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

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.

Outbreak of B.cepacia bacteremia following use of contaminated drug vials in a tertiary care centre

PURPOSE

We report an outbreak of Burkholderia cepacia bacteremia related to contaminated drug vials.

MATERIALS AND METHODS

All patients having fever post coronary angiography were analysed from February 12, 2019 to March 18, 2019. A thorough inspection of the cath lab was done by the infection control team. Surveillance cultures were taken from various places including swabs from the all the drug vials used for the patients.

RESULTS

During the above period, a total of 898 cases had been taken up for angiographic procedures in all the four cath labs, out of which 72 were for neurological issues. Among these patients only 60 patients reported fever. No fever was reported among those who underwent angiograms for neurological issues. Of the 60 patients who had fever, 38 patients satisfied the case definition. Blood cultures were sent for 7(18.4%) patients and 17(44.7%) had been started on antibiotics. After identification of 2 cases with the positive culture and following the news that a drug manufacturing company had recalled a particular batch of drug (diltiazem), the source of the outbreak was thought to be contaminated diltiazem vials. Retrospectively it was noted that the 38 patients had received the diltiazem from three different batches. Subsequently the same organism was isolated from the drug vials also. Both the isolates were phenotypically the same. There were no patients with fever post procedure reported the week after the batch of diltiazem was recalled.

CONCLUSION

The outbreak was thus linked to the contaminated diltiazem vials. Physicians should thus be aware of such outbreaks that can cause bacteremias.

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.

Investigation of Burkholderia cepacia complex bacteremia outbreak in a neonatal intensive care unit: a case series

INTRODUCTION

Burkholderia cepacia complex is a ubiquitous organism with a high virulence potential. It is found most commonly in moist environments. Hospital outbreaks have been reported from diverse sources such as contaminated faucets, nebulizers, disinfectant solutions, multidose antibiotic vials, tap water, bottled water, nasal sprays, and ultrasound gels. In this article, we present our experience in investigating and successfully managing an outbreak of nosocomial transmission of Burkholderia cepacia sepsis in the neonatal intensive care unit at SGT Hospital, Haryana, India.

CASE PRESENTATION

During the month of March, multiple Burkholderia cepacia complex isolates were recovered from blood cultures of Caucasian babies admitted to the neonatal intensive care unit of our hospital. The organisms were multidrug-resistant, with in vitro sensitivity to meropenem alone (minimum inhibitory concentration = 4 μg/ml). An outbreak was suspected, and the neonatal intensive care unit in-charge and hospital infection control teams were alerted. Outbreak investigation was initiated, and surveillance samples were collected. Burkholderia cepacia complex was successfully isolated from suction apparatus. The isolates were phenotypically typed (biotyping and antimicrobial susceptibility testing) and found to be identical.

CONCLUSIONS

In our study, the index case might have been exposed to infection due to a physiological state of low immunity (preterm, low birth weight, and mechanical ventilation). The rest of the cases might have been exposed to this organism due to inadequate hand hygiene/improper cleaning and disinfection practices. Timely reporting and implementation of infection control measures played a significant role in curtailing this outbreak.

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.