Moisturizing body milk as a reservoir of Burkholderia cepacia: outbreak of nosocomial infection in a multidisciplinary intensive care unit

Burkholderia cepacia cervical spondylodiscitis in a 39-year-old immunocompetent woman after a rhinoplasty: A case report and review of literature

Background

Burkholderia cepacia has been described as a rare etiology for spondylodiscitis (SD) after surgical procedures.

Case Description

We report a rare case of cervical SD caused by B. cepacia in a 39-year-old immunocompetent woman after a rhinoplasty treated with complex cervical surgery and prolonged antibiotic therapy. The follow-up visits showed no recurrence of symptoms.

Conclusion

Diagnostic and therapeutic of rare spinal infections, particularly those caused by atypical pathogens such as B. cepacia, are challenging. Identification and personalized therapy are crucial.

A culture-independent nucleic acid diagnostics method for use in the detection and quantification of Burkholderia cepacia complex contamination in aqueous finished pharmaceutical products

The Burkholderia cepacia complex (Bcc) is the number one bacterial complex associated with contaminated Finished Pharmaceutical Products (FPPs). This has resulted in multiple healthcare related infection morbidity and mortality events in conjunction with significant FPP recalls globally. Current microbiological quality control of FPPs before release for distribution depends on lengthy, laborious, non-specific, traditional culture-dependent methods which lack sensitivity. Here, we present the development of a culture-independent Bcc Nucleic Acid Diagnostic (NAD) method for detecting Bcc contaminants associated with Over-The-Counter aqueous FPPs. The culture-independent Bcc NAD method was validated to be specific for detecting Bcc at different contamination levels from spiked aqueous FPPs. The accuracy in Bcc quantitative measurements was achieved by the high degree of Bcc recovery from aqueous FPPs. The low variation observed between several repeated Bcc quantitative measurements further demonstrated the precision of Bcc quantification in FPPs. The robustness of the culture-independent Bcc NAD method was determined when its accuracy and precision were not significantly affected during testing of numerous aqueous FPP types with different ingredient matrices, antimicrobial preservative components and routes of administration. The culture-independent Bcc NAD method showed an ability to detect Bcc in spiked aqueous FPPs at a concentration of 20 Bcc CFU/mL. The rapid (≤ 4 hours from sample in to result out), robust, culture-independent Bcc NAD method presented provides rigorous test specificity, accuracy, precision, and sensitivity. This method, validated with equivalence to ISO standard ISO/TS 12869:2019, can be a valuable diagnostic tool in supporting microbiological quality control procedures to aid the pharmaceutical industry in preventing Bcc contamination of aqueous FPPs for consumer safety.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Real-time qPCR to evaluate bacterial contamination of cosmetic cream and the efficiency of protective ingredients

AIMS

The absence of objectionable micro-organisms in cosmetics and the efficiency of preservatives are still mainly assessed by time-consuming cultivation-based methods. We explored the applicability of real-time quantitative polymerase chain reaction (qPCR) and reported on the behaviour of different bacteria in artificially contaminated creams.

METHODS AND RESULTS

Real-time qPCR on DNA from Burkholderia cepacia, Pluribacter gergoviae, Pseudomonas aeruginosa and Sphingomonas paucimobilis identified specific primer pairs that amplify accurately and efficiently two strains/isolates of each species. Using DNeasy mericon Food Kit, we detected bacterial growth in an inoculated cosmetic cream and persistency of DNA from heat-inactivated bacteria. We were also able to monitor the growth inhibitory effect of caprylyl glycol and EDTA, also showing how different bacterial species interact depending on the presence/absence of these ingredients. Finally, creams supplemented with the protective cosmetic ingredients revealed the various behaviour of five strains/isolates from P. aeruginosa.

CONCLUSIONS

Successfully extracting bacterial DNA from artificially contaminated cosmetic creams, we could perform real-time qPCR to identify and follow the growth of various strains of 4 bacteria species under different conditions.

SIGNIFICANCE AND IMPACT OF THE STUDY

Real-time qPCR appears as a promising method to detect bacterial contamination in cosmetic creams and/or to monitor growth inhibition by ingredients.

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.

In vitro study to evaluate the antimicrobial activity of various multifunctional cosmetic ingredients and chlorphenesin on bacterial species at risk in the cosmetic industry

AIMS

We evaluated the activity of the preservative chlorphenesin and of four antimicrobial cosmetic multifunctional ingredients against various strains of gram-negative and gram-positive human opportunistic pathogens.

METHODS AND RESULTS

Growth kinetics, modelling growth parameters and statistical analyses enabled comparing bacterial behaviour in the presence and in the absence of the compound. Whatever compound tested (i.e. chlorphenesin, phenylpropanol, hexanediol, ethylhexylglycerin, hydroxyacetophenone) and strain origin (i.e. clinical versus industrial), the growth of 42 strains belonging to Acinetobacter spp., Burkholderia cepacia complex and Stenotrophomonas maltophilia, was totally inhibited. On the opposite all of the P. aeruginosa strains (n = 13) as well as 4 and 6 out of 10 strains of Pluralibacter gergoviae grew in the presence of chlorphenesin and ethylhexylglycerin, respectively. Some P. gergoviae and Staphylococcus hominis strains withstand hydroxyacetophenone. Within a species, the different strains show variable latency phase, growth rate (r) and carrying capacity (K). They can be similar, lower or higher than those measured in control conditions.

CONCLUSIONS

Data showed differences in the antimicrobial activity of compounds. Upon exposure, strains differed in their behaviour between and within species. Whatever species and strains, compound sensitivity could not be related to antibiotic resistance.

SIGNIFICANCE AND IMPACT OF THE STUDY

Most multifunctional ingredients showed significant antimicrobial properties against the wide panel of species and strains evaluated. This will help adjusting preservation strategies in the cosmetic industry.

The Use of Catalytic Amounts of Selected Cationic Surfactants in the Design of New Synergistic Preservative Solutions

Preservation using combinations of antibacterial molecules has several advantages, such as reducing the level of usage and broadening their antimicrobial spectrum. More specifically, the use of quaternary ammonium surfactants (QAS)—which are profusely used in hair care products and some are known as efficient antimicrobial agents—is limited due to some potential cytotoxicity concerns. This study shows that the concentration of some widely used cosmetic preservatives can be decreased when combined with very small quantities of QAS, i.e., Polyquaternium-80 (P-80) and/or Didecyldimethylammonium chloride (DDAC). The antimicrobial activity of their mixtures was first evaluated by determining the minimum inhibitory concentration (MIC) before and after the addition of QAS. Following up on this finding and targeting an ultimate consumer friendly antimicrobial blend, yet with optimal safety, we chose to utilize the food-grade preservative Maltol as the main natural origin antimicrobial agent mixed with minimum concentrations of QAS to improve its moderate antimicrobial properties. The preservatives were tested for MIC values, challenge tests and synergy using the fractional inhibitory concentration index (FICI). The antimicrobial efficacy of Maltol was found to be synergistically improved by introducing catalytic amounts of P-80 and/or DDAC.

Distribution of Burkholderia cepacia complex species isolated from industrial processes and contaminated products in Argentina

Burkholderia cepacia complex (Bcc) members have clinical relevance as opportunistic pathogens in patients with cystic fibrosis and are responsible of numerous nosocomial infections. These closely related bacteria are also reported as frequent contaminants of industrial products. In this retrospective study, we use PCR and recA gene sequence analysis to identify at species level Bcc isolates recovered from massive consumption products and industrial processes in Argentina during the last 25 years. The sequences obtained were also compared with recA sequences from clinical Bcc isolates deposited in GenBank database. We detected Bcc in purified water and preserved products from pharmaceutics, cosmetics, household cleaning articles, and beverages industries. B. contaminans (which is prevalent among people with cystic fibrosis in Argentina) was the most frequent Bcc species identified (42% of the Bcc isolates studied). B. cepacia (10%), B. cenocepacia (5%), B. vietnamiensis (16%), B. arboris (3%), and the recently defined B. aenigmatica (24%) were also detected. Rec A sequences from all B. cepacia and most B. contaminans industrial isolates obtained in this study displayed 100% identity with recA sequences from isolates infecting Argentinean patients. This information brings evidence for considering industrial massive consumption products as a potential source of Bcc infections. In addition, identification at species level in industrial microbiological laboratories is necessary for a better epidemiological surveillance. Particularly in Argentina, more studies are required in order to reveal the role of these products in the acquisition of B. contaminans infections.

Consecutive outbreaks of Burkholderia cepacia complex caused by intrinsically contaminated chlorhexidine mouthwashes

BACKGROUND

We report 2 consecutive outbreaks of the Burkholderia cepacia complex (Bcc) in an intensive care unit (ICU) and describe its characteristics and consequences.

METHODS

Over a 72-day period, a multidisciplinary ICU team detected 2 distinct periods of high and unusual incidence of Bcc isolates that were recovered from cultures of endotracheal aspirate. Cultures of tap water, ultrasound gel and mouthwash (opened and unopened bottles) were performed. Bcc was identified with the BD-Phoenix and MALDI-TOF MS systems, with molecular typing using the enterobacterial repetitive intergenic consensus-polymerase chain reaction technique.

RESULTS

In both outbreak 1 (6 patients) and outbreak 2 (5 patients), the point sources of Bcc were chlorhexidine mouthwashes of 2 different brands, both of them intrinsically contaminated. All patients had a clinical diagnosis of ventilator-associated pneumonia (VAP), and 6 died. MALDI-TOF MS identified 2 species of Bcc (B. cenocepacia and B. cepacia). Enterobacterial repetitive intergenic consensus-polymerase chain reaction typing confirmed 100% genetic similarity between patient and mouthwash isolates from each period. The first outbreak was controlled in 20 days and the second in 6 days.

CONCLUSIONS

The surveillance program for multidrug-resistant organisms, especially in high-risk patients, with the active participation of a multidisciplinary team, was crucial for success in controlling these outbreaks.

Mapping the Efficacy and Mode of Action of Ethylzingerone [4-(3-Ethoxy-4-Hydroxyphenyl) Butan-2-One] as an Active Agent against Burkholderia Bacteria

Burkholderia cepacia complex (Bcc) bacteria are intrinsically antimicrobial-resistant opportunistic pathogens and key risk species in the contamination of nonfood industrial products. New agents and formulations to prevent growth of Burkholderia in home care (cleaning agents) and personal-care (cosmetics and toiletries) products are required. We characterized how ethylzingerone [4-(3-ethoxy-4-hydroxyphenyl) butan-2-one] (HEPB) acts as a preservative with activity against Burkholderia species encountered in industry. Burkholderia (n = 58) and non-Burkholderia (n = 7) bacteria were screened for susceptibility to HEPB, and its mode of action and resistance were determined for a model Burkholderia vietnamiensis strain using transposon mutagenesis, transcriptomics, and genome resequencing analysis. The susceptibility of Burkholderia spp. to HEPB (MIC = 0.45% ± 0.11% [wt/vol]; MBC = 0.90% ± 0.3% [wt/vol]) was characterized, with limited inter- and intraspecies differences. HEPB (1% [wt/vol]) was rapidly bactericidal, producing a 6-log reduction in viability within 4 h. Spontaneous resistance to HEPB did not develop, but transient phenotypes with altered growth characteristics and susceptibility to antibiotics were identified after prolonged exposure to sublethal HEPB concentrations. Transposon mutagenesis and RNA-sequencing analysis identified multiple genetic pathways associated with HEPB exposure, including stress response mechanisms, altered permeability, regulation of intracellular pH, damage and repair of intracellular components, and alteration and repair of lipopolysaccharides. Key pathways included the stringent response, homeostasis of intracellular pH by the kdp operon, protection against electrophiles by KefC, and repair of oxidized proteins by methionine sulfoxide reductase enzymes. In summary, we show that HEPB has potent, targeted efficacy against Burkholderia bacteria without promoting wider stable antimicrobial resistance. The mode of action of HEPB against Burkholderia is multifactorial, but killing by intracellular oxidation is a key mechanism of this promising agent.IMPORTANCE Burkholderia bacteria are opportunistic pathogens that can overcome preservatives used in the manufacture of nonsterile industrial products and occasionally cause contamination. Consequently, new preservatives to prevent the growth of key risk Burkholderia cepacia complex bacteria in nonfood industrial products are urgently required. Here, we show that ethylzingerone is active against these problematic bacteria, killing them via a multifactorial mode of action which involves intracellular oxidation.

Systematic review of healthcare-associated Burkholderia cepacia complex outbreaks: presentation, causes and outbreak control

Background

Over the past decades, the Burkholderia cepacia complex (BCC) has been linked to multiple healthcare-associated outbreaks. No systematic analysis of these outbreaks has been carried out to date. The aim of this study was to conduct a systematic review of reports on nosocomial BCC outbreaks.

Methods

Published studies from 1971 until 9/12/2019 presenting nosocomial BCC outbreaks were identified using Embase, Pubmed and abstracts from professional meetings.

Results

We identified a total of 111 outbreak reports. Thirty-two percent of the affected institutions were academic hospitals and 43.8% community hospitals. The average outbreak duration was 198.6 ± 604.4 days. A total of 240 deaths (10% of the 2390 case patients) were reported but only 28 (1.2% of the 2390 case patients and 11.7% of the 240 deaths) were directly attributable to BCC. The source could be identified in 73.9% of the outbreaks; 53.2% were caused by contaminated medical solutions and medications, 12% were due to a contaminated disinfectant. In 28.2% of the outbreaks intrinsic product contamination was reported. Multidrug resistance was noted in 26.1% of the BCC strains. PFGE was the most frequently used typing method (43.2%) in the context of outbreak work-up.

Conclusion

Medical products are the most frequent source of BCC outbreaks, representing over half of the identified sources, with 12% of the outbreaks caused by disinfectant products. Intrinsic product contamination was detected frequently, suggesting a need for stricter regulation. While BCC-related mortality was low, our systematic review revealed significant heterogeneity in both investigations and reporting of BCC outbreaks.

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.

Outbreak of Burkholderia cepacia complex infections associated with contaminated octenidine mouthwash solution, Germany, August to September 2018

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.

Microbiological Safety of Non-Food Products: What Can We Learn from the RAPEX Database?

For consumer protection across borders, the European Union has established the rapid alert system for dangerous non-food products (RAPEX), with the overarching goal of preventing or limiting the sale and use of non-food products that present a serious risk for the health and safety of consumers. In our study, we comprehensively analyzed RAPEX notifications associated with products posing a microbiological risk from 2005 through 2017. Additional information was retrieved from national laboratory reports. A total of 243 microbiologically harmful consumer products triggered notifications in 23 out of 31 participating countries. About half of the products were reported by Spain, Germany, and Italy. Notifications mainly included contaminated toys, cosmetics, and chemical products. Depending on the notifying country, measures taken to prevent the spread of dangerous products were predominantly ordered either by public authorities or economic operators. The interval between microbiological diagnosis and the date of RAPEX notifications considerably varied between RAPEX member states, ranging between a few days and 82 weeks. The nature and extent of RAPEX usage substantially differed among member states, calling for harmonization and optimization. Slight modifications to RAPEX could help to systematically record microbiological hazards, which may improve the assessment of potential health risks due to contaminated non-food products.

Pseudobrote por Burkholderia cepacia en dos unidades de cuidados intensivos de un Hospital Universitario en Bogotá – Colombia

Introducción: Burkholderia cepacia es causante de brotes cuyo origen frecuentemente son fuentes ambientales.Materiales y métodos: Ante la sospecha de brote por B. cepacia en hemocultivos. Se realizó toma de cultivos ambientales y de insumos. Los aislamientos microbiológicos fueron sometidos a análisis molecular.Resultados: Se identificaron 8 pacientes con hemocultivos para B. cepacia en la UCI Adultos y UCI Pediátrica, edades entre 3 meses y 88 años, Los hemocultivos fueron tomados a través de catéter venoso central. Ningún paciente presentó infección por este microorganismo. Se documentó crecimiento de B. cepacia en lote de bolsitas (“sachet”) jabón de clorhexidina al 4% y en lavamanos que se correlacionaron con el clon identificado en los pacientes. Con el retiro del lote de jabón de clorhexidina, optimización de los procesos de limpieza y desinfección, lavado de manos y medidas de aislamiento se controló el pseudobrote .Conclusiones: Se presenta un pseudobrote por B. cepacia causado por la contaminación de un lote de clorhexidina jabón y de los lavamanos, llamando la atención acerca de la posibilidad de contaminación de antisépticos con este microorganismo.

Burkholderia cepacia, a cause of post pars plana vitrectomy silicone oil related endophthalmitis: clinico-pathological presentation and outcome of management

Aim

To report the long-term outcome of the management of a series of culture proven post pars plana vitrectomy endophthalmitis in which the infective agent was in the silicone oil used as an endotamponade. The isolates were Burkholderia cepacia and Pseudomonas aeruginosa.

Method

A retrospective interventional reporting of a series consisting of a cluster of five cases.

Cases

Five consecutive patients received the same batch of 5000-centistoke silicone oil as endotamponade at the conclusion of vitreoretinal surgery and presented with features of acute intraocular inflammation, which was due to an infective cause. The infective organism isolated from the mixture of silicone oil and fluid was B. cepacia in three out of the initial cluster of four eyes and P. aeruginosa in the fifth eye.

Outcome of management

The initial 4 eyes evolved into eyes with poor vision (hand motion, perception of light and no perception of light), advanced proliferative vitreoretinopathy, hypotony, phthisis bulbi and cornea opacity. The poor visual outcome was deemed to be consequent to delay in removal of the silicone oil, despite use of intravitreal, systemic and topical antibiotics. The fifth case, because of the heightened index of suspicion gained from the preceding four cases, had a prompt removal of the silicone oil, vitreal lavage with antibiotics, and intravitreal injection of antibiotics and steroid. He regained a 6/9 vision.

Conclusion

Gram-negative bacilli can colonize silicone oil resulting in post pars plana vitrectomy endophthalmitis. The index of suspicion for this should be high and can be managed successfully with prompt removal of the silicone oil, microbial sensitive antibiotic lavage of the vitreous cavity, followed by a repeat tamponade.

Burkholderia stabilis outbreak associated with contaminated commercially-available washing gloves, Switzerland, May 2015 to August 2016

We describe an outbreak of Burkholderia stabilis associated with contaminated washing gloves, a commercially available Class I medical device. Triggered by an increase in Burkholderia cepacia complex (BCC) bacteremias and the detection of BCC in unopened packages of washing gloves, an ad hoc national outbreak committee comprising representatives of a public health organisation, a regulatory agency, and an expert association convened and commissioned an outbreak investigation. The investigation included retrospective case finding across Switzerland and whole genome sequencing (WGS) of isolates from cases and gloves. The investigation revealed that BCC were detected in clinical samples of 46 cases aged 17 to 91 years (33% females) from nine institutions between May 2015 and August 2016. Twenty-two isolates from case patients and 16 from washing gloves underwent WGS. All available outbreak isolates clustered within a span of < 19 differing alleles, while 13 unrelated clinical isolates differed by > 1,500 alleles. This BCC outbreak was rapidly identified, communicated, investigated and halted by an ad hoc collaboration of multiple stakeholders. WGS served as useful tool for confirming the source of the outbreak. This outbreak also highlights current regulatory limitations regarding Class I medical devices and the usefulness of a nationally coordinated outbreak response.

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

BACKGROUND

Burkholderia cepacia is an important opportunistic organism in hospitalized and immunocompromised patients, particularly in cystic fibrosis.

AIMS

To describe the epidemiological investigation of an outbreak of B. cepacia bacteraemia.

METHODS

The study examined 14 patients during their admission to three intensive care units in a tertiary care hospital between January and June 2016. The outbreak involved nine (57%) female and six (43%) male patients. All patients were adults of ages ranging from 19 to 85 years with a median age of 52 years. Patients' medical charts, laboratory cultures, exposures, and central line insertion procedures were reviewed.

FINDINGS

B. cepacia was isolated from the blood cultures of 14 patients resulting from contamination of the gel applied to the ultrasound probe used to guide the insertion of a central venous catheter. Molecular pathogen typing using pulsed-field gel electrophoresis showed 95% similarity between the B. cepacia isolates from the blood of these patients and those isolated from the ultrasound gel.

CONCLUSION

Ongoing surveillance and prompt investigation of unusual disease outbreaks are vital for identifying sources of contamination of B. cepacia and protecting at-risk patients. Sound epidemiological methods are very important for identifying the source of any hospital infection outbreak.

Clinical characteristics of bacteraemia caused by Burkholderia cepacia complex species and antimicrobial susceptibility of the isolates in a medical centre in Taiwan

This study investigated the clinical characteristics and outcomes of bacteraemia due to Burkholderia cepacia complex (BCC) species among 54 patients without cystic fibrosis from January 2013 to February 2015. BCC isolates were identified to the species level by the Bruker Biotyper MALDI-TOF MS system and by sequencing analysis of the 16S rRNA and recA genes. Antimicrobial susceptibilities of the isolates were determined by the agar dilution method. Sequencing of the recA gene in the 54 blood isolates revealed 37 (68.5%) isolates of B. cenocepacia, 9 (16.7%) of B. cepacia, 4 (7.4%) of B. multivorans and one isolate each of B. arboris, B. pseudomultivorans, B. seminalis, and B. vietnamiensis. The overall performance of the Bruker Biotyper MALDI-TOF MS system for correctly identifying the 54 BCC isolates to the species level was 79.6%, which was better than that (16.7%) by 16S RNA sequencing analysis. Bacteraemic pneumonia (n = 23, 42.6%) and catheter-related bacteraemia (n = 21, 38.9%) were the most common types of infection. Higher rates of ceftazidime and meropenem resistance were found in B. cepacia isolates (33.3% and 22.2%, respectively) than in isolates of B. cenocepacia (21.6% and 10.8%, respectively) and other species (12.5% and 12.5%, respectively). Overall, the 30-day mortality rate was 38.9% (21/54). Bacteraemia caused by BCC species other than B. cenocepacia and B. cepacia (adjusted odds ratio [aOR] 20.005, P = 0.024) and high SOFA score (aOR 1.412, P = 0.003) were predictive of higher 30-day mortality. Different BCC species are associated with different outcomes of bacteraemia and exhibit different susceptibility patterns.

Suspicious outbreak of ventilator-associated pneumonia caused by Burkholderia cepacia in a surgical intensive care unit

BACKGROUND

We reviewed Burkholderia cepacia infections in a hospital from 2013-2016 to report a suspicious outbreak that occurred in a surgical intensive care unit in 2015, and to outline the infection control measures adopted thereafter.

METHODS

Review of the health care-associated infection data regarding B cepacia via the surveillance system, hospital information system, electronic medical records, and laboratory information system together with the outbreak investigation was managed by the health care-associated infection control team.

RESULTS

During June 1-14, 2015, 4 cases of ventilator-associated pneumonia (VAP) were identified; B cepacia was isolated from endotracheal aspirate samples. On June 16, 120 environmental samples were collected and analyzed for microbiologic differentiation. Thirteen strains of B cepacia were prominently found in the expiratory blocks of ventilators, revealing the biocontamination source. After chemical disinfection without damaging ventilator components, repeat microbiologic testing of random ventilator samples yielded negative results until July 30, 2015. Retrospective data showed that isolation rates of B cepacia strains had increased since 2014. Although the resistance phenotype of these strains varied slightly, they exhibited similar patterns of antibiotic susceptibility.

CONCLUSIONS

Routine cleaning and disinfection of ventilators, in addition to an intervention bundle, should form part of an integrated VAP prevention and management approach.

Ethylhexylglycerin Impairs Membrane Integrity and Enhances the Lethal Effect of Phenoxyethanol

Preservatives are added to cosmetics to protect the consumers from infections and prevent product spoilage. The concentration of preservatives should be kept as low as possible and this can be achieved by adding potentiating agents. The aim of the study was to investigate the mechanisms behind potentiation of the bactericidal effect of a commonly used preservative, 2-phenoxyethanol (PE), by the potentiating agent ethylhexylglycerin (EHG). Sub-lethal concentrations of EHG (0.075%) and PE (0.675%) in combination led to rapid killing of E. coli (> 5 log reduction of cfu after 30 min), leakage of cellular constituents, disruption of the energy metabolism, morphological deformities of cells and condensation of DNA. Used alone, EHG disrupted the membrane integrity even at low concentrations. In conclusion, sub-lethal concentrations of EHG potentiate the effect of PE through damage of the cell membrane integrity. Thus, adding EHG to PE in a 1:9 ratio has a similar effect on membrane damage and bacterial viability as doubling the concentration of PE. This study provides insight about the mechanism of action of a strong potentiating agent, EHG, which is commonly used in cosmetics together with PE.

Microbiological risk assessment for personal care products

Regulatory decisions regarding microbiological safety of cosmetics and personal care products are primarily hazard-based, where the presence of a potential pathogen determines decision-making. This contrasts with the Food industry where it is a commonplace to use a risk-based approach for ensuring microbiological safety. A risk-based approach allows consideration of the degree of exposure to assess unacceptable health risks. As there can be a number of advantages in using a risk-based approach to safety, this study explores the Codex Alimentarius (Codex) four-step Microbiological Risk Assessment (MRA) framework frequently used in the Food industry and examines how it can be applied to the safety assessment of personal care products. The hazard identification and hazard characterization steps (one and two) of the Codex MRA framework consider the main microorganisms of concern. These are addressed by reviewing the current industry guidelines for objectionable organisms and analysing reports of contaminated products notified by government agencies over a recent 5-year period, together with examples of reported outbreaks. Data related to estimation of exposure (step three) are discussed, and examples of possible calculations and references are included. The fourth step, performed by the risk assessor (risk characterization), is specific to each assessment and brings together the information from the first three steps to assess the risk. Although there are very few documented uses of the MRA approach for personal care products, this study illustrates that it is a practicable and sound approach for producing products that are safe by design. It can be helpful in the context of designing products and processes going to market and with setting of microbiological specifications. Additionally, it can be applied reactively to facilitate decision-making when contaminated products are released on to the marketplace. Currently, the knowledge available may only allow a qualitative or semi-quantitative rather than fully quantitative risk assessment, but an added benefit is that the disciplined structuring of available knowledge enables clear identification of gaps to target resources and if appropriate, instigate data generation.

An Outbreak of Burkholderia cepacia Bacteremia in a Neonatal Intensive Care Unit

OBJECTIVES

To identify the source of infection, to study the clinical profile and outcomes of neonates with Burkholderia septicemia and to determine the antimicrobial susceptibility patterns of the isolates.

METHODS

The authors describe a 3 mo outbreak of nosocomial Burkholderia cepacia bacteremia involving 12 neonates. During the outbreak, ventilator humidifier water, intravenous solutions and other possible sources were taken from the concerned neonatal intensive care units (NICUs); cultured and isolates identified by standard microbiological techniques and VITEK system. Clinical details of affected babies were also obtained to ascertain the clinical significance of the isolates.

RESULTS

All neonates had clinical and biochemical evidence of sepsis and the source could be tracked to intravenous solutions of 5% dextrose, normal saline (opened bottles) and continuous positive airway pressure humidifier water. Strain relatedness of the environmental isolates with the clinical isolates is likely as antibiotic susceptibility patterns were similar.

CONCLUSIONS

The investigations revealed the source of the nosocomial outbreak which is crucial for initiating appropriate control measures.

Outbreak of Burkholderia cepacia complex bacteremia in a chemotherapy day care unit due to intrinsic contamination of an antiemetic drug

BACKGROUND

In the end of 2009, a large number of patients with cancer undergoing chemotherapy at the day care unit of a private hospital in Mumbai, India developed Burkholderia cepacia complex (BCC) blood stream infection (BSI).

OBJECTIVE

The objectives were to identify the source of the outbreak and terminate the outbreak as rapidly as possible.

MATERIALS AND METHODS

All infection control protocols and processes were reviewed. Intensive training was started for all nursing staff involved in patient care. Cultures were sent from the environment (surfaces, water, air), intravenous fluids, disinfectants and antiseptics and opened/unopened medication.

RESULTS

A total of 13 patients with cancer with tunneled catheters were affected with BCC BSI. The isolates were of similar antimicrobial sensitivity. No significant breach of infection control protocols could be identified. Cultures from the prepared intravenous medication bags grew BCC. Subsequently, culture from unused vials of the antiemetic granisetron grew BCC, whereas those from the unopened IV fluid bag and chemotherapy medication were negative. On review, it was discovered that the outbreak started when a new brand of granisetron was introduced. The result was communicated to the manufacturer and the brand was withdrawn. There were no further cases.

CONCLUSIONS

This outbreak was thus linked to intrinsic contamination of medication vials. We acknowledge a delay in identifying the source as we were concentrating more on human errors in medication preparation and less on intrinsic contamination. We recommend that in an event of an outbreak, unopened vials be cultured at the outset.

A demonstration of the susceptibility of clinical isolates obtained from cystic fibrosis patients to manuka honey

Pseudomonas and Burkholderia pose a significant health threat to people with chronic respiratory conditions; the resistance inherent in these bacteria indicates that new antimicrobial strategies are required. Susceptibility of 56 strains of P. aeruginosa and 55 strains of Burkholderia to manuka honey, tobramycin and colistin using microbroth dilution and E strip was determined. MICs of antibiotics with honey were determined to search for synergistic combinations against two representative strains of each genus. All strains exhibited susceptibility to honey ≤10 % (w/v); mean susceptibility of Burkholderia (4.6 % w/v) was lower than P. aeruginosa (7.3 % w/v). Synergistic or additive combinations were found with all four strains tested. Combinations of manuka honey with antibiotics can be used to lower the MIC need to successfully inhibit both P. aeruginosa and B. cepacia. The use of honey as a combination agent may be possible for the management of P. aeruginosa and B. cepacia.

Bacillus cereus in personal care products: risk to consumers

Bacillus cereus is ubiquitous in nature and thus occurs naturally in a wide range of raw materials and foodstuffs. B. cereus spores are resistant to desiccation and heat and able to survive dry storage and cooking. Vegetative cells produce several toxins which on ingestion in sufficient numbers can cause vomiting and/or diarrhoea depending on the toxins produced. Gastrointestinal disease is commonly associated with reheated or inadequately cooked foods. In addition to being a rare cause of several acute infections (e.g. pneumonia and septicaemia), B. cereus can also cause localized infection of post-surgical or trauma wounds and is a rare but significant pathogen of the eye where it may result in severe endophthalmitis often leading to loss of vision. Key risk factors in such cases are trauma to the eye and retained contaminated intraocular foreign bodies. In addition, rare cases of B. cereus-associated keratitis (inflammation of the cornea) have been linked to contact lens use. Bacillus cereus is therefore a microbial contaminant that could adversely affect product safety of cosmetic and facial toiletries and pose a threat to the user if other key risk factors are also present. The infective dose in the human eye is unknown, but as few as 100 cfu has been reported to initiate infection in a susceptible animal model. However, we are not aware of any reports in the literature of B. cereus infections in any body site linked with use of personal care products. Low levels of B. cereus spores may on occasion be present in near-eye cosmetics, and these products have been used by consumers for many years. In addition, exposure to B. cereus is more likely to occur through other routes (e.g. dustborne contamination) due to its ubiquity and resistance properties of spores. The organism has been recovered from the eyes of healthy individuals. Therefore, although there may be a perceived hazard, the risk of severe eye infections as a consequence of exposure through contaminated near-eye cosmetics is judged to be vanishingly small. It is unlikely that more stringent microbiological standards for near-eye cosmetics will have any impact on the risk of severe eye infections caused by B. cereus, as these are not linked to use of personal care products.

Polyclonal outbreak of bloodstream infections caused by Burkholderia cepacia complex in hematology and bone marrow transplant outpatient units

Aim: The objective was to describe an outbreak of bloodstream infections by Burkholderia cepacia complex (Bcc) in bone marrow transplant and hematology outpatients.

Methods: On February 15, 2008 a Bcc outbreak was suspected. 24 cases were identified. Demographic and clinical data were evaluated. Environment and healthcare workers' (HCW) hands were cultured. Species were determined and typed. Reinforcement of hand hygiene, central venous catheter (CVC) care, infusion therapy, and maintenance of laminar flow cabinet were undertaken. 16 different HCWs had cared for the CVCs. Multi-dose heparin and saline were prepared on counter common to both units.

Findings: 14 patients had B. multivorans (one patient had also B. cenopacia), six non-multivorans Bcc and one did not belong to Bcc. Clone A B. multivorans occurred in 12 patients (from Hematology); in 10 their CVC had been used on February 11/12. Environmental and HCW cultures were negative. All patients were treated with meropenem, and ceftazidime lock-therapy. Eight patients (30%) were hospitalized. No deaths occurred. After control measures (multidose vial for single patient; CVC lock with ceftazidime; cleaning of laminar flow cabinet; hand hygiene improvement; use of cabinet to store prepared medication), no new cases occurred.

Conclusions: This polyclonal outbreak may be explained by a common source containing multiple species of Bcc, maybe the laminar flow cabinet common to both units. There may have been contamination by B. multivorans (clone A) of multi-dose vials.

Burkholderia cepacia septicemia in a patient with acute myeloid leukemia in postchemotherapy bone marrow aplasia

The patients with hematologic malignancies are predisposed to develop infections with unusual bacteria, like Burkholderia cepacia, which is frequently resistant to many antibiotics and antiseptics. We present the case of a female patient with acute myeloid leukemia type 2 on the background of myelodysplastic syndrome, from whom Burkholderia cepacia was isolated in blood culture, after the 2^nd cycle of induction. She was sensitive to ceftazidime, but its eradication was not easy. Five other patients were contaminated with this bacteria, but all of them had favourable evolution. The case is discussed in the context of those similar in literature.

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.

Key role for efflux in the preservative susceptibility and adaptive resistance of Burkholderia cepacia complex bacteria

Bacteria from the Burkholderia cepacia complex (Bcc) are encountered as industrial contaminants, and little is known about the species involved or their mechanisms of preservative resistance. Multilocus sequence typing (MLST) revealed that multiple Bcc species may cause contamination, with B. lata (n = 17) and B. cenocepacia (n = 11) dominant within the collection examined. At the strain level, 11 of the 31 industrial sequence types identified had also been recovered from either natural environments or clinical infections. Minimal inhibitory (MIC) and minimum bactericidal (MBC) preservative concentrations varied across 83 selected Bcc strains, with industrial strains demonstrating increased tolerance for dimethylol dimethyl hydantoin (DMDMH). Benzisothiazolinone (BIT), DMDMH, methylisothiazolinone (MIT), a blend of 3:1 methylisothiazolinone-chloromethylisothiazolinone (M-CMIT), methyl paraben (MP), and phenoxyethanol (PH), were all effective anti-Bcc preservatives; benzethonium chloride (BC) and sodium benzoate (SB) were least effective. Since B. lata was the dominant industrial Bcc species, the type strain, 383(T) (LMG 22485(T)), was used to study preservative tolerance. Strain 383 developed stable preservative tolerance for M-CMIT, MIT, BIT, and BC, which resulted in preservative cross-resistance and altered antibiotic susceptibility, motility, and biofilm formation. Transcriptomic analysis of the B. lata 383 M-CMIT-adapted strain demonstrated that efflux played a key role in its M-CMIT tolerance and elevated fluoroquinolone resistance. The role of efflux was corroborated using the inhibitor l-Phe-Arg-β-napthylamide, which reduced the MICs of M-CMIT and ciprofloxacin. In summary, intrinsic preservative tolerance and stable adaptive changes, such as enhanced efflux, play a role in the ability of Bcc bacteria to cause industrial contamination.

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.

Classification of dermatological disorders in critical care patients: a prospective observational study

PURPOSE

The objective of this study was to identify dermatological disorders detected in the intensive care unit (ICU), to analyze their specific characteristics, and to define a useful classification for intensive care physicians.

MATERIALS AND METHODS

This was a prospective, observational study over a 3-year period (2006-2009) in a mixed ICU. This included all patients presenting with dermatological disorders that were detected at the time of ICU admission or developed along the ICU stay. We recorded the specific characteristics of the disorders and its evolution and treatment, which enabled us to classify the different observed conditions. As general variables, we analyzed demographic factors, the principal diagnosis, ICU procedures, the severity score (Acute Physiology and Chronic Health Evaluation II), length of stay, and mortality.

RESULTS

One hundred thirty-three patients showed at least one dermatological disorder (9.3%) and were classified into (1) preexisting dermatological disorders, (2) life-threatening dermatologic disorders, (3) systemic dermatological disorders, (4) infectious dermatological disorders, (5) reactive dermatological disorders, and (6) others.

CONCLUSIONS

Dermatological disorders are a frequent problem in the ICU, and their recognition is key to set up an appropriate care plan. We propose a classification and description of the different types of dermatological disorders that are most commonly found in ICUs.

Low-level efficacy of cosmetic preservatives

Preservation using combinations of preservatives has several advantages. This study shows that the concentration of some of the most frequently used allergenic preservatives can be markedly lowered when they are combined with phenoxyethanol. The antimicrobial efficacy of cosmetic preservatives and known allergens of various potency [diazolidinyl urea, methylchloroisothiazolinone/methylisothiazolinone (MCI/MI), methylisothiazolinone (MI) and phenoxyethanol] was tested alone and in various combinations of two or three preservatives together. The preservatives were tested for minimum inhibitory concentration (MIC) values and possible synergy using fractional inhibitory concentration. MCI/MI was the only preservative showing low-level MIC against all four tested microorganisms: Staphylococcus aureus, Pseudomonas aeruginosa, Candida albicans and Aspergillus niger. Different combinations of the preservatives indicated additive effects against the microorganisms. No combination of preservatives showed any inhibitory action on each other. Challenge tests with different concentrations and combinations were performed in a cosmetic cream. Diazolidinyl urea and MCI/MI alone were ineffective against C. albicans in a challenge test at concentrations up to 16 times higher than the observed MIC values. When combining phenoxyethanol with either one of the allergenic preservatives diazolidinyl urea, MCI/MI or MI, the cosmetic cream was adequately preserved at concentrations well below the preservatives' MIC values as well as 10-20 times below the maximum permitted concentrations. By using combinations of preservatives, effective preservation can be achieved with lower concentrations of allergenic preservatives.

Hospital-wide outbreak of Burkholderia contaminans caused by prefabricated moist washcloths

We experienced a hospital outbreak of Burkholderia contaminans (Burkholderia cepacia Group K) in a German university hospital with two campuses. Cases were defined as the microbiological detection of B. cepacia complex (BCC) in any clinical specimen sent to the laboratory during 30 June to 21 October 2008. Species identification of BCC was performed by recA gene sequencing, followed by pulsed-field gel electrophoresis (PFGE; SpeI digest) for clonal identity. In total, 61 BCC-positive cases were diagnosed at the two campuses. At least nine patients contracted a ventilator-associated pneumonia with BCC. One patient suffered an infection of a pacing wire insertion site and four patients had septicaemia. Sixteen patients died in hospital, none thought to be due to the outbreak strain. BCC was eventually found in packages of moist prefabricated washcloths used for intensive care patients. German healthcare authorities were informed and a Europe-wide alarm (RAPEX) was initiated through the systems to prevent infections in other hospitals. PFGE proved clonal identity between isolates from clinical specimens and washcloths of both campuses. After elimination of the contaminated washcloths no further cases occurred. This example of a relatively newly introduced product raises the question of whether current regulations are adequate to protect consumers. For critically ill patients, care products should be carefully evaluated. In case of infections due to contaminated products, immediate communication to healthcare authorities is required, including RAPEX warning if products are sold across Europe.

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?