[[alternative]]Presence of multidrug-resistant organisms in residents and environments of long-term care facilities

Abstract

[[abstract]]長期照護機構在收治的對象及機構特性與一般急性醫療機構不同。而且在人力、設備、教育及資源上也與急性醫療機構醫照護有所差異。本研究目的在於暸解國內長期照護機構住民與環境的多重抗藥性微生物的存在情形，提供給主管機關參考以研擬適合國內長照機構使用之相關感染政策。 以台灣地區中部5家及北部1家不同類別長期照護機構進行住民與環境的多重抗藥性微生物存在情形研究。參與的長期照護機構都是志願性的。長期照護機構的總床數為621床。本研究採取前瞻性研究，期間自2015年01月01日至2015年12月31日止。研究方法如下：(1)經住民或家屬同意後，每四個月採檢住民的鼻腔和肛門。如果發現有多重抗藥性微生物(Multidrug-resistant organisms (MDROs)存在的情形，如抗甲氧苯青黴素金黃色葡萄球菌（Methicillin-resistant Staphylococcus aureus，MRSA）、抗萬古黴素腸球菌（Vancomycin-resistant Enterococcus，VRE）、多重抗藥性鮑氏不動桿菌（MDR -Acinetobacter baumannii，MDRAB）等、抗碳青黴烯類腸道菌（Carbapenem-resistant Enterobacteriaceae，CRE）或抗碳青黴烯類的綠膿桿菌(Carbapenem-resistant Pseudomonas aeruginosa (CRPA)時會再加採住民周邊環境。環境採檢至少有4-5點，包括住民的床、床旁的桌子、房間的門把、圍簾、浴室和廁所門把等。(2)所有多重抗藥性微生物都做抗生素敏感試驗，以了解長期照護機構細菌抗藥性的情形。(3)住民和環境多重抗藥性微生物的檢體如果是屬於目前國內比較重要的抗甲氧西林金黃色葡萄球菌、抗碳青黴烯類肺炎克雷伯氏菌(Carbapenem-resistant K. pneumoniae (CRKP)或者多重抗藥性包氏不動桿菌，則再進行分子生物學分析，探討這些多重抗藥性微生物在住民間和/或環境間可能的相關性。 總共有154株多重抗藥性微生物從住民或環境被培養出來。其中最多的是抗甲氧西林金黃色葡萄球菌，有83株(佔53.9%)，其次分別為抗碳青黴烯類的腸桿菌有35株(佔22.7%)，多重抗藥性包氏不動桿菌細菌有30株(佔19.5%)，以及抗碳青黴烯類的綠膿桿菌有6株(佔3.9%)。多重抗藥性微生物中從鼻腔培養出來有60株，佔27.9% (60/215) ，從肛門處培養出來有34株，佔15.8% (34/215)，其他從環境中培養出來有60株，佔11.1% (60/542)。本研究也觀察到多重抗藥性微生物的分佈和持續性會因為不同的長期照護機構或不同的時間而有差異性。 如何預防和控制多重抗藥性微生物在長期照護機構的產生和傳播是一個很重要的課題。建議各長期照護機構可以根據衛生福利部疾病管制署訂定的:長期照護機構多重抗藥性微生物(MDRO)服務對象之感染管制措施指引(如附錄一) 確實地去執行。為了要進一步了解台灣長期照護機構多重抗藥性微生物存在的真正情況，需要再做進一步全面性的流行病學調查。關鍵字: 長期照護機構、住民、環境、多重抗藥性微生物[[abstract]]We prospectively investigated the distribution of multidrug-resistant organisms (MDROs) in residents of six long-term care facilities (LTCFs, 621 beds) and their environments from January to December 2015. Active surveillance of colonization of MDROs was performed by culturing rectal and nasal swab samples every four months for the residents: 63, 79, and 73 in the first, second and third surveillance investigations, respectively. If MDROs, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), carbapenem-resistant Enterobacteriacae (CRE), carbapenem-resistant Pseudomonas aeruginosa (CRPA), and MDR Acinetobacter baumannii (MDRAB) were identified, then swab specimens from environmental sources (including beds, bedside tables, ward door handles, curtains, bathroom and toilet door handles) were also collected and cultured. The genetic relatedness of MRSA, carbapenem-resistant Klebsiella pneumoniae (CRKP), and MDRAB were determined by pulsed-field gel electrophoresis (PFGE) analysis. A total of 154 samples from residents and environmental sources were positive for MDROs. MRSA (n = 83, 53.9%) was the predominant organism, followed by CRE (n = 35, 22.7%), MDRAB (n = 30, 19.5%), and CRPA (n = 6, 3.9%). The rates of detection of MDROs were 27.9% (60/215) in nasal swabs, 15.8% (34/215) in rectal swabs, and 11.1% (60/542) in the environmental sources. Closely related strains were demonstrated within MRSA, MDRAB and CRKP isolates. For example, among 80 MRSA isolates, we found the same strains and closely related strains in different institutions, different patients, and different patient environments. An extensive investigation of antibiotic susceptibility patterns for each MDRO was conducted and our finding suggested that antibiotic resistance was a remarkable problem in LTCFs in Taiwan. The distribution and persistence of MDROs varied among the different LTCFs and time periods. More effective infection prevention and control measures are needed to reduce the prevalence of these multidrug-resistant organisms in long-term care facilities. Conducting a comprehensive study on the prevalence of MDROs carriage among the residents and environments in LTCFs in Taiwan is needed in further study. Keywords: Long-term care facility, residents, environment, multidrug-resistant organism