析。结果2018年11月4日至5日,本院肿瘤内科有4例患者在出现寒战、发热等症状时均正在使用PVC进行输液,4例患者除PVC外无其他明确的感染源。其中病例1、2号从导管尖端细菌和外周血、病例3号从导管尖端细菌中均培养出种类相同、药敏结果相同的非耐药AB。此次事件被认定为一起非耐药AB所致PVC血流感染聚集事件。感染的危险因素主要为医源性因素。采取综合防控方案后再无新发病例出现。结论护理人员静脉治疗护理操作时未严格执行消毒及手卫生规范、治疗输液用器械被污染、住院患者多、医护人员人力配置不足等是造成此次事件的主要原因,积极上报、迅速调研并分析制定综合防控措施,能有效控制医院感染事件的聚集发生。
Objective To report the investigation,analysis,prevention and control of a rare aggregation event of peripheral venous catheter(PVC) bloodstream infection induced by non resistant Aeirzetobacter baumannii(AB).Methods The epidemiological investigation and analsis of the hospital infection aggregation event were carried out by the combination method of descriptive study and field experimental study.Results On November 4-5,2018,four patients in the oncology department of the hospital were using PYC for infusion when the patients had chills,fever and other symptoms.Four patients had no other clear source of infection except PYC.Among them,non resistant AB of the same type and results of drug sensitivity were cultured from catheter tip bacteria and peripheral blood culture in case 1 and case 2,and from catheter tip bacteria in case 3.This incident was identified as an aggregation event of non resistant AB induced PYC bloodstream infection.The risk factors of infection mainly was iatrogenic factors.No new cases occurred after the comprehensive prevention and control plan was adopted.Conclusion The main reasons for this event are that the nursing staff did not strictly implement the disinfection and hand hygiene standards during the intravenous treatment and nursing operation,the equipment used for treatment and infusion was polluted,there were many inpatients and the staffing of medical staff was insufficient.Actively reporting,quickly investigating and analyzing and formulating comprehensive prevention and control measures can effectively control the aggregation occurence of hospital infection events.
作者
梁晓雅
魏秋霞
杨致霈
魏巧妙
张志刚
张强
索瑶
LIANG Xiao-ya;WEI Qiu-xia;YANG Zhi-pei;WEI Qiao-miao;ZHANG Zhi-gang;ZHANG Qiang;SUO Yao(Affiliated Hospital of Shaanxi University of Chinese Medicine,Xianyang 712000;the Second Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710004,China)
出处
《临床医学研究与实践》
2020年第11期7-9,共3页
Clinical Research and Practice
基金
中国医院协会《中国医院感染管理工作30周年总结》项目(No.CHA-2016-026-053)。
关键词
鲍曼不动杆菌
医院感染聚集事件
流行病学调查
Acinetobacter baumannii
hospital infection aggregation event
epidemiological investigation
