Dobbs Thomas E, Guh Alice Y, Oakes Peggy, Vince Mary Jan, Forbi Joseph C, Jensen Bette, Moulton-Meissner Heather, Byers Paul
Mississippi State Department of Health, Jackson, MS.
Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA.
Am J Infect Control. 2014 Jul;42(7):731-4. doi: 10.1016/j.ajic.2014.03.007.
Four patients were hospitalized July 2011 with Pseudomonas aeruginosa bloodstream infection (BSI), 2 of whom also had Klebsiella pneumoniae BSI. All 4 patients had an indwelling port and received infusion services at the same outpatient oncology center.
Cases were defined by blood or port cultures positive for K pneumoniae or P aeruginosa among patients receiving infusion services at the oncology clinic during July 5-20, 2011. Pulsed-field gel electrophoresis (PFGE) was performed on available isolates. Interviews with staff and onsite investigations identified lapses of infection control practices. Owing to concerns over long-standing deficits, living patients who had been seen at the clinic between January 2008 and July 2011 were notified for viral blood-borne pathogen (BBP) testing; genetic relatedness was determined by molecular testing.
Fourteen cases (17%) were identified among 84 active clinic patients, 12 of which involved symptoms of a BSI. One other patient had a respiratory culture positive for P aeruginosa but died before blood cultures were obtained. Available isolates were indistinguishable by PFGE. Multiple injection safety lapses were identified, including overt syringe reuse among patients and reuse of syringes to access shared medications. Available BBP results did not demonstrate iatrogenic viral infection in 331 of 623 notified patients (53%).
Improper preparation and handling of injectable medications likely caused the outbreak. Increased infection control oversight of oncology clinics is critical to prevent similar outbreaks.
2011年7月，4名患者因铜绿假单胞菌血流感染（BSI）住院，其中2名患者还患有肺炎克雷伯菌血流感染。所有4名患者均有植入式输液港，并在同一家门诊肿瘤中心接受输液服务。
病例定义为2011年7月5日至20日在肿瘤门诊接受输液服务的患者中，血培养或输液港培养肺炎克雷伯菌或铜绿假单胞菌阳性。对可用分离株进行脉冲场凝胶电泳（PFGE）。与工作人员的访谈和现场调查确定了感染控制措施的失误。由于担心长期存在的缺陷，通知了2008年1月至2011年7月期间在该诊所就诊的在世患者进行病毒性血源性病原体（BBP）检测；通过分子检测确定基因相关性。
在84名活跃的门诊患者中发现了14例（17%），其中12例出现了血流感染症状。另一名患者呼吸道培养铜绿假单胞菌阳性，但在获得血培养结果前死亡。可用分离株通过PFGE无法区分。发现了多次注射安全失误，包括明显的患者间注射器重复使用以及用注射器重复取用共用药物。623名被通知患者中的331名（53%）的可用BBP检测结果未显示医源性病毒感染。
注射用药物的不当配制和处理可能导致了此次暴发。加强对肿瘤门诊的感染控制监督对于预防类似暴发至关重要。
