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目的调查一起鲍曼不动杆菌感染不良事件在某医院神经外科重症监护室发生的原因。方法采用现场调查和回顾性调查方法,对神经外科重症监护室一起鲍曼不动杆菌感染情况进行调查。结果 2014年连续发生4例病人痰标本中均检出鲍曼不动杆菌。经调查,有2例患者痰标本培养出的鲍曼不动杆菌为定植菌或污染菌,判定此次感染事件为一次由鲍曼不动杆菌引发的医院感染不良事件。该病区心电监护仪、床头柜表面培养出同源鲍曼不动杆菌,及时采取消毒隔离措施后,病区物体表面未再检出致病菌。结论该病区所发生的鲍曼不动杆菌医院感染不良事件是由于环境或医务人员手接触传播所致,经采取有效消毒隔离,疫情得到有效控制。
Objective To investigate the causes of adverse events of Acinetobacter baumannii infection in a neurosurgical intensive care unit at a hospital. Methods A field investigation and a retrospective investigation were conducted to investigate the prevalence of Acinetobacter baumannii infection in neurosurgical intensive care unit. Results Acinetobacter baumannii was detected in all the sputum samples from 4 consecutive patients in 2014. After investigation, Acinetobacter baumannii cultured in sputum from 2 patients was used as the colonization bacteria or contamination bacteria, and the infection was judged to be a nosocomial infection-induced adverse event by Acinetobacter baumannii. The wards ECG, bedside cabinet surface culture of the same Acinetobacter baumannii, promptly taken disinfection and isolation measures, the ward no longer detect pathogens on the surface of objects. Conclusions Adverse events of hospital infection caused by Acinetobacter baumannii in this ward are caused by the environmental or medical staff’s contact with the hands. After being disinfected effectively, the outbreak is effectively controlled.