投稿分類 群突發處理

主委發表種類: 口頭

投稿標題(中): 輸尿管鏡導致綠膿桿菌感染群突發調查

投稿標題(英): Pseudomonas aeruginosa outbreak occurred in ureteroscope

投稿摘要: Background:An outbreak investigation was performed in 8 patients with symptomatic urinary tract infection after ureteroscope procedure.
Methods:The 8 patients received ureteroscope procedure from 18th June, 2014. The UTIs clustered from 20th to 25th. Comparison with last season, the incidence increase significant (p＜0.05). An outbreak committee encompassing member crossing over relevant departments was set up. An outbreak investigation including demographic analysis, observation of operation procedure, cultures from the environment and equipment were performed. The data were discussed in the committee to find out the index cases and infection source. We also performed genotype analysis by pulsed-field gel electrophoresis (PFGE) for comparison among the isolates from the patients and the environment.Results:The average age of the patient was 55 years old, with major symptom of fever. All the cultures from the 8 patients are Pseudomonas aeruginosa with the same antibiogram. One of them complicated with blood stream infection. No case died. There were 3 days from surgery to occurring to UTIs. We collected 8 specimens from scopes, washing machines, sterilizing agents. Three of the 8 specimens grow Pseudomonas aeruginosa. All the 3 isolates show the same PFGE patterns as the strains from the 8 pateints. Thus, we suggested that sterilizing procedure should be changed into EO sterilization. There is no new cases in the following 3 months.Conclusions:The outbreak is caused by failure of sterilization of the ureteroscope.

稿件檔: