重症监护病房4例泛耐药鲍氏不动杆菌肺部感染暴发

Outbreak of Four Pan-drug resistant Acinetobacter baumanii Pulmonary Infections in Intensive Care Unit

目的分析重症监护病房鲍氏不动杆菌感染暴发的原因与经过,为预防与控制感染提供依据。方法对重症监护病房于2009年2月11-16日,陆续发生的4例鲍氏不动杆菌肺部感染开展流行病学调查,查找感染源与传播途径,并采取干预措施控制感染。结果采取综合性干预措施,泛耐药鲍氏不动杆菌感染患者集中隔离、停用自动清洗消毒机、加强医务人员手卫生、加强环境物体表面与医疗设备的清洁消毒等,有效地控制了感染。结论自动清洗消毒机消毒不彻底、医护人员手卫生较差、环境物体表面与医疗设备物体表面污染严重,是造成该次鲍氏不动杆菌感染暴发发生的原因。

OBJECTIVE To analyze the reasons and process of the outbreak of 4 pan-resistant Acinetobacter bauma- nii pulmonary infections in intensive care unit, in order to find out the ways to prevent and control infections. METHODS The epidemiology of 4 inpatients who were infected pan-drug A. baumannii on lung in ICU from Feb 11 to 16, 2009 was investigated. The infection source and route of transmission were sought, intervention to control infection was taken. RESULTS Integrated interventions, such as isolation of 4 patients infected by pandrug resistant A. baumaniiwas taken, stoping using automatic cleaning and sterilizing machine, strengthening the hand hygiene of medical personnal, strengthening the cleaning and disinfection of medical equipments and environmental surfaces. CONCLUSIONS No thorough cleaning and disinfection, poor hand hygiene of medical personnel and contamination of medical equipments and environmental surface, are the reasons of the outbreak of by pan-drug resistant A. baumannii infection.