UNASSIGNED:从2019年5月6日至5月23日,24例(80.00%)在教学医院日间病房接受腹腔镜胆囊切除术(LC)的患者在手术后4-8小时内出现双眼结膜充血。
UNASSIGNED:医院感染预防和控制人员进行了程序和环境调查,进行了病例对照回顾性研究(包括24例和48例对照),并审查了所有生物材料产品的批号,以调查怀疑爆发的医疗保健相关感染。
未经批准:最初,假设由细菌引起的医疗保健相关感染爆发。我们首先怀疑覆盖患者眼睛的膜是使用非无菌剪刀切割的,因此被污染了,但是它们没有产生细菌。此外,病例患者的角膜和结膜荧光素染色结果均为阴性,并且在日间手术和日间病房的218份样本中,分离出的细菌普遍存在于环境或常见皮肤群落或正常结膜菌群中.因此,我们认为非感染性因素是双眼结膜充血的最可能原因.然后,在一项回顾性病例-对照研究中,我们发现病例-患者比没有双眼结膜充血的LC手术患者更有可能暴露于生物材料.当我们查看批号时,使用期限,以及在日间病房接受LC期间接受四种生物材料产品的患者人数,我们发现BLK1821很多改性的壳聚糖医用膜(主要成分是壳聚糖,线性阳离子多糖)在出现病例聚集时同时使用。最后,我们推测该产品与双眼结膜充血的爆发之间存在相关性。自停止使用该产品6个月以来,尚未观察到假性爆发的复发。
UNASSIGNED:LC后诊断的一组双眼非感染性结膜充血被证明是假性爆发。医院应重视生物材料引起的不良事件。
UNASSIGNED: From May 6 to May 23, 2019, 24 (80.00%) patients who underwent laparoscopic cholecystectomy (LC) developed binocular conjunctival congestion within 4-8 h after their operation in the day ward of a teaching hospital.
UNASSIGNED: Nosocomial infection prevention and control staff undertook procedural and environmental investigations, performed a case-control retrospective study (including 24 cases and 48 controls), and reviewed all lot numbers of biological material products to investigate the suspected outbreak of health care-associated infection.
UNASSIGNED: Initially, an outbreak of health care-associated infection caused by bacteria was hypothesized. We first suspected the membranes that covered patients\' eyes were cut using non-sterile scissors and thus contaminated, but they failed to yield bacteria. In addition, both corneal and conjunctival fluorescein staining results were negative in case-patients and isolated bacteria were ubiquitous in the environment or common skin commensals or normal flora of conjunctiva from 218 samples from day surgery and the day ward. Hence, we considered a non-infectious factor as the most likely cause of the binocular conjunctival congestion. Then, we found that case-patients were more likely than LC surgery patients without binocular conjunctival congestion to be exposed to biological materials in a retrospective case-control study. When we reviewed lot numbers, duration of use, and the number of patients who received four biological material products during LC in the day ward, we found that the BLK1821 lot of a modified chitosan medical membrance (the main ingredient is chitosan, a linear cationic polysaccharide) was used concurrently to when the case aggregation appeared. Finally, we surmised there was a correlation between this product and the outbreak of binocular conjunctival congestion. Relapse of the pseudo-outbreak has not been observed since stopping usage of the product for 6 months.
UNASSIGNED: A cluster of binocular non-infectious conjunctival congestion diagnosed after LC proved to be a pseudo-outbreak. We should pay more attention to adverse events caused by biomaterials in hospitals.