臺灣博碩士論文加值系統

院內感染退伍軍人病是一種因退伍軍人桿菌感染所引起的伺機性細菌性肺炎。退伍軍人桿菌廣泛存在於自然界中，感染來源與自來水供水系統有關。前瞻性院內供水系統退伍軍人桿菌培養，作為院內感染退伍軍人病之防制策略，已廣為其他國家所採用。在台灣，院內感染退伍軍人病很少被發表；院內自來水供水系統環境培養退伍軍人桿菌亦尚未有系統性的實行。本研究目的在確認台灣是否有院內退伍軍人病發生，同時建構院內感染退伍軍人病之風險管理策略。
本研究選擇南台灣一家軍醫院，進行一年期的前瞻性監控計畫。針對所有包含院內感染型及社區感染型肺炎病例的檢體進行退伍軍人桿菌的檢驗。同時每三個月收集供水系統檢體，進行醫院環境流行病學的調查。分離出來的嗜肺性退伍軍人桿菌皆進行血清分型和脈衝式電泳分析。
95年11月01日起至96年10月31日，共有300例社區感染型和54例院內感染型肺炎病例，只有一例院內感染退伍軍人病發現。環境採檢結果陽性率為20.7%(17/84)，82.4%(14/17)為血清第一型退伍軍人桿菌。唯一陽型病例，經環境調查結果，發現其感染來源為另一家醫院的自來水系統。由本研究結果得知以下結論：1. 院內感染退伍軍人病的感染來源與醫院供水系統中存在的退伍軍人菌有關。2. 環境採檢退伍軍人桿菌陽性率的高低，是一項合理、可靠的院內防制感染退伍軍人病的風險管理指標。3. 醫院進行前瞻性退伍軍人病之主動篩檢調查，將會診斷出一些未曾發現潛在的退伍軍人病個案。因此本研究建議：1. 醫院，安養照護機構，大型飯店，餐廳，SPA，游泳池，溫泉，學校，軍隊等機構，在常規水質採檢中，應增加退伍軍人桿菌的培養檢驗。2. 建議政府衛生機關進行國內多家醫院的「前瞻性肺炎病患痰液退伍軍人桿菌培養研究」，以發掘潛在的病患，調查出國內真正的疾病發生率。3. 加強國內醫療從業人員診斷退伍軍人病的能力，以避免誤診和延誤治療發生。

Hospital-acquired Legionnaires’ Disease (LD) is a bacterial pneumonia caused by the genus of Legionella. It is an opportunistic pathogen with the characteristic of widespread distribution in the environment. Its source of infection associates with potable water systems. Proactively culturing hospital water supply for Legionella as a strategy for prevention of nosocomial LD has been widely adopted in other countries. Nosocomial LDs has been hardly reported in Taiwan. In addition, environmental cultures of Legionella in potable water systems in hospitals have not been systematically implemented. Thus, the purpose of the research is to confirm if LD presents in the hospital in Taiwan, and developing risk management strategy in hospital-acquired LD.
To practice one-year prospective surveillance program for LD, we choose a military hospital in Southern Taiwan, collecting the specimens from the nosocomial and community-acquired pneumonia patients for legionella investigations. In the meanwhile, we collect water samples for hospital epidemiological investigation every 3 months. Isolated Legionella pneumophila is serotyped and analyzed by pulsed-field gel electrophoresis.
From Nov 1, 2006 to Oct 30, 2007, within 54 cases of nosocomial and 300 cases of community-acquired pneumonia, only one case of nosocomial LD was found. Environmental investigations detected L. pneumophila in 17(20.7%) of the 84 water samples, of which 82.4% (14/17) belonged to serogroup 1. The result demonstrated the infection source of the only positive case of nosocominal pneumonia is the potable water supply system of another hospital. In conclusion: 1. The infection source of nosocomial LD is the potable water supply system of the hospital. 2. The positive rate of distal outlets for L. pneumophila is a reasonable and reliable indicator in risk management for nosocomial LD. 3. Uncovered cases of nosocomial LD will be found in prospective clinical surveillance for LD. Suggestions: 1. Routine water-quality monitoring should be added in environmental water culture for L. pneumophila in the institution, such as hospital, nursing home, hotel, restaurant, SPA, swimming pool, hot spring, school, army, etc. 2. We advise that government health department carries out national surveillance for hospital water environment in determining the risk of hospital-acquired LD. 3. Education and training program need to be provided for medical staffs in the diagnostic skills of nosocomial LD to avoid misdiagnosing and delaying the treatment.

論文審定書..............................................................................................................................................................................I
論文提要.................................................................................................................................................................................II
致謝詞....................................................................................................................................................................................III
中文摘要................................................................................................................................................................................IV
英文摘要................................................................................................................................................................................V
目錄.......................................................................................................................................................................................VII
圖目錄....................................................................................................................................................................................IX
表目錄....................................................................................................................................................................................X
第一章 緒...............................................................................................................................................................................1
第一節 研究背景與動機.......................................................................................................................................................1
第二節 研究目的...................................................................................................................................................................2
第三節 研究流程...................................................................................................................................................................2
第四節 研究範圍與限制.......................................................................................................................................................5
第二章 文獻探討...................................................................................................................................................................6
第一節 疾病介紹...................................................................................................................................................................6
第二節 環境中的退伍軍人菌.............................................................................................................................................12
第三節 醫院環境的監測.....................................................................................................................................................16
第四節 風險評估與風險管理.............................................................................................................................................22
第三章 研究方法.................................................................................................................................................................27
第一節 研究架構.................................................................................................................................................................27
第二節 研究對象與研究方法.............................................................................................................................................29
第四章 資料分析.................................................................................................................................................................33
第一節 個案醫院-國軍高雄總醫院介紹...........................................................................................................................33
第二節 醫院內環境採檢結果.............................................................................................................................................34
第三節 肺炎病例檢體檢驗結果.........................................................................................................................................35
第四節 陽性病例檢體與環境檢體結果比對分析.............................................................................................................36
第五節 院內感染退伍軍人症的風險評估.........................................................................................................................39
第六節 討論.........................................................................................................................................................................43
第五章 結論與建議.............................................................................................................................................................48
第一節 結論.........................................................................................................................................................................48
第二節 建議.........................................................................................................................................................................49
參考文獻..............................................................................................................................................................................52
中文文獻..............................................................................................................................................................................52
英文文獻..............................................................................................................................................................................53
附錄一：美國國家病人安全中心安全評估法典(SAC)...................................................................................................58
附錄二：退伍軍人桿菌鑑定流程......................................................................................................................................61
附錄三：退伍軍人桿菌之聚合酶鏈反應(Polymerase Chain Reaction)操作流........................................................62

參考文獻
一、中文文獻
1.朱育增、石富元、許筱稜、吳宗樹、胡賦強、金傳春，2005，「由嚴重急性呼吸道症候群(SARS)2003年跨國流行疫情回顧院內感染預防措施」，疫情報導21卷7期477-498
2.行政院研究發展考核委員會，2007，「風險管理作業手冊第三版」
3. 行政院衛生署疾病管制局，2007，「退伍軍人菌控制作業建議指引」
4. 宋明哲，2001，現代風險管理，五版，台北市：五南
5. 周振英、鄭麗容、姚淑滿、陳英彥，2004，「台灣退伍軍人病流行病學現狀」， 疫情報導20卷5期254-264
6. 郭佳周，2005，發展即時定量聚合脢鏈於退伍軍人菌及肺炎披衣菌之檢驗，並以2004年高雄榮民總醫院社區型肺炎病患為研究對象，國立中山大學生物醫學研究所碩士論文。
7.許國敏、莊秀文、莊淑婷，2006，病人安全管理與風險管理實務導引，一版，台北市：華杏
8.陳佩伶、巫坤彬、黃子玫、陳昶勳，2007，水體環境中退伍軍人菌控制方式之探討，疫情報導，23卷11期：631-644
9.黃文貴，2004，退伍軍人症之實驗室診斷與環境調查，感染控制雜誌，14卷1期：31-39
10.張上淳、林昇鋒、1997，「退伍軍人症」，臺灣醫學，1卷1期：72-80
11.詹廖明義，2003，醫療事故的風險管理，初版，台北縣新店市：安立
12.潘子明、林勝育、洪其璧，1995，「退伍軍人症與冷卻水塔」，疫情報導，11卷1期：7-10
13.蘇勳璧、鄭麗容、周振英，2005，「退伍軍人桿菌檢測方法」，疫情報導，21卷12期：930-940
14.蘇勳璧、鄭麗容、李憲郎、蔡韶慧、賴珮芳、林朱徤、張瑞炘、江春雪、吳和生、李翠鳳、廖龍仁、張登欽，2007，「台灣地區疑似退伍軍人症群聚感染之病例調查」，疫情報導，23卷11期：623-630
15.蘇勳璧、鄭麗容、周振英、張登欽，2007，「台灣地區之退伍軍人症」，臺灣衛誌，26卷3期：177-183
16.蘇勳璧、鄭麗容、曾士展、周振英、張登欽，2008，「疑似退伍軍人症家庭群聚感染之病例調查」，疫情報導，24卷2期：98-111
二、英文文獻
1. Allegheny County Health Department. 1997. Approaches to prevention and control of Legionella infection in Allegheny County health care facilities. 2nd ed. Pittsburgh, PA: Allegheny County Health Department: 1–15. Download from Www.legionella.org Oct 26 2007
2. Benson, R.F., & Fields, B.S. 1998. Classification of the genus Legionella.Semin Respir Infect, 13:90-99.
3. Boccia, S., Laurenti, P., Borella, P., Moscato, U., Capalbo, G., Cambieri, A., Amore, R., Quaranta, G., Boninti, F., Orsini, M., Branca, G., Fadda, G., Spica V.R., Ricciardi, G. 2006. Prospective 3-Year Surveillance for Nosocomial and Environmental Legionella pneumophila: Implications for Infection Control. Infect Control Hosp Epidemiol, 27:459-465
4. Chen, Y.S., Lin, W.R., Liu, Y.C., Chang, C.L., Gan, V.L., Huang, W.K., Huang, T.S., Wann, S.R., Lin, H.H., Lee, S.J., Huang, C.K., Chin, C., Lin, Y.E., & Yen, M.Y. 2002. Community-acquired Legionnaires’ disease in an immunocompromised host linked to a contaminated home water supply. Eur J Clin Microbiol,21:706-9.
5. Chen, Y.S., Liu, Y.C., Lee, S.S., Tsai, H.C., Wann, S.R., Kao, C.H., Chang, C.L., Huang, W.K., Huang, T.S., Chao, H.L., Li, C.H., Ke, C.M., & Lin, Y.E. 2005. Superheat-and-flush and disinfection of taps for Legionella disinfection: lessons learned from failure. AM J Infect Control, 33: 606-10.
6. Den Boer, J.W., Yzerman, E.P., Schellekens, J., Lettinga K.D., Boshuizen H.C., Van Steenbergen J.E., Bosman A., Van den Hof S., Van Vliet H.A., Peeters M.F., Van Ketel R.J., Speelman P., Kool J.L., & Conyn-Van Spaendonck M.A. 2002. A large outbreak of Legionnaires'' disease at a flower show, the Netherlands, 1999. Emerging infectious diseases, 8:37-43.
7. Fields, B.S., Benson, R.F., & Besser, R.E. 2002. Legionella and Legionnaires'' disease: 25 years of investigation. Clin Microbiol Rev,15: 506-26.
8. Fraser, D.W., Tsai, T.R., Orenstein, W., Parkin, W.E., Beecham, H.J., Sharrar, R.G., Harris, J., Mallison, G.F., Martin, S.M., McDade, J.E., Shepard, C.C., & Brachman, P.S. 1977. Legionnaires’ disease: description of an epidemic of pneumonia. N Engl J Med,297:1189-1197.
9. Gilmour, M.W., Bernard, K., Tracz, D.M., Olson, A.B., Corbett, C.R., Burdz, T., Ng, B., Wiebe, D., Broukhanski, G., Boleszczuk, P., Tang, P., Jamieson, F., Van Domselaar, G., Plummer, F.A., & Berry, J.D. 2007. Molecular typing of a Legionella pneumophila outbreak in Ontario, Canada. J Med Microbiol, 56: 336-41.
10. Glick, T.H., Gregg, M.B., Berman, B., Mallison, G., Rhodes, Jr.W.W., & Kassanoff, I. 1978. Pontiac fever. An epidemic of unknown etiology in a health department. I. Clinical and epidemiologic aspects. Am J Epidemiol, 107: 149-160.
11. Goetz, A.M., Stout, J.E., Jacobs, S.L., Fisher, M.A., Ponzer, R.E., Drenning, S., & Yu, V.L., 1998. Nosocomial legionnaires’ disease discovered in community hospitals following cultures of the water system: seek and ye shall find. Am J Infect Control, 26:6-11.
12. Johnson, J.T., Yu, V.L., Best, M.G., Vickers, R.M., Goetz, A., Wagner, R., Wicker, H., & Woo, A. 1985. Nosocomial legionellosis in surgical patients with head-and-neck cancer: implications for epidemiological reservoir and mode of transmission. Lancet, 2:298-300.
13. Joly, J., & Alary, M.1994. Occurrence of nosocomial Legionnaires'' disease in hospitals with contaminated potable water supply. In: Barbaree, J.D., Breiman, R.F., Dufour, A.P., Eds., Current Status and Emerging Perspectives:39. Washington, DC: American Society of Microbiology.
14. Liu, Y.C., Cheng, D.L., Shi, F.W., Huang, W.K., & Wong, J.H. 1998. Legionnaires’disease: a case report. J Formos Med Assoc,84:1180-5.
15. Muder, R.R., Yu, V.L., McClure, J., & Kominos, S. 1983. Nosocomial legionnaires’disease uncovered in a prospective pneumonia study: implications for underdiagnosis. JAMA, 249:3184-3188.
16. Nygård, K., Werner-Johansen, Ø., Rønsen, S., Caugant, D.A., Simonsen, Ø., Kanestrøm, A., Ask, E., Ringstad, J., Ødegård, R., Jensen, T., Krogh, T., Høiby, E.A., Ragnhildstveit, E., Aaberge, I.S., & Aavitsland, P. 2008. An outbreak of legionnaires disease caused by long-distance spread from an industrial air scrubber in Sarpsborg, Norway. Clin Infect Dis, 46(1):61-9.
17. Okada, M., Kawano, K., Kura, F., Amemura-Maekawa, J., Watanabe, H., Yagita, K., Endo, T., & Suzuki, S. 2005. The largest outbreak of legionellosis in Japan associated with spa baths: epidemic curve and environmental investigation [Article in Japanese] Kansenshogaku Zasshi,79(6):365-74
18. Ricketts, K., & Joseph, C. 2007. Legionnaires’ disease in Europe: 2005-2006. Euro Surveill,12(12)[Epub ahead of print]. Available online: http://www.eurosurveillance.org/em/v12n12/1212-224.asp. Download from www.euroserveillance.org April 21 2008.
19. Rudin, J.E., & Wing, E.J. 1986. Prospective Study of Pneumonia: Unexpected Incidence of Legionellosis. Southern Medical Journal, 79(4):417-419.
20. Sabrià, M., Mòdol, J.M., Garcia-Nuñez, M., Reynaga, E., Pedro-Botet, M.L., Sopena, N., & Rey-Joly, C. 2004. Environmental cultures and hospital-acquired legionnaires disease: a 5-year prospective study in 20 hospitals in Catalonia, Spain. Infect Control Hosp Epidemiol, 25:1072-1076
21. Steels, T.W. 1989. Legionnaires’ disease in South Australia, 1979-1988. Med J Aust, 151: 322,325-326,328.
22. Stout, J.E., & Yu, V.L. 2003. Experiences of the first 16 hospitals using coppersilver ionization for Legionella control: implications for the evaluation of other disinfection modalities. Infect Control Hosp Epidemiol, 24:563-8.
23. Stout, J.E., Muder, R.R., Mietzner, S., Wagener, M.M., Perri, M.B.,
DeRoos, K., Goodrich,D., Arnold, W., Williamson, T., Ruark, O., Treadway, C., Eckstein, E.C., Marshall, D., Rafferty, M.E., Sarro, K., Page, J., Jenkins, R., Oda, G., Shimoda, K.J., Zervos, M.J., Bittner, M., Camhi, S.L., Panwalker, A.P., Donskey, C.J., Nguyen, M.H., Holodniy, M., & Yu,V.L. 2007. Role of environmental surveillance in determining the risk of hospital-acquired Legionellosis:a national surveillance study with clinical correlations. Infect Control Hop Epidemiol;,28:818-824
24. Wang, R.S., Liu, C.Y., Liu, Y.C., & Cheng, K.K.1989. Legionnaires’ disease following cardiac transplantation. Zhonghua Yi Xue Za Zhi, 44:336-40.
25. Yu, P.Y., Lin, Y.E., Lin, W.R., Shih, H.Y., Chuang, Y.C., Ben, R.J., Huang, W.K., Chen, Y.S., Liu, Y.C., Chang, F.Y., Yen, M.Y., Liu, C.C., Ko, W.C., Lin, H.H., & Shi, Z.Y. 2008. The high prevalence of Legionella pneumophila contamination in hospital potable water systems in Taiwan: implications for hospital infection control in Asia. Int J Infect Dis, In Press.
26. Yu, V.L., Beam, T.R., Lumish, R.M., Vickers, R.M., Fleming, J., McDermott, C., & Romano, J. 1987. Routine culturing for Legionella
in the hospital environment may be a good idea: a three-hospital prospective study. Am J Med Sci, 294:97-99.