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Kumar SP, Uthra KT, Chitra V, Damodharan N, Pazhani GP. Challenges and mitigation strategies associated with Burkholderia cepacia complex contamination in pharmaceutical manufacturing. Arch Microbiol 2024; 206:159. [PMID: 38483625 DOI: 10.1007/s00203-024-03921-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 02/15/2024] [Accepted: 03/02/2024] [Indexed: 03/19/2024]
Abstract
Burkholderia cepacia complex (BCC) is a Gram-negative, non-spore-forming bacterium with more than 20 opportunistic pathogenic species, most commonly found in soil and water. Due to their rapid mutation rates, these organisms are adaptable and possess high genomic plasticity. BCC can cause life-threatening infections in immunocompromised individuals, such as those with cystic fibrosis, chronic granulomatous disease, and neonates. BCC contamination is a significant concern in pharmaceutical manufacturing, frequently causing non-sterile product recalls. BCC has been found in purified water, cosmetics, household items, and even ultrasound gel used in veterinary practices. Pharmaceuticals, personal care products, and cleaning solutions have been implicated in numerous outbreaks worldwide, highlighting the risks associated with intrinsic manufacturing site contamination. Regulatory compliance, product safety, and human health protection depend on testing for BCC in pharmaceutical manufacturing. Identification challenges exist, with BCC often misidentified as other bacteria like non-lactose fermenting Escherichia coli or Pseudomonas spp., particularly in developing countries where reporting BCC in pharmaceuticals remains limited. This review comprehensively aims to address the organisms causing BCC contamination, genetic diversity, identification challenges, regulatory requirements, and mitigation strategies. Recommendations are proposed to aid pharmaceutical chemists in managing BCC-associated risks and implementing prevention strategies within manufacturing processes.
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Affiliation(s)
- Sethuraman Prem Kumar
- Department of Pharmaceutical Quality Assurance, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, 603203, India
| | - Karupanagounder Thangaraj Uthra
- Department of Pharmaceutical Chemistry, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, 603 203, India
| | - Vellapandian Chitra
- Department of Pharmacology, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, 603203, India
| | - Narayanasamy Damodharan
- Department of Pharmaceutics, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, 603203, India
| | - Gururaja Perumal Pazhani
- Department of Pharmaceutical Chemistry, SRM College of Pharmacy, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, 603 203, India.
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Mansour KE, Qi Y, Yan M, Ramström O, Priebe GP, Schaefers MM. Small-molecule activators of a bacterial signaling pathway inhibit virulence. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.02.569726. [PMID: 38076823 PMCID: PMC10705554 DOI: 10.1101/2023.12.02.569726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The Burkholderia genus encompasses multiple human pathogens, including potential bioterrorism agents, that are often extensively antibiotic resistant. The FixLJ pathway in Burkholderia is a two-component system that regulates virulence. Previous work showed that fixLJ mutations arising during chronic infection confer increased virulence while decreasing the activity of the FixLJ pathway. We hypothesized that small-molecule activators of the FixLJ pathway could serve as anti-virulence therapies. Here, we developed a high-throughput assay that screened over 28,000 compounds and identified 11 that could specifically active the FixLJ pathway. Eight of these compounds, denoted Burkholderia Fix Activator (BFA) 1-8, inhibited the intracellular survival of Burkholderia in THP-1-dervived macrophages in a fixLJ-dependent manner without significant toxicity. One of the compounds, BFA1, inhibited the intracellular survival in macrophages of multiple Burkholderia species. Predictive modeling of the interaction of BFA1 with Burkholderia FixL suggests that BFA1 binds to the putative ATP/ADP binding pocket in the kinase domain, indicating a potential mechanism for pathway activation. These results indicate that small-molecule FixLJ pathway activators are promising anti-virulence agents for Burkholderia and define a new paradigm for antibacterial therapeutic discovery.
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Affiliation(s)
- Kathryn E. Mansour
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital; Boston, MA, USA
| | - Yunchuan Qi
- Department of Chemistry, University of Massachusetts Lowell, One University Ave., Lowell, MA 01854
| | - Mingdi Yan
- Department of Chemistry, University of Massachusetts Lowell, One University Ave., Lowell, MA 01854
| | - Olof Ramström
- Department of Chemistry, University of Massachusetts Lowell, One University Ave., Lowell, MA 01854
- Department of Chemistry and Biomedical Sciences, Linnaeus University, SE-39182 Kalmar, Sweden
| | - Gregory P. Priebe
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital; Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School; Boston, MA, USA
| | - Matthew M. Schaefers
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital; Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School; Boston, MA, USA
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Singhal T, Wani S, Shah S, Thakkar P, Vidisha Daiya, Veeraraghavan B. Burkholderia cepacia complex as a cause of community acquired bacteremia in a young immuncompetent male. Indian J Med Microbiol 2023; 46:100422. [PMID: 37945116 DOI: 10.1016/j.ijmmb.2023.100422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/18/2023] [Accepted: 06/26/2023] [Indexed: 11/12/2023]
Abstract
Burkholderia cepacia complex (BCC) is a well-recognized cause of nosocomial infections. We describe here a young healthy male who presented with fever and chest pain with ECG changes of acute pericarditis. Two sets of blood cultures at separate timings grew gram negative bacilli identified as BCC by molecular methods. The patient responded to intravenous ceftazidime despite high ceftazidime MIC's. The source of infection was probably contaminated nasal spray/nasal saline wash which he used after a balloon sinoplasty procedure one month ago. Issues related to accurate identification and susceptibility testing of BCC are also discussed.
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Affiliation(s)
- Tanu Singhal
- Department of Infectious Disease, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Sunil Wani
- Department of Cardiology, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Sweta Shah
- Department of Microbiology and Infection Control, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Pooja Thakkar
- Department of Microbiology and Infection Control, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Vidisha Daiya
- Department of Infectious Disease. Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Balaji Veeraraghavan
- The Hilda Lazarus Core Research Chair, Christian Medical College & Hospital, Vellore, India.
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Burkholderia cepacia Complex, an Emerging Nosocomial Pathogen at Health Care Facilities in Sebha, Libya. JOURNAL OF MEDICAL MICROBIOLOGY AND INFECTIOUS DISEASES 2021. [DOI: 10.52547/jommid.9.4.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Bilgin H, Altınkanat Gelmez G, Bayrakdar F, Sayın E, Gül F, Pazar N, Çulha G, Süzük Yıldız S, Cinel I, Korten V. An outbreak investigation of Burkholderia cepacia infections related with contaminated chlorhexidine mouthwash solution in a tertiary care center in Turkey. Antimicrob Resist Infect Control 2021; 10:143. [PMID: 34629114 PMCID: PMC8502507 DOI: 10.1186/s13756-021-01004-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We report a nosocomial outbreak caused by Burkholderia cepacia that occurred among six patients admitted in the medical and surgical intensive care unit between 04 March 2019 and 02 April 2019 in Istanbul, Turkey. METHODS The outbreak investigation was launched on 11 March 2019 five days after the detection of B. cepacia in four different patients. We defined potential reservoirs and started environmental screening. We sampled the liquid solutions used in patient care activities. Pulse-field gel electrophoresis (PFGE) was performed to determine the genetic relatedness of environmental and patient samples. RESULTS Burkholderia cepacia was isolated in tracheal aspiration cultures of six patients. Three out of six patients developed healthcare-associated pneumoniae due to B. cepacia. Environmental cultures in the ICUs revealed B. cepacia growth in 2% chlorhexidine-gluconate mouthwash solution that been used in the colonized patients as well as in samples obtained from the unused products. PFGE revealed the patient and a specific batch of chlorhexidine mouthwash solution samples had a 96% similarity. CONCLUSION Contamination of medical solutions used in critical patient care could cause outbreaks and should be detected early by infection control teams.
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Affiliation(s)
- Hüseyin Bilgin
- Infectious Diseases, and Clinical Microbiology, Marmara University Hospital, Istanbul, Turkey. .,Marmara University Hospital, Fevzi Cakmak Mah, Muhsinyazicioglu Cad No: 10 Pendik, Istanbul, Turkey.
| | | | - Fatma Bayrakdar
- National Molecular Microbiology Reference Laboratory, Public Health General Directorate, Ankara, Turkey
| | - Elvan Sayın
- Medical Microbiology, Marmara University Hospital, Istanbul, Turkey
| | - Fethi Gül
- Anesthesiology & Reanimation, and Critical Care, Marmara University Hospital, Istanbul, Turkey
| | - Nazlı Pazar
- Infection Prevention and Control, Marmara University Hospital, Istanbul, Turkey
| | - Gülcan Çulha
- Infection Prevention and Control, Marmara University Hospital, Istanbul, Turkey
| | - Serap Süzük Yıldız
- National Molecular Microbiology Reference Laboratory, Public Health General Directorate, Ankara, Turkey
| | - Ismail Cinel
- Anesthesiology & Reanimation, and Critical Care, Marmara University Hospital, Istanbul, Turkey
| | - Volkan Korten
- Infectious Diseases, and Clinical Microbiology, Marmara University Hospital, Istanbul, Turkey
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Abstract
Bacteria in the Burkholderia cepacia complex (BCC) are significant pathogens for people with cystic fibrosis (CF) and are often extensively antibiotic resistant. Here, we assess the impacts of clinically observed mutations in fixL, which encodes the sensor histidine kinase FixL. FixL along with FixJ compose a two-component system that regulates multiple phenotypes. Mutations in fixL across two species, B. dolosa and B. multivorans, have shown evidence of positive selection during chronic lung infection in CF. Herein, we find that BCC carrying the conserved, ancestral fixL sequence have lower survival in macrophages and in murine pneumonia models than mutants carrying evolved fixL sequences associated with clinical decline in CF patients. In vitro phosphotransfer experiments found that one evolved FixL protein, W439S, has a reduced ability to autophosphorylate and phosphorylate FixJ, while LacZ reporter experiments demonstrate that B. dolosa carrying evolved fixL alleles has reduced fix pathway activity. Interestingly, B. dolosa carrying evolved fixL alleles was less fit in a soil assay than those strains carrying the ancestral allele, demonstrating that increased survival of these variants in macrophages and the murine lung comes at a potential expense in their environmental reservoir. Thus, modulation of the two-component system encoded by fixLJ by point mutations is one mechanism that allows BCC to adapt to the host infection environment.
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Outbreak of Burkholderia contaminans endophthalmitis traced to a clinic ventilation system. Infect Control Hosp Epidemiol 2021; 43:1705-1707. [PMID: 34250879 DOI: 10.1017/ice.2021.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We describe the follow-up investigation of an outbreak of endophthalmitis due to Burkholderia contaminans following cataract surgery in a single clinic. Whole-genome sequence analysis of bacteria recovered from affected patients and the clinic identified the clinic's ventilation system as the source of infection.
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Lind C, Olsen K, Angelsen NK, Krefting EA, Fossen K, Gravningen K, Depoorter E, Vandamme P, Bertelsen G. Clinical course, treatment and visual outcome of an outbreak of Burkholderia contaminans endophthalmitis following cataract surgery. J Ophthalmic Inflamm Infect 2021; 11:12. [PMID: 33870459 PMCID: PMC8053629 DOI: 10.1186/s12348-021-00242-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Background Postoperative endophthalmitis is a rare but dreaded complication of intraocular surgery and often results in severe visual impairment or blindness. The present study describes the clinical course, treatment and visual outcome of an outbreak of Burkholderia contaminans endophthalmitis following cataract surgery. Methods Among 290 patients who underwent uneventful phacoemulsification cataract surgery at one outpatient clinic between January 4th and 28th 2019, 6 cases developed Burkholderia contaminans endophthalmitis. Clinical data were collected by retrospective review of patient records. Microbiological samples from vitreous aspirates, intraocular lenses (IOL) and lens capsules were cultured, and recA and draft whole genome sequences analysed. Results The recA sequences of all Burkholderia contaminans isolates and the allelic profile of the isolates were identical. All cases had a similar clinical presentation with rapid development of endophthalmitis symptoms with variable time to onset. The mean time to admission was 34 days (12–112 days). All cases had a seemingly favourable response to intravitreal antibiotics. However, acute recurrences occurred after long time periods (12–71 days). The cases experienced between 0 and 3 recurrences. Due to persistent infection, the cases received between 5 and 15 treatments (mean 7.8) including IOL and lens capsule explantation in 5 of 6 cases. Burkholderia contaminans was detected in all explanted lens capsules. The final corrected distance visual acuity (CDVA, Snellen chart) was between 0.8 and 1.2 and all cases had final CDVA ≥0.8. Conclusions A persistent and intensive treatment approach including total lens capsule and IOL explantation is recommended for Burkholderia contaminans endophthalmitis following cataract surgery and may lead to a favourable visual result.
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Affiliation(s)
- Caroline Lind
- Department of Ophthalmology, University Hospital of North Norway, Tromsø, Norway
| | - Karina Olsen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway
| | - Nina K Angelsen
- Department of Ophthalmology, University Hospital of North Norway, Tromsø, Norway
| | - Einar A Krefting
- Department of Ophthalmology, University Hospital of North Norway, Tromsø, Norway
| | - Kristian Fossen
- Department of Ophthalmology, University Hospital of North Norway, Tromsø, Norway
| | - Kirsten Gravningen
- Department of Microbiology and Infection Control, University Hospital of North Norway, Tromsø, Norway.,Department of Infection Prevention and Preparedness, Norwegian Institute of Public Health, Oslo, Norway
| | - Eliza Depoorter
- Laboratory of Microbiology, Department of Biochemistry and Microbiology, Ghent University, Ghent, Belgium
| | - Peter Vandamme
- Laboratory of Microbiology, Department of Biochemistry and Microbiology, Ghent University, Ghent, Belgium
| | - Geir Bertelsen
- Department of Ophthalmology, University Hospital of North Norway, Tromsø, Norway. .,Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.
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Rai VK, Neonatology D, Saxena A, Kumar N, Shafi OM, Kumar P. Case 3: Apnea in Preterm Neonates. Neoreviews 2021; 22:e198-e200. [PMID: 33649093 DOI: 10.1542/neo.22-3-e198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | | | | | - Navin Kumar
- Microbiology, Manipal Hospital, Dwarka, New Delhi, India
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Abstract
The regulation and timely expression of bacterial genes during infection is critical for a pathogen to cause an infection. Bacteria have multiple mechanisms to regulate gene expression in response to their environment, one of which is two-component systems (TCS). TCS have two components. One component is a sensory histidine kinase (HK) that autophosphorylates when activated by a signal. The activated sensory histidine kinase then transfers the phosphoryl group to the second component, the response regulator, which activates transcription of target genes. The genus Burkholderia contains members that cause human disease and are often extensively resistant to many antibiotics. The Burkholderia cepacia complex (BCC) can cause severe lung infections in patients with cystic fibrosis (CF) or chronic granulomatous disease (CGD). BCC members have also recently been associated with several outbreaks of bacteremia from contaminated pharmaceutical products. Separate from the BCC is Burkholderia pseudomallei, which is the causative agent of melioidosis, a serious disease that occurs in the tropics, and a potential bioterrorism weapon. Bioinformatic analysis of sequenced Burkholderia isolates predicts that most strains have at least 40 TCS. The vast majority of these TCS are uncharacterized both in terms of the signals that activate them and the genes that are regulated by them. This review will highlight TCS that have been described to play a role in virulence in either the BCC or B. pseudomallei Since many of these TCS are involved in virulence, TCS are potential novel therapeutic targets, and elucidating their function is critical for understanding Burkholderia pathogenesis.
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Fine LS. Non-ventilator health care-associated pneumonia (NV-HAP): Pathogenesis and microbiology of NV-HAP. Am J Infect Control 2020; 48:A7-A9. [PMID: 32331565 DOI: 10.1016/j.ajic.2020.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 03/02/2020] [Indexed: 12/27/2022]
Abstract
Studies demonstrate that those at risk for developing nonventilator associated pneumonia (NV-HAP) include the very young and the very old, as well as persons with compromised immune systems cardiovascular and/or pulmonary disease. This section includes a review of the pathogenesis and microbiology of NV-HAP, including bacterial as well as viral and fungal pathogens. Etiology, modes of transmission, and specific prevention strategies associated with various causative microorganisms are highlighted.
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Burkholderia cepacia Complex Bacteria: a Feared Contamination Risk in Water-Based Pharmaceutical Products. Clin Microbiol Rev 2020; 33:33/3/e00139-19. [PMID: 32295766 DOI: 10.1128/cmr.00139-19] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Becker SL, Berger FK, Feldner SK, Karliova I, Haber M, Mellmann A, Schäfers HJ, Gärtner B. Outbreak of Burkholderia cepacia complex infections associated with contaminated octenidine mouthwash solution, Germany, August to September 2018. ACTA ACUST UNITED AC 2019; 23. [PMID: 30352639 PMCID: PMC6199865 DOI: 10.2807/1560-7917.es.2018.23.42.1800540] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Three German patients developed nosocomial pneumonia after cardiac surgery and had Burkholderia cepacia complex detected in respiratory specimens. Two patients died of septic multi-organ failure. Whole-genome sequencing detected genetically identical B. cepacia complex strains in patient samples, from a batch of octenidine mouthwash solution, which had been used for nursing care, as well as in samples obtained from the manufacturer during production. Contamination of medical products during manufacturing may lead to international outbreaks.
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Affiliation(s)
- Sören L Becker
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Fabian K Berger
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
| | - Susanne K Feldner
- Department of Thoracic and Cardiovascular Surgery, Saarland University, Homburg/Saar, Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University, Homburg/Saar, Germany
| | - Manfred Haber
- Hospital Pharmacy, Saarland University, Homburg/Saar, Germany
| | | | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University, Homburg/Saar, Germany
| | - Barbara Gärtner
- Institute of Medical Microbiology and Hygiene, Saarland University, Homburg/Saar, Germany
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Sfeir MM. Burkholderia cepacia complex infections: More complex than the bacterium name suggest. J Infect 2018; 77:166-170. [DOI: 10.1016/j.jinf.2018.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 07/07/2018] [Accepted: 07/09/2018] [Indexed: 01/23/2023]
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Glowicz J, Crist M, Gould C, Moulton-Meissner H, Noble-Wang J, de Man TJ, Perry KA, Miller Z, Yang WC, Langille S, Ross J, Garcia B, Kim J, Epson E, Black S, Pacilli M, LiPuma JJ, Fagan R. A multistate investigation of health care-associated Burkholderia cepacia complex infections related to liquid docusate sodium contamination, January-October 2016. Am J Infect Control 2018; 46:649-655. [PMID: 29329922 DOI: 10.1016/j.ajic.2017.11.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Outbreaks of health care-associated infections (HAIs) caused by Burkholderia cepacia complex (Bcc) have been associated with medical devices and water-based products. Water is the most common raw ingredient in nonsterile liquid drugs, and the significance of organisms recovered from microbiologic testing during manufacturing is assessed using a risk-based approach. This incident demonstrates that lapses in manufacturing practices and quality control of nonsterile liquid drugs can have serious unintended consequences. METHODS An epidemiologic and laboratory investigation of clusters of Bcc HAIs that occurred among critically ill, hospitalized, adult and pediatric patients was performed between January 1, 2016, and October 31, 2016. RESULTS One hundred and eight case patients with Bcc infections at a variety of body sites were identified in 12 states. Two distinct strains of Bcc were obtained from patient clinical cultures. These strains were found to be indistinguishable or closely related to 2 strains of Bcc obtained from cultures of water used in the production of liquid docusate, and product that had been released to the market by manufacturer X. CONCLUSIONS This investigation highlights the ability of bacteria present in nonsterile, liquid drugs to cause infections or colonization among susceptible patients. Prompt reporting and thorough investigation of potentially related infections may assist public health officials in identifying and removing contaminated products from the market when lapses in manufacturing occur.
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Mali S, Dash L, Gautam V, Shastri J, Kumar S. An Outbreak of Burkholderia cepacia Complex in the Paediatric Unit of a Tertiary Care Hospital. Indian J Med Microbiol 2017; 35:216-220. [DOI: 10.4103/ijmm.ijmm_16_258] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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An Outbreak of Burkholderia cepacia Complex Infections Associated with Contaminated Liquid Docusate. Infect Control Hosp Epidemiol 2017; 38:567-573. [PMID: 28166854 DOI: 10.1017/ice.2017.11] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate an outbreak of Burkholderia cepacia complex and describe the measures that revealed the source. SETTING A 629-bed, tertiary-care, pediatric hospital in Houston, Texas. PATIENTS Pediatric patients without cystic fibrosis (CF) hospitalized in the pediatric and cardiovascular intensive care units. METHODS We investigated an outbreak of B. cepacia complex from February through July 2016. Isolates were evaluated for molecular relatedness with repetitive extragenic palindromic polymerase chain reaction (rep-PCR); specific species identification and genotyping were performed at an independent laboratory. The investigation included a detailed review of all cases, direct observation of clinical practices, and respiratory surveillance cultures. Environmental and product cultures were performed at an accredited reference environmental microbiology laboratory. RESULTS Overall, 18 respiratory tract cultures, 5 blood cultures, 4 urine cultures, and 3 stool cultures were positive in 24 patients. Among the 24 patients, 17 had symptomatic infections and 7 were colonized. The median age of the patients was 22.5 months (range, 2-148 months). Rep-PCR typing showed that 21 of 24 cases represented the same strain, which was identified as a novel species within the B. cepacia complex. Product cultures of liquid docusate were positive with an identical strain of B. cepacia complex. Local and state health departments, as well as the CDC and FDA, were notified, prompting a multistate investigation. CONCLUSIONS Our investigation revealed an outbreak of a unique strain of B. cepacia complex isolated in clinical specimens from non-CF pediatric patients and from liquid docusate. This resulted in a national alert and voluntary recall by the manufacturer. Infect Control Hosp Epidemiol 2017;38:567-573.
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Ahn Y, Kim JM, Kweon O, Kim SJ, Jones RC, Woodling K, Gamboa da Costa G, LiPuma JJ, Hussong D, Marasa BS, Cerniglia CE. Intrinsic Resistance of Burkholderia cepacia Complex to Benzalkonium Chloride. mBio 2016; 7:e01716-16. [PMID: 27879334 PMCID: PMC5120141 DOI: 10.1128/mbio.01716-16] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/26/2016] [Indexed: 12/16/2022] Open
Abstract
Pharmaceutical products that are contaminated with Burkholderia cepacia complex (BCC) bacteria may pose serious consequences to vulnerable patients. Benzyldimethylalkylammonium chloride (BZK) cationic surfactants are extensively used in medical applications and have been implicated in the coselection of antimicrobial resistance. The ability of BCC to degrade BZK, tetradecyldimethylbenzylammonium chloride (C14BDMA-Cl), dodecyldimethylbenzylammonium chloride (C12BDMA-Cl), decyldimethylbenzylammonium chloride (C10BDMA-Cl), hexyldimethylbenzylammonium chloride, and benzyltrimethylammonium chloride was determined by incubation in 1/10-diluted tryptic soy broth (TSB) to determine if BCC bacteria have the ability to survive and inactivate these disinfectants. With BZK, C14BDMA-Cl, and C12BDMA-Cl, inhibition of the growth of 20 BCC strains was observed in disinfectant solutions that ranged from 64 to 256 µg/ml. The efflux pump inhibitor carbonyl cyanide m-chlorophenylhydrazone increased the sensitivity of bacteria to 64 µg/ml BZK. The 20 BCC strains grew well in 1/10-diluted TSB medium with BZK, C12BDMA-Cl, and C10BDMA-Cl; they absorbed and degraded the compounds in 7 days. Formation of benzyldimethylamine and benzylmethylamine as the initial metabolites suggested that the cleavage of the C alkyl-N bond occurred as the first step of BZK degradation by BCC bacteria. Proteomic data confirmed the observed efflux activity and metabolic inactivation via biodegradation in terms of BZK resistance of BCC bacteria, which suggests that the two main resistance mechanisms are intrinsic and widespread. IMPORTANCE Benzyldimethylalkylammonium chloride is commonly used as an antiseptic in the United States. Several recent microbial outbreaks were linked to antiseptics that were found to contain strains of the Burkholderia cepacia complex. Burkholderia species survived in antiseptics, possibly because of the degradation of antiseptic molecules or regulation of relevant gene expression. In this study, we assessed the efflux pump and the potential of B. cepacia complex bacteria to degrade benzyldimethylalkylammonium chloride and improved our understanding of the resistance mechanisms, by using proteomic and metabolic information. To our knowledge, this is the first systematic report of the intrinsic mechanisms of B. cepacia complex strain resistance to benzyldimethylalkylammonium chloride, based on the metabolic and proteomic evidence for efflux pumps and the complete biodegradation of benzyldimethylalkylammonium chloride.
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Affiliation(s)
- Youngbeom Ahn
- Division of Microbiology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Jeong Myeong Kim
- Division of Microbiology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Ohgew Kweon
- Division of Microbiology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Seong-Jae Kim
- Division of Microbiology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | | | - Kellie Woodling
- Division of Biochemical Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - Gonçalo Gamboa da Costa
- Division of Biochemical Toxicology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
| | - John J LiPuma
- Department of Pediatrics & Communicable Diseases, University of Michigan, Ann Arbor, Michigan, USA
| | - David Hussong
- Office of Pharmaceutical Science, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bernard S Marasa
- Division of Microbiology Assessment, Office of Pharmaceutical Quality, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Carl E Cerniglia
- Division of Microbiology, National Center for Toxicological Research, U.S. Food and Drug Administration, Jefferson, Arkansas, USA
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Karanth SS, Regunath H, Chawla K, Prabhu M. A rare case of community acquired Burkholderia cepacia infection presenting as pyopneumothorax in an immunocompetent individual. Asian Pac J Trop Biomed 2015; 2:166-8. [PMID: 23569891 DOI: 10.1016/s2221-1691(11)60215-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Revised: 08/03/2011] [Accepted: 08/28/2011] [Indexed: 11/16/2022] Open
Abstract
Burkholderia cepacia (B. cepacia) infection is rarely reported in an immunocompetent host. It is a well known occurence in patients with cystic fibrosis and chronic granulomatous disease where it increases both morbidity and mortality. It has also been included in the list of organisms causing nosocomial infections in an immunocompetent host, most of them transmitted from the immunocompromised patient in which this organism harbors. We report a rare case of isolation of B. cepacia from the bronchoalveolar lavage fluid of an immunocompetent agriculturist who presented with productive cough and fever associated with a pyopneumothorax. This is the first case of community acquired infection reported in an immunocompetent person in India.
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Dolan SA, Littlehorn C, Glodé MP, Dowell E, Xavier K, Nyquist AC, Todd JK. Association ofBacillus cereusInfection with Contaminated Alcohol Prep Pads. Infect Control Hosp Epidemiol 2015; 33:666-71. [DOI: 10.1086/666334] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Background.Bacillusspecies have caused healthcare-associated outbreaks of invasive disease as well as pseudo-outbreaks. We report an outbreak investigation of blood cultures positive forBacillus cereusassociated with alcohol prep pads (APPs) contaminated withB. cereusandBacillusspecies resulting in a rapid internal product recall and subsequent international product recall.Design.Epidemiologic and microbiologic outbreak investigation.Setting.A 300-bed tertiary care children's hospital in Aurora, Colorado.Patients.Patients with blood or cerebrospinal fluid cultures positive forB. cereus.Methods.Three patients with blood cultures positive forB. cereuswere identified in late 2010. Breaches in procedural and surgical techniques, common interventions, and products were explored. The following 3 common products were cultured: sterile saline syringes, chlorhexidine/alcohol skin preparation solution, and APPs. Repetitive sequence-based polymerase chain reaction (Rep-PCR) was used to compare isolates obtained from patients and from APPs and was confirmed by independent pulsed-field gel electrophoresis.Results.There appeared to be a significant increase in blood cultures positive forB. cereusduring 2009-2010.B. cereusand otherBacillusspecies were cultured from the internal contents of 63.3% of APPs not labeled as sterile, and 8 of the 10 positive lots were manufactured after 2007. None of the isolates obtained from the patients matched strains isolated from the APPs. However, some lots of APPs had strains that were indistinguishable from one another.Conclusions.APPs that were not labeled as sterile were contaminated withBacillusspecies. The product was immediately recalled internally and replaced with APPs from another manufacturer that were labeled as sterile. On January 3, 2011, the manufacturer voluntarily recalled its APPs. Healthcare facilities, healthcare providers, and users of APPs should avoid the use of APPs not specifically labeled as sterile.
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Ottaviano G, Staffieri C, Favaretto N, Fasanaro E, Abate D, de Filippis C, Staffieri A, Marioni G. Burkholderia cepacia complex isolation in non-polypoid chronic rhinosinusitis. Am J Otolaryngol 2014; 35:598-602. [PMID: 24976594 DOI: 10.1016/j.amjoto.2014.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/12/2014] [Indexed: 01/26/2023]
Abstract
PURPOSE Burkholderia cepacia complex (Bcc) infections of the head and neck have been infrequently reported in immunocompetent patients, while their association with cystic fibrosis is quite well known. One of the main problems associated with Bcc is their intrinsic resistance to most clinically-available antimicrobials. Bcc has already been isolated in sinonasal polyposis, while here we report for the first time on its isolation in patients with chronic rhinosinusitis (CRS) but no nasal polyposis. MATERIALS AND METHODS Thirty-four consecutive surgically-treated CRS patients without cystic fibrosis were recruited. RESULTS Bcc was isolated in 4 cases of CRS without polyposis, and in another case in sinonasal polyposis. All tested Bcc strains isolated in non-polypotic CRS were resistant to ciprofloxacin, amikacin, ertapenem, amoxicillin/clavulanate, cefotaxime, and gentamicin. CONCLUSIONS The novel finding of Bcc species in CRS without polyposis as well suggests that the mechanism by which these bacteria adhere to the epithelium of the upper respiratory tract may be important in the host's colonization.
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Peterson AE, Chitnis AS, Xiang N, Scaletta JM, Geist R, Schwartz J, DeMent J, Lawlor E, LiPuma JJ, O'Connell H, Noble-Wang J, Kallen AJ, Hunt DC. Clonally related Burkholderia contaminans among ventilated patients without cystic fibrosis. Am J Infect Control 2013; 41:1298-300. [PMID: 23973426 DOI: 10.1016/j.ajic.2013.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 10/26/2022]
Abstract
We investigated a cluster of 10 Burkholderia cepacia complex-positive cultures among ventilated patients and those with a tracheostomy in an acute care hospital. Isolates from 5 patients had outbreak-strain-related Burkholderia contaminans. Isolates of B. cepacia complex unrelated to the outbreak strain were cultured from a sink drain. The investigation identified practices that might have led to contamination of patient respiratory care supplies with tap water, which might have contributed to the cluster.
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Papp-Wallace KM, Taracila MA, Gatta JA, Ohuchi N, Bonomo RA, Nukaga M. Insights into β-lactamases from Burkholderia species, two phylogenetically related yet distinct resistance determinants. J Biol Chem 2013; 288:19090-102. [PMID: 23658015 DOI: 10.1074/jbc.m113.458315] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Burkholderia cepacia complex and Burkholderia pseudomallei are opportunistic human pathogens. Resistance to β-lactams among Burkholderia spp. is attributable to expression of β-lactamases (e.g. PenA in B. cepacia complex and PenI in B. pseudomallei). Phylogenetic comparisons reveal that PenA and PenI are highly related. However, the analyses presented here reveal that PenA is an inhibitor-resistant carbapenemase, most similar to KPC-2 (the most clinically significant serine carbapenemase), whereas PenI is an extended spectrum β-lactamase. PenA hydrolyzes β-lactams with k(cat) values ranging from 0.38 ± 0.04 to 460 ± 46 s(-1) and possesses high k(cat)/k(inact) values of 2000, 1500, and 75 for β-lactamase inhibitors. PenI demonstrates the highest kcat value for cefotaxime of 9.0 ± 0.9 s(-1). Crystal structure determination of PenA and PenI reveals important differences that aid in understanding their contrasting phenotypes. Changes in the positioning of conserved catalytic residues (e.g. Lys-73, Ser-130, and Tyr-105) as well as altered anchoring and decreased occupancy of the deacylation water explain the lower k(cat) values of PenI. The crystal structure of PenA with imipenem docked into the active site suggests why this carbapenem is hydrolyzed and the important role of Arg-220, which was functionally confirmed by mutagenesis and biochemical characterization. Conversely, the conformation of Tyr-105 hindered docking of imipenem into the active site of PenI. The structural and biochemical analyses of PenA and PenI provide key insights into the hydrolytic mechanisms of β-lactamases, which can lead to the rational design of novel agents against these pathogens.
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Affiliation(s)
- Krisztina M Papp-Wallace
- Research Service, Louis Stokes Cleveland Department of Veterans Affairs, Cleveland, Ohio 44106, USA
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Dursun A, Zenciroglu A, Karagol BS, Hakan N, Okumus N, Gol N, Tanir G. Burkholderia gladioli sepsis in newborns. Eur J Pediatr 2012; 171:1503-9. [PMID: 22648018 DOI: 10.1007/s00431-012-1756-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 05/08/2012] [Indexed: 12/16/2022]
Abstract
UNLABELLED Burkholderia gladioli is a rare cause of bacteremia and sepsis in the absence of such predisposing factors as chronic granulomatous disease, cystic fibrosis, and immunosuppression. Little is known about B. gladioli infection in newborns. The aim of this study was to present the features of B. gladioli infection in newborns. Clinicopathological characteristics, patterns of antimicrobial susceptibility, predisposing factors, and outcomes of B. gladioli bloodstream infection were retrospectively analyzed in newborns treated between 2008 and 2011. During the 3-year study period, B. gladioli was isolated from the blood cultures of 14 patients (3.7 per 1,000 admissions). In all, 5 (35.7 %) of the 14 cases had a positive blood culture at the time of initial admission. Primary diagnoses in the neonates were severe major congenital anomalies, congenital leukemia, prematurity with respiratory distress syndrome, pneumonia, and parapneumonic pleural effusion. In total, 10 (71.4 %) of the patients underwent ≥2 invasive procedures. The overall in-hospital mortality rate was 21.4 %, whereas the mortality rate due to B. gladioli infection was 7 %. CONCLUSION B. gladioli might be a causative microorganism of both early neonatal and nosocomial sepsis in newborns. To the best of our knowledge, this is the first study on B. gladioli infection in newborns. Invasive procedures and severe major congenital anomalies may be predisposing factors for B. gladioli bloodstream infection in neonates. Although it appears to have low pathogenic potential and an insidious clinical course in newborns, resistance to antibiotics may be a potential problem. Mortality was primarily associated with underlying diseases.
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Affiliation(s)
- Arzu Dursun
- Department of Neonatology, Dr. Sami Ulus Maternity and Children's Health and Diseases Training and Research Hospital, Ankara, Turkey.
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Oie S, Arakawa J, Furukawa H, Matsumoto S, Matsuda N, Wakamatsu H. Microbial contamination of a disinfectant-soaked unwoven cleaning cloth. J Hosp Infect 2012; 82:61-3. [DOI: 10.1016/j.jhin.2012.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 06/08/2012] [Indexed: 10/28/2022]
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Affiliation(s)
- Evonne T Curran
- Health Protection Scotland, NHS National Services Scotland, Glasgow, UK
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