医院内侵入性霉菌感染暴发－空气和水源控制
在意大利举办的“3rd TIMM”会议，主要是关于真菌感染的诊断和治疗，也有部分涉及预防的内容。其中有研究指出，空气和水，是医院内曲霉菌感染的重要来源。M10
Hospitals outbreaks of invasive mould infections: controlling the air and water
acquisition
A. Warris1, M. Richardson 2
1Radboud University Nijmegen Medical Center, Nijmegen University Center of
Infectious Diseases, Nijmegen, The Netherlands 2Helsinki University Central
Hospital, University of Helsinki, Finland
Invasive mould infections present a formidable problem in terms of diagnosis, and
even more so in terms of therapy. The outcome is often fatal and prevention
measures are of major importance in the control of invasive mould infections.
Molecular investigations to determine the source in case of an increase in number of
invasive mould infections or even outbreaks are hampered by the huge genetic
diversity of these micro-organisms. Invasive aspergillosis is the most frequent
invasive mould infection encountered, and therefore most studies have been
focussed on this mould. We would argue strongly that it is of paramount importance
to monitor the hospital environment for the presence of contamination with moulds on
a regular, prospective basis. In particular, those areas were patients at risk for
invasive mould infectious are cared for such as haemato-oncology wards and
isolation rooms for SCT-patients and immunocompromised patients. Quite often the
investigation of the environment starts at the moment an increased number of
patients is diagnosed with an invasive mould infection, while no adequate
background information exists about the level of environmental fungal contamination
before the outbreak. Air filtration methods like high efficiency particulate air (HEPA)
filtration and laminar airflow measurements are well established. The maintenance of
these systems should be done properly. Prospective particle counting should be
performed. Numerous outbreaks have been described due to insufficient functioning
of these ventilation systems. Investigation of the water and its tubing system should
be done properly and when the water is contaminated with moulds, preventive
measurements like point-of-use filtration or cleaning measurements should be
established. New, rapid quantitative PCR methods have been described which could
prompt the elimination of fungal pathogens from the water supply of
immunocompromised patients. During a period of construction work inside or around
the hospital, additional preventive measurements should be taken to deal with a
higher number of fungal spores in the environment. Quantitative PCR can be used to
monitor Aspergillus species in air during hospital construction. In case of an
outbreak, a thorough investigation of the environment is obligatory in order to
abandon the (potential) source of fungal contamination either be physically removing
the contaminated source or improving the filtration measurements. In the literature,
numerous sources have been detected, unexpectedly on forehand. From an
epidemiological point of view, molecular investigation of moulds either isolated from
patients or the environment will increase our understanding of the acquisition and
route of infection. Various molecular techniques are available to genotype moulds.
For Aspergillus fumigatus, the amplified fragment length polymorfism (AFLP) and the
short tandem repeat analysis seem to be the most discriminative typing methods.
Key references:
Warris A, Verweij P.E. Clinical implications of environmental sources for Aspergillus. Medical
Mycology 2005; 43(S): 59-65. Morrison J., Yang C, Lin K-T et al. Monitoring Aspergillus
species by quantitative PCR during construction of a multi-story hospital building. Journal of
Hospital Infection 2004; 57: 85-87. Nihtinen A, Antttila V-J, Richardson M et al. The utility of
intensified environmental surveillance for pathogenic moulds in a stem cell transplantation
ward during construction work to monitor the efficacy of HEPA filtration. Bone Marrow
Transplantation 2007; 40: 457-460.
Perdelli F, Cristina ML, Sartini M et al. Fungal contamination in hospital environments.
Infection Control and Hospital Epidemiology 2006; 27: 44-47. Vesper SJ, Rogers ME, Neely
AN et al. Opportunistic Aspergillus pathogens measured in home and hospital tap water by
quantitative PCR (QPCR). Journal of Water and Health 2007; 5: 427-431. Warris A, Klaassen
CHW, Meis JFGM, et al. Molecular epidemiology of Aspergillus fumigatus isolates recovered
from water, air and patients shows two clusters of genetically distinct strains. Journal Clinical
Microbiology 2003; 41: 4101-4106.
De Valk HA, Meis JF, de Pauw BE, et al. Comparison of two highly discriminatory molecular
fingerprinting assays for analysis of multiple Aspergillus fumigatus isolates from patients with
invasive aspergillosis. Journal Clinical Microbiology 2007; 45:1415-1419. 专门组织了一次为时一个小时的专家见面会（meeting the experts）
回复 #1 icchina 的帖子
空气和水，是医院内曲霉菌感染的重要来源。它的传播机制是什么？空气通过吸入？水通过清洁消毒的物品？:L :L
最近对我院中央空调送风管壁进行采样，细菌污染情况倒不严重，真菌还挺丰富的。而且觉得送风管口垂直向地面的污染较轻，送风管口水平位的污染则严重些。是不是垂直向下的更能保持干燥？不知同仁体会如何？
回复 #7 icchina 的帖子
Moulds are found in potable water systems and reservoirs.Surface water harbours all kind various moulds.
Ground water harbours less moulds compared to surface water.
Moulds can be grown from biofilms.
Moulds can inhabit the hospital water system including those causing invasive infections in immunocompromised patients (Aspergillus,Fusarium)
Molecular studies have shown that water and patient isolates are genetically identical.
Conidial air counts higher in hospital rooms with major water use.
Route of transmission might be secondarily airborne in addition of aspiration of contaminated water or direct inoculation.
回复 #8 柳莹依 的帖子
有道理！水应该跟渗漏有关吧。回复 #7 icchina 的帖子
谢谢分享！看来要做的工作还很多很多啊！最近我院的应急水源正有点头痛！ 水源污染？医院感染管理范围，真是越来越“宽广”啦！ 原帖由 icchina 于 2007-11-3 00:21 发表 http://bbs.sific.com.cn/images/common/back.gif
水源污染？
医院感染管理范围，真是越来越“宽广”啦！
主要是应急水源很长时间没用了，培养有点东东，做了两次培养了，ＣＤＣ也来了专家指导，明天去看处理后的三次培养结果，应该是ＯＫ了！ Route of transmission might be secondarily airborne in addition of aspiration of contaminated water or direct inoculation.传播途径：除了吸入被污染的水或直接接种，其次是空气传播。是不是这样翻的？:funk:
回复 #13 hxwsw 的帖子
医院应该是不允许有二次供水的，不过由于特殊原因实际上还是有二次供水的情况，因此疾控中心每年来进行一次消毒。回复 #1 icchina 的帖子
医院侵入性霉菌感染爆发：空气和水源控制侵入性霉菌感染是已经成为一当前不容忽视的问题，无论在诊断方面甚至是在治疗方面。其预后通常是致命的，预防措施在控制侵入性霉菌感染方面具有重要意义。开展分子生物学调查以确定大量增加的受到基因多态性影响的微生物引起侵入性霉菌感染或者爆发的来源。侵入性曲霉菌感染是最常见的霉菌感染，因此大多数的研究的焦点都在该霉菌上。我们强烈建议开展环境中常规的、前瞻性的霉菌污染监测是非常重要的。特别是在那些病人可能受到侵入性霉菌感染威胁的区域比如血液肿瘤病房和为脊髓损伤病人和免疫低下病人设置的隔离病房。在被诊断为侵入性霉菌感染不断增加时，在爆发前没有适当的环境中霉菌污染水平信息的情况下通常调查从环境开始。空气过滤方法如高效空气过滤器和层流气流装置被采用，这些系统的维护应适当进行，还应开展空气粒子计数。当水质被霉菌污染时，水源和供水系统应进行全面调查，并采取使用点过滤和清洗等预防措施。新的，快速定量聚合酶链反应方法被用来消除供应给免疫低下病人水质病原菌污染。在医院周围和内部建筑物内工作期间，应采取额外预防措施来应付环境中高浓度的真菌孢子。定量PCR能够被用来监测医院中的曲霉菌污染。防止爆发，为了消除真菌污染来源不管是物理清除还是改善空气过滤措施一个全面的环境调查是必要的。在本文中，大量的污染源被分离到。从流行病学观点来看，霉菌的分子生物学调查不管是对病人的分离还是环境检测都将扩大我们对侵袭性真菌的传播途径和感染的认识。不同的分子技术可用来进行霉菌基因分型，对于曲霉菌扩增片段长度多态性分析和短串联重复序列分析，似乎是最好的分型方法。
试着翻译一下。下面这一句请教！
In the literature, numerous sources have been detected, unexpectedly on forehand. From an epidemiological point of view, molecular investigation of moulds either isolated from patients or the environment will increase our understanding of the acquisition and route of infection.在本文中，大量的污染源被分离到。从流行病学观点来看，霉菌的分子生物学调查不管是对病人的分离还是环境检测都将扩大我们对侵袭性真菌的传播途径和感染的认识。 原帖由 莲雾 于 2007-11-3 15:41 发表 http://bbs.sific.com.cn/images/common/back.gif
Route of transmission might be secondarily airborne in addition of aspiration of contaminated water or direct inoculation.传播途径：除了吸入被污染的水或直接接种，其次是空气传播。是不是这样翻的？:funk:
我个人觉得应该是:
吸入被污染的水或直接接种的传播途径可能是仅次于空气的又一传播途径. 不知有多少医院常规开展了环境中霉菌污染监测，希望快点推广。
回复 #18 xiangboshu 的帖子
我们就在做，非常令人担忧啊！但院感科不让报说是卫生部发的资料上没要求这项！
我真是晕死了，和他们说这些简直说不通的。
知识陈旧，观念陈旧不说，还是典型的“吃山核桃”式的工作作风，难怪我院呼吸科有这样高的肺曲霉病。
回复 #10 无极紫晶 的帖子
不是渗漏，南方地区到了霉雨季节，时不时有几天那个潮湿啊，墙壁都在“出汗”
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