Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Frankfort, KY, USA; Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY, USA.
Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY, USA.
Am J Infect Control. 2023 Apr;51(4):454-460. doi: 10.1016/j.ajic.2022.06.013. Epub 2022 Jun 19.
We describe the investigation of a nosocomial outbreak of rapidly growing mycobacteria (RGM) infections and the results of mitigation efforts after 8 years.
A cluster of RGM cases in a Kentucky hospital in 2013 prompted an investigation into RGM surgical site infections following joint replacement surgery. A case-control study was conducted to identify risk factors.
Eight cases were identified, 5 caused by M. wolinskyi and 3 by M. goodii. The case-control study showed the presence of a particular nurse in the operating room was significantly associated with infection. Environmental sampling at the nurse's home identified an outdoor hot tub as the likely source of M. wolinskyi, confirmed by pulsed-field gel electrophoresis and whole genome sequencing. The hot tub reservoir was eliminated, and hospital policies were revised to correct infection control lapses. No new cases of RGM infections have been identified as of 2021.
Breaches in infection control practices at multiple levels may have led to a chain of infection from a nurse's hot tub to surgical sites via indirect person-to-person transmission from a colonized health care worker (HCW).
The multifactorial nature of the outbreak's cause highlights the importance of overlapping or redundant layers of protection preventing patient harm. Future investigations of RGM outbreaks should consider the potential role of colonized HCWs as a transmission vector.
我们描述了一起医院内快速生长分枝杆菌（RGM）感染暴发的调查以及 8 年后的缓解措施结果。
2013 年，肯塔基州一家医院发生了一组 RGM 病例，促使我们对关节置换手术后 RGM 手术部位感染进行了调查。我们开展了病例对照研究，以确定危险因素。
共发现 8 例病例，其中 5 例由 M. wolinskyi 引起，3 例由 M. goodii 引起。病例对照研究表明，手术室中特定护士的存在与感染显著相关。在护士家中进行的环境采样发现户外热水浴缸是 M. wolinskyi 的可能来源，经脉冲场凝胶电泳和全基因组测序证实。热水浴缸储水器被淘汰，医院政策也进行了修订以纠正感染控制失误。截至 2021 年，尚未发现新的 RGM 感染病例。
多个层面的感染控制措施失误可能导致了一条从护士的热水浴缸到手术部位的感染链，通过定植的卫生保健工作者（HCW）间接的人与人之间传播。
暴发原因的多因素性质突出了保护患者免受伤害的重叠或冗余保护层的重要性。未来对 RGM 暴发的调查应考虑定植的 HCW 作为传播媒介的潜在作用。
