临床常见病原体检测英文版(2011).ppt

1 临床常见病原体检测Examinationofclinicalcommonpathogens 呼吸内科熊维宁DepartmentofRespiratoryMedicineXiong Weining 2 目的Objective 确定感染的发生和性质 及早明确诊断 Determinetheoccuringandnatureofinfection andmakediagnosisearly 尽早选择适当的治疗方案 Selecttheappropriatetreatmentassoonaspossible 采取有效的预防措施 防止感染可能广泛传播所造成的危害 Takeeffectivepreventionmeasurestopreventinfectiontocausewidespreaddamage 3 基本程序BasicProcedures 正确采集和运送标本 Correctcollectionandtransportationofspecimens初步诊断 直接镜检 免疫学和分子生物学检测 Initialdiagnosis directmicroscopy immunologyandmolecularbiologyexamination 确定诊断 病原体的分离 鉴定及药敏实验 报告结果 Determineddiagnosis pathogenisolation identificationandsensitivitytest reportingresults 合理用药Appropriatedruguse 4 第一节SectionOne 标本的采集运送 实验室评价和检查方法Transportationandcollectionofspecimen laboratoryevaluationandexaminationmethods 5 一 标本采集和运送One CollectionandtransportationofSpecimen 6 基本原则Basicprinciples 根据病史与临床表现确定标本采集的时间 部位 种类和数量 尽量采集病变明显部位标本 Accordingtohistoryandclinicalmanifestationstodeterminethecollectiontime location typeandquantityofspecimens collectspecimensatsignificantpartsoflesions 无菌操作 防止污染 Useaseptictechniquetopreventcontamination 采取适宜的方式进行储存 尽快送检 Appropriatewaytostore assoonaspossibleforexamination 要视所有标本为传染品 高度危险性的标本要有明显标识 急症或危重患者标本要特别注明 Toviewallthespecimensforinfectious highriskspecimensshouldbeclearlymarked acuteorcriticallyillpatientspecimensshouldbespecified 7 一 血液 One Blood 适应症 疑为菌血症 败血症或脓毒血症的病人 Indications suspectedbacteremia sepsisorsepsispatients 一般在抗生素使用前 于发热初期或高峰期采血 已用过抗菌药物治疗者 在下次用药前采集 Ingeneral priortouseofantibiotics intheearlyorpeakheat tocollectblood ifantibiotictreatmenthasbeenused collectbloodbeforethenextadministration 以无菌法由肘静脉穿刺 一般成人采血量每次10 20ml 婴儿和儿童1 5ml 在床边接种 Puncturecubitalveinbyasterilemethod ingeneral 10 20mlbloodpertimeforadult 1 5mlforinfantsandchildren andinoculateatthebedside 注明抗生素使用情况 选择合适类型的培养瓶 Indicatetheuseofantibiotics selecttheappropriatetypeofcultureflask 24小时内在不同部位采血3次可提高阳性率 Collectingbloodatdifferentparts3timeswithin24hourscanincreasethepositiverate 8 血液标本的采集方法Collectionmethodofbloodsamples 9 二 尿液 Two Urine 无菌采集中段尿 Sterilecollectionofmid portionurine 如考虑厌氧菌感染 采取膀胱穿刺法采集标本 无菌厌氧小瓶运送 Ifconsiderationofanaerobicinfections applybladderpuncturetocollectspecimens transportthemwithsterileanaerobicvial 排尿困难者考虑导尿采集标本 Applycatheterizationtocollectspecimensfordysuriapatients 10 三 粪便 Three Stool 挑取脓 血或粘液部分于清洁容器中送检 Pickpus bloodormucusfromstollintocleancontainersforexamination 排便困难者或婴儿采用直肠拭子采集 置于有保存液的试管内送检 Applyrectalswabforinfantsordifficultdefecation placeitwithpreservationsolutioninthetesttubeforexamination 怀疑霍乱弧菌感染引起的腹泻 将标本置于碱性蛋白胨水或卡 布 Cary Blair 运送培养液送检 SuspectedinfectionscausedbyVibriocholerae thespecimenswereplacedinalkalinepeptonewaterorcard cloth Cary Blair transportmediumforexamination 传染性腹泻应连续送检3次 Continuousexamination3timesforinfectiousdiarrhea 11 四 呼吸道标本 Four Respiratoryspecimens 类型 鼻咽拭子 痰和经气管采集的标本 Types nasopharyngealswab sputum andspecimenscollectedthroughtracheal上呼吸道存在正常菌群 在采集标本与结果分析时应予考虑 Thereisnormalflorainupperrespiratorytract thespecimenscollectionandresultsanalysisshouldbeconsidered 12 五 脑脊液与其他无菌体液 Five Cerebrospinalfluidandothersterilebodyfluids 脑脊液应立即保温送检或床边接种 CSFshouldbetransportedimmediatelywithinsulationorculturedbedside 胸腔积液 腹腔积液和心包积液等应采集较大量标本送检 离心后再接种培养 Pleuraleffusion ascitesandpericardialeffusionwithalargevolumeshouldbecollected centrifugatedandthencultured 13 六 眼 耳部标本 Six Eye earspecimens 拭子采样Swabsamples 14 七 泌尿生殖道标本 Seven Urogenitalspecimens 男性 无菌采集尿道口分泌物或前列腺液 Male urethraorprostaticfluidsecretionswithsterilecollection 女性 无菌采集阴道或宫颈分泌物 Female vaginalorcervicalsecretionscollectedaseptically 15 八 创伤 组织和脓肿标本 Eight Trauma organization andabscessspecimens 对损伤范围较大的创伤 从不同部位采集多份标本 Onawiderrangeoftraumainjuries specimenscollectedfrommanydifferentparts 采集部位应首先清除污物 消毒皮肤 Firstlyremovedirt disinfecttheskinaroundcollectionsite 标本较少则需加入无菌生理盐水以防干燥 Fewersamplesmustbeaddedtosterilesalinetopreventdrying 开放性脓肿及脓性分泌物 用无菌棉纤采取脓液或病灶深部分泌物 Openabscessandpurulentsecretions collectdeepdischargepusorlesionswithsterilecottonfibers 封闭性脓肿用注射器抽取 Collectspecimeninclosedabscesswithasyringe 怀疑厌氧菌感染 应隔绝空气采集 Suspectedanaerobicinfections collectionshouldbeisolatedfromair 16 九 血清 Nine Serum 用于检测特异性抗体 Forthedetectionofspecificantibodies 血液自然凝固后吸取血清 灭活补体 Drawserumafternaturalcoagulationofblood theninactivatecomplement 17 二 标本的实验室质量评估标准Two Standardoflaboratoryqualityassessmentofspecimens 18 检验申请单的基本内容Thebasiccontentofanapplicationforexamination Thepatient snameandhospitalnumber Ageandsex Collectiondateandtime Suspecteddiagnosis Exactnatureandsourceofthespecimen Immunizationhistoryandantimicrobialtherapy Objective Signedbyphysician 19 标本接收和拒收准则Receptionandrejectioncriteriaforspecimens 1Theinformationonthelabeldoesnotexistornotmatchtheinformationontherequisition 2Delayindeliveryofthespecimens 3Thespecimenisleaking 4Thespecimenhasbeentransportedattheimpropertemperatureorinimpropermedium 20 5Contaminatedsamples 6Thequantityofspecimenisinsufficientfortesting 7Duplicatesubmissionofspecimens exceptbloodcultures 8Thetransportationofspecimensofsevereinfectiousdiseasesshouldcomplywiththerelevantrules 21 三 检查方法Three Examinationmethods 22 一 直接显微镜检查 One Directmicroscopicexamination 不染色标本检查法 用于观察病原体的生长 形态与运动等特性 Notstainedspecimentestmethod toobservethegrowth shapeandmotioncharacteristicsofpathogens 评价 部分病原体可借此初步诊断 Evaluation forsomepathogens theinitialdiagnosiscanbetaken 23 染色标本检查法 观察细菌的形态 染色性或观察宿主细胞内包涵体的特征 Stainedspecimentestmethod toobservebacterialmorphology stainingorobservethecharacteristicsoftheinclusionbodiesinhostcell 评价 为临床初步诊断提供依据 Evaluation availablebasisforthepreliminaryclinicaldiagnosis 24 革兰氏 染色 阳性球菌Gram staining positivecocci 革兰氏 染色 阴性杆菌Gram staining negativebacilli 25 抗酸染色阳性杆菌 抗酸杆菌 Acid faststain positivebacilli Acid fastbacilli 26 二 病原体特异性抗原检查 Two Pathogen specificantigentest 免疫荧光技术Immunofluorescencetechnique酶联免疫技术ELISA化学发光技术Chemiluminescencetechnology乳胶凝集试验Latexagglutinationtest对流免疫电泳Counterimmunoelectrophoresis蛋白质芯片Proteinchips 27 病原体特异性抗原检测结果评价Evaluationofpathogen specificantigentestresults 如果能排除交叉抗原的影响 病原体抗原检测可明确感染的病原体 Iftheimpactofcross antigencanbeexcluded pathogenantigentestcouldcleartheinfectionofpathogens 28 三 病原体核酸检查 Three Pathogennucleicacidtest 聚合酶链式反应 扩增病原体微生物特异的DNA或RNA片段 Polymerasechainreaction PCR amplifythespecificfragmentsofDNAorRNAofmicrobialpathogens 实时荧光定量PCR技术 Real timePCR 核酸探针杂交技术 通过已知序列的探针与标本中的病原体的核苷酸杂交 用以了解病原体的有无 Nucleicacidprobehybridization hybridizationbetweentheknownsequenceoftheprobeandthenucleotideofpathogensinthesamples toexplorewhetherpathogensexist 基因芯片技术 GenechiporDNAmicroarray 29 病原体核酸检查结果评价EvaluationofpathogenDNAtestresults 是检测病原体微生物最灵敏的方法 但具有一定的假阳性与假阴性 isthemostsensitivedetectionmethodformicrobialpathogens buthassomefalsepositiveandfalsenegative 阳性只表明存在某种病原体的核酸 是否正被感染应结合临床具体分析 istheonlyshowthattheexistenceofapositivepathogennucleicacid whetherbeinginfectedshouldbecombinedwithclinicalspecificanalysis 30 四 病原体的分离培养与鉴定 Four Isolation cultureandidentificationofpathogens 1细菌感染性疾病病原体的分离培养1Isolationandculturethepathogensofbacterialinfections明确感染病原体 Clearthepathogens 为临床提供体外抗微生物药物敏感试验结果 Providevitrotestresultsofanti microbialdrugsensitivityforclinical 31 2不能人工培养的病原体感染性疾病2Notcultivatedpathogensofinfectiousdisease将标本接种易感动物 鸡胚或行细胞培养 Specimenswereinoculatedintosusceptibleanimals eggsorcelllines 32 五 血清学实验 Five Serologicaltest 特异性IgM可作为感染性疾病的早期诊断指标 且可区分原发与复发感染 SpecificIgMcanbeindicatorofearlydiagnosisforinfectiousdiseasesandcandistinguishbetweenprimaryandrecurrentinfections 特异性IgG 尤其双份血清的滴度呈4倍或4倍以上升高 考虑现症感染 ForIgG thetiterofdoubleserumhigher4timesormorethan4times currentpathogeninfectionshouldbeconsidered 33 第二节病原体耐药性检测SectiontwoDetectionofpathogendrugresistance 34 抗生素压力Antibioticpressure 35 一 耐药性及其发生机制One Drugresistanceanditsmechanism 36 一 耐药病原体 One Drugresistantpathogens 革兰氏阴性杆菌 内酰胺酶 超广谱 内酰胺酶 ESBL 类 内酰胺酶 多重耐药等 Gram negativebacillus lactamase extendedspectrum lactamase ESBL type lactamases multidrugresistance etc 革兰氏阳性球菌 耐甲氧西林葡萄球菌 MRS 耐青霉素肺炎链球菌 PRSP 耐万古霉素肠球菌 VRE 高耐氨基糖苷类抗生素肠球菌 Gram positivecoccus methicillin resistantStaphylococcus MRS penicillin resistantStreptococcuspneumoniae PRSP vancomycin resistantenterococcus VRE enterococcuswithhighresistancetoaminoglycosideantibiotics 37 二 耐药机制 Two Drugresistancemechanism 1细菌水平和垂直传播耐药基因的整合子系统 1Horizontalandverticaltransmissionofbacterialdrugresistancegenesthroughintegrons 2产生灭活抗生素的水解酶和钝化酶 如ESBLs AmpC 内酰胺酶 碳青霉烯酶 氨基糖苷类钝化酶 2proteolyticenzymeandinactiveenzymeproducedforinactivationofantibiotics suchasESBLs AmpC lactamase carbapenemase aminoglycosideinactiveenzyme 38 3细菌抗生素作用靶位的改变 3Changesinthebacterialantibioticstarget 4细菌膜外排泵出系统 4Bacterialmembraneeffluxpumpsystem 5细菌生物膜的形成 5Bacterialbiofilm BF formation 39 二 检查项目 结果和临床应用examinationprojects resultsandclinicalapplication 40 一 药物敏感试验Drugsensitivitytest 抗微生物药物敏感试验 antimicrobialsusceptibilitytest AST 对敏感性不能预测的临床分离菌株进行药敏试验 以指导临床选择治疗药物 ASTcannotbepredictedonthesensitivityofclinicalisolatesforsusceptibilitytestingtoguideclinicaltreatmentofdrug 41 目的Objective 临床分离菌株 如不能对抗生素敏感性进行预测 必须常规进行药敏试验 Clinicalisolates iftheycannotpredictthesensitivitytoantibioticsshouldberoutinesusceptibilitytesting临床治疗效果差而考虑调整抗菌药物时 Poorclinicaltreatmenttoconsideradjustingtheantimicrobialdrugs 了解细菌耐药的流行病学情况 Understandtheepidemiologyofbacterialresistance 评价新抗菌药物的抗菌谱和抗菌活性等 Evaluationofnewantibioticsandantibacterialactivityofantibacterialspectrum 42 方法Methods 1K B纸片琼脂扩散法 Kirby Bauerdiscagardiffusionmethod 43 参照NCCLS标准NCCLSstandardreference 敏感 susceptible S 表示测试菌能被测定药物常规剂量给药后在体内达到的血药浓度所抑制或杀灭 Bacteriacanbedeterminedthatthetestdrugsinthebodyafteradministrationofconventionaldosestoachieveplasmaconcentrationsinhibitorkill 耐药 resistant R 表示测试菌不能被测定药物常规剂量给药后在体内达到的血药浓度所抑制或杀灭 治疗无效 Testbacteriathatcannotbemeasuredafteradministrationofconventionaldoseofdruginthebodytotheplasmaconcentrationsinhibitorkill thetreatmentineffective 中介 intermediate I 该范围作为敏感与耐药之间的缓冲区 避免由于微小技术误差影响实验结果 Therangeasabufferbetweensensitiveandresistanttoavoidtheimpactofthesmalltechnicalerrorresults 44 2稀释法 Dilutiontest 最低抑菌浓度 MIC 能够抑制检测菌肉眼可见生长的最低药物浓度称为测定药物对检测菌的最低抑菌浓度 Minimuminhibitoryconcentration MIC Detectionofbacteriaabletoinhibitvisiblegrowthoftheminimumdrugconcentrationdeterminationofdrugsonthedetectionofbacteriaknownastheminimuminhibitoryconcentration 3E试验法 Etest 4耐药筛选试验Drugscreeningtest5折点敏感试验Sensitiveturningpointtest 45 二 耐药菌监测试验Resistanttomonitortest 由于细菌存在一种或几种耐药机制 造成了细菌的多重耐药性 单一的药敏试验已不能完全表示细菌的耐药性 必须进行一些特殊的耐药性监测试验 Becausethereisoneorseveralbacterialresistancemechanisms resultinginmultipledrugresistanceofbacteria Singlesusceptibilitytestcannotfullyexpressthedrugresistanceofbacteriatoberesistanttosomespecialmonitoringtests 46 1 耐甲氧西林的葡萄球菌 methecillinresistancestaphylococcus MRS 1 g甲氧西林 苯唑青霉素 纸片的抑菌圈直径 10mm 或MIC 4 g ml的金黄色葡萄球菌 1 g苯唑青霉素纸片的抑菌圈直径 17mm 或MIC 0 5 g ml的凝固酶阴性葡萄球菌称耐甲氧西林葡萄球菌 1 gofmethicillin oxacillin paperoftheinhibitionzonediameter 10mm orMIC 4 g mlStaphylococcusaureus 1 goxacillindiskinhibitionzonediameter 17mm orMIC 0 5 g mlofcoagulase negativemethicillin resistantStaphylococcusaureus said 47 临床意义Clinicalsignificance 对所有 内酰胺类药物均无效 并对氨基糖苷类 大环内酯类 克林霉素和四环素等抗生素多重耐药 治疗首选药物为万古霉素 Forall lactamdrugsareineffective andaminoglycosides macrolides clindamycinandtetracyclineantibioticssuchasmulti drugresistant Thepreferreddrugforthetreatmentofvancomycin 48 2 氨基糖苷类抗生素高耐药肠球菌High resistantenterococciaminoglycosides 对氨基糖苷类和青霉素等作用于细胞壁的等抗生素联用无效 Theroleofaminoglycosidesandpenicillinandotherantibioticsinthecellwallcombinedwithnullandvoid 49 3 耐青霉素的肺炎链球菌Penicillin resistantStreptococcuspneumoniae 定义 1 g苯唑青霉素纸片的抑菌圈直径2 g ml应视为耐青霉素肺炎链球菌 penicillinresistantstreptococcuspneumonia PRSP Definition 1 goxacillindiskinhibitionzonediameter2 g mlshouldberegardedaspenicillin resistantStreptococcuspneumoniae 50 临床意义Clinicalsignificance PRSP对氨苄西林 氨苄西林 舒巴坦 头孢唑啉的临床治疗疗效很差 治疗时参考药敏结果选择药物 经验治疗重症感染时 可用头孢曲松或头孢噻肟联合万古霉素用药 PRSPtoampicillin ampicillin sulbactam cefazolinpoorclinicalefficacyofthetreatmentdrugofchoicewhendrugsusceptibilityresultsforreference experiencethetreatmentofsevereinfection canbecombinedceftriaxoneorcefotaximetovancomycintherapy 51 4 内酰胺酶的检测 lactamasedetection 内酰胺酶 可水解 内酰胺类抗生素 lactamases hydrolyzed lactamantibiotics 临床意义 1 流感嗜血杆菌 淋病奈瑟菌以及卡拉莫拉菌等阳性 表示对青霉素 氨苄西林以及阿莫西林耐药 2 葡萄球菌属以及肠球菌属等 阳性表示对青霉素 氨基组青霉素 羧基组青霉素以及脲基组青霉素耐药 Clinicalsignificance 1 Haemophilusinfluenzae Neisseriagonorrhoeae andkaraoke positivemicroorganismsinMora saidtopenicillin ampicillinandamoxicillinresistance 2 suchasStaphylococcusandEnterococcus thepositivethatpenicillin penicillinaminogroup carboxylgroupofpenicillinandpenicillin resistanturea basedgroup 52 5 产超广谱 内酰胺酶 extendspectrum lactamase ESBL 的肠杆菌科细菌ProducingESBLEnterobacteriaceae 超广谱 内酰胺酶是由质粒介导的 内酰胺酶 可水解青霉素类 头孢菌素和氨曲南 主要在大肠埃希菌和克雷伯菌属等肠杆菌科细菌中产生 Extendedspectrum lactamasemediatedbyplasmid lactamases canbehydrolyzedpenicillins cephalosporinsandaztreonam mainlyinEscherichiacoliandKlebsiellaspeciesandotherEnterobacteriaceaeGenerated 53 临床意义Clinicalsignificance 产ESBL细菌 不论体外药物敏感试验结果如何 对青霉素类 头孢菌素类和氨曲南治疗均无效 ESBLproducingbacteria regardlessoftheoutcomeofinvitrodrugsensitivitytests topenicillin cephalosporinsandaztreonamtreatmentwereineffective 54 6 耐万古霉素的肠球菌Vancomycinresistantenterococci 定义 对30 g万古霉素纸片抑菌圈直径 19mm 或MIC 32 g ml应视为耐万古霉素肠球菌 vancomycinresistantenterococcus VRE Definition paper30 gvancomycininhibitionzonediameter 19mm orMIC 32 g mlshouldbeconsideredasVRE 55 临床意义Clinicalsignificance 耐万古霉素肠球菌目前尚无有效的治疗方法 但是对青霉素敏感的VRE可用青霉素和庆大霉素联合治疗 若对青霉素耐药而不是高水平耐氨基糖苷类可用白霉素和庆大霉素 另外氯霉素 红霉素 四环素 或多西环素 或米诺环素 及利福平可用于VRE株 Vancomycinresistantenterococciiscurrentlynoeffectivetreatment buttheVREtopenicillin sensitivepenicillinandgentamicincombinationtherapycanbeused ifnotthehigh levelresistancetopenicillin resistantavailableaminoglycosidesneomycinandcelebrategreatwhiteAdriamycin Additionofchloramphenicol erythromycinandtetracycline ordoxycycline orminocycline andrifampincanbeusedforVREstrains 56 三 病原菌耐药基因的检测Detectionofpathogenresistancegenes 更早Earlier确证Confirmed准确Accurate金标准Goldstandard 57 第三节临床感染常见病原体检查Checkthecommonpathogensofclinicalinfection 58 感染性疾病指各种生物性病原体 病原微生物 寄生虫 寄生人体所引起的传染性感染疾病和非传染性感染疾病 Referstoavarietyofinfectiousdiseases biologicalpathogens pathogens parasites causedbyhumaninfectiousparasiticdiseasesandnon communicablediseases 59 一 流行病学和临床类型Epidemiologyandclinicaltypes 60 一 流行病学Epidemiology 新传染病陆续被发现 老传染病死灰复燃Beendiscoverednewinfectiousdiseases theresurgenceofolddiseases多重耐药株Multi drugresistantstrains新医疗技术的开展Thelaunchingofnewmedicaltechnologies 61 二 临床类型Clinicaltypes 临床常见病原体为 细菌 真菌 病毒 支原体 衣原体 螺旋体 立克次体以及寄生虫等 Commonclinicalpathogens bacteria fungi viruses mycoplasma chlamydia spirochetes rickettsia andparasites 62 二 检查项目和临床应用inspectionitemsandclinicalapplications 63 一 细菌感染检查项目的选择Theselectionofcheckingprojectsonbacterialinfection 普通细菌 常采用直接镜检 分离培养与鉴定 抗原检测 Commonbacteria directmicroscopicexaminationisoftenused Isolationandidentificationofantigen 病原体抗体检测 Antibodydetectionofpathogens难培养或培养要求高的细菌 综合运用免疫学或分子生物学检测 如结核分枝杆菌感染以及幽门螺杆菌感染等 Difficultforhighcultureorbacterialculture theintegrateduseofimmunologyormolecularbiology suchasMycobacteriumtuberculosisandHelicobacterpyloriinfection 细菌培养是最重要的确诊方法 Bacterialcultureisthemostimportantdiagnosticmethod 64 二 实验结果分析和临床应用Analysisandclinicalapplicationofexperimentalresults 显微镜检查或分离培养的阴性结果不能完全排除感染 Microscopyorisolationandcultureofnegativeresultscannotbecompletelyruledoutinfection共同抗原引起的交叉反应 Antigeniccross reactivitycausedbythecommon核酸检测的假阳性 False positivenucleicaciddetection血清学的动态检测 Dynamicdetectionofserological 65 第六节医院感染常见病原体检测Detectionofcommonpathogensofnosocomialinfection 66 医院感染 nosocomialinfection 又称医院获得性感染 hospitalacquiredinfection 指患者在入院时不存在 也不处于潜伏期 而在医院内发生的感染 包括医院内获得的而在出院后发病的感染 广义的医院感染对象不仅指住院患者 还包括门诊病人 医院职工 探视人员与陪护人员等 Nosocomialinfection nosocomialinfection alsoknownashospital acquiredinfection hospitalacquiredinfection thatdoesnotexistonadmissionofpatients norintheincubationperiod whileinthehospitalinfectionsoccurred includingthehospitalafterdischargefromhospitalacquireddiseaseinInfection Generalizedinfection notonlybymeansofhospitalinpatients includingoutpatient hospitalstaff visitingofficersandescortpersonnel 67 一 流行病学和临床类型Epidemiologyandclinicaltypes 68 一 流行病学Epidemiology 69 病原学Pathogen 细菌是最常见的病原体 Bacterialisthemostcommonpathogens 变化趋势 革兰氏阴性杆菌比例在增加 革兰氏阳性球菌比例在减少 Trend increasingtheproportionofGram negativebacteria Gram positivecocciratiodecreased 罕见细菌变成流行株 阴沟肠杆菌 洋葱假单孢菌 军团菌等Strainsofbacteriabecomerare Enterobactercloacae Pseudomonasonion Armymonocytogenes其它 病毒 真菌等Other viruses fungi etc 70 2 感染源Sourceofinfection 住院病人 医院职工 探视人员 陪伴人员 Patients hospitalstaff visitingstaff hiscompanion 医院环境 未彻底消毒的医疗器械 血液制品等 Hospitalenvironment withoutthoroughdisinfectionofmedicald