醫療照護相關退伍軍人病事件處理經驗

Experience in Handling Healthcare Associated Legionnaires’Disease

醫療照護相關退伍軍人病死亡率高達30-50%，突顯出醫療機構中控制及監測環境中退伍軍人菌在預防院內感染中扮演重要角色。本院自2013年起定期每半年進行退伍軍人菌水質檢測，均無異常檢出報告。2019年6月於外科大樓骨科病房發生一例醫療照護相關退伍軍人病個案，經退伍軍人菌尿液抗原檢測陽性確診，同時於指標病室熱水供水管線中檢出退伍軍人菌2-14型，遂展開相關調查及改善措施，包括：(1)回溯性檢視過去半年醫療照護相關肺炎個案是否有群聚之情形，(2)加強監測新收案醫療照護相關肺炎個案，主動進行退伍軍人菌尿液抗原篩檢2個月，期間共收案23例肺炎個案，其中12例有進行主動篩檢，陽性率為0%，(3)因未常規執行熱水儲水槽之清洗消毒，故工務單位緊急進行相關維護作業，(4)於病室安裝0.2μm過濾器作為緊急應變之用，並僅開放非高風險病患入住該病室，(5)於環境調查中，增加水質檢測頻率，藉由擴大採檢釐清管線汙染範圍，進行汙染區域局部管消，於改善後半年內未再有案例發生。

Healthcare-associated Legionnaires' disease has a high mortality rate ranging from 30% to 50%, highlighting the importance of legionellosis prevention in healthcare facilities. In June 2019, a case of healthcare-associated Legionnaire’s disease occurred in the orthopedic ward of a surgical building. The diagnosis was confirmed using the Legionella urine antigen test. Simultaneously, Legionella pneumophila serogroup 2-14 was isolated from the hot water supply pipeline of the ward. The several interventions conducted have been described as follows. First, a retrospective investigation of nosocomial pneumonia cases showed unit clustering over the past six months. Second, active monitoring of Legionella urine antigen test was performed for nosocomial pneumonia infection cases for two months. Twelve of the 23 patients with pneumonia were screened without any positive results. Third, because cleaning and disinfection of hot water storage tanks are not routinely performed, maintenance work was immediately performed. Fourth, a point-of-use (0.22μm) filter was installed for emergency use to allow only the non-high-risk patients into the room. Lastly, in the environmental survey, the frequency of detection increased, and the sampling range was expanded to clarify the pollution area and local pipe disinfection in contaminated areas. No additional cases were recorded after improvement.