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目的了解某病区导管相关性血流感染发生的原因,落实改进措施。方法采用现场调查方式和流行病学方法,对某病区中心静脉置管术后患者感染病例进行了调查。结果某病区在1周内连续发生3例中心静脉置管患者血流感染,感染病原菌为阴沟肠杆菌,且3例感染病原菌具有同源性。3例患者中心静脉置管术由同一名医生实施,操作者隔离措施和手卫生均不规范。结论该病区3例CRBSI病原菌来源相同,可能因医务人员操作时消毒隔离措施不规范所致。
Objective To understand the causes of catheter-related bloodstream infections in a ward and to implement improvement measures. Methods In-situ investigation and epidemiological methods were used to investigate the cases of infection after central venous catheterization in a ward. Results The bloodstream infection of three patients with central venous catheterization occurred continuously in one ward for one week. The pathogen was Enterobacter cloacae, and the three pathogens were homologous. Central venous catheterization was performed by the same physician in 3 patients, with no operator isolation and hand hygiene. Conclusion The source of CRBSI pathogens in the three cases in the ward is the same, which may be caused by the non-standard disinfection and isolation measures taken by medical staff.