오염된 0.5% 클로르헥시딘 수용액 제품과 관련된 Burkholderia cepacia 가성균혈증의 반복 유행 (Recurrent Burkholderia cepacia Pseudo-bacteremia Related to Contaminated Commercial Product of 0.5% Chlorhexidine Solution)

서지정보

· 발행기관 : 대한의료관련감염관리학회
· 수록지 정보 : 의료관련감염관리 / 22권 / 1호 / 1 ~ 8페이지
· 저자명 : 고수희, 안혜선, 방지환, 박상원

초록

Background: Burkholderia cepacia is one of the key pathogens involved in the nosocomial outbreaks via contaminated supplies. We describe here an experience of recurrent B. cepacia pseudo-bacteremia caused by the contaminated commercial product of 0.5% chlorhexidine solution in a hospital.Methods: B. cepacia bacteremias detected from 30 November to 17 December 2014 were defined as cases. Epidemiological data were collected by reviewing the medical records and interviews with the healthcare workers. Suspected antiseptics were cultured using blood culture media.Results: Using regular active surveillance of microbiological results, 15 B. cepacia isolates were found in 13 patients. Pseudo-bacteremia was suspected in all of the cases based on the clinical analysis of individual patients. Misuse of 0.5% chlorhexidine in its solution rather than its tincture form as a skin antiseptic prior to drawing blood for blood culture procedures was the only identifiable risk factor for B. cepacia pseudo-bacteremia. Culture of 0.5% chlorhexidine solution was negative. Suspending the use of 0.5% chlorhexidine solution and educating healthcare workers on the proper use of the antiseptic ended the outbreak. Conclusion: Regular surveillance of unusual pathogens may lead to early detection of nosocomial outbreaks. Epidemiological analysis is a strong indicator for the source of outbreak even when there is no microbiological evidence of contamination source.

영어초록

Background: Burkholderia cepacia is one of the key pathogens involved in the nosocomial outbreaks via contaminated supplies. We describe here an experience of recurrent B. cepacia pseudo-bacteremia caused by the contaminated commercial product of 0.5% chlorhexidine solution in a hospital.Methods: B. cepacia bacteremias detected from 30 November to 17 December 2014 were defined as cases. Epidemiological data were collected by reviewing the medical records and interviews with the healthcare workers. Suspected antiseptics were cultured using blood culture media.Results: Using regular active surveillance of microbiological results, 15 B. cepacia isolates were found in 13 patients. Pseudo-bacteremia was suspected in all of the cases based on the clinical analysis of individual patients. Misuse of 0.5% chlorhexidine in its solution rather than its tincture form as a skin antiseptic prior to drawing blood for blood culture procedures was the only identifiable risk factor for B. cepacia pseudo-bacteremia. Culture of 0.5% chlorhexidine solution was negative. Suspending the use of 0.5% chlorhexidine solution and educating healthcare workers on the proper use of the antiseptic ended the outbreak. Conclusion: Regular surveillance of unusual pathogens may lead to early detection of nosocomial outbreaks. Epidemiological analysis is a strong indicator for the source of outbreak even when there is no microbiological evidence of contamination source.

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