Investigation of Burkholderia cepacia Nosocomial Outbreak with High Fatality in Patients Suffering from Diseases other than Cystic Fibrosis

An outbreak of Burkholderia cepacia bloodstream infections in a tertiary-care facility in northern India detected by a healthcare-associated infection surveillance network

OBJECTIVE

The burden of healthcare-associated infections (HAIs) is higher in low- and middle-income countries, but HAIs are often missed because surveillance is not conducted. Here, we describe the identification of and response to a cluster of Burkholderia cepacia complex (BCC) bloodstream infections (BSIs) associated with high mortality in a surgical ICU (SICU) that joined an HAI surveillance network.

SETTING

A 780-bed, tertiary-level, public teaching hospital in northern India.

METHODS

After detecting a cluster of BCC in the SICU, cases were identified by reviewing laboratory registers and automated identification and susceptibility testing outputs. Sociodemographic details, clinical records, and potential exposure histories were collected, and a self-appraisal of infection prevention and control (IPC) practices using assessment tools from the World Health Organization and the US Centers for Disease Control and Prevention was conducted. Training and feedback were provided to hospital staff. Environmental samples were collected from high-touch surfaces, intravenous medications, saline, and mouthwash.

RESULTS

Between October 2017 and October 2018, 183 BCC BSI cases were identified. Case records were available for 121 case patients. Of these 121 cases, 91 (75%) were male, the median age was 35 years, and 57 (47%) died. IPC scores were low in the areas of technical guidelines, human resources, and monitoring and evaluation. Of the 30 environmental samples, 4 grew BCC. A single source of the outbreak was not identified.

CONCLUSIONS

Implementing standardized HAI surveillance in a low-resource setting detected an ongoing Burkholderia cepacia outbreak. The outbreak investigation and use of a multimodal approach reduced incident cases and informed changes in IPC practices.

Outbreak of health care-associated Burkholderia cenocepacia bacteremia and infection attributed to contaminated sterile gel used for central line insertion under ultrasound guidance and other procedures

BACKGROUND

We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia.

METHODS

Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures.

RESULTS

The outbreak investigation identified the point source as contaminated gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of B cenocepacia with the same multilocus sequence type were identified within 4 hospitals across Australia. This typing was the same as identified in the contaminated gel isolate with single nucleotide polymorphism-based typing, demonstrating that all linked isolates clustered together.

CONCLUSION

Arresting the national point-source outbreak within multiple jurisdictions was critically reliant on a rapid, integrated, and coordinated response and the use of informal professional networks to first identify it. All institutions where the product is used should look back at Burkholderia sp blood culture isolates for speciation to ensure this outbreak is no larger than currently recognized given likely global distribution.

Community-acquired urinary tract infections caused by Burkholderiacepacia complex in patients with no underlying risk factor

Introduction. Urinary tract infections (UTIs) remain common infections diagnosed in outpatients as well as hospitalized patients. Community-acquired UTIs are generally caused by Escherichia coli and other members of the family Enterobacteriaceae.Burkholderiacepacia is an opportunistic pathogen mainly affecting immunocompromised and hospitalized patients, particularly those who have received prior broad-spectrum antibacterial therapy.

Case presentation. Urine samples were collected from 157 outpatients clinically diagnosed with UTI and from 100 healthy control subjects. Samples were cultured on differential media and non-motile lactose-non-fermentors were identified via the Remel RapID ONE system. The isolates were tested by the disc diffusion method against 17 antimicrobial agents. Burkholderia was isolated as a single organism from four patients having uncomplicated infections, and one from recurrent infection. None of these patients had an underlying risk factor for this pathogen. Identification of these isolates by the Remel-RapID ONE system was confirmed by recA gene amplification. The four isolates were resistant to lincomycin, nalidixic acid, oxacillin and penicillin G. These cases received monotherapy of oral co-trimoxazole.

Conclusions. Our findings alert urologists and diagnostic laboratories to the potential of B.cepacia complex infections in similar cases, and that this bacterium should not be ruled out.

Risk Factors forBurkholderia cepaciaComplex Bacteremia Among Intensive Care Unit Patients Without Cystic Fibrosis: A Case-Control Study

Background.

TheBurkholderia cepaciacomplex is associated with colonization or disease in patients with cystic fibrosis (CF). For patients without CF, this complex is poorly understood apart from its presence in occasional point source outbreaks.

Objective.

To investigate risk factors forB. cepaciabacteremia in hospitalized, intensive care unit patients without CF.

Methods.

We identified patients with 1 or more blood cultures positive forB. cepaciabetween May 1, 1996, and March 31, 2002, excluding those with CF. Control patients were matched to case patients by ward, duration of hospitalization, and onset date of bacteremia. Matched analyses were used to identify risk factors forB. cepaciabacteremia.

Results.

We enrolled 40 patients withB. cepaciabacteremia into the study. No environmental or other point source forB. cepaciacomplex was identified, although horizontal spread was suspected. Implementation of contact precautions was effective in decreasing the incidence ofB. cepaciabacteremia. We selected 119 matched controls. Age, sex, and race were similar between cases and controls. In multivariable analysis, renal failure that required dialysis, recent abdominal surgery, 2 or more bronchoscopic procedures before detection ofB. cepaciabacteremia, tracheostomy, and presence of a central line before detection ofB. cepaciabacteremia were independently associated with development ofB. cepaciabacteremia, whereas presence of a percutaneous feeding tube was associated with a lower risk of disease.

Conclusions.

B. cepaciacomplex is an important emerging group of nosocomial pathogens in patients with and patients without CF. Nosocomial spread is likely facilitated by cross-transmission, frequent pulmonary procedures, and central venous access. Infection control measures appear useful for limiting the spread of virulent, transmissible clones ofB. cepaciacomplex.

An Outbreak ofBurkholderia cepaciaComplex Associated with Intrinsically Contaminated Nasal Spray

Objective.

To determine the source ofBurkholderia cepaciacomplex associated with a hospital outbreak and describe the measures taken to identify and confirm the source.

Setting.

A 250-bed, tertiary care pediatric hospital in Denver, Colorado.

Methods.

An epidemiologic investigation was used to identify possible causes for an apparent outbreak ofB. cepaciacomplex in pediatric patients who had new positive cultures with this organism from December 2003 to February 2004. Chart review, microbiology reports, surgical records, site visits, literature review, staff interviews, and cultures of common products and equipment were performed to determine a source of contamination. Random amplified polymorphic DNA and pulsed-field gel electrophoresis typing, performed by 2 independent laboratories, were used for molecular typing of patient and source isolates.

Results.

Five pediatric patients had new positiveB. cepaciacomplex cultures from either the sinus or the respiratory tract, and all 5 patients had prior exposure to 0.05% oxymetazoline hydrochloride Major Twice-A-Day 12-hour nasal spray (Proforma, Miami, FL). Four of the 5 patients had isolates that were identical to theB. cepaciacomplex isolates recovered from the unopened Twice-A-Day 12-hour nasal spray.

Conclusions.

Intrinsic contamination of Major Twice-A-Day 12-hour nasal spray withB. cepaciacomplex resulted in nosocomial transmission to 4 patients at our facility and resulted in a voluntary product recall by the manufacturer.B. cepaciacomplex species are common contaminants of an increasing variety of nonsterile medical products. Enhanced culture techniques may be useful in evaluating possible product contamination, suggesting additional measures that should be considered to assure the safety of products that may be used in high-risk patients.

Multi-institutional outbreak of Burkholderia cepacia complex associated with contaminated mannitol solution prepared in compounding pharmacy

BACKGROUND

Burkholderia cepacia complex (BCC) has been described as a cause of nosocomial outbreaks. We describe an outbreak of and identify risk factors for nosocomial BCC infections associated with intrinsically contaminated mannitol 3% solution.

METHODS

Urinary and bloodstream infection caused by BCC were identified in hospitalized patients who underwent urologic surgery and received intraoperative irrigation of 3% mannitol solution in February 2009. The investigation included retrospective chart review, case control study, procedural review, and culture of mannitol solution.

RESULTS

Seven BCC infections were identified. BCC isolates were recovered from blood and/or urine from patients and lots of mannitol in use during the outbreak period. Mannitol solution was produced by a compounding pharmacy. Receipt of larger volumes of contaminated solution was identified as a significant risk factor for infection (odds ratio, 1.5; P value < .05). BCC was also cultured in lots of mannitol in use in other hospitals.

CONCLUSION

Manipulated mannitol solution is a potential source of infection. Contamination with paraben-degrading organisms can occur at the time of manufacture. Our findings suggest that contamination of mannitol at a compounding pharmacy occurred. Prompt communication to other hospitals and implementation of infection control measures were effective in avoiding further cases of infection.

An outbreak of Burkholderia cepacia bacteremia in hospitalized hematology patients selectively affecting those with acute myeloid leukemia

BACKGROUND

Burkholderia cepacia complex (Bcc) is a group of common environmental bacteria that preferentially colonize and infect patients with cystic fibrosis but are also emerging as nosocomial pathogens, possibly due to their resistance to disinfectants and antimicrobials.

METHODS

We investigated a 3-month outbreak of Bcc bacteremia among hospitalized hematology patients. Environmental investigation and infection control measures were implemented. A retrospective, cross-sectional study was conducted to identify risk factors.

RESULTS

Bcc was repeatedly isolated from the blood of 9 patients without central venous catheter who did not easily respond to targeted antibiotic treatment and 3 died of the infection. A point source was not identified and horizontal spread was suspected. Strict infection control measures terminated the outbreak. Interestingly, diagnosis of acute myeloid leukemia but not neutropenia or prior chemotherapy was a risk factor for infection acquisition. Neutropenia was positively correlated with infection duration.

CONCLUSIONS

Bcc is not only a serious threat among immunocompromized hematology patients, but is also transmissible in clinical settings. Acute myeloid leukemia appears to confer additional risk for infection acquisition.

Burkholderia cepacia septicemia in a pediatric oncology patient: a pharmacotherapy challenge

OBJECTIVE

To discuss pharmacotherapy challenges encountered during treatment of a pediatric oncology patient with Burkholderia cepacia septicemia.

CASE SUMMARY

An 11-year-old male with a history of aplastic anemia presented to the emergency department with a 1-day history of cough and purulent nasal discharge 6 months after undergoing bone marrow transplant. Blood cultures obtained from the patient's Broviac catheter revealed gram-negative rods. Piperacillin/tazobactam and tobramycin were administered, but the patient worsened clinically, with fever and chills. B. cepacia was identified as the offending pathogen, and the therapy was changed to meropenem and ciprofloxacin, as piperacillin/ tazobactam and tobramycin are ineffective against Burkholderia spp. Intravenous trimethoprim/sulfamethoxazole, the drug of choice for Burkholderia spp. infections, was unavailable as it had been placed on national manufacturer backorder. The patient improved initially, but he later experienced recurrence of fever, and blood culture results were positive for Burkholderia spp. Infection was eradicated after removal of the central line and administration of ceftazidime and oral minocycline.

DISCUSSION

Literature reveals few cases of B. cepacia in pediatric oncology patients, and to our knowledge, no cases have been reported in bone marrow transplant patients in the US. Burkholderia spp. is highly resistant to many antibiotics, and commonly used agents for the empiric treatment of febrile neutropenia are not active against this organism. This indicates that most oncology patients who present with this infection would not receive appropriate initial treatment. In addition, antibiotic therapy may need to be modified, based on drug availability.

CONCLUSIONS

B. cepacia is an emerging multidrug-resistant pathogen that can produce severe infection in immunocompromised patients. It is pertinent to consider this organism in oncology patients who do not improve with standard therapy, as prompt use of correct pharmacotherapy is necessary to avoid serious morbidity as well as mortality in this population.

Naturally occurring Class A ss-lactamases from the Burkholderia cepacia complex

Chromosomally encoded ss-lactamases from the Burkholderia cepacia complex species (formerly Pseudomonas cepacia) were characterized. Cloning and sequencing identified an Ambler class A ss-lactamase (PenB) from B. cenocepacia. It shares 82% amino acid identity with the PenA ss-lactamases previously identified from B. multivorans 249. Its expression was dependent upon a LysR-type regulatory protein. Its narrow-spectrum hydrolysis activity mostly included penicillins but also included expanded-spectrum cephalosporins and aztreonam at lower levels. In that study, Pen-like ss-lactamases (PenC, PenD, PenE, PenF) that shared 63 to 92% identity with PenB from B. cenocepacia were identified from other Burkholderia species. The corresponding ss-lactamase genes might be used as genetic tools for accurate Burkholderia species identification.

The role of molecular methods in the prevention of nosocomial methicillin-resistant Staphylococcus aureus clusters in cancer patients

In 2002, an increased incidence of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) in our institution triggered a conventional investigation that failed to identify a common source. Molecular typing of the 70 nosocomial MRSA isolates obtained identified a predominant health care-associated clone A in the first trimester. Aggressive infection control measures led to a significant decrease in the number of isolates per 10,000 hospital days between the first trimester and the last 2 trimesters of 2003 (6.4 vs 3.8; P = .04). This was attributed to a decrease in clone A: SCCmec II, USA100, PVL gene-negative (2.3 per 10.000 patient-days vs 0.1 per 10,000 patient-days; P = .004). However, in 2003, 23% of the nosocomial isolates were SCCmec IV, USA300, PVL gene-positive. At that time, molecular methods allowed the detection and prevention of a nosocomial MRSA outbreak caused by a health care-associated clone; however, the community strains (SCCmec IV) have become a frequent cause of nosocomial infection in our institution.

Disinfection of Burkholderia cepacia complex from non-touch taps in a neonatal nursery

Burkholderia cepacia complex (Bcc) comprises nine closely related species or genomovars. It is an important causative agent of opportunistic infections and waterborne nosocomial infections. B. cepacia (formerly genomovar I) was identified from the blood culture of a baby in our neonatal unit (NU) in March 2005. B. cepacia was isolated four times from clinical specimens since the introduction of non-touch taps in the NU from 2000 to 2005 and only once from 1994 to 2000. Environmental samples were collected from the NU, including tap water from non-touch taps. Clinical and environmental isolates of Bcc were characterized using molecular identification and strain typing. A literature review was undertaken to delineate a method for eradication of Bcc. Several variations for hot water eradication of the organism from the taps were attempted. Genotyping and molecular analysis revealed that tap water isolates were B. cenocepacia which was a different species from the B. cepacia isolated from blood cultures of the neonate. However, B. cenocepacia has been known to cause nosocomial outbreaks and it was eventually eradicated from the NU by using repeated thermal shock (hot water at 65 degrees C for 10 min), changing taps and decolonizing sinks with hypochlorite. Molecular typing is useful in assisting the investigation of Bcc nosocomial infections.

More than skin deep: moisturizing body milk and Burkholderia cepacia

Alvarez-Lerma and colleagues observed over an 18-day period that five critically ill patients admitted to a multidisciplinary 18-bed intensive care unit contracted Burkholderia cepacia from unopened containers of moisturizing body milk, calling into question the use in critical care settings of cosmetic products that do not guarantee sterilization during the manufacturing process. Is this the answer to the problem, however, or should the use of lotions in such settings be re-examined?

Sustained endemicity of Burkholderia cepacia complex in a pediatric institution, associated with contaminated ultrasound gel

OBJECTIVE

To determine whether contaminated ultrasound gel is the source of intermittent outbreaks of nosocomial infection due to Burkholderia cepacia complex in patients without cystic fibrosis since 1992.

DESIGN

A prospective clinical and in vitro study of all in-use bottles of ultrasound gel, as well as a retrospective analysis of archived bacterial strains, were performed. Handling of gel for clinical purposes throughout the hospital was evaluated. Gel and archived clinical isolates of B. cepacia complex were speciated to genomovar level and characterized by pulsed-field gel electrophoresis, and the pulsed-field gel electrophoresis patterns were compared.

SETTING

The Hospital for Sick Children, a 300-bed, tertiary care, pediatric academic health sciences center in Toronto, Canada.

PATIENTS

All patients without cystic fibrosis from whom B. cepacia complex was recovered at the Hospital for Sick Children since 1992.

RESULTS

No standardized protocol for storage or handling of ultrasound gel was found. Gel from 39% of bottles grew either B. cepacia (genomovar I) or Burkholderia stabilis (genomovar IV). These isolates had pulsed-field gel electrophoresis patterns identical to 2 of the 7 clinical pulsed-field gel electrophoresis types that are responsible for 88% of clinical isolates.

CONCLUSIONS

Contaminated ultrasound gel contributed to nosocomial infection due to B. cepacia complex in this institution over the course of 10 years. Suggested guidelines for the handling of ultrasound gel are provided.

Update on the Burkholderia cepacia complex

PURPOSE OF REVIEW

The Burkholderia cepacia complex is comprised of a group of related bacterial species that are capable of causing life-threatening respiratory tract infection in persons with cystic fibrosis. This article reviews advances in our understanding of Burkholderia cepacia complex infection in cystic fibrosis, focusing on the taxonomy, clinical microbiology, and epidemiology, as well as the natural history and clinical outcomes associated with Burkholderia cepacia complex infection.

RECENT FINDINGS

Each of the nine species of the Burkholderia cepacia complex has now received a formal species name. These names are the preferred nomenclature, replacing the former 'genomovar' designations. Studies from several countries reiterate that two species, Burkholderia cenocepacia and Burkholderia multivorans, account for most Burkholderia cepacia complex infection in cystic fibrosis. Bacterial genotyping studies indicate that specific Burkholderia cepacia complex strains infect multiple cystic fibrosis patients, implying that they may have an enhanced capacity for interpatient spread. Emerging clinical outcomes data suggest that at least some of these so-called transmissible or epidemic strains are also more virulent in the cystic fibrosis host. Ongoing research is aimed at gaining a better understanding of Burkholderia cepacia complex ecology, defining Burkholderia cepacia complex virulence factors and pathogenic mechanisms, and determining the relative virulence of distinct strains.

SUMMARY

Significant advances in our understanding of the Burkholderia cepacia complex serve as a critical foundation for further efforts that ultimately will enable better infection control and the development of novel therapeutics to treat Burkholderia cepacia complex infection in persons with cystic fibrosis.