1987年 7月至2005年12月期间美国CDC医院感染暴发调查报告选编(1988年)

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为帮助大家对医院感染暴发的流行病学调查方法有所了解，现将我整理的美国CDC1987年7月至2005年12月对医院感染暴发流行病学调查情况，发到SIFIC论坛，共同学习，从中掌握一些感染流行病学的调查方法。因内容太多，暂不全文翻译。今后有时间，再译成中文。

1988年

1. 血液透析患者龟分枝杆菌感染----加利福尼亚州

Mycobacterium chelonae infection among patients receiving high-flux dialysis in a hemodialysis clinic in California.Lowry PW1, Beck-Sague CM, Bland LA, Aguero SM, Arduino MJ, Minuth AN, Murray RA, Swenson JM, Jarvis WR.
Author information

• 1Hospital Infections Program, Centers for Disease Control, Atlanta, Georgia 30333.
  
  AbstractBetween July 1987 and January 1988, five patients dialyzed at a hemodialysis outpatient clinic developed systemic Mycobacterium chelonae abscessus (MCA) infections. Four of the five patients had arteriovenous graft infections, and two died during antimicrobial therapy. Case-patients were more likely than control-patients to have received high-flux dialysis during the 6 mo before their infection (100% vs. 30%, P = .009). MCA was cultured from the hose connected to a water spray device used for manual reprocessing of high-flux but not regular dialyzers. Renalin was the germicide used to manually disinfect dialyzers for reuse and was prepared at a concentration of 2.5%. Laboratory studies documented survival of MCA from two high-flux dialyzers that were reprocessed in a manner similar to that used in the clinic. Early diagnosis with complete rather than partial graft removal in combination with antimicrobial therapy is recommended for MCA graft infections. In addition, 2.5% Renalin did not appear to ensure complete killing of MCA in high-flux dialyzers that were manually reprocessed at this hemodialysis clinic.
  
  
  
  

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2. 胸外科手术患者烟曲霉菌手术部位感染----田纳西州
Aspergillus fumigatus sternal wound infections in patients undergoing open heart surgery.Richet HM1, McNeil MM, Davis BJ, Duncan E, Strickler J, Nunley D, Jarvis WR, Tablan OC.
Author information

• 1Epidemiology Branch, National Center for Infectious Diseases, Centers for Disease Control, Atlanta, GA 30333.
  

AbstractDuring a 21-month period (July 1986-April 1988), six patients who underwent open heart surgery at Holston Valley Hospital and Medical Center in Kingsport, Tennessee, developed sternal would infections caused by Aspergillus fumigatus. All patients required sternectomy, reconstructive surgery, and long term amphotericin B therapy; no patient died. By univariate analysis, the following were significantly associated with A. fumigatus sternal would infection: chronic lung disease, a recent history of pneumonia, a greater mean number of admission diagnoses, and a particular surgeon. However, multivariate analysis identified chronic lung disease as the only independent risk factor and the best predictor of A. fumigatus sternal wound infections. No factors related to the surgical procedure or operating room personnel were associated with infection. A review of the characteristics of the patients undergoing open heart surgery showed that since 1985, there had been a trend for these patients at Holston Valley Hospital and Medical Center to be older and sicker, which may have contributed to the occurrence of infections never observed before. Despite an extensive investigation, no environmental source for A. fumigatus was identified. A. fumigatus, however, grew from the bronchial washing of one patient at the time the sternal wound infection was diagnosed, and a prospective study showed that the rate of A. fumigatus colonization among open heart surgery patients was the same as the rate of sternal wound infections caused by A. fumigatus. These data suggest that patients with chronic lung disease and respiratory colonization with A. fumigatus are at increased risk for A. fumigatus sternal wound infections after open heart surgery.

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3. 血液透析患者流行性溶血性贫血----宾夕法尼亚州
Illness in hemodialysis patients after exposure to chloramine contaminated dialysate.Tipple MA1, Shusterman N, Bland LA, McCarthy MA, Favero MS, Arduino MJ, Reid MH, Jarvis WR.
Author information

• 1Hospital Infections Program, Center for Infectious Diseases, Atlanta, Georgia 30333.
  

AbstractIn September 1987, patients at an outpatient dialysis center were exposed to chloramine contaminated dialysate when the carbon filter in a recently modified water treatment system failed. Forty-one patients required transfusion to treat the resultant hemolytic anemia. Epidemiologic investigation demonstrated that the mortality rate among dialysis center patients increased during the 5 months after chloramine exposure when compared with the 12 months before chloramine exposure, but no deaths could be attributed to the exposure. Chloramine is commonly used as a disinfectant in municipal water supplies, and has previously been reported to cause hemolytic anemia in patients undergoing dialysis. Hemodialysis centers in cities that use chloramine in water supplies must design water treatment systems with adequate means for removing chloramine and must monitor processed water closely to ensure that chloramine contamination does not occur. Dialysis centers that make changes in their water processing systems should evaluate all components of the system before changes are made, and must ensure that after modifications are made, processed water meets the standards set by the Association for Advancement of Medical Instrumentation.

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4. 养老院中的胃肠炎----加利福尼亚州
Foodborne Snow Mountain agent gastroenteritis with secondary person-to-person spread in a retirement community.Gordon SM1, Oshiro LS, Jarvis WR, Donenfeld D, Ho MS, Taylor F, Greenberg HB, Glass R, Madore HP, Dolin R, et al.
Author information

• 1Hospital Infections Program, Centers for Disease Control, US Public Health Service, Atlanta, GA.
  

AbstractA variety of small round-structured viruses are being recognized with increasing frequency as a cause of gastroenteritis in the community, but have rarely been reported to cause outbreaks in hospitals or extended-care facilities. From March 20 through April 15, 1988, an outbreak of gastroenteritis occurred in a retirement facility in the San Francisco Bay area. Illness was characterized by diarrhea, nausea, and vomiting; two residents died. Attack rates were 46% (155 of 336) in residents and 37% (28 of 75) in employees. During the initial outbreak period, illness among residents was associated with two shrimp meals served in the facility dining hall (odds ratio = 6.7). Person-to-person transmission probably occurred: The risk of becoming ill one or two days after a roommate became ill was significantly greater than that of becoming ill at other times during the outbreak (risk ratio = 6.5). Microbiologic examinations for bacterial and parasitic enteric pathogens were negative; however, 27-nm viral particles were detected by immune electron microscopy and by blocking enzyme immunoassay to Snow Mountain agent in stools obtained at the onset of illness from one of six ill residents. Seroconversion (greater than fourfold antibody rise) to Snow Mountain agent was detected in acute- and convalescent-phase serum specimens from five of six ill residents as measured by enzyme immunoassay, but not for Norwalk agent as measured by radioimmunoassay. This report of an outbreak of Snow Mountain agent gastroenteritis in an extended-care facility documents that these difficult-to-identify 27-nm viruses can cause outbreaks in inpatient settings.

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5. 血液透析患者发热反应/血流感染----亚利桑那州
Outbreak of gram-negative bacteremia and pyrogenic reactions in a hemodialysis center.Beck-Sague CM1, Jarvis WR, Bland LA, Arduino MJ, Aguero SM, Verosic G.
Author information

• 1Centers for Disease Control, Public Health Service, US Department of Health and Human Services, Atlanta, GA.
  

AbstractDuring the period from April 4, 1988, to April 20, 1988, nine pyrogenic reactions and five gram-negative bacteremias occurred in 11 patients undergoing dialysis. All pyrogenic reactions and gram-negative bacteremias occurred among patients in whom a reprocessed dialyzer was used. The rate of pyrogenic reactions or bacteremias per 100 sessions using a reprocessed dialyzer was higher than in sessions during which a new dialyzer was used (4.5 vs. 0; p = 0.03). Dialyzers were manually reprocessed with 2.5% Renalin germicide. The Renalin concentrations varied widely in 12 dialyzers stored after manual reprocessing during the epidemic period (0.9-4.2%); the median endotoxin concentrations varied from 0 to 246 ng/ml and were higher in dialyzers with Renalin concentrations less than or equal to 1.0% than in dialyzers with higher concentrations (p = 0.01). Experiments using a dilution technique described by a technician resulted in Renalin concentrations ranging from 1.4% at the surface to 3.5% at the bottom of the preparation container. These findings suggest that failure to adequately admix Renalin during dilution may be associated with low levels of disinfectant, high levels of bacteria and endotoxins in dialyzers, and outbreaks of pyrogenic reactions and gram-negative bacteremias in dialysis patients.

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6. 小儿血液透析患者溶血现象----德克萨斯州
Hemolysis associated with hydrogen peroxide at a pediatric dialysis center.Gordon SM1, Bland LA, Alexander SR, Newman HF, Arduino MJ, Jarvis WR.
Author information

• 1Hospital Infections Program, Centers for Disease Control, Atlanta, Ga.
  

AbstractPatients receiving hemodialysis therapy risk exposure to disinfectants used to reduce bacterial burdens in hemodialysis equipment and to reprocess hemodialyzers. From April 29 through May 9, 1988, 3 patients undergoing hemodialysis treatments at a single center were exposed to dialysis fluid that was inadvertently contaminated with hydrogen peroxide (HP). All patients showed a significant decline in blood hemoglobin level and required packed red blood cell transfusions during the 11-day exposure to HP. Contamination of dialysis fluid may have been due to the inadequate rinsing of HP from the water treatment system (WTS) following its disinfection on April 27-28, 1988. The failure to check water at point-of-use stations with a sensitive enough test kit after the disinfection for HP permitted patient exposure to contaminated dialysis fluid. To prevent similar occurrences, we recommend that after each disinfection (or other modifications of the WTS), the WTS be adequately rinsed to remove potentially toxic chemicals. Dialysis center personnel need to be aware of the potential effects that each modification or disinfection of the WTS may have on the product water used.

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7. 血液肿瘤患者侵袭性念珠菌感染----法国
Risk factors for candidemia in patients with acute lymphocytic leukemia.Richet HM1, Andremont A, Tancrede C, Pico JL, Jarvis WR.
Author information

• 1Hospital Infections Program, Center for Infectious Diseases, Centers for Disease Control, Atlanta, Georgia 30333.
  

AbstractBetween 1983 and 1987 the overall incidence of candidemia at the Institut Gustave Roussy, a tertiary care referral hospital for patients with cancer, increased from 0.1% (7 of 6,801) to 0.32% (24 of 7,515) (P = .009). Because acute lymphocytic leukemia (ALL) was the most common underlying disease in patients with candidemia, risk factors for candidemia were analyzed in this subset of patients. A case-control study comparing the eight ALL patients who had candidemia with 18 ALL control patients revealed that previous bacteremia, prolonged neutropenia, prolonged fever, prolonged administration of antimicrobial agents, treatment with multiple antimicrobial agents, and a relatively high concentration of Candida organisms in stool were significant risk factors for candidemia. In a logistic regression analysis, however, only receipt of vancomycin and/or imipenem was identified as an independent risk factor for candidemia. Further analysis showed that administration of vancomycin promoted proliferation of Candida organisms in the gastrointestinal tract and that this proliferation was associated with an increased risk of candidemia.

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8. 心脏手术患者弥散性血管内凝血(DIC)----加利福尼亚州
A cluster of severe postoperative bleeding following open heart surgery.Villarino ME1, Gordon SM, Valdon C, Potts D, Fish K, Uyeda C, McCarthy PM, Bland LA, Anderson RL, Jarvis WR.
Author information

• 1Hospital Infections Program, Centers for Disease Control, Atlanta, GA 30333.
  

AbstractOBJECTIVE: To investigate a cluster of postoperative bleeding following open heart surgery.
DESIGN: A cohort and case/control study.
SETTING: Palo Alto Veterans Administration Medical Center, Palo Alto, California.
PARTICIPANTS: Six (21.4%) of 28 patients undergoing open heart surgery who developed severe, nonsurgical, postoperative bleeding from July 1 through August 30, 1988 (outbreak period). All case-patients had chest tube drainage of greater than or equal to 1000 ml within 4 hours of surgery but did not have identifiable bleeding vessel(s) on exploration.
RESULTS: Upon comparison of the pre-outbreak (January 1986 through June 1988) and the outbreak period, a significant increase was found in the incidence of postoperative nonsurgical bleeding (5/440 versus 6/28, p = .0006), but not of postoperative surgical bleeding (8/440 versus 0/28, p = 1.0). Of all patients undergoing open heart surgery during the outbreak period, case patients were found to be older (67.8 versus 60.6, p = .02) and to have received a larger volume of hetastarch (HES), a synthetic colloidal plasma-volume expander (mean = 19.4 ml/kg versus 14.1 ml/kg, p = .02).
CONCLUSIONS: We conclude that the use of large volumes of HES during surgery in the elderly open heart surgery patient may increase the risk for severe, nonsurgical postoperative bleeding, probably caused by alterations of the coagulation system. As the incidence of open heart surgery increases among the elderly, surgeons and anesthesiologists should be alert to possible adverse reactions from exposures not associated with adverse reactions in younger patients.