新生兒眼睛 Serratia marcescens感染之群聚調查

Survey Analysis of Serratia Marcescens Bacterial Eye Colony Cluster Infection in Neonates

Serratia marcescens 是醫院內常見的伺機性病原菌，2017 年 5 月，某醫院嬰兒房感染密度為 8.54‰ 較 4 月份 4.59‰ 上升，經由統計學（住院人日數加權）卡方檢定：df = 1, χ2 = 1.474, P < 0.000 呈現顯著差異，為避免疫情擴大而進行調查；調查結果：感染個案中有 5 個新生兒眼睛分泌物分離出 S. marcescens；經環境採檢後，由分裝的 3 瓶嬰兒沐浴乳中培養出相同菌株，判定為沐浴乳遭污染，再經由工作人員手部，觸摸新生兒眼睛造成之伺機性感染，結論：規定原裝沐浴乳不可分裝及稀釋，並且須隨時保持沐浴水槽清潔與乾燥，加強工作人員宣導教育，三個月內不再有感染情形發生。 Serratia marcescens is an opportunistic pathogen that is frequently observed in hospitals. In May 2017, the incidence of infection with this organism increased to 8.54‰, which was much higher than the incidence of 4.59‰ noted in April 2017. Statistical analysis of the number of hospital days using the chi-squared test revealed significant differences (df = 1, X2 = 1474, P < 0.000). To avoid spreading the disease, further investigation was conducted. Results of the investigation showed that 5 cases of neonatal eye infections were due to S. marcescens. After environmental inspection, culture of 3 bottles of bath solutions showed the same bacteria. The bacteria was determined to be from the bath solution; the staff were infected through their hands, and they, in turn, infected the neonates' eyes with their hands. Conclusion: The standard neonatal bath solution must not be divided or diluted, and the bath tub must be maintained clean and dry at all times when not in use. An increase in personnel education may stop this infection from spreading.

Serratia marcescens is an opportunistic pathogen that is frequently observed in hospitals. In May 2017, the incidence of infection with this organism increased to 8.54‰, which was much higher than the incidence of 4.59‰ noted in April 2017. Statistical analysis of the number of hospital days using the chi-squared test revealed significant differences (df = 1, X2 = 1474, P < 0.000). To avoid spreading the disease, further investigation was conducted. Results of the investigation showed that 5 cases of neonatal eye infections were due to S. marcescens. After environmental inspection, culture of 3 bottles of bath solutions showed the same bacteria. The bacteria was determined to be from the bath solution; the staff were infected through their hands, and they, in turn, infected the neonates' eyes with their hands. Conclusion: The standard neonatal bath solution must not be divided or diluted, and the bath tub must be maintained clean and dry at all times when not in use. An increase in personnel education may stop this infection from spreading.