中部某地區醫院微生物實驗室檢體受羅爾斯頓氏菌(Ralstonia species)汙染之事件調查與改善

Pseudo-outbreak of Ralstonia species Infections by Laboratory Contamination of Saline Solution at a District Hospital in Central Taiwan

羅爾斯頓氏菌(Ralstonia species)為一種伺機性革蘭氏陰性菌，常存在於水、土壤和植物中。在醫療環境中，可以通過污染的溶液引起醫療相關感染或群突發。我們報告了在台灣中部一家地區醫院微生物實驗室中，因生理食鹽水分裝瓶污染引起的羅爾斯頓氏菌偽群突發(pseudo-outbreak)。在2020年4月至7月間，在此家醫院共出現5例羅爾斯頓氏菌病例。經調查發現，微生物實驗室用來濕潤手術組織培養檢體的生理食鹽水分裝瓶溶液，被羅爾斯頓氏菌所污染，可能是此次偽群突發發生的原因。經進行改善措施，包括：對微生物實驗室工作人員進行無菌技術的教育訓練與稽核及明文規定，使用一次性生理鹽水小瓶代替生理食鹽水分裝瓶來濕潤手術組織培養檢體等，自2020年7月7日後未發現新的羅爾斯頓氏菌病例。此次羅爾斯頓氏菌偽群突發事性再次提醒我們，及時的群突發辨識機制和發現微生物實驗室運作過程中的缺失，以避免誤導臨床診斷和治療是非常重要的。

Ralstonia species is an emerging pathogen, and an opportunistic gram-negative bacterium that often exists in water, soil, and plants causing healthcare-associated infections or outbreaks through contaminated solutions. We report a pseudo-outbreak of Ralstonia species infections resulting from a contaminated saline dispenser in the microbiological laboratory at a hospital in central Taiwan. A cluster of five cases with Ralstonia species infections was noted from April to July in 2020. The investigation revealed that contamination of the dispensed saline solution by the Ralstonia species used for damping desiccated surgical specimens in the microbiological laboratory may have caused the pseudo-outbreak. After using single-used saline vials instead of dispensed saline solution for the laboratory procedure and implementation of education program on sterile technique for the microbiological laboratory staffs, no new case of infection by Ralstonia species was identified. Thus, rapid identification and correction of flaws in running processes in a microbiological laboratory is crucial to avoid misdiagnoses and treatments in clinical patients.