推動環境清潔策略降低多重抗藥性鮑氏不動桿菌醫療照護相關感染之成效

Reducing Healthcare-associated Infections Caused by Multidrug-resistant Acinetobacter baumannii by Implementing Hospital-wide Environmental Cleaning Measures

多重抗藥性鮑氏不動桿菌(multidrug-resistant Acinetobacter baumannii; MDRAB)可存於醫院環境中的任何角落，若醫療環境及設備消毒不完全時，污染環境之MDRAB會透過人員接觸而散播給病人。2007年全院醫療照護相關感染，MDRAB菌株數佔所有醫療照護相關感染A. baumannii菌株數比率有逐季上升趨勢，甚至2008年1～2月間本院某內科加護病房出現MDRAB群突發事件，經根本原因分析及處理經驗顯示：環境污染是主要問題之一。為改善醫院環境清潔效果，擬定三種清潔策略，1.制定新清潔用具管理作業，用具依其清潔順序分區使用，分別用綠、藍及紅三種顏色標示，以易清楚辨識；2.安排在職教育，強化清潔人員認知，清潔順序由上而下、從乾淨區到污染區的原則，3.制定加護病房清潔點工作流程，提供清潔人員依循。之後，將清潔用具管理作業與加護病房清潔點工作流程在全院各加護病房擴大推行，並要求每日以高濃度漂白水 （游離氯5,000ppm，其泡製方法為1份5％漂白水加9份清水稀釋，且於24小時內使用）消毒包括病室在內的加護病房所有環境。該加護病房於MDRAB群突發事件期間（2007年9月～2008年2月）與改善後（2008年3～12月），整體醫療照護相關感染率(23.2‰vs.15.8‰)顯著下降(P=0.03)，而且醫療照護相關感染MDRAB感染率亦呈現顯著下降(P=0.02)。另全院醫療照護相關感染MDRAB菌株數與MDRAB群突發事件改善後一年與群突發事件前一年之全院及全院加護病房醫療照護相關感染MDRAB感染率皆呈現顯著下降(P<0.001)。本研究顯示，環境清潔對降低多重抗藥性鮑氏不動桿菌傳播是有效的。

Multidrug-resistant Acinetobacter baumannii (MDRAB) may colonize the inanimate hospital environment if the environment is not properly disinfected. Environmental MDRAB isolates may become pathogenic as a result of therapeutic and nursing contact between healthcare personnel and patients. Root cause analysis of a cluster of MDRAB isolated from an intensive care unit (ICU) of a medical center indicated that the hospital management system was responsible. This led to the revision of the hospital environment cleaning policy with respect to cleaning instruments and the cleaning techniques used by ward cleaners. Different colorcoded cleaning instruments were used for cleaning different areas of the ward, depending on their contamination level (i.e., clean, intermediately contaminated, and contaminated areas). A standard operating procedure (SOP) was established for guiding orderly environment cleaning practices. The SOP included practices such as cleaning the environment in a downward manner by starting the procedure at upper levels and in a forward manner by starting in clean areas (nurse station) and ending in the most contaminated areas (isolation room) of the ward. An education program was arranged to increase the ward cleaners’ awareness of the SOPs and ensure its strict enforcement. This SOP was then applied to the cleaning of all ICUs in the hospital. Additionally, the environments in these ICUs were disinfected on a daily basis with household bleach (1:10 dilution of a 5% solution of sodium hypochlorite). Compared to the period when the cluster of MDRAB was identified (September 2007-February 2008), the overall healthcare-associated infection rate in the affected ICU decreased significantly (23.2% vs.15.8%, P = 0.03) after implementation of the new environmental cleaning strategy (March-December 2008). Similarly, MDRAB healthcare-associated infection rate also reduced significantly (5.1% vs. 1.4%, P = 0.02). One year after the revision of the hospital cleaning policy (March 2008-February 2009), we found that compared to the infection rates during March 2007-February 2008, when MDRAB-associated nosocomial infection rates were high, the MDRAB healthcare-associated infection rate was significantly reduced both in the ICU (0.4% vs. 0.9%, P < 0.001) and in the hospital as a whole (0.09% vs. 0.18%, P < 0.001). Our data emphasize the importance of environmental cleaning to prevent the spread of MDRAB within a hospital.