針灸需要感染控制指引

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　March 19, 2010 — 根據一項線上發表3月18日英國醫學期刊的主編評論，需要贊助來發展針灸的感染控制指引。
　　
　　香港大學的Patrick C.Y. Woo醫師與其同事們寫到，針灸，以植入與操控細針於經脈網絡上特定針灸點的理論，可以促進「氣」的流動和諧，這是另類療法中最廣泛使用的。由於這些細針必須插入皮膚層達數公分，針灸可能對病患造成風險。其中一個最重要的併發症就是傳播病源性微生物，從環境轉染給病患，然後再傳給不同的病患。
　　
　　主編們宣稱，據報因為針灸傳播的疾病數目（世界各地通報的病例數為50例）可能只是冰山一角。由於針灸相關的感染經常沒有被診斷出來，臨床醫師們應該抱持著高度警覺。
　　
　　針灸前沒有徹底的皮膚消毒，可能使得病患皮膚上或是環境菌叢，傳播致病性細菌。局部感染經常會沿著脈絡或是在針灸點上而發生。
　　
　　雖然這些感染事件大部份預後良好，但大約有5%-10%的通報發熱性細菌感染是致命的，另外有10%以上可能造成更嚴重的併發症，包括：
　　* 使關節破壞的敗血性關節炎
　　* 多重器官衰竭
　　* 腐肉性疾病
　　* 癱瘓
　　
　　也曾經有感染性心內膜炎、腦膜炎、眼內感染、頸部脊椎炎、腹腔後膿瘍、腹腔內膿瘍、以及胸腔肺膿瘍的報告。
　　
　　超過一半與針灸有關的細菌感染是金黃葡萄球菌所造成。第一個由針灸傳播抗藥性金黃色葡萄球菌的病例發生在2009年。除此之外，也曾有與針灸相關傳播，造成B型肝炎爆發的報告，這些據報與重覆使用於感染病患後未適當消毒的針頭有關。然而，在一項針灸相關B型肝炎爆發的案例中，被認為自針灸者傳給病患。理論上，B型肝炎與HIV可能透過針灸傳播，有部份來自流行病學與病例控制研究的證據顯示C型肝炎病毒與針灸之間的關係。
　　
　　針灸分支桿菌疾病是一種新的臨床症候群，於21世紀後首次被發現。受到汙染的棉花球、毛巾、以及熱敷袋可能促使分支桿菌在針灸下針點附近快速生長。在一段較長的潛伏期後，經常會形成很大的水泡、膿瘍與潰瘍病灶。
　　
　　主編們的結論是，為了預防針灸傳播的感染，應該落實感染控制措施，例如可拋棄性針頭、皮膚消毒措施以及無菌技術。也需要嚴格的設備管控與認證。臨床醫師們也應保持高度警覺，特別是由針灸傳播的病毒與分支桿菌感染，因為這些病源的潛伏期長，以及如果有群聚病例，應立即通報衛生主管機關。
　　
　　作者們表示沒有相關資金上的往來。


Infection Control Guidelines Needed for Acupuncture

By Laurie Barclay, MD
Medscape Medical News

March 19, 2010 — Funding is needed to develop infection control guidelines for acupuncture, according to an editorial posted online March 18 in the British Medical Journal.

"Acupuncture, which is based on the theory that inserting and manipulating fine needles at specific acupuncture points located in a network of meridians will promote the harmonious flow of 'Qi,' is one of the most widely practised modalities of alternative medicine," write Patrick C.Y. Woo, MD, and colleagues from the University of Hong Kong. "Because needles are inserted up to several centimetres beneath the skin, acupuncture may pose risks to patients. One of the most important complications is transmission of pathogenic micro-organisms, from environment to patient or from one patient to another."

The editorialists claim that the number of reported acupuncture-transmitted diseases (namely, 50 cases of infection described worldwide) may be "the tip of the iceberg." Because acupuncture-related infections are typically underdiagnosed, clinicians should have a high index of suspicion.

Inadequate skin disinfection before acupuncture may result in transmission of pyogenic bacteria from the patient's skin flora or the environment. Localized infections typically occur along meridians or at acupuncture points.

Although the prognosis is good for most of these infections, about 5% to 10% of reported pyogenic bacterial infections are fatal, and another 10% or more result in serious complications including:

septic arthritis with joint destruction,
multiorgan failure,
flesh eating disease, and
paralysis.
Infective endocarditis, meningitis, endophthalmitis, cervical spondylitis, retroperitoneal abscess, intraabdominal abscess, and thoracic empyema have also been reported.

Staphylococcus aureus accounts for more than half of the reported cases of acupuncture-related bacterial infection. The first reports of methicillin-resistant S aureus transmitted by acupuncture surfaced in 2009. In addition, outbreaks of hepatitis B have been attributed to acupuncture-related transmission, thought to be the result of the reuse of improperly sterilized needles from an infected patient. In one acupuncture-associated hepatitis B outbreak, however, transmission was thought to be from the acupuncturist to the patients. Hepatitis C and HIV could, in theory, be transmitted by acupuncture, with some evidence for the association of hepatitis C virus infection with acupuncture from epidemiological and case-control studies.

Acupuncture mycobacteriosis is a new clinical syndrome first recognized in the 21st century. Contaminated cotton wool swabs, towels, and hot pack covers may promote rapid growth of mycobacteria around the acupuncture insertion point. After a long incubation period, large pustules, abscesses, and ulcerative lesions typically develop.

"To prevent infections transmitted by acupuncture, infection control measures should be implemented, such as use of disposable needles, skin disinfection procedures, and aseptic techniques," the editorialists conclude. "Stricter regulation and accreditation requirements are also needed. Clinicians should also have a high index of suspicion, particularly for viral and mycobacterial infections transmitted by acupuncture because of their prolonged incubation periods, and they should alert health authorities about clusters of cases."

The authors have disclosed no relevant financial relationships.

BMJ. Published online March 18, 2010.