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Outbreak of Burkholderia Cepacia Bacteremia Traced to Contaminated Hospital Water Used for Dilution of an Alcohol Skin Antiseptic

Published online by Cambridge University Press:  02 January 2015

Rana M. Nasser ,
Amal C. Rahi ,
Mona F. Haddad ,
Ziad Daoud ,
Noha Irani-Hakime  and
Wassim Y. Almawi
Rana M. Nasser*
Affiliation:
Department of Infection Control, Saint George Hospital, Beirut, Lebanon
Amal C. Rahi
Affiliation:
Department of Epidemiology and Biostatistics, American University of Beirut, Beirut, Lebanon
Mona F. Haddad
Affiliation:
Department of Infection Control, Saint George Hospital, Beirut, Lebanon Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon
Ziad Daoud
Affiliation:
Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon Faculty of Health Sciences, Balamand University, Beirut, Lebanon
Noha Irani-Hakime
Affiliation:
Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon Department of Pathology, Saint George Hospital, Beirut, Lebanon
Wassim Y. Almawi
Affiliation:
Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon
*
Department of Infectious Diseases, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449
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Abstract

Objective:

To identify the source of an epidemic of Burkholderia cepacia bloodstream infections during 7 years (411 episodes in 361 patients).

Design:

Outbreak investigation.

Setting:

A 250-bed university hospital in Beirut, Lebanon.

Methods:

Matched case-control and retrospective cohort studies, and microbiological surveillance and polymerase chain reaction–restriction fragment length ascertainment were employed. Special media and filtration techniques were used to isolate organisms from water and diluted alcohol solutions.

Results:

In a group of 50 randomly selected case-matched patients from 1999, the positive blood cultures were concomitant with fever in 98%, intravenous phlebitis in 44%, and recurrent bacteremia in 20%. Fever disappeared approximately 6 hours after intravenous catheter removal. Polymerase chain reaction–restriction fragment length polymorphism revealed strain homogeneity in patient, water, and alcohol isolates. Contaminated tap water had been used to dilute alcohol for skin antisepsis and for decontamination of the caps of heparin vials. Only sporadic cases directly attributable to breach of protocol were reported after single-use alcohol swabs were substituted.

Conclusion:

This is potentially the largest single-source nosocomial bloodstream infection outbreak ever reported, and the first report of an alcohol skin antiseptic contaminated by tap water as a source for nosocomial bacteremia.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 25 , Issue 3 , March 2004 , pp. 231 - 239
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2004

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References

1.Larson, EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251–269.Google Scholar
2.Larsen, EL, Morton, HE. Alcohols. In: Block, SS, ed. Disinfection, Sterilization and Preservation, ed. 4. Philadelphia: Lea and Febiger; 1991:191–203.Google Scholar
3.Groschel, DHM, Pruett, TL. Surgical antisepsis. In: Block, SS, ed. Disinfection, Sterilization and Preservation, ed. 4. Philadelphia: Lea and Febiger; 1991:642–654.Google Scholar
4.Rotter, ML. Hygienic hand disinfection. Infect Control 1984;5:18–22.Google Scholar
5.Geelhoed, GW, Sharpe, K, Simon, GL. A comparative study of surgical skin preparation methods. Surg Gynecol Obstet 1983;157:265–268.Google Scholar
6.Butz, AM, Laughon, BE, Gullette, DL, Larson, EL. Alcohol-impregnated wipes as an alternative in hand hygiene. Am J Infect Control 1990;18:70–76.Google Scholar
7.O'Grady, NP, Alexander, M, Dellinger, EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR 2002;51:1–29.Google Scholar
8.Vierkant, RA, Therneau, TM, Kosanke, JL, Naessens, JM. A SAS macro to analyze data from a matched or finely stratified case-control design. Presented at the 24th Annual SAS Users Group International Conference (SUGI-24); April 11–14, 1999; Miami Beach, FL. Available at www2.sas.com/proceedings/sugi24/Stats/p285-24.pdf. Accessed August 20, 2003.Google Scholar
9.Maki, DG, Weise, CE, Sarafin, HW. A semiquantitative culture method for identifying intravenous-catheter-related infection. N Engl J Med 1977;296:1305–1309.Google Scholar
10.Kerr, TJ, McHale, BB. Applications in General Microbiology, ed. 6Winston-Salem, NC: Hunter Textbooks; 2001.Google Scholar
11.National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Disk Susceptibility Tests, ed. 5. Villanova, PA: National Committee for Clinical Laboratory Standards; 1993. Approved standard M2-A5.Google Scholar
12.Mahenthiralingam, E, Bischof, J, Byrne, SK, et al. DNA-based diagnostic approaches for the identification of Burkholderia cepacia complex, Burkholderia vietnamiensis, Burkholderia multivorans, Burkholderia stabilis, Burkholderia cepacia genomovars I and III. J Clin Microbiol 2000;38:3165–3173.Google Scholar
13.Henry, DA, Mahenthiralingam, E, Vandamme, P, Coenye, T, Speert, DP. Phenotypic methods for determining genomovar status of the Burkholderia cepacia complex, J Clin Microbiol 2001;39:1073–1078.Google Scholar
14.Coenye, T, Spilker, T, Martin, A, LiPuma, JJ. Comparative assessment of genotyping methods for epidemiologic study of Burkholderia cepacia genomovar III. J Clin Microbiol 2002;40:3300–3307.Google Scholar
15.Heath, DG, Hohneker, K, Carriker, C, et al. Six-year molecular analysis of Burkholderia cepacia complex isolates among cystic fibrosis patients at a referral center for lung transplantation. J Clin Microbiol 2002;40:1188–1193.Google Scholar
16.Kronfol, NM, Sibai, AM, Rafeh, N. The impact of civil disturbances on the migration of physicians: the case of Lebanon. Med Care 1992;30:208–215.Google Scholar
17.Sibai, AM, Fletcher, A, Armenian, HK. Variations in the impact of long-term wartime stressors on mortality among the middle-aged and older population in Beirut, Lebanon, 1983-1993. Am J Epidemiol 2001;154:128–137.Google Scholar
18.Sibai, AM, Nuwayhid, I, Beydoun, M, Chaaya, M. Inadequacies of death certification in Beirut: who is responsible? Bull World Health Organ 2002;80:555–561.Google Scholar
19.Fiore, A, Laevens, S, Bevivino, A, et al. Burkholderia cepacia complex: distribution of genomovars among isolates from the maize rhizosphere in Italy. Environ Microbiol 2001;3:137–143.Google Scholar
20.Zinner, SH. Changing epidemiology of infections in patients with neutropenia and cancer: emphasis on gram-positive and resistant bacteria. Clin Infect Dis 1999;29:490–494.Google Scholar
21.Vartivarian, S, Anaissie, E. Stenotrophomonas maltophilia and Burkholderia cepacia. In: Mandell, GL, Bennett, JE, Dolin, R, eds. Principles and Practice of Infectious Diseases, ed. 5. New York: Churchill Livingstone; 2000.Google Scholar
22.Drabick, JA, Gracely, EJ, Heidecker, GJ, LiPuma, JJ. Survival of Burkholderia cepacia on environmental surfaces. J Hosp Infect 1996;32:267–276.Google Scholar
23.Yu, WL, Wang, DY, Lin, CW, Tsou, MF. Endemic Burkholderia cepacia bacteraemia: clinical features and antimicrobial susceptibilities of isolates. Scand J Infect Dis 1999;31:293–298.Google Scholar
24.Lu, DC, Chang, SC, Chen, YC, Luh, KT, Lee, CY, Hsieh, WC. Burkholderia cepacia bacteremia: a retrospective analysis of 70 episodes. J Formos Med Assoc 1997;96:972–978.Google Scholar
25.Panlilio, AL, Beck-Sague, CM, Siegel, JD, et al. Infections and pseudoinfec-tions due to povidone-iodine solution contaminated with Pseudomonas cepacia. Clin Infect Dis 1992;14:1078–1083.Google Scholar
26.Frank, MJ, Schaffner, W. Contaminated aqueous benzalkonium chloride: an unnecessary hospital infection hazard. JAMA 1976:236:2418–2419.Google Scholar
27.Kaitwatcharachai, C, Silpapojakul, K, Jitsurong, S, Kalnauwakul, S. An outbreak of Burkholderia cepacia bacteremia in hemodialysis patients: an epidemiologic and molecular study. Am J Kidney Dis 2000;36:199–204.Google Scholar
28.Pegues, DA, Carson, LA, Anderson, RL, et al. Outbreak of Pseudomonas cepacia bacteremia in oncology patients. Clin Infect Dis 1993;16:407–411.CrossRefGoogle ScholarPubMed
29.Schaffner, W, Reisig, G, Verrall, RA. Outbreak of Pseudomonas cepacia infection due to contaminated anaesthetics. Lancet 1973;1:1050–1051.Google Scholar
30.Flaherty, JP, Garcia-Houchins, S, Chudy, R, Arnow, PM. An outbreak of gram-negative bacteremia traced to contaminated O-rings in reprocessed dialyzers. Ann Intern Med 1993;119:1072–1078.Google Scholar
31.Gravel-Tropper, D, Sample, ML, Oxley, C, Toye, B, Woods, DE, Garber, GE. Three-year outbreak of pseudobacteremia with Burkholderia cepacia traced to a contaminated blood gas analyzer. Infect Control Hosp Epidemiol 1996;17:737–740.Google Scholar
32.Kahan, A, Philippon, A, Paul, G, et al. Nosocomial infections by chlorhexidine solution contaminated with Pseudomonas pickettii (bio-var VA-I). J Infect 1983;7:256–263.Google Scholar
33.Keys, TF, Melton, LJ 3rd, Maker, MD, Ilstrup, DM. A suspected hospital outbreak of pseudobacteremia due to Pseudomonas stutzeri. J Infect Dis 1983;147:489–493.Google Scholar
34.Keeven, J, Wrobel, S, Portoles, M, DeCicco, BT. Evaluating the preservative effectiveness of RGP lens care solutions. CLAO J 1995;21:238–241.Google Scholar
35.Rudnick, JR, Beck-Sague, CM, Anderson, RL, Schable, B, Miller, JM, Jarvis, WR. Gram-negative bacteremia in open-heart-surgery patients traced to probable tap-water contamination of pressure-monitoring equipment. Infect Control Hosp Epidemiol 1996;17:281–285.Google Scholar
36.Sobel, JD, Hashman, N, Reinherz, G, Merzbach, D. Nosocomial Pseudomonas cepacia infection associated with chlorhexidine contamination. Am J Med 1982;73:183–186.Google Scholar
37.Jimenez, L, Smalls, S, Jimenez, L, Smalls, S. Molecular detection of Burkholderia cepacia in toiletry, cosmetic, and pharmaceutical raw materials and finished products. JAOAC Int 2000;83:963–966.CrossRefGoogle ScholarPubMed
38.Hsueh, PR, Teng, LJ, Yang, PC, Pan, HL, Ho, SW, Luh, KT. Nosocomial pseudoepidemic caused by Bacillus cereus traced to contaminated ethyl alcohol from a liquor factory. J Clin Microbiol 1999;37:2280–2284.Google Scholar
39.Manzoor, SE, Lambert, PA, Griffiths, PA, Gill, MJ, Fraise, AP. Reduced glutaraldehyde susceptibility in Mycobacterium chelonae associated with altered cell wall polysaccharides. J Antimicrob Chemother 1999;43:759–765.Google Scholar
40.Woo, PC, Leung, KW, Wong, SS, Chong, KT, Cheung, EY, Yuen, KY. Relatively alcohol-resistant mycobacteria are emerging pathogens in patients receiving acupuncture treatment. J Clin Microbiol 2002;40:1219–1224.Google Scholar
41.Svendsen, A, Borch, K, Barfoed, M, Nielsen, TB, Gormsen, E, Patkar, SA. Biochemical properties of cloned lipases from the Pseudomonas family. Biochim Biophys Acta 1995;1259:9–17.Google Scholar
42.Schulz, T, Pleiss, J, Schmid, RD. Stereoselectivity of Pseudomonas cepacia lipase toward secondary alcohols: a quantitative model. Protein Sci 2000;9:1053–1062.CrossRefGoogle ScholarPubMed
43.Secundo, F, Spadaro, S, Carrea, G, Overbeeke, PL. Optimization of Pseudomonas cepacia lipase preparations for catalysis in organic solvents. Biotechnol Bioeng 1999;62:554–561.Google Scholar
44.Carson, LA, Favero, MS, Bond, WW, Petersen, NJ. Morphological, biochemical, and growth characteristics of Pseudomonas cepacia from distilled water. Appl Microbiol 1973;25:476–483.Google Scholar
45.van Laer, F, Raes, D, Vandamme, P, et al. An outbreak of Burkholderia cepacia with septicemia on a cardiology ward. Infect Control Hosp Epidemiol 1998;19:112–113.Google Scholar
46.Siddiqui, AH, Mulligan, ME, Mahenthiralingam, E, et al. An episodic outbreak of genetically related Burkholderia cepacia among non-cystic fibrosis patients at a university hospital. Infect Control Hosp Epidemiol 2001;22:419–422.Google Scholar
47.Centers for Disease Control and Prevention. Protecting the Nation's Health in an Era of Globalization: CDC's Global Infectious Disease Strategy. Atlanta, GA: Centers for Disease Control and Prevention; 2002. Available at www.cdc.gov/globalidplan. Accessed March 14, 2002.Google Scholar