Department of Disease Prevention and Control, First Medical Center of Chinese PLA General Hospital, Beijing, China.
Center for Clinical Laboratory Medicine, First Medical Center of Chinese PLA General Hospital, Beijing, China.
Antimicrob Resist Infect Control. 2021 Jan 6;10(1):1. doi: 10.1186/s13756-020-00855-x.
This report describes an outbreak of 71 patients developed B. cepacia urinary tract infection (UTI) by contaminated single-use anesthetic gel.
Epidemiological investigation of patients with B. cepacia-positive urine or blood samples between March 19, 2018 and Novemeber 15, 2018 was conducted to identify the source of infection. Microbiological samples from hospital surfaces, endoscopes, disposable items, and the hands of staff were tested for B. cepacia contamination. Pulsed-field gel electrophoresis (PFGE) was used to compare homology in B. cepacia isolates.
During the outbreak, nosocomial B. cepacia UTI was confirmed in 71 patients. Epidemiological investigation showed that 66 patients underwent invasive urological diagnosis and treatment, while the remaining five patients underwent bedside indwelling catheterization, with all patients exposed to single-use anesthetic gel. All batches of anesthetic gel were recalled and the outbreak abated. Overall, 155 samples were collected from environmental surfaces and disposable items, and B. cepacia contamination was confirmed in samples from one used cystoscope and three anesthetic gels from the same batch. PFGE showed homology between 17 out of 20 B. cepacia isolates from patients and three isolates from the contaminated anesthetic gel. All patients achieved cure.
Contaminated single-use anesthetic gel was confirmed as the source of the B. cepacia outbreak, with infection occurring during invasive urological diagnostic and treatments. Thus, investigations of nosocomial outbreaks of B. cepacia infection should consider contamination of diagnostic and treatment items used in infected patients.
本报告描述了一起由污染的一次性使用麻醉凝胶引起的 71 例鲍曼不动杆菌尿路感染（UTI）暴发事件。
对 2018 年 3 月 19 日至 2018 年 11 月 15 日期间鲍曼不动杆菌阳性尿液或血液样本的患者进行了流行病学调查，以确定感染源。对医院表面、内窥镜、一次性物品以及医务人员的手部样本进行了鲍曼不动杆菌污染检测。采用脉冲场凝胶电泳（PFGE）比较鲍曼不动杆菌分离株的同源性。
暴发期间，确认 71 例患者发生医院获得性鲍曼不动杆菌 UTI。流行病学调查显示，66 例患者接受了侵入性泌尿科诊断和治疗，而其余 5 例患者接受了床边留置导尿，所有患者均接触过一次性使用麻醉凝胶。所有批次的麻醉凝胶均被召回，暴发得到控制。共采集环境表面和一次性物品 155 份样本，确认来自一个使用过的膀胱镜和同一批次的三个麻醉凝胶样本中存在鲍曼不动杆菌污染。PFGE 显示，20 株患者分离的鲍曼不动杆菌中有 17 株与污染的麻醉凝胶中分离的 3 株存在同源性。所有患者均治愈。
污染的一次性使用麻醉凝胶被确认为鲍曼不动杆菌暴发的源头，感染发生在侵入性泌尿科诊断和治疗期间。因此，在调查医院获得性鲍曼不动杆菌感染暴发时，应考虑受感染患者使用的诊断和治疗物品的污染情况。
