Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
Infect Control Hosp Epidemiol. 2011 Dec;32(12):1179-86. doi: 10.1086/662712. Epub 2011 Oct 17.
Seven organ/space surgical site infections (SSIs) that occurred after arthroscopic procedures and were due to Pseudomonas aeruginosa of indistinguishable pulsed-field gel electrophoresis (PFGE) patterns occurred at hospital X in Texas from April 22, 2009, through May 7, 2009.
To determine the source of the outbreak and prevent future infections.
Infection control observations and a case-control study.
Laboratory records were reviewed for case finding. A case-control study was conducted. A case patient was defined as someone who underwent knee or shoulder arthroscopy at hospital X during the outbreak period and subsequently developed organ/space SSI due to P. aeruginosa. Cultures of environmental and surgical equipment samples were performed, and selected isolates were analyzed by PFGE. Surgical instrument reprocessing practices were reviewed, and surgical instrument lumens were inspected with a borescope after reprocessing to assess cleanliness.
The case-control study did not identify any significant patient-related or operator-related risk factors. P. aeruginosa grew from 62 of 388 environmental samples. An isolate from the gross decontamination sink had a PFGE pattern that was indistinguishable from that of the case patient isolates. All surgical instrument cultures showed no growth. Endoscopic evaluation of reprocessed arthroscopic equipment revealed retained tissue in the lumen of both the inflow/outflow cannulae and arthroscopic shaver handpiece. No additional cases occurred after changes in instrument reprocessing protocols were implemented. After this outbreak, the US Food and Drug Administration released a safety alert about the concern regarding retained tissue within arthroscopic shavers.
These SSIs were likely related to surgical instrument contamination with P. aeruginosa during instrument reprocessing. Retained tissue in inflow/outflow cannulae and shaver handpieces could have allowed bacteria to survive sterilization procedures.
2009 年 4 月 22 日至 5 月 7 日，德克萨斯州 X 医院发生了 7 例关节镜手术后的器官/腔隙性外科部位感染（SSI），这些感染归因于无法通过脉冲场凝胶电泳（PFGE）模式区分的铜绿假单胞菌。
确定暴发的源头并预防未来的感染。
感染控制观察和病例对照研究。
通过实验室记录进行病例发现，进行病例对照研究。病例患者定义为在暴发期间在 X 医院接受膝关节或肩关节关节镜检查，随后因铜绿假单胞菌发生器官/腔隙性 SSI 的患者。对环境和手术设备样本进行了培养，并对选定的分离株进行了 PFGE 分析。审查了手术器械再处理操作，并在再处理后使用内窥镜检查手术器械管腔，以评估清洁度。
病例对照研究未发现任何与患者或操作人员相关的重要危险因素。从 388 个环境样本中培养出 62 株铜绿假单胞菌。来自粗去污水槽的分离株的 PFGE 模式与病例患者分离株无法区分。所有手术器械培养均未生长。对重新处理的关节镜设备进行内镜评估显示，在流入/流出套管和关节镜锯手机的管腔内均有残留组织。在实施器械再处理方案的变更后，未再发生其他病例。此次暴发后，美国食品和药物管理局发布了有关关节镜锯中残留组织的安全警报。
这些 SSI 可能与器械再处理过程中手术器械受到铜绿假单胞菌污染有关。流入/流出套管和锯手机管腔内的残留组织可能使细菌能够存活于灭菌过程中。
