Multistate Outbreak of Burkholderia cepacia Complex Bloodstream Infections After Exposure to Contaminated Saline Flush Syringes: United States, 2016-2017

Outbreak of Burkholderia cenocepacia in an intensive care unit of a tertiary care hospital identified by pulsed-field gel electrophoresis

Nosocomial outbreaks of Burkholderia cepacia complex, transmitted through contaminated medical surfaces or equipment have been reported. Pulsed-field Gel Electrophoresis (PFGE) is recognized as the "gold standard" for molecular subtyping, yet studies on clonal relationships in India are limited. PFGE was used to study the clonal relationships of 22 isolates of Burkholderia cenocepacia from 12 patients admitted to a critical care unit during 2 months (November and December 2021). PFGE revealed three different profiles with 15 isolates belonging to a single cluster suggesting a common source within the hospital, emphasizing the need for preventive measures to control B. cenocepacia transmission.

Construction of a postoperative infection outbreak investigation form: A tool for early detection and control measures

BACKGROUND

To develop an investigation form for postoperative infection outbreak (PIO), and to identify sources of the outbreak in the early stage.

METHODS

After an exhaustive literature review, we used the Delphi method to determine the indicators and relative risk scores of the assessment tools through 2 rounds of specialist consultation and overall consideration of the opinions and suggestions of 20 specialists.

RESULTS

A total of 203 studies of PIO were eligible for inclusion. The mean authority coefficient (Cr) was 0.87. Kendall's W coefficient of the specialist consultation was 0.704 after 2 rounds of consultation (P < .005), suggesting that the specialists had similar opinions. Based on 4 primary items and 19 secondary items of the source of PIO, and tripartite distribution characteristics of infected patients, we constructed the PIO investigation form.

CONCLUSIONS

The PIO investigation form can be used in the investigation of the early-stage cluster of cases, it's a prerequisite for taking effective control measures, avoiding PIO occurrence. However, the effect of the investigation form needs to be further evaluated.

An outbreak of Burkholderia contaminans at a quaternary children's hospital linked to equipment reprocessing

Burkholderia cepacia complex (BCC) has been increasingly implicated in local and multistate outbreaks in both adult and pediatric healthcare settings. However, a lack of source identification may be common for BCC outbreak investigations. We describe, in detail, the investigation of an outbreak of BCC (B. contaminans) among pediatric patients at a large quaternary-care children's hospital and our system-level changes and outcomes.

Burkholderia cepacia-contaminated dentures possibly cause pneumonia

We report a case in which a patient was suspected of developing pneumonia due to wearing dentures that were immersed in a storage solution contaminated with 3.0 × 10⁸ colony-forming units (cfu)/mL of Burkholderia cepacia. It is highly possible that the contaminated denture solution entered the trachea and caused the pneumonia, possibly due to the prolonged supine positioning of the patient. We demonstrated that B. cepacia isolated from the sputum and B. cepacia isolated from the denture storage solution had the same DNA fingerprint, and that the patient recovered from pneumonia after stopping the use of dentures. These findings suggest the storage solution as the main source of infection.

Multivalent Fucosides Targeting β-Propeller Lectins from Lung Pathogens with Promising Anti-Adhesive Properties

Fungal and bacterial pathogens causing lung infections often use lectins to mediate adhesion to glycoconjugates at the surface of host tissues. Given the rapid emergence of resistance to the treatments in current use, β-propeller lectins such as FleA from Aspergillus fumigatus, SapL1 from Scedosporium apiospermum, and BambL from Burkholderia ambifaria have become appealing targets for the design of anti-adhesive agents. In search of novel and cheap anti-infectious agents, we synthesized multivalent compounds that can display up to 20 units of fucose, the natural ligand. We obtained nanomolar inhibitors that are several orders of magnitude stronger than their monovalent analogue according to several biophysical techniques (i.e., fluorescence polarization, isothermal titration calorimetry, and bio-layer interferometry). The reason for high affinity might be attributed to a strong aggregating mechanism, which was examined by analytical ultracentrifugation. Notably, the fucosylated inhibitors reduced the adhesion of A. fumigatus spores to lung epithelial cells when administered 1 h before or after the infection of human lung epithelial cells. For this reason, we propose them as promising anti-adhesive drugs for the prevention and treatment of aspergillosis and related microbial lung infections.

Fungal Endophthalmitis Outbreak after Cataract Surgery, South Korea, 2020

In November 2020, an unusual increase in fungal endophthalmitis cases after cataract surgery was reported to the Korea Disease Control and Prevention Agency, South Korea. We initiated an outbreak investigation to identify the cause. We identified 156 cases nationwide, 62 confirmed and 94 probable. Most case-patients were exposed during surgery to ocular viscoelastic devices (OVDs) from the same manufacturer (company A). We isolated Fusarium spp. from 50 confirmed cases. Molecular identification of 39 fungal isolates from clinical samples and 13 isolates from OVDs confirmed F. oxysporum caused the infections. The risk ratio for fungal endophthalmitis from company A’s OVDs was 86.0 (95% CI 27.4–256.9), much higher than risk from other manufacturers’ products. We determined this fungal endophthalmitis outbreak was caused by a contaminated lot of OVDs and recommended discontinued use of this product. Early recognition of outbreaks and joint responses from related government agencies can reduce risk for fungal endophthalmitis.

Combined clinical, epidemiological and genome-based analysis identified a nationwide outbreak of Burkholderia cepacia complex infections caused by contaminated mouthwash solutions

Background

In September 2018, Burkholderia cepacia complex (BCC) infections in 3 patients associated with exposure to a mouthwash solution (MWS) were reported to the Robert Koch Institute (RKI). As the product was still on the market and the scale of the outbreak was unclear, a nation-wide investigation was initiated.

Methods

We aimed to investigate BCC infections/colonizations associated with MWS. Hospitals, laboratories, and public health services were informed that BCC isolates should be sent to the RKI. These isolates were typed by pulsed-field gel electrophoresis (PFGE) and whole-genome sequencing (WGS) including development of an ad hoc core genome MLST (cgMLST) scheme.

Results

In total, 36 patients from 6 hospitals met the case definition, the last patient in November 2018. Twenty-nine isolates from 26 of these patients were available for typing. WGS analysis revealed 2 distinct cgMLST clusters. Cluster 1 (Burkholderia arboris) contained isolates from patients and MWS obtained from 4 hospitals and isolates provided by the manufacturer. Patient and MWS isolates from another hospital were assigned to cluster 2 (B. cepacia).

Conclusions

The combined clinical, epidemiological, and microbiological investigation, including whole-genome analysis, allowed for uncovering a supraregional BCC outbreak in health care settings. Strains of B. arboris and B. cepacia were identified as contaminating species of MWS bottles and subsequent colonization and putative infection of patients in several hospitals. Despite a recall of the product by the manufacturer in August 2018, the outbreak lasted until December 2018. Reporting of contaminated medical products and recalls should be optimized to protect patients.

An intermittent outbreak of Burkholderia cepacia contaminating hematopoietic stem cells resulting in infusate-related blood stream infections

Microbial contamination of hematopoietic stem cells (HSC), used for autologous and allogenic transplantations, is rare but could cause serious blood stream infection in transplanted patients. These infections occur immediately, or later following the formation of biofilm on the catheter lumen. The present study describes an intermittent B. cepacia HSC contamination associated with nosocomial bacteremia: from October 2011 to April 2015, 17 B. cepacia strains were isolated in HSC bags (n = 14) and blood cultures (n = 3) in patients hospitalized in the National Bone Marrow Transplant Center. Two epidemiologic investigations in the National Blood Transfusion Center, allowing the isolation of three strains in hygiene samples, and four interventions in this institution were done. To identify the source of this contamination, a molecular investigation was done on 23 B. cepacia strains isolated in our center from 2007 to 2015. PFGE analysis revealed five clusters. The major cluster included 18 strains isolated from HSC bags (n = 14), blood culture (n = 1), and water cans and bath (n = 3). The second cluster (B) including only two and the remaining clusters (C, D, and E) contained single strains isolated before the epidemic period. These findings confirmed that the origin of the outbreak was the contaminated water used in the water bath during the thawing step of HSC bags. Based on this result, new sterile water was used for every defrosting, but HSC bags contamination persisted. In May 2015, the water bath was replaced with a dry bath and no B. cepacia strain was isolated from that date to April 2020.

A pseudo-outbreak of Burkholderia cepacia complex in a Kentucky hospital

A cluster of Burkholderia cepacia complex cases from January to October 2020 among outpatients undergoing urologic procedures within a Kentucky hospital's operating rooms was investigated. This investigation included a laboratory look-back, chart reviews, exposure tracing, staff interviews, and direct observation of infection prevention and control practices. A significant protocol breach in a laboratory procedure led to contamination of surgical specimens submitted for culture with nonsterile saline. Pseudo-outbreaks often highlight gaps in infection control processes. Healthcare facilities can make substantial improvements in patient care quality and safety as they respond to identified gaps and improve systems and protocols.

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.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Ocular Infections

The variety and complexity of ocular infections have increased significantly in the last decade since the publication of Cumitech 13B, Laboratory Diagnosis of Ocular Infections (L. D. Gray, P. H. Gilligan, and W. C. Fowler, Cumitech 13B, Laboratory Diagnosis of Ocular Infections, 2010). The purpose of this practical guidance document is to review, for individuals working in clinical microbiology laboratories, current tools used in the laboratory diagnosis of ocular infections. This document begins by describing the complex, delicate anatomy of the eye, which often leads to limitations in specimen quantity, requiring a close working bond between laboratorians and ophthalmologists to ensure high-quality diagnostic care. Descriptions are provided of common ocular infections in developed nations and neglected ocular infections seen in developing nations. Subsequently, preanalytic, analytic, and postanalytic aspects of laboratory diagnosis and antimicrobial susceptibility testing are explored in depth.

Diagnostic methods and identification challenges experienced in a Burkholderia contaminans outbreak occurred in a tertiary care centre

BACKGROUND

Recently, a novel species contaminans belonging to the family Burkholderia cepacia complex (Bcc) is rising as a hospital pathogen. Detection of Burkholderia contaminans, a member of Bcc can be done only by MALDI TOF and sequencing techniques. We report the diagnostic challenges faced in an outbreak of bacteremia due to B. contaminans grown in diltiazem vials.

METHOD

The department of microbiology notified the infection control team about a cluster of eleven patients with B. contaminans isolated from blood culture. An outbreak investigation was initiated by performing environmental surveillance and sterility testing of solutions given for the patients. Routine phenotypical methods for identification of species followed by MALDI-TOF and sequencing was performed to identify the pathogen.

RESULTS

All the patients detected with B. contaminans were having cardiac disease and received diltiazem. Sterility testing of diltiazem vials given for the patient and an unopened vial of same batch has grown B. contaminans. Clonal typing has confirmed the sequence similarities between patient and solution isolates.

CONCLUSION

Due to diagnostic challenge in identifying the species of Bcc, MALDI TOF and clonal typing remains the key diagnostic tools available to detect Bcc species at an earliest especially in an outbreak.

Nosocomial Infections: A History of Hospital-Acquired Infections

In the United States, healthcare acquired infections (HAIs) or nosocomial infections are the sixth leading cause of death. This article reviews the history, prevalence, economic costs, morbidity and mortality, and risk factors associated with HAIs. Types of infections described include bacterial, fungal, viral, and multidrug resistant infections that contribute to the most common causes of HAIs, which include catheter- associated urinary tract infections, hospital-acquired pneumonias, bloodstream infections, and surgical site infections. Most nosocomial infections are preventable and monitoring and prevention strategies are described.

Polyclonal Burkholderia cepacia Complex Outbreak in Peritoneal Dialysis Patients Caused by Contaminated Aqueous Chlorhexidine

Whether Burkholderia cepacia complex should be an objectionable organism in antiseptic solutions with acceptable total bacterial counts is controversial. By using next-generation sequencing, we documented a polyclonal B. cepacia complex outbreak affecting peritoneal dialysis patients in Hong Kong that was caused by contaminated chlorhexidine solutions. Epidemiologic investigations at a manufacturing site identified a semiautomated packaging machine as the probable source of contamination in some of the brands. Use of whole-genome sequencing differentiated the isolates into 3 brand-specific clonal types. Changes in exit site care recommendations, rapid recall of affected products, and tightening of regulatory control for chlorhexidine-containing skin antiseptics could prevent future similar outbreaks. Environmental opportunistic pathogens, including B. cepacia complex, might be included in regular surveillance as indicator organisms for monitoring environmental contamination.

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.

Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017

OBJECTIVE

Water exposures in healthcare settings and during healthcare delivery can place patients at risk for infection with water-related organisms and can potentially lead to outbreaks. We aimed to describe Centers for Disease Control and Prevention (CDC) consultations involving water-related organisms leading to healthcare-associated infections (HAIs).

DESIGN

Retrospective observational study.

METHODS

We reviewed internal CDC records from January 1, 2014, through December 31, 2017, using water-related terms and organisms, excluding Legionella, to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare. We determined plausible exposure pathways and routes of transmission when possible.

RESULTS

Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, that involved the investigation of potential water-related HAIs or infection control lapses with the potential for water-related HAIs. Nontuberculous mycobacteria were involved in the greatest number of investigations (n = 40, 29.9%). Most frequently, investigations involved medical products (n = 48, 35.8%), and most of these products were medical devices (n = 40, 83.3%). We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices.

CONCLUSIONS

Water-related investigations represent a substantial proportion of CDC HAI consultations and likely represent only a fraction of all water-related HAI investigations and outbreaks occurring in US healthcare facilities. Water-related HAI investigations should consider all potential pathways of water exposure. Finally, healthcare facilities should develop and implement water management programs to limit the growth and spread of water-related organisms.