Lalande V, Barbut F, Varnerot A, Febvre M, Nesa D, Wadel S, Vincent V, Petit J C
Department of Microbiology, Saint-Antoine Hospital, Assistance Publique-Hopitaux de Paris, 184 rue du faubourg Saint-Antoine, 75571 Paris Cedex 12, France.
J Hosp Infect. 2001 May;48(1):76-9. doi: 10.1053/jhin.2000.0929.
Between March 1997 and December 1997, acid-fast bacilli (AFB) were detected on sputum and/or gastric aspirates smears from five patients hospitalized in the chest medicine department. These specimens grew M. gordonae. Based on AFB-positive smear and clinical presentation, four out of five patients received antituberculous treatment until species identification was known. Epidemiological investigation revealed a heavy contamination of water collected from refrigerated fountains located on the same floor as the patient cases. Strains isolated from four patients and the refrigerated fountain exhibited the same pulsed gel electrophoresis pattern (using DraI and XbaI enzymes) suggesting that positive smears were related to drinking water from the refrigerated fountain. This cluster of pseudo-infections underlines the necessity for a proper maintenance of water supply equipment in order to avoid inappropriate decisions deleterious for patients.
1997年3月至1997年12月期间，在胸内科住院的5名患者的痰液和/或胃吸出物涂片上检测到抗酸杆菌（AFB）。这些标本培养出戈登分枝杆菌。基于抗酸杆菌阳性涂片和临床表现，5名患者中有4名在菌种鉴定结果出来之前接受了抗结核治疗。流行病学调查显示，从与病例患者同一楼层的冷藏饮水机采集的水受到严重污染。从4名患者和冷藏饮水机分离出的菌株表现出相同的脉冲凝胶电泳图谱（使用DraI和XbaI酶），这表明阳性涂片与冷藏饮水机的饮用水有关。这一系列假感染事件突显了妥善维护供水设备的必要性，以避免做出对患者有害的不当决策。
