投稿分類 群突發處理

主委發表種類: 壁報

投稿標題(中): 南部某區域醫院尿路動力學檢查引起Klebsiella pneumoniae感染群突發事件調查

投稿標題(英): An Outbreak of Klebsiella pneumoniae Urinary Tract Infection Caused by Urodynamic Study at a Regional Hospital in Southern Taiwan

投稿摘要: Nine men had fever after urodynamic study (UDS) in March-May, 2012. Their urine yielded Klebsiella pneumoniae (KP) and the susceptibility were the same. An UTI outbreak due to UDS was suspected and investigated. We found 10ml syringe and normal saline in the container were repeatedly used; the instrument was easily contaminated by penis; operators had poor hand hygiene and residual xylocaine jelly was collected. KP from the normal saline was found by environmental sampling. This KP isolate had identical pulsotype with 3 clinical urine isolates. The most possible common source of this outbreak proposed to be xylocaine jelly cross-contamination. We recommended operators’ hand hygiene and set up the standard of cleanliness and operating procedure. Then, no more new case was found after UDS.

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