龟分枝杆菌切口感染暴发的调查分析

目的 探讨发生于某院内暴发168例手术后切口感染的原因。方法 采集感染病人切口分泌物。进行细菌培养，菌种鉴定，药敏试验病理学检查以及环境监测。结果 通过上述实验证实引起本次暴发切口感染的病原体为龟分支杆菌污染切口所致，0.137%戊二醛浸泡的，手术器械受到龟分枝杆菌污染导致大规模切口感染。结论 0.137%戊二醛作为手术器械消毒剂，因其浓度过低，不促以杀灭分枝杆菌，鉴于本次暴发龟分枝杆菌感染切口的教训，作者建议手术室医护人员应加强对非典型分枝杆菌的监测，控制医源性感染，以减少甚至杜绝大规模切口感染事故。

Investigation and Analysis of the Outbreak of Incisional Infection Caused By Mycobacterium Chelonei

Objective To explore the causes of an outbreak of 168 cases of incisional infection in one hospital.Methods The secretory substances of incisioral wound infection from 168 cases of operation patients were collected,cultured and identified in bacterium strain.We also did drug sensitivity test,pathological examination and investigation of environment.Results Above these experinental studies demostrated that the large-scale outbreak of incisiona infection was caused by mycobacterium chelonei in operation room.Used 0.137% glutaradehyde as disinfectant immersion surgical tools ,but the concentration too low to kill the mycobacterium chelonei,which polluted the hickeyes of surgical instrument.The pollution leading to outbreak of incisional infection.Conclusions By reason of the event lesson,authors suggest that the doctors and nurses should strengthen the detection of atypical mycobacterium,so as to reduce the iatrogenic infection,reducing,or stoping the outbreak of incisinal Infection.