Global burden, point sources, and outbreak management of healthcare-associated Burkholderia cepacia infections: An integrative review

Epidemiology, microbiological, clinical characteristics, and outcome of Burkholderia cepacia complex infections in non-cystic fibrosis adult patients from Qatar

Objectives

Burkholderia species infections are associated with diverse and challenging clinical presentations because of distinct virulence and antimicrobial resistance factors. The study aims to evaluate the epidemiology, microbiological, and clinical outcomes of Burkholderia cepacia complex (Bcc) infections in non-cystic fibrosis (CF) patients from Qatar.

Methods

A retrospective study was conducted on adult patients across all hospitals at Hamad Medical Corporation between January 2012 and December 2018 to evaluate clinically relevant Bcc in non-CF adult patients.

Results

Over 7 years, 72 episodes of Burkholderia species infections were recorded, 64 were secondary to Bcc primarily affecting males (78.12%) with a mean age of 53 years, from the Middle and Southeastern region (92.2%) affected predominantly by diabetes mellitus (34.4%), chronic kidney (23.4%), coronary heart (20.3%), and hypertensive diseases (17.2%) while recent hospitalization and admission to critical care were evident in 45.3% and 93.8% of cases, respectively. Main infection sites were urinary (43.8%) and respiratory (29.7%) with associated bacteremia recorded in 26.6% of cases. Microbiological characteristics demonstrated high-level resistance profiles leading to delayed microbiological clearance in case of bacteremia (61%) and management with multiple therapeutic agents (range 4-6) resulting in disease resolution in 90.6% of cases with observed 30-day mortality of 7.8%.

Conclusions

B. cepacia infections are infrequent, recorded mainly in middle-aged males with chronic comorbidities presenting as urinary, respiratory, and bacteremia associated with hospitalization, admission to critical care, and invasive procedures. High-level antimicrobial resistance is observed necessitating multiple therapeutic agents and suboptimal bacteriological clearance.

Evaluation of the prevention effect of high-quality nursing quality control in disinfection supply center on nosocomial infection

To explore the application effect of high-quality nursing quality control in disinfection supply center. The control group consisted of 1850 medical devices managed using the conventional quality control mode from January 2021 to December 2021, while the observation group consisted of 1900 medical devices managed using the high-quality nursing quality control mode from January 2022 to December 2022. The qualified rates of equipment cleaning, sterilization, and packaging were analyzed in both the observation and control groups. The occurrence of nosocomial infections in 2021 and 2022 were compared, and the changes in the Beck-Srivaatava stress scale index (BSSI) and Symptom Checklist-90 scores of the staff before and after implementing the high-quality nursing quality control mode were analyzed. The qualified rate of equipment cleaning, sterilization, and packaging in the observation group were 99.08%, 99.73%, and 99.78%, respectively, which were significantly higher than those in the control group (P < .05). The incidence of nosocomial infections in interventional and surgical cases in 2022 was 0.79%, which was significantly lower than that in 2021 (P < .05). The BSSI score of female staff was (68.76 ± 7.81) points, which was higher than that of male staff (P < .05). After the implementation of the high-quality nursing quality control mode, the BSSI score of the staff was (47.76 ± 9.12) points, which was significantly lower than that before implementation (P < .05). After the implementation of the high-quality nursing quality control mode, the staff's Symptom Checklist-90 scores for somatization, compulsion, interpersonal sensitivity, depression, hostility, and paranoia were (1.28 ± 0.29), (1.53 ± 0.24), (1.50 ± 0.21), (1.46 ± 0.32), (1.44 ± 0.26), and (1.38 ± 0.30) points, respectively, showing a decrease compared to before implementation (P < .05). The high-quality nursing quality control mode has great application value in the disinfection supply center. It can effectively improve the qualified rates of equipment cleaning, sterilization, and packaging, prevent nosocomial infections and improve the working pressure and psychological health of staff.

Two consecutive outbreaks caused by chlorhexidine mouthwash contaminated with Burkholderia contaminans in a two-hospital tertiary care system

BACKGROUND

Hospital outbreaks caused by Burkholderia spp. have been linked to contamination of several medical solutions and products and are frequently associated with delayed detection and high mortality.

AIM

To describe the management of two consecutive Burkholderia contaminans outbreaks caused by contaminated mouthwash of different brands during the COVID-19 pandemic.

METHODS

This was a retrospective cohort study of all patients involved in two outbreaks caused by B. contaminans detected in 2021 and 2022. The investigation was initiated after a cluster of positive respiratory specimens, followed by retrospective and prospective case-finding.

FINDINGS

A total of 69 patients were affected, 47 in 2021 and 22 in 2022. The majority of affected patients had positive respiratory specimens (85.5%); 55.1% of cases had COVID-19, and 72.5% had multidrug-resistant organisms. Almost all (97.1%) patients required ventilation and 42.0% died. Seventeen percent of cases in the first outbreak were deemed to have been acquired by patient-to-patient transmission, whereas all of the cases in the second outbreak were infected directly from using mouthwash. The experience gained from the first outbreak and the formation of a multidisciplinary Infection Control Rapid Response Team resulted in more rapid recognition and control of the second outbreak. Multivariate analysis showed that older age, intensive care unit admission, and COVID-19 infection were independent predictors of mortality.

CONCLUSION

Burkholderia outbreaks at the time of COVID-19 were associated with high mortality. Rapid detection and response by a dedicated experienced team (as in the second outbreak) can reduce mortality and prevent superimposed cross-transmission between patients.

Burkholderia cepacia complex as a cause of community acquired bacteremia in a young immuncompetent male

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.

Outbreak investigation of NDM-producing Burkholderia cepacia causing neonatal sepsis in Pakistan

Aim: To investigate the outbreak of Burkholderia cepacia complex (BCC), mortality, antimicrobial resistance and associated risk factors in the neonatal intensive care unit. Method: Eighteen blood culture samples from neonates and twenty swab samples from different neonatal intensive care unit surfaces were collected. The VITEK 2 was used to confirm the isolates and generate the antibiogram. PCR was used to identify blaNDM. Results: Eighteen samples tested positive for BCC, and 10/18 (55.5%) of the neonates died. 13/18 (72%) of the neonates had late-onset neonatal sepsis, and 10/18 (55%) had low birth weight. Resistance to minocycline and chloramphenicol was 100%, 72.2% to meropenem; 72.2% NDM gene was found in neonates and was 20% from the environment. Conclusion: Outbreak of NDM-producing BCC resulting in high neonatal mortality in NICU.

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.

Single-Center Experience of Control of Ventilator-Circuit-Transmitted Burkholderia cepacia Outbreak in an Intensive Care Unit

Burkholderia cepacia is an emerging nosocomial pathogen frequently associated with outbreaks, but the exact transmission route of this pathogen can at times be elusive in spite of extensive environmental investigative cultures. Active surveillance for sputum cultures was performed for all patients from September 2008 to September 2009 in an intensive care unit (ICU) with B. cepacia outbreak. With evidence of persistent positive conversion of sputum cultures (colonization) and infections among patients, discontinuing re-usable ventilator circuits was introduced. A total of 689 patients were admitted to this unit for a mean duration of 8.7 ± 7.5 days. There were 489 patients (71.0%) with a stay for one to ten days; 161 (23.4%) patients for 11 to 20 days; and 39 (5.7%) with over 20 days. In the first group, 13.5% of patients had cultures converting from negative to positive, in contrast to 66.7% in the last group (p < 0.01). With intervention of using disposable ventilator circuits since June 2009, the incidence of isolated B. cepacia decreased gradually. The estimated 30-day isolation-free probabilities of the groups before, during, one month (August 2009) after, and two months (September 2009) after this intervention were 38.5%, 47.3%, 66.5%, and 96.0%, respectively (p < 0.01). Furthermore, the effect of discontinuing reusable ventilator circuit persisted in the following 6 years; both total isolates of B. cepacia and the infection caused by it were much lower compared to the outbreak period. In summary, this six-year outbreak in a medical ICU persisted until reusable ventilator circuits were discontinued in 2009. The effect of disposable circuits on the decreased incidence of B. cepacia infection maintained in the following years.

Clinical characteristics, drug resistance and death risk factors of Burkholderia cepacia infection in hematopoietic stem cell transplant patients

Background

Burkholderia cepacia (BC) has been detected more and more in infected patients in recent years. However, as a high-risk population, the clinical characteristics and prognosis of BC infection in hematopoietic stem cell transplantation (HSCT) patients have not been reported. The purpose of this study is to obtain data that will help fill in the gaps in this field, provide evidence for reducing the mortality rate of BC infection in HSCT patients, and guide the use of antibiotics in the future.

Methods

Electronic medical records of patients with BC infection who underwent HSCT in Xiangya Hospital of Central South University from September 1, 2015 to August 31, 2021 were collected. At the same time, 1:1 case–control matching was conducted according to gender, age and disease type. Comparisons between patients with/without BC infection and respiratory failure were made respectively, and the sensitivity of BC to five clinically commonly used antibiotics was also evaluated. Univariate and multivariate analyses were performed to identify independent risk factors for death.

Results

The most common site of BC infection in HSCT patients was the lung (75%). Although BC infection rate (3.74%) and antibiotic resistance were not significant, it was closely associated with a higher risk of death (P = 0.022), which even further increased to 90.9% when combined with respiratory failure (P = 0.008). Procalcitonin > 10 µg/L (HR = 40.88, 95% CI 6.51–256.63, P = 0.000) and septic shock (HR = 4.08, 95% CI 1.02–16.33, P = 0.047) were two independent risk factors for death.

Conclusion

HSCT patients with BC infection are in critical condition, and the management of respiratory infection should be especially strengthened to improve the prognosis of these patients.

Cluster of Burkholderia cepacia Complex Infections Associated with Extracorporeal Membrane Oxygenation Water Heater Devices

BACKGROUND

Burkholderia cepacia complex is a group of potential nosocomial pathogens often linked to contaminated water. We report on a cluster of 8 B.cepacia complex infections in cardiothoracic ICU patients attributed to contaminated ECMO water heaters.

METHODS

In December 2020, we identified an increase in B.cepacia complex infections in the cardiothoracic ICU at Brigham and Women's Hospital. We sought commonalities, sequenced isolates, obtained environmental specimens, and enacted mitigation measures.

RESULTS

Whole genome sequencing of 13 B.cepacia complex clinical specimens between November 2020-February 2021 identified 6 clonally related isolates, speciated as Burkholderia contaminans. All 6 occurred in patients on ECMO. Microbiology review identified two additional B.contaminans cases from June 2020, including one ECMO patient, that may have been cluster-related as well. All 8 definite/probable cluster cases required treatment; 3 died and 3 developed recurrent infections. After ECMO was identified as the major commonality, all 9 of the hospital's ECMO water heaters were cultured; all grew B.contaminans. Air sampling adjacent to the water heaters was culture-negative. Water heater touch screens were culture-positive for B.contaminans. The sink drain in the ECMO heater reprocessing room also grew clonal B.contaminans. Observations of reprocessing revealed opportunities for cross-contamination between devices via splash from the contaminated sink. The cluster was aborted by removing all water heaters from clinical service.

CONCLUSIONS

We identified a cluster of 8 B.cepacia complex infections associated with contaminated ECMO water heaters. This cluster underscores the potential risks associated with water-based ECMO heaters and, more broadly, water-based care for vulnerable patients.

Bacterial lectin BambL acts as a B cell superantigen

B cell superantigens crosslink conserved domains of B cell receptors (BCRs) and cause dysregulated, polyclonal B cell activation irrespective of normal BCR-antigen complementarity. The cells typically succumb to activation-induced cell death, which can impede the adaptive immune response and favor infection. In the present study, we demonstrate that the fucose-binding lectin of Burkholderia ambifaria, BambL, bears functional resemblance to B cell superantigens. By engaging surface glycans, the bacterial lectin activated human peripheral blood B cells, which manifested in the surface expression of CD69, CD54 and CD86 but became increasingly cytotoxic at higher concentrations. The effects were sensitive to BCR pathway inhibitors and excess fucose, which corroborates a glycan-driven mode of action. Interactome analyses in a model cell line suggest BambL binds directly to glycans of the BCR and regulatory coreceptors. In vitro, BambL triggered BCR signaling and induced CD19 internalization and degradation. Owing to the lectin's six binding sites, we propose a BCR activation model in which BambL functions as a clustering hub for receptor glycans, modulates normal BCR regulation, and induces cell death through exhaustive activation.

[Infection Prevention in the Intensive Care Unit (ICU)]

Secondary to the underlying disease, the need for invasive devices and frequent drug-induced changes in immunocompetence and microbiota, critically ill patients have a high risk of suffering nosocomial infections. According to data from the European Centre for Disease Prevention and Control (ECDC) this affects 8,4% of patients treated in an ICU for more than 48 hours. Key points of infection prevention are maintenance of the patients' microbiota and sometimes individually chosen interventions to its restoration or focused manipulation; development and implementation of care bundles for frequently used medical devices and invasive treatments (esp. intravenous catheters and invasive ventilation); adequate staffing not only for physicians, nurses and other medical staff but also for housekeeping staff, infection surveillance and motivational feedback, patient empowerment and visitor involvement. Functional building design and well organized logistics assist in achieving infection prevention goals by fostering adherence to basic hygiene procedure, esp. hand hygiene and risk-adjusted use of personal protective equipment. Daily interdisciplinary rounds following the principles of crew resource management strategies allow the structured check for unnecessary devices and inadequate use of antiinfective agents in particular and the discussion of all aspects of the patients' situation in general.