2023年臺灣南部某嬰兒室新生兒退伍軍人病病例調查報告

Investigation of a Neonatal Legionnaires' Disease Case in a Southern Taiwan Newborn Ward, 2023

新生兒肺炎檢出退伍軍人菌是少見的，南部一名11天大新生兒經醫院診斷為退伍軍人病，其痰檢體檢出退伍軍人菌，衛生福利部疾病管制署將菌株進行檢驗比對，顯示與出生醫院的嬰兒室RO水分離菌株相同。衛生福利部疾病管制署會同地方衛生單位進行實地院內感染輔導、環境水源調查和清消，及新生兒接觸者健康監測追蹤等防治措施，後續未新增退伍軍人病個案。本報告呈現新生兒肺炎病例，須將退伍軍人病列入診斷考慮，並對院內感染提高警覺，且務必落實定期用水管路清洗及水源監測等，以減低退伍軍人菌對新生兒的危害。

Legionella spp. are rarely identified as the causative agent in neonatal pneumonia. In this report, we describe a case of neonatal Legionnaires’disease in which the patient’s isolates were identical to those from the reverse osmosis water system of a newborn ward, as confirmed by pulsed-field gel electrophoresis. The Taiwan Centers for Disease Control collaborated with local health authorities to provide on-site infection-control audits, environmental management, and contact tracing. No additional cases were linked to this ward. This report highlights the need for heightened surveillance for legionellosis in neonatal pneumonia and the importance of raising awareness about nosocomial infections. Regular proactive maintenance and a comprehensive disinfection program for the entire water system are crucial to mitigate the risk of Legionella spp. growth.