Outbreak of Burkholderia cepacia bacteraemia in a tertiary care centre due to contaminated ultrasound probe gel

Practice 'safe scans': why ultrasound transducer covers should be considered best practice

Single-injection, ultrasound-guided nerve block procedures involve puncturing the skin in close proximity to an ultrasound transducer, creating a potential vector for transmission of microbial organisms when skin flora and blood come into contact with the probe. Practice patterns regarding disinfection of the transducer and the use of barrier protection are inconsistent, ranging from sterile sleeve probe covers to no cover at all. Although sleeve probe covers are easy and straightforward to use and serve to protect patients, providers and medical equipment, their utilisation remains controversial. Standardisation of their use eliminates the impact of improper or haphazard probe disinfection and makes infection control practices consistent and reproducible. This position is shared by multiple societies and authorities on ultrasound and acute care medicine. In this Daring Discourse, we outline the arguments supporting the utilisation of single-use sleeve probe covers to ensure patient safety with respect to vector-borne transmission of microbes during single-injection regional anaesthesia procedures.

Diving deep for the needle in the haystack: An outbreak investigation of Burkholderia cenocepacia bacteremia

In an Indian oncology setting, between August and December 2021, 56 patients, developed Burkholderia cenocepacia bacteremia. An investigation revealed a contaminated batch of the antiemetic drug palonosetron. The outbreak was terminated by withdrawing the culprit batch and the findings were reported promptly to regulatory authorities.

Development of a duplex droplet digital PCR assay for the detection of Burkholderia cepacia complex and Stenotrophomonas maltophilia in bloodstream infections

Burkholderia cepacia complex (BCC) and Stenotrophomonas maltophilia are nosocomial pathogens that cause various infections and exhibit high resistance to multiple antimicrobial agents. In this study, we aimed to develop a duplex droplet digital PCR (ddPCR) assay for detecting BCC and S. maltophilia in bloodstream infections. We optimized the experimental conditions by setting the annealing temperature to 51°C and determining the optimal concentrations of primers and probes, as well as the thermal cycle numbers. The feasibility of the duplex ddPCR reaction system with the optimal conditions was established and verified through parallel reactions with reference strains of BCC and S. maltophilia. The specificity of the assay, tested with 33 reference strains, was found to be 100%. The duplex ddPCR assay demonstrated good repeatability and could detect as low as 5.35 copies/reaction of BCC and 7.67 copies/reaction of S. maltophilia. This level of sensitivity was consistent in the simulated blood and blood bottle samples. We compared nucleic acid extraction methods and found that the Chelex-100 boiling method and kit extraction method exhibited similar detection sensitivity, suggesting the potential application of the Chelex-100 boiling method in the ddPCR assay. In the clinical samples, the duplex ddPCR assay accurately detected BCC and S. maltophilia in 58 cases. In conclusion, our study successfully developed a duplex ddPCR assay that provides accurate and convenient detection of BCC and S. maltophilia in bloodstream infections.IMPORTANCEBurkholderia cepacia complex (BCC) and Stenotrophomonas maltophilia are implicated in a wide range of infections, including bloodstream infections (BSIs), pneumonia, and meningitis, and often exhibit high intrinsic resistance to multiple antimicrobial agents, limiting therapeutic options. The gold standard for diagnosing bloodstream infections remains blood culture. However, current blood culture detection and positivity rates do not meet the "rapid diagnosis" required for the diagnosis and treatment of critically ill patients with BSIs. The digital droplet PCR (ddPCR) method is a potentially more powerful tool in the diagnosis of BSIs compared to other molecular methods due to its greater sensitivity, specificity, accuracy, and reproducibility. In this study, a duplex ddPCR assay for the detection of BCC and S. maltophilia in BSIs was developed.

Infected aortic endograft with an unusual microbe, Burkholderia cepacia

With the growing use of endovascular aortic repair for aortic aneurysm pathology, multiple cases have been reported of associated endovascular graft infections. Explantation of the infected endograft and the revascularization procedure performed should be individualized with attention to the offending organism. We present the cases of two patients who underwent endovascular aortic repair with the same endograft and developed a graft infection with Burkholderia cepacia, a gram-negative organism with low virulence. Both endografts cultured Burkholderia cepacia complex; however, the organisms were genetically tested and found to be separate, unrelated strains. Both patients underwent successful explantation and revascularization procedures without any surgical-related complications to date.

Two consecutive outbreaks caused by chlorhexidine mouthwash contaminated with Burkholderia contaminans in a two-hospital tertiary care system

BACKGROUND

Hospital outbreaks caused by Burkholderia spp. have been linked to contamination of several medical solutions and products and are frequently associated with delayed detection and high mortality.

AIM

To describe the management of two consecutive Burkholderia contaminans outbreaks caused by contaminated mouthwash of different brands during the COVID-19 pandemic.

METHODS

This was a retrospective cohort study of all patients involved in two outbreaks caused by B. contaminans detected in 2021 and 2022. The investigation was initiated after a cluster of positive respiratory specimens, followed by retrospective and prospective case-finding.

FINDINGS

A total of 69 patients were affected, 47 in 2021 and 22 in 2022. The majority of affected patients had positive respiratory specimens (85.5%); 55.1% of cases had COVID-19, and 72.5% had multidrug-resistant organisms. Almost all (97.1%) patients required ventilation and 42.0% died. Seventeen percent of cases in the first outbreak were deemed to have been acquired by patient-to-patient transmission, whereas all of the cases in the second outbreak were infected directly from using mouthwash. The experience gained from the first outbreak and the formation of a multidisciplinary Infection Control Rapid Response Team resulted in more rapid recognition and control of the second outbreak. Multivariate analysis showed that older age, intensive care unit admission, and COVID-19 infection were independent predictors of mortality.

CONCLUSION

Burkholderia outbreaks at the time of COVID-19 were associated with high mortality. Rapid detection and response by a dedicated experienced team (as in the second outbreak) can reduce mortality and prevent superimposed cross-transmission between patients.

Ultrasound guidance practices used for the placement of vascular accesses in intensive care units: an observational multicentre study

BACKGROUND

Central catheters expose ICU patients at risk of catheter-related bloodstream infections. A mechanism by which these infections occur is the contamination of the catheter during its insertion if aseptic techniques are not strictly applied. Recent studies suggest that the use of ultrasound guidance (USG) may increase the risk of catheter contamination during insertion. We assessed current practices regarding the use of USG during catheter insertion, with a focus on identifying breaches of the surgical asepsis required for this invasive procedure.

METHODS

In 26 intensive care units, we evaluated the use of USG during catheter insertion, using a questionnaire addressed to intensivists and direct observation of their practices.

RESULTS

We analyzed 111 questionnaires and 36 observations of intensivists placing catheters. The questionnaires revealed that 88% of intensivists used USG for catheter insertion. Among those using USG, 56% had received specific training, 17% benefited from specific recommendations, 76% marked the insertion site before skin antisepsis, and during catheter insertion, 96% used sterile gel and 100% used a sterile sheath and sterile gloves. We identified potential deviations from strict aseptic technique, including contact between the sheath and the needle (19.4%), handling of the US system during catheter insertion (2.8%), and use of sterile devices, where they were not yet necessary (during the marking site or skin antisepsis), resulting in their contamination at the time of catheter insertion.

CONCLUSIONS

Interventions aimed at ensuring compliance with measures to prevent CRBs should be organized to prevent an increase in infections associated with US-guided catheter insertion.

Outbreak investigation of NDM-producing Burkholderia cepacia causing neonatal sepsis in Pakistan

Aim: To investigate the outbreak of Burkholderia cepacia complex (BCC), mortality, antimicrobial resistance and associated risk factors in the neonatal intensive care unit. Method: Eighteen blood culture samples from neonates and twenty swab samples from different neonatal intensive care unit surfaces were collected. The VITEK 2 was used to confirm the isolates and generate the antibiogram. PCR was used to identify blaNDM. Results: Eighteen samples tested positive for BCC, and 10/18 (55.5%) of the neonates died. 13/18 (72%) of the neonates had late-onset neonatal sepsis, and 10/18 (55%) had low birth weight. Resistance to minocycline and chloramphenicol was 100%, 72.2% to meropenem; 72.2% NDM gene was found in neonates and was 20% from the environment. Conclusion: Outbreak of NDM-producing BCC resulting in high neonatal mortality in NICU.

A study on the occurrence of Burkholderia cepacia complex in ultrasound gels used in different veterinary clinical settings in India

Burkholderia cepacia complex (Bcc) organisms are emerging multidrug-resistant pathogens. They are opportunistic and cause severe diseases in humans that may result in fatal outcomes. They are mainly reported as nosocomial pathogens, and transmission often occurs through contaminated pharmaceutical products. From 1993 to 2019, 14 Bcc outbreaks caused by contaminated ultrasound gels (USGs) have been reported in several countries, including India. We screened a total of 63 samples of USGs from various veterinary and human clinical care centers across 17 states of India and isolated 32 Bcc strains of Burkholderia cenocepacia (46.8%), B. cepacia (31.3%), B. pseudomultivorans (18.8%) and B. contaminans (3.1%) species. Some isolates were co-existent in a single ultrasound gel sample. The isolation from unopened gel bottles revealed the intrinsic contamination from manufacturing sites. The MALDI-TOF analysis to identify the Bcc at the species level was supported by the partial sequencing of the recA gene for accurate species identification. The phylogenetic analysis revealed that isolates shared clades with human clinical isolates, which is an important situation because of the possible infections of Bcc by USGs both in humans and animals. The pulsed field gel electrophoresis (PFGE) typing identified the genetic variation among the Bcc isolates present in the USGs. The findings indicated USGs as the potential source of Bcc species.

Systematic review of ultrasound gel associated Burkholderia cepacia complex outbreaks: Clinical presentation, sources and control of outbreak

BACKGROUND

Burkholderia cepacia complex (Bcc) is an emerging opportunistic pathogen among immunocompromised patients. It frequently contaminates saline, fluids and ultrasound (US) gel used in hospitals. This systematic review was conducted to analyze Bcc outbreaks due to ultrasound (US) gel for better management of these outbreaks.

METHODS

As per PRISMA guidelines, electronic databases "Embase" and "Pubmed" and "Web of sciences" were searched from 1991 to April, 2021 to identify studies causing Burkholderia spp outbreak due to contamination of US gels.

RESULTS

The search identified 14 outbreak reports that met our inclusion criteria. Bacteremia was the most common clinical presentation in ten studies followed by urinary tract infections in 4 studies. In most of the studies B. cepacia was the most common isolated organism. Other members like B. ambifaria, B. contaminans, and B. stabilis caused outbreaks in two studies. Pulsed field gel electrophoresis and multilocus sequence typing were commonly employed methods to study the clonal association. In 8 outbreaks, intrinsic contamination of the gel, that is, contamination from manufacturing site, was present and 4 studies, extrinsic contamination, that is, contamination from environment was responsible for outbreak.

CONCLUSION

This review highlights the importance of US gel as a source of outbreak in health-care facilities. Ensuring sterility of US gel, sound epidemiological investigation of outbreak and prompt response by infection control team can prevent these outbreaks.

Bacterial Contamination of Ultrasound and Stethoscope Surfaces in Low- and High-Resource Settings

Point-of-care ultrasound is an accurate diagnostic and monitoring tool. Its increasing affordability, portability, and versatility make it an excellent component of standard clinical evaluation alongside the stethoscope. However, like the stethoscope, ultrasound carries risks of surface contamination and potential cross-infection. In this international observational study, we compared the surface contamination of ultrasound equipment to stethoscopes in two medical centers: a tropical low-resource hospital and academic high-resource hospital. Ultrasound equipment and coupling gel had similar prevalence of microbial surface contamination compared with observed stethoscopes. Most microbes were commensal Gram-positive, but some were opportunistic and pathogenic microbes (such as Escherichia coli and Staphylococcus aureus). In conclusion, it is crucial to appreciate and reduce the risk of ultrasound device contaminations. When ultrasound is used bedside, similar to stethoscopes, conscientious hygiene measures are equally fundamental.

Ultrasound-guided regional anesthesia in COVID-19 and future pandemics: infection control

PURPOSE OF REVIEW

Infection control is inherent in ultrasound-guided regional anesthesia practice, because ultrasound transducer and coupling gel can be vectors for pathogen transmission. We reviewed the current standards and recommendations of ultrasound transducer cleaning, disinfection, and safe handling of ultrasound equipment. Based on the available data, we propose a set of practical recommendations applicable to coronavirus disease 2019 (COVID-19) pandemic and future epidemics.

RECENT FINDINGS

Regional anesthesia is often preferred over general anesthesia for COVID-19 patients. Avoidance of general anesthesia reduces the need for aerosol generating procedures. Administration of ultrasound-guided regional anesthesia and surgery under regional anesthesia in COVID-19 patients requires careful infectious precautions to prevent the viral spread through the use equipment.

SUMMARY

Ultrasound machine, transducer and coupling gel can serve as a vector for transmission of pathogens. In the era of COVID-19 pandemic, standardized strategies are recommended to minimize the risk of spread of COVID-19 to both patients and the healthcare providers.

Global burden, point sources, and outbreak management of healthcare-associated Burkholderia cepacia infections: An integrative review

OBJECTIVE

To examine the global burden, associated point sources, and successful prevention and control measures for documented outbreaks of Burkholderia cepacia healthcare-associated infections (HAIs).

DESIGN

Integrative review.

METHODS

A review of all outbreaks of Burkholderia cepacia HAIs published in the peer-reviewed literature between January 1970 and October 2019 was conducted to identify the global burden, associated point sources, and successful prevention and control measures using the Guidelines for Outbreak Reports and Intervention Studies of Nosocomial Infections (ORION).

RESULTS

In total, we reviewed 125 documented outbreaks of Burkholderia cepacia-related HAIs worldwide. The reported B. cepacia HAIs for this period involved 3,287 patients. The point sources were identified in most outbreaks of B. cepacia HAIs (n = 93; 74.4%); they included medication vials, disinfectants, and antiseptics. Moreover, 95 of the outbreak reports (76%) described effective prevention and control measures, but only 33 reports indicated the use of a combination of environment-, patient- and staff-related measures. None of the outbreak reports used the ORION guidelines.

CONCLUSIONS

Outbreaks of Burkholderia cepacia HAIs are an ongoing challenge. They are often associated with immunocompromised patients who acquire the infection from exposure to contaminated medications, products, and equipment. These outbreaks are not infrequent, and a range of infection prevention and control measures have been effective in arresting spread. The use of ORION guidelines for outbreak reporting would improve the quality of information and data to generate evidence for translation into practice.

Continuous monitoring of deep-tissue haemodynamics with stretchable ultrasonic phased arrays

Stretchable wearable devices for the continuous monitoring of physiological signals from deep tissues are constrained by the depth of signal penetration and by difficulties in resolving signals from specific tissues. Here, we report the development and testing of a prototype skin-conformal ultrasonic phased array for the monitoring of haemodynamic signals from tissues up to 14 cm beneath the skin. The device allows for active focusing and steering of ultrasound beams over a range of incident angles so as to target regions of interest. In healthy volunteers, we show that the phased array can be used to monitor Doppler spectra from cardiac tissues, record central blood flow waveforms and estimate cerebral blood supply in real time. Stretchable and conformal skin-worn ultrasonic phased arrays may open up opportunities for wearable diagnostics.

Atypical Burkholderia Cepacia Resistance to Ceftazidime/Avibactam and Co-trimoxazole: A Case of Open Wound Contamination and Persistent Bacteremia

Wound contamination and subsequent colonization by microbes can significantly impair tissue repair and lead to the development of chronic non-healing ulcers. Atypical Burkholderia and Actinomycetes bacterial species are common in cases of soil contamination of open wounds leading to a complex infection that is both difficult to diagnose and treat. Despite much research on the involvement of atypical organisms, including Burkholderia and Actinomycetes, in antibiotic resistance, there is no consensus on the timeline from contamination to infection and on an algorithm for early diagnosis and management. Thus, the ways in which these organisms interact in settings of co-infection and contribute to cross-resistance remains unclear. The generally low index of clinical suspicion for atypical microbial infections and the absence of clear diagnostic protocols have multiple consequences, ranging from excessive reliance on pathology, delayed treatment, expensive and ineffective investigations and treatment, and progressive wound sepsis and morbidity. We are reporting a case of Burkholderia cepacia infection, co-infection with Actinomyces spp., and resistance to ceftazidime/avibactam and co-trimoxazole in a 28-year-old previously healthy farmer following soil contamination of an open wound. This is one of only a few reported cases of Burkholderia resistance to ceftazidime/avibactam and the first reported case ofB. cepacia bacteremia due to peripheral contamination.

The need for participation in the development and critical review of recommendations for infection control policies involving vascular ultrasound

Recently reported guidelines from the Society of Diagnostic Medical Sonography regarding disinfection of ultrasound probes and infection control policies for ultrasound procedures conflict with accepted clinical norms in vein practices and recommendations from the American Institute for Ultrasound in Medicine. We have provided a review of these conflicting policy recommendations and new proposed practice recommendations and a call for physicians who perform ultrasound-guided procedures to be involved in the process of development and critical review of societal recommendations.

Investigation and control of an outbreak of urinary tract infections caused by Burkholderia cepacian-contaminated anesthetic gel

Background

This report describes an outbreak of 71 patients developed B. cepacia urinary tract infection (UTI) by contaminated single-use anesthetic gel.

Methods

Epidemiological investigation of patients with B. cepacia-positive urine or blood samples between March 19, 2018 and Novemeber 15, 2018 was conducted to identify the source of infection. Microbiological samples from hospital surfaces, endoscopes, disposable items, and the hands of staff were tested for B. cepacia contamination. Pulsed-field gel electrophoresis (PFGE) was used to compare homology in B. cepacia isolates.

Results

During the outbreak, nosocomial B. cepacia UTI was confirmed in 71 patients. Epidemiological investigation showed that 66 patients underwent invasive urological diagnosis and treatment, while the remaining five patients underwent bedside indwelling catheterization, with all patients exposed to single-use anesthetic gel. All batches of anesthetic gel were recalled and the outbreak abated. Overall, 155 samples were collected from environmental surfaces and disposable items, and B. cepacia contamination was confirmed in samples from one used cystoscope and three anesthetic gels from the same batch. PFGE showed homology between 17 out of 20 B. cepacia isolates from patients and three isolates from the contaminated anesthetic gel. All patients achieved cure.

Conclusion

Contaminated single-use anesthetic gel was confirmed as the source of the B. cepacia outbreak, with infection occurring during invasive urological diagnostic and treatments. Thus, investigations of nosocomial outbreaks of B. cepacia infection should consider contamination of diagnostic and treatment items used in infected patients.

Unusual Penile Prolapse with an Infectious Background Caused by the Burkholderia cepacia Complex in a Stallion

Penile prolapse is a disease manifested by an inability to retract the penis into the preputial sheath. It is reported in a variety of animal species, especially in young and intact males. However, penile prolapse in horses is commonly caused by trauma, sexual activity, pseudohermaphroditism, or neurological deficits, and less often by an infectious background. The present case report aimed to determine the etiological factor of penis infection associated with penile prolapse in a stallion in Poland. Our report indicates that the infectious background of penile prolapse was related to the Burkholderia cepacia complex. Based on antibiotic susceptibility results, the stallion was administered effective streptomycin and enrofloxacin treatment and recovered without complications. The following options are likely to be the infection source: contamination of hay or animal hygiene products. Finally, given its ability to grow in antiseptic solutions, difficulties in culturing, and innate multidrug resistance, this microorganism is currently a challenge to both detection and treatment in veterinary medicine cases.

Ultrasound Guidance and Risk for Central Venous Catheter-Related Infections in the Intensive Care Unit: A Post Hoc Analysis of Individual Data of 3 Multicenter Randomized Trials

BACKGROUND

Ultrasound (US) guidance is frequently used in critically ill patients for central venous catheter (CVC) insertion. The effect of US on infectious risk remains controversial, and randomized controlled trials (RCTs) have assessed mainly noninfectious complications. This study assessed infectious risk associated with catheters inserted with US guidance vs use of anatomical landmarks.

METHODS

We used individual data from 3 large RCTs for which a prospective, high-quality data collection was performed. Adult patients were recruited in various intensive care units (ICUs) in France as soon as they required short-term CVC insertion. We applied marginal Cox models with inverse probability weighting to estimate the effect of US-guided insertion on catheter-related bloodstream infections (CRBSIs, primary outcome) and major catheter-related infections (MCRIs, secondary outcome).We also evaluated insertion site colonization at catheter removal.

RESULTS

Our post hoc analysis included 4636 patients and 5502 catheters inserted in 2088 jugular, 1733 femoral, and 1681 subclavian veins, in 19 ICUs. US guidance was used for 2147 catheter insertions. Among jugular and femoral CVCs and after weighting, we found an association between US and CRBSI (hazard ratio [HR], 2.21 [95% confidence interval {CI}, 1.17-4.16]; P = .014) and between US and MCRI (HR, 1.55 [95% CI, 1.01-2.38]; P = .045). Catheter insertion site colonization at removal was more common in the US-guided group (P = .0045) among jugular and femoral CVCs in situ for ≤7 days (n = 606).

CONCLUSIONS

In prospectively collected data in which catheters were not randomized to insertion by US or anatomical landmarks, US guidance was associated with increased risk of infection.

Ultrasound guidance and risk for intravascular catheter-related infections among peripheral arterial catheters: a post-hoc analysis of two large randomized-controlled trials

BACKGROUND

The impact on infectious risk of ultrasound guidance at insertion remains controversial in short-term arterial catheters (ACs). The present study investigated the association between ultrasound guidance (US) during AC insertion and major catheter-related infections (MCRI), catheter-related bloodstream infections (CR-BSI) or colonization, using univariate and multivariate marginal Cox model for clustered data. The skin colonization at catheter removal was evaluated to explain our results.

RESULTS

We used individual data from two multicenter randomized-controlled trials (RCTs) that included a total of 3029 patients, 10 ICUs and 3950 ACs. US guidance was used for 386 (9.8%) catheter placements. In the univariate Cox model analysis, AC insertion with US versus without US exhibited similar risks for MCRI (HR 0.86, CI 95% 0.27-2.72, p = 0.79), CR-BSI (HR 0.87, CI 95% 0.20-3.72, p = 0.85) and catheter colonization (HR 1.31, CI 95% 0.92-1.86, p = 0.13). After adjustment on confounders, risks associated with US guidance remained similar versus non-US for MCRI (HR 0.71, CI 95% 0.23-2.24, p = 0.56), CR-BSI (HR 0.71, CI 95% 0.17-3.00, p = 0.63) and catheter colonization (HR 0.92, CI 95% 0.63-1.34, p = 0.67). No differences between US and non-US for MCRI, CR-BSI and colonization were observed according to the insertion site, radial or femoral. At catheter removal, the skin colonization was similar between US and non-US groups (p = 0.69).

CONCLUSIONS

Using the largest dataset ever collected from large multi-centric RCTs conducted with relatively consistent insertion and maintenance catheter protocols, we showed that the risk of infectious complications for ACs inserted under US guidance is not superior compared to those inserted without US guidance. Trial registration These studies were registered within ClinicalTrials.gov (numbers NCT01629550 and NCT01189682).

Prevention of pathogen transmission during ultrasound use in the Intensive Care Unit: Recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group (USIG)

ICU ultrasonography constitutes important part of modern car patient care. Current standards and practice of infection control and prevention are inadequate. This purpose of this document is to adapt and expand the 2017 Australasian Society for Ultrasound in Medicine (ASUM) and the Australasian College for Infection Prevention Control (ACIPC) guidelines on minimum standards for reprocessing/cleaning of ultrasound transducers to the specifics of intensive care medicine and provide advice to the ICU practitioners and health care administrators. It considers the medical, administrative, financial and practical controversies surrounding implementation, and addresses emerging issues of care for patients with confirmed or suspected Corona Virus Disease 2019 (COVID-19).

Burkholderia cepacia Complex Bacteria: a Feared Contamination Risk in Water-Based Pharmaceutical Products

Burkholderia cepacia (formerly Pseudomonas cepacia) was once thought to be a single bacterial species but has expanded to the Burkholderia cepacia complex (Bcc), comprising 24 closely related opportunistic pathogenic species. These bacteria have a widespread environmental distribution, an extraordinary metabolic versatility, a complex genome with three chromosomes, and a high capacity for rapid mutation and adaptation. Additionally, they present an inherent resistance to antibiotics and antiseptics, as well as the abilities to survive under nutrient-limited conditions and to metabolize the organic matter present in oligotrophic aquatic environments, even using certain antimicrobials as carbon sources. These traits constitute the reason that Bcc bacteria are considered feared contaminants of aqueous pharmaceutical and personal care products and the frequent reason behind nonsterile product recalls. Contamination with Bcc has caused numerous nosocomial outbreaks in health care facilities, presenting a health threat, particularly for patients with cystic fibrosis and chronic granulomatous disease and for immunocompromised individuals. This review addresses the role of Bcc bacteria as a potential public health problem, the mechanisms behind their success as contaminants of pharmaceutical products, particularly in the presence of biocides, the difficulties encountered in their detection, and the preventive measures applied during manufacturing processes to control contamination with these objectionable microorganisms. A summary of Bcc-related outbreaks in different clinical settings, due to contamination of diverse types of pharmaceutical products, is provided.

Methionine dietary supplementation potentiates ionizing radiation-induced gastrointestinal syndrome

Methionine is an essential amino acid needed for a variety of processes in living organisms. Ionizing radiation depletes tissue methionine concentrations and leads to the loss of DNA methylation and decreased synthesis of glutathione. In this study, we aimed to investigate the effects of methionine dietary supplementation in CBA/CaJ mice after exposure to doses ranging from 3 to 8.5 Gy of ¹³⁷Cs of total body irradiation. We report that mice fed a methionine-supplemented diet (MSD; 19.5 vs. 6.5 mg/kg in a methionine-adequate diet, MAD) developed acute radiation toxicity at doses as low as 3 Gy. Partial body irradiation performed with hindlimb shielding resulted in a 50% mortality rate in MSD-fed mice exposed to 8.5 Gy, suggesting prevalence of radiation-induced gastrointestinal syndrome in the development of acute radiation toxicity. Analysis of the intestinal microbiome demonstrated shifts in the gut ecology, observed along with the development of leaky gut syndrome and bacterial translocation into the liver. Normal gut physiology impairment was facilitated by alterations in the one-carbon metabolism pathway and was exhibited as decreases in circulating citrulline levels mirrored by decreased intestinal mucosal surface area and the number of surviving crypts. In conclusion, we demonstrate that a relevant excess of methionine dietary intake exacerbates the detrimental effects of exposure to ionizing radiation in the small intestine.NEW & NOTEWORTHY Methionine supplementation, instead of an anticipated health-promoting effect, sensitizes mice to gastrointestinal radiation syndrome. Mechanistically, excess of methionine negatively affects intestinal ecology, leading to a cascade of physiological, biochemical, and molecular alterations that impair normal gut response to a clinically relevant genotoxic stressor. These findings speak toward increasing the role of registered dietitians during cancer therapy and the necessity of a solid scientific background behind the sales of dietary supplements and claims regarding their benefits.

Investigation of an outbreak of Burkholderia cepacia infection caused by drug contamination in a tertiary hospital in China

BACKGROUND

Contamination of drugs used in minimally invasive treatment may to lead to infection outbreaks and catastrophic public health events that require prompt detection and control. Our aim was to investigate the outbreak of Burkholderia cepacia infection and its source in a tertiary care, general hospital in Beijing, China.

METHODS

We investigated the outbreak of B cepacia infection from January 2017 to March 2018. The investigation included a detailed review of all cases, and field investigations. Environmental and product cultures were performed at the microbiology laboratory in the hospital. Isolates were evaluated for molecular relatedness using pulsed-field gel electrophoresis performed in an independent laboratory.

RESULTS

In total, 9 patients were infected from November 2017 to March 2018, and all patients had undergone the following surgeries: transurethral resection of the prostate (n = 4), perineal prostate biopsy (n = 2), transurethral resection of bladder tumors (n = 2), and ureteroscopy (n = 1). B cepacia was isolated from the urine of 9 patients, blood of 2 patients, grilles used for puncturing, and 2 samples in 1 batch of analgesic gels. Pulsed-field gel electrophoresis confirmed that the isolates from the patients and gels were homologous.

CONCLUSIONS

Our investigation revealed that the outbreak of B cepacia infection was caused by drug contamination.

Outbreak of Acinetobacter baumannii associated with extrinsic contamination of ultrasound gel in a tertiary centre burn unit

Background

During 2011 and 2012, an increase in occurrence of multidrug-resistant Acinetobacter baumannii infections was recorded in the Shands Hospital Burn Intensive Care Unit (BICU). An epidemic curve together with strain typing was consistent with an intermittent common source outbreak. An investigation was therefore initiated.

Aim

To identify risk factors for A. baumannii infection, characterize the source of the pathogen, implement control measures to terminate the outbreak, and institute preventive measures.

Methods

We conducted a retrospective case-control study; reviewed BICU infection control policies, practices and procedures, and patient exposure to healthcare workers (HCWs), and obtained epidemiologically-directed environmental cultures.

Findings

Eleven patients met the case definition. On multivariate analysis, case-patients were more likely to have undergone an ultrasound procedure in the BICU (adjusted odds ratio [AOR]: 19.5; confidence interval [CI]: 2.4-435) or have a FlexiSeal™ device (AOR: 11.9, CI:1.3-276). Epidemiologically-directed cultures of the environment, ultrasound equipment, and ultrasound gel from opened containers on the ultrasound trolley and in the Ultrasound Department were negative for the outbreak pathogen. Culture of an open ultrasound gel dispenser stored in the Ultrasound Department yielded an A. baumannii strain with DNA banding patterns identical to the outbreak strain.

Conclusions

Based on data from our epidemiologic, microbiologic, and observational studies, we believe that inadvertent extrinsic contamination of the gel dispenser occurred in the Ultrasound Department. Contaminated gel was then dispensed into multiuse vials of gel stored on the mobile carts. The outbreak was stemmed by instituting changes in practices in the Ultrasound Department, including introduction of single-use ultrasound vials and storage of ultrasound gel.

Ultrasound gel as a source of hospital outbreaks: Indian experience and literature review

Purpose

Hospital outbreaks are observed increasingly worldwide with various organisms from different sources such as contaminated ultrasound gel, intravenous (IV) fluids and IV medications. Among these, ultrasound gel is one of the most commonly reported sources for Burkholderia cepacia complex (Bcc) outbreaks. In this study, we describe our experience on investigation and the management of Bcc bacteraemia outbreak due to contaminated ultrasound gel from a tertiary care centre, South India.

Materials and Methods

Over a 10-day period in October 2016, seven children in our Paediatric intensive care unit (ICU) were found to have bacteraemia with Bcc isolated from their blood culture. Repeated isolation of the same organism with similar antimicrobial susceptibility pattern over a short incubation period from the same location, confirmed the outbreak. An active outbreak investigation, including environmental surveillance, was carried out to find the source and control the outbreak. Isolates were subjected to multi-locus sequence typing (MLST) and global eBURST (goeBURST) analysis.

Results

Environmental surveillance revealed contaminated ultrasound gel as the source of infection. MLST and goeBURST analysis confirmed that the outbreak was caused by a novel sequence type 1362 with the same clonal complex CC517. The outbreak was controlled by stringent infection control measures, withdrawal of contaminated ultrasound gel from regular usage and implementing the practice of using ultrasonogram (USG) probe cover for USG screening and guided procedures.

Conclusion

This report highlights the importance of early identification of an outbreak, prompt response of the ICU and infection control teams, sound environmental and epidemiological surveillance methods to identify the source and stringent infection control measures to control the outbreak. Contaminated ultrasound gel can be a potential source for healthcare-associated infection, which cannot be overlooked.

Medical Ultrasound Disinfection and Hygiene Practices: WFUMB Global Survey Results

As ultrasound technology rapidly evolves and is used more frequently in every area of medical diagnosis and treatment, it may be overlooked as a potential vector in the transmission of a health care-associated infection. A survey on disinfection and hygiene practice in medical ultrasound was disseminated via the World Federation for Ultrasound in Medicine and Biology (WFUMB) to its six member federations and associated ultrasound societies globally. One thousand twenty-nine responses were obtained across a broad range of ultrasound practitioners. A total of 76% of respondents used transducer covers every time to scan open wounds and 71% when blood and bodily fluids were present or for an interventional procedure. Approved high-level disinfectants are not always used, even when blood comes into contact with the transducer or after endocavity scans. Alcohol-based wipes were used by many respondents to clean both external transducers and endocavity transducers. Open-ended responses indicated that a large caseload hindered the time required for cleaning and that access to clear guidelines would be beneficial. Global survey results indicate that some users do not comply with disinfection practice, and there is a gap in knowledge on basic infection prevention and control education within the ultrasound unit. As the infectious status of a patient is not often disclosed prior to an ultrasound examination, training in suitable protocols for the cleaning and disinfection of ultrasound equipment is imperative to mitigate the risk of potential infection.

Outbreak of Burkholderia Cepacia Infection: a Systematic Study in a Hematolooncology Unit of a Tertiary Care Hospital from Eastern India

Background

Burkholderia cepacia, an aerobic gram-negative bacillus, is a frequent colonizer of fluids used in the hospital ward. It poses little risk of infection to healthy people; however it is a known important opportunistic pathogen causing morbidity and mortality due to its intrinsic resistance to most of the antibiotics in hospitalized patients. Small hospital outbreaks are frequent. B. cepacia may occur as an opportunistic infection in hemato-oncology patients. Here we present an outbreak of Burkholderia cepacia infection in hematology ward of our institute.

Methods

Febrile episodes as defined by IDSA guideline, 2010 were followed, and blood for culture and sensitivity was sent in all the events. The culture was done by an automated method using Bactalert 3d Biomeriux & sensitivity pattern by Microscan Siemens method and subsequently detected by PCR based method.

Results

During September 2016 to February 2017 (six months), a total of 498 blood cultures were sent during febrile episodes. Out of which 60 (12%) came out to be positive for different microorganisms. Out of all positive cultures, Burkholderia cepacia was detected in 29 (48%) patients, which reduced drastically following the change in antibiotic administration practice. All isolates showed sensitivity to pipercillin+tazobactum, cefoperazone+sulbactum, fluoroquinolones, cotrimoxazole and carbapenems and resistance to polymyxin B and colistin. With timely intervention by appropriate intravenous antibiotics as per culture sensitivity result and change in antibiotic preparation practice, overall mortality was low 1 (4%) out of 29 culture positive episodes.

Conclusion

Change of antibiotic preparation practice was the key to control this outbreak, and overall mortality was low.

Ultrasound probe use and reprocessing: Results from a national survey among U.S. infection preventionists

BACKGROUND

Improper infection prevention practice associated with ultrasound probe use has been linked to increased infection risk, outbreaks, and death. Although guidelines for reprocessing and use of probes exist, it is unclear how extensively these have been adopted in practice.

METHODS

Infection preventionists from U.S. health care facilities were surveyed (N = 358). The anonymous survey had 31 multiple choice, sliding scale, and text response questions. The survey was developed and deployed and the data were stored in the REDCap system.

RESULTS

A high degree of noncompliance with U.S. guidelines was identified. Surface probes used in invasive procedures were not high-level disinfected or sterilized 15% (intraoperative) to 78% (peripheral line placements) of the time. Of invasive procedures, 5%-47% did not use sterile gel (same procedures, respectively). Of the participants, 20% were aware of instances where an ultrasound probe was used but was not correctly reprocessed. Extensive breaches of infection control guidelines were reported. The rapid expansion in use of ultrasound has brought clinical benefit but may be exposing patients to preventable infection risk.

CONCLUSIONS

Infection preventionists are well placed to act as major drivers of change based on their expertise and experience in the management of infection risk across facilities and health systems. They, along with clinicians responsible for probe use and reprocessing, should review practices relating to ultrasound in their facilities. Where practice does not comply with guidelines, policy and training should be updated to ensure patient safety.