149 Klebsiella pneumoniae 1 1,2,3 1,2,3 1,2 1 1 2 3 2015 7 14 2015 10 31 (Klebsiella pneumoniae) 12 K. pneumoniae 10 (8 1 1 ) 2 12 11 (Third-generation cephalosporins) 92% (11/12) 10 2 K. pneumoniae 20% (2/10) ATP (adenosine triphosphate) - 12 36.3% (4/12) 8 7 6 11 7.9 central venous catheter (CVC) bundle CVC bundle - 2015 11 K. pneumoniae 2018:28:149-163 106 8 10 106 10 30 107 7 6 95 (02) 2833-2211 2095 DOI: 10.6526/ICJ.201808_28(4).0001 107 8
150 Klebsiella pneumoniae ( Klebsiella pneumoniae) [1] [2-4] - 2010 2016 K. pneumoniae (Acinetobacter baumannii) 2017 A. baumannii K. pneumoniae [5] K. pneumoniae K. pneumoniae 50% [2-4] K. pneumoniae [6-7] [8] 10 2 5 ( ) 60 2 2 1:2.5
151 K. pneumoniae 3 3,100 2015 7 14 2015 10 31 1~2 2004 2015 8 5 7 8 5 2 1 K. pneumoniae 3 107 8
152 Klebsiella pneumoniae 8 7 2 5 K. pneumoniae K. pneumoniae 2 5 (third-generation cephalosporins) 2 K. pneumoniae 2015 7 14 2015 10 31 12 K. pneumoniae 10 (8 1 1 ) 2 ( ) 6 7 31 8 5 12 ( ) 11 92% (11/12) K. pneumoniae ( ) (2015 7~10 ) (2015 1~6 ) K. pneumoniae ( ) K. pneumoniae AN CAZ CIP CMZ CRO CXM CZ DOR ETP FEP GM IPM LVX PIP TZP 1 PI03 7/14 S R S R R R R S R R S S S R S 2 PI09 7/31 R S S S R R R S S S R S S R S 3 PI06 7/31 S R S I R R R S S S I S S R R 4 PI01 8/3 S R S I R R R S S R I I S R S 5 PI02 8/3 S R S I R R R S S R I I S R S 6 PI05 8/4 S R S I R R R S S R R S S R I 7 PI03 8/5 S R S I R R R S S R I S S R S 8 PI09 8/17 R S S S R R R S S R R S S R S 9 PI08 8/20 S R S I R R R S S R R S S R S 10 PI11 9/5 S S S I R R S S S I I S S 11 PI11 10/6 R R S S R R S S R R S S S 12 PI01 10/31 S S S S S I S S S S S S S AN (Amikin) CAZ (Ceftazidime) CIP (Ciprofloxacin) CMZ (Cefmetazole) CRO (Ceftriaxone) CXM (Cefuroxime) CZ (Cefazolin) DOR (Doripenem) ETP (Ertapenem) FEP (Cefepime) GM (Gentamicin) IPM (Imipenem) LVX (Levofloxacin) PIP (Piperacillin) TZP (Piperacillin + Tazobactam)
153 介入感染管制措施 7 6 5 4 3 2 1 0 ( 月 ) K. pneumoniae K. pneumoniae (2015 7 ~2015 10 ) 10 181 191 (2015 1 ~2015 6 ) 0 205 205 10 386 396 P value 0.001* * Fisher s exact test (2-tailed) (P = 0.001) ATP (adenosine triphosphate)- K. pneumoniae K. pneumoniae (PI03) (agar plate method) 1. ATP- 107 8
154 Klebsiella pneumoniae ATP ATP ATP ATP 16 (cm 2 ) (relative light unit, RLU) 200 RLU ATP 2. 35 48 BAP (blood agar plate )/EMB (eosin methylene blue) 3. ( ) 4. Vitek 2 (API bio-mérieux, La Balme, Les Grottes, Franc) K. pneumoniae (clinical and laboratory standards institutes, CLSI) [9] central venous catheter (CVC) bundle - ( ) 1. 8 5 ( ) 8 31 2. 3. 2 2% chlorhexidine gluconate (CHG) CVC bundle CVC bundle 1 2 75% 5~7.5
155 > 30 5. 8 9 ( ) 1. 8 5 1:100 (500 ppm) ( ) 1:10 (5,000 ppm) ( ) 1:10 (5,000 ppm) 2. 3. ATP- 3 8 6 8 7 9 9 8 21 ( ) 1. 2. 2 10 3 10 ( ) 2015 8 5 2015 7 14 ~10 31 12 K. pneumoniae 10 8 1 ( ) 1 2 10 ( ) 10 107 8
156 Klebsiella pneumoniae K. pneumoniae 編號床號性別 出生週數 Apgar score 入住 ICU 日期 感染日 感染部位 入住 ICU 日期至感染日 侵入性導管置放天數 臍動靜脈導管 中心靜脈導管 導管相關 1 PI06 男 24 3 7/23 7/31 血流 8 8 天 14 天 Y 2 PI05 女 28 7 7/24 8/3 血流 10 無置放 13 天 Y 3 PI03 男 24 3 6/20 8/3 血流 44 無 26 天 Y 4 PI02 女 25 7 7/11 8/5 血流 25 3 天 22 天 Y 5 PI01 男 23 4 8/4 8/5 血流 1 11 天無置放 Y 6 PI08 男 39 8 8/15 8/17 血流 2 無置放無置放 N 7 PI09 男 29 7 8/10 8/20 血流 10 2 天 7 天 Y 8 PI11 女 30 7 8/20 9/5 腸胃 16 4 天 12 天 N 9 PI11 女 30 7 8/20 10/6 血液 47 無置放 12 天 N 10 PI01 男 29 7 9/14 10/31 尿液 47 8 天 9 天 N
157 K. pneumoniae 28.1 4.6 Apgar score 6 21 18.5 8 7 6 11.2 7.9 8 6 ATP- K. pneumoniae PI05 PI06 PI10 PI11 (2 ) (2 ) (1 ) (2 ) (1 ) (1 ) (2 ) (1 ) 12 ( ) ATP > 200 RLU ( *2 ) 36.3% (4/12) 8 7 14 PI01 PI06 (2 ) (2 ) (4 ) (2 ) IV pump (2 ) IV Bag (2 ) K. pneumoniae 3 (yeast) 4 (coagulase- ATP- ATP (RLU 1 PI11 55 2 PI11 12 3 PI11 116 4 PI11 49 5 PI11 62 6 PI10 242 7 PI10 5 8 PI05 28 9 PI06 4 10 PI05-06 1352 11 PI10-11 815 12 PNICU 309 >200RLU =36.3%(4/12) 107 8
158 Klebsiella pneumoniae negative Staphylococci, CoNS) 9 8 21 3 2 10 1 K. pneumoniae 2 1 CoNS 1 A. baumannii 8 25 50% 67% 2015 12 9 1 K. pneumoniae 10 1 1 K. pneumoniae 2015 11 K. pneumoniae ( ) 9 9 8 50% 90% 67% 78% ATP- 15 8 36.3% 27% (11/15) K. pneumoniae [10-13] [14-16] Khan- Fatima 2015 6 2015 9 K. pneumoniae K. pneumoniae [17]
159 12 K. pneumoniae 10 2 10 6 K. pneumoniae K. pneumoniae K. pneumoniae 50% 67% Khan-Fatima 2015 2011~2015 18,604 27% (495/18,604) K. pneumoniae K. pneumoniae 2011 8.6% 2015 42.8% 7~9 61.8% K. pneumoniae [18] Richet, H. 1970~2012 [19] K. pneumoniae 3 K. pneumoniae 2012~2015 5~9 (Enterobacter cloacae) E. cloacae 5.7 [20] 2015 11 K. pneumoniae 2003 107 8
160 Klebsiella pneumoniae > 7 > 7 2 [21] 8 6 6 11.2 7.9 7 3 2003 CVC bundle CVC bundle 2015 11 K. pneumoniae K. pneumoniae PFGE K. pneumoniae 1. Centers for Disease Control and Prevention (2017, Jan 09). K. pneumoniae in Healthcare Settings: Centers for Disease Control and Prevention (CDC). Available https://www.cdc.gov/hai/ organisms/klebsiella/klebsiella.html 2. Gastmeier P, Groneberg K, Weist K, et al: A cluster of nosocomial Klebsiella pneumoniae bloodstream infections in a neonatal intensive care department: identification of transmission and intervention. Am J Infect Control 2003;31:424-30. 3. Skogberg K, Lyytikäinen O, Ruutu P, et al: Increase in bloodstream infections in Finland, 1995-2002. Epidemiol Infect 2008;136:108-14. 4. Sohn AH, Garrett DO, Sinkowitz-Cochran RL,
161 et al: Prevalence of nosocomial infections in neonatal intensive care unit patients: results from the first national point-prevalence survey. J Pediatr 2001;139:821-7. 5. (TNIS) 2017 http://www.cdc.gov.tw/ professional/info.aspx?treeid=beac9c103df952c4 &nowtreeid=4d41d91ffd50d559&tid=24fb18 0307C2DCBD 6. French G, Shannon K, Simmons N: Hospital outbreak of Klebsiella pneumoniae resistant to broad-spectrum cephalosporins and betalactam-beta-lactamase inhibitor combinations by hyperproduction of SHV-5 beta-lactamase. J Clin Microbiol 1996;34:358-63. 7. Hobson R, MacKenzie F, Gould I: An outbreak of multiply-resistant Klebsiella pneumoniae in the Grampian region of Scotland. J Hosp Infect 1996;33:249-62. 8. Royle J, Halasz S, Eagles G, et al: Outbreak of extended spectrum lactamase producing Klebsiella pneumoniae in a neonatal unit. Arch Dis Child Fetal Neonatal Ed 1999;80:64-8. 9. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing. CLSI guideline M100S-26. Wayne, P.A: CLSI, 2016 10. Eisenach KD, Reber RM, Eitzman DV, et al: Nosocomial infections due to kanamycinresistant,[r]-factor carrying enteric organisms in an intensive care nursery. Pediatrics 1972;50:395-402. 11. Hable KA, Matsen JM, Wheeler DJ, et al: Klebsiella type 33 septicemia in an infant intensive care unit. J Pediatr 1972;80:920-4. 12. Hill HR, Hunt CE, Matsen JM: Nosocomial colonization with Klebsiella, type 26, in a neonatal intensive-care unit associated with an outbreak of sepsis, meningitis, and necrotizing enterocolitis. J Pediatr 1974;85:415-9. 13. Zafir Kayyali M, Nicholson DP, Smith IM: A Klebsiella outbreak in a pediatric nursery: emergency action and preventive surveillance. Clin Pediatr 1972;11:422-6. 14. Drewett S, Tuke W, Payne D, et al: Eradication of Pseudomonas aeruginosa infection from a specialcare nursery. Lancet 1972;299:946-8. 15. Rapkin RH: Pseudomonas cepacia in an intensive care nursery. Pediatrics 1976;57:239-43. 16. Stone J, Das B: Investigation of an outbreak of infection with Acinetobacter calcoaceticus in a special care baby unit. J Hosp Infect 1986;7:42-8 17. Khan F, Siddiqui N, Sultan A, et al: Seasonal variation in Klebsiella pneumoniae blood stream infection: A five year study. Clinical Microbiology: Open Access 2016. 18. Khan F, Siddiqui N, Sultan A, et al: Klebsiella pneumoniae Outbreak in Paediatric Ward: Detection and Prevention. Int J Curr Microbiol App Sci. ISSN 2015:81-7. 19. Richet H: Seasonality in Gram negative and healthcare associated infections. Clin Microbiol Infect 2012;18:934-40. 20. Harbarth S, Sudre P, Dharan S, et al: Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices. Infect Control Hosp Epidemiol 1999;20:598-603. 21. 2005;15:273-85. 107 8
162 Klebsiella pneumoniae Investigating outbreak of Klebsiella pneumoniae infection in a Neonatal Intensive Care Unit Yu-Chiao Hung 1, Tsrang-Neng Jang 1,2,3, Chien-Shien Huang 1,2,3, Tai-Chin Hsieh 1,2, Shu-Hua Lee 1 1 Committee of Nosocomial Infection Control, 2 Section of Infectious Diseases, Department of Medicine, Shin Kong Wu Ho-Su Memorial Hospital, 3 School of Medicine, Catholic Fu-Jen University, Taipei, Taiwan An outbreak of Klebsiella pneumoniae infection occurred in a Neonatal Intensive Care Unit (ICU) of Taipei medical center from July through October 2015, during which time K. pneumoniae was isolated from 12 critically ill neonates. Of these, 10 were identified as health-care associated infections (8 blood stream, 1 urinary tract, 1 gastrointestinal tract) and 2 were sputum colonization. Although the antibiotic susceptibility of 12 K. pneumoniae isolates from patients was not completely identical, 11of 12 (92%) were ESBL (Extended-spectrum -lactamases) strains which were resistant to 3rd generation cephalosporins. We used ATP (Adenosine triphosphate) bioluminescence method to detect environmental cleanliness. Of 12 collected environmental sample, detection result of the failure rate was 36.3% (4/12). Besides, among the 8 patients with blood stream infection, seven had placement of central venous catheter (CVC) and/or umbilical arteriovenous catheter before infections. Six of them were identified as catheterrelated blood steam infection according to CDC definition. The mean interval from catheter insertion to infection was 11.2 7.9 days. Epidemiological investigation failed to reveal a common source of the outbreak, although the epidemic K. pneumoniae strain was isolated from hand-washes. We inferred that cross-transmission was the major route for this outbreak. Besides, we found that catheter-related blood stream infection played an important role in this outbreak. However, central venous catheter (CVC) bundle was not introduced in neonatal ICU before due to patient characteristics. Therefore, the management
163 of this outbreak included: implementing a modified CVC care bundle, strengthen staff education and training, strict handwashing practices, cohorting and isolation of colonized and infected patients, aggressive cleaning of the environment surfaces with disposable paper towels, and ICU space improvement. The outbreak was successfully controlled, no further K. pneumoniae infection was identified since Nov 2015. Key words: Neonatal intensive care unit, Klebsiella pneumoniae, outbreak 107 8