Burkholderia cepacia lower respiratory tract infection associated with exposure to a respiratory therapist

Updates on Infection Control in Alternative Health Care Settings

Patients increasingly receive care from a large spectrum of different settings, placing them at risk for exposure to pathogens by many different sources. Each health care environment has its own specific challenges, and thus infection control programs must be tailored to each specific setting. High-turnover outpatient settings may require additional considerations, such as establishing patient triage and follow-up protocols, and broadened cleaning and disinfection procedures. In nursing homes, infection control programs should focus on surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

The Role of Patient Care Items as a Fomite in Healthcare-Associated Outbreaks and Infection Prevention

Patient-care items can serve as a source or reservoir for healthcare-associated pathogens in hospitals. We reviewed healthcare- associated outbreaks from medical equipment and provide infection prevention recommendations. Multiple healthcare-associated outbreaks via a contaminated patient-care item were identified, including infections with multidrug-resistant organisms. The type of patient care items implicated as a fomite causing healthcare-associated infections (HAIs) has changed over time. Patient populations at risk were most commonly critically ill patients in adult and neonatal intensive care units. Most fomite related healthcare-associated outbreaks were due to inappropriate disinfection practices. Repeated healthcare-associated outbreaks via medical equipment highlight the need for infectious disease professionals to understand that fomites/medical devices may be a source of HAIs. The introduction of new and more complex medical devices will likely increase the risk that such devices serve as a source of HAIs. Assuring appropriate cleaning and disinfection or sterilization of medical equipment is necessary to prevent future fomite-associated outbreaks.

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.

Infection Control in Alternative Health Care Settings: An Update

With changing health care delivery, patients receive care at various settings including acute care hospitals, nursing homes, outpatient primary care and specialty clinics, and at home, exposing them to pathogens in various settings. Various health care settings face unique challenges, requiring individualized infection control programs. Infection control programs in nursing homes should address surveillance for infections and antimicrobial resistance, outbreak investigation and control plan for epidemics, isolation precautions, hand hygiene, staff education, and employee and resident health programs.

Infection Prevention and Control Guideline for Cystic Fibrosis: 2013 Update

The 2013 Infection Prevention and Control (IP&C) Guideline for Cystic Fibrosis (CF) was commissioned by the CF Foundation as an update of the 2003 Infection Control Guideline for CF. During the past decade, new knowledge and new challenges provided the following rationale to develop updated IP&C strategies for this unique population:

1.The need to integrate relevant recommendations from evidence-based guidelines published since 2003 into IP&C practices for CF. These included guidelines from the Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control Practices Advisory Committee (HICPAC), the World Health Organization (WHO), and key professional societies, including the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). During the past decade, new evidence has led to a renewed emphasis on source containment of potential pathogens and the role played by the contaminated healthcare environment in the transmission of infectious agents. Furthermore, an increased understanding of the importance of the application of implementation science, monitoring adherence, and feedback principles has been shown to increase the effectiveness of IP&C guideline recommendations.

2.Experience with emerging pathogens in the non-CF population has expanded our understanding of droplet transmission of respiratory pathogens and can inform IP&C strategies for CF. These pathogens include severe acute respiratory syndrome coronavirus and the 2009 influenza A H1N1. Lessons learned about preventing transmission of methicillin-resistantStaphylococcus aureus(MRSA) and multidrug-resistant gram-negative pathogens in non-CF patient populations also can inform IP&C strategies for CF.

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.

Risk Factors forBurkholderia cepaciaComplex Bacteremia Among Intensive Care Unit Patients Without Cystic Fibrosis: A Case-Control Study

Background.

TheBurkholderia cepaciacomplex is associated with colonization or disease in patients with cystic fibrosis (CF). For patients without CF, this complex is poorly understood apart from its presence in occasional point source outbreaks.

Objective.

To investigate risk factors forB. cepaciabacteremia in hospitalized, intensive care unit patients without CF.

Methods.

We identified patients with 1 or more blood cultures positive forB. cepaciabetween May 1, 1996, and March 31, 2002, excluding those with CF. Control patients were matched to case patients by ward, duration of hospitalization, and onset date of bacteremia. Matched analyses were used to identify risk factors forB. cepaciabacteremia.

Results.

We enrolled 40 patients withB. cepaciabacteremia into the study. No environmental or other point source forB. cepaciacomplex was identified, although horizontal spread was suspected. Implementation of contact precautions was effective in decreasing the incidence ofB. cepaciabacteremia. We selected 119 matched controls. Age, sex, and race were similar between cases and controls. In multivariable analysis, renal failure that required dialysis, recent abdominal surgery, 2 or more bronchoscopic procedures before detection ofB. cepaciabacteremia, tracheostomy, and presence of a central line before detection ofB. cepaciabacteremia were independently associated with development ofB. cepaciabacteremia, whereas presence of a percutaneous feeding tube was associated with a lower risk of disease.

Conclusions.

B. cepaciacomplex is an important emerging group of nosocomial pathogens in patients with and patients without CF. Nosocomial spread is likely facilitated by cross-transmission, frequent pulmonary procedures, and central venous access. Infection control measures appear useful for limiting the spread of virulent, transmissible clones ofB. cepaciacomplex.

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.

The changing microbial epidemiology in cystic fibrosis

Infection of the airways remains the primary cause of morbidity and mortality in persons with cystic fibrosis (CF). This review describes salient features of the epidemiologies of microbial species that are involved in respiratory tract infection in CF. The apparently expanding spectrum of species causing infection in CF and recent changes in the incidences and prevalences of infection due to specific bacterial, fungal, and viral species are described. The challenges inherent in tracking and interpreting rates of infection in this patient population are discussed.

Infection control in cystic fibrosis: cohorting, cross-contamination, and the respiratory therapist

Cystic fibrosis (CF) is a complex genetic disease characterized by lung infections that lead to early morbidity and death. Pathogens that commonly infect the lungs of patients with CF include Staphylococcus aureus, Haemophilus influenzae, Pseudomonas aeruginosa, and Burkholderia cepacia. Aggressively treating pulmonary infection with antibiotics has contributed to improved survival in patients with CF but has also promoted multiple-drug-resistant bacteria. Other complexities include the ability of bacteria to form biofilms, which makes them more resistant to antibiotics, and emerging pathogens in CF, of which the clinical importance is not yet clear. Increasing evidence of patient-to-patient transmission of CF pathogens led the Cystic Fibrosis Foundation to produce evidence-based infection-control recommendations, which stress 4 principles: standard precautions, transmission-based precautions, hand hygiene, and care of respiratory equipment. Respiratory therapists need to know and follow these infection-control recommendations. Cohorting patients infected with B. cepacia complex is one of several interventions successful at keeping the spread of this pathogen low, but cohorting patients who are infected/colonized with other microbes is controversial, the main argument of which is not being certain of a patient's present respiratory culture status at any given patient visit.

Infection Control Practice in Cystic Fibrosis Centers

In this article, the authors outline some of the major historical events that signaled the need to better understand mechanisms of infection in cystic fibrosis (CF). The authors discuss general principles of infection control, focusing on issues of particular importance to patients who have CF. The authors also describe the major pathogens associated with the CF airway, provide a review of findings from inpatient and outpatient studies of infection control, and provide an outline of future directions for investigation.

Hospital-acquired infections related to contaminated substances

Drug-related outbreaks are frequently reported from various medical departments. A systematic review was performed to describe characteristics of these outbreaks and to determine the most frequent occasions in which contamination of substances for patient care take place. Articles were assessed by a search of the outbreak database, a search of PubMed, and hand search of reference lists from relevant articles. Articles published before 1990 were excluded. Data on affected patients, hospital-acquired infections, substances, pathogens and graded information about the location of the contamination incidence were extracted. A total of 2250 patients in 128 articles were included, mostly from intensive care units or haematological departments. Septicaemia was the most frequent hospital-acquired infection. Most often articles report contamination of blood products and heparin-sodium chloride solutions. The most frequent pathogens were hepatitis A virus, Yersinia enterocolitica, and Serratia spp. for blood products and Burkholderia cepacia and Enterobacter spp. for substances other than blood products. Mortality was highest if red blood cells or total parenteral nutrition formulas were contaminated. In 64 of the outbreaks multi-dose vials had been used against the manufacturers' recommendations. Thus, drug-related outbreaks are likely to occur particularly when basic hygiene measures are disobeyed. A large proportion of drug-related nosocomial infections could have been prevented, for example, by avoiding the use of multi-dose vials.

An Outbreak of Burkholderia cepacia Associated With Contamination of Albuterol and Nasal Spray

BACKGROUND

Species within the Burkholderia cepacia complex (Bcc) can contaminate medications and disinfectants and cause severe pneumonia in critically ill patients or persons with cystic fibrosis. In March 2004, we investigated a hospital outbreak of Bcc possibly associated with a contaminated nasal spray.

METHODS

We conducted a matched case-control study, environmental sampling, and observations of infection control practices. Case patients had infection or colonization with Bcc, and control patients had sputum culture not yielding Bcc. Isolates from patients and environmental samples were compared by pulsed-field gel electrophoresis (PFGE).

RESULTS

Bcc was recovered from sputum in 18 patients. Compared with matched control patients (n = 18), case patients were more likely to be receiving mechanical ventilation (p = 0.01), to have been hospitalized > 6 days (p = 0.01), and to have received antimicrobial treatment within 7 days before sputum collection (p = 0.03). Bcc was cultured from opened, but not unopened, multidose albuterol bottles, a nebulizer attached to a ventilator, and opened and unopened nasal spray bottles from contaminated lots. PFGE showed that isolates from albuterol samples and from patients were indistinguishable but unrelated to the nasal spray strain. Observations revealed improper aseptic techniques during respiratory therapy procedures and inadequate nebulizer cleaning.

CONCLUSIONS

Despite a temporal association with use of a contaminated nasal spray, this outbreak was caused by extrinsic contamination of multidose albuterol used for nebulization treatments and lack of adherence to infection control precautions. Implementation and re-enforcement of infection control measures successfully terminated the outbreak.

[Epidemiology of nosocomial infections due to Pseudomonas aeruginosa, Burkholderia cepacia and Stenotrophomonas maltophilia]

Non-fermentative Gram negative rods are opportunistic pathogens responsible for nosocomial infections. Using phenotypic markers (serotypes for Pseudomonas aeruginosa and antibiotic susceptibility) allows a preliminary screening of epidemiologically-related strains. However, genotypic markers are necessary to better characterize nosocomial strains for the investigation of outbreaks or cross-transmissions in the hospital setting. Infections due to P. aeruginosa, Burkholderia. cepacia or Stenotrophomonas. maltophilia are usually hospital-acquired and responsible for a high mortality rate as illustrated by the lethality of nosocomial pneumonia due to P. aeruginosa. The severity of these infections is due to the virulence factors of the bacteria and to their occurrence in debilitated patients in whom invasives devices are used. The hospital environment can act as a reservoir with a rate of exogeneous transmission of these bacteria as high as 50% in some studies. To better prevent nosocomial infections related to Gram negative non fermentative rods, the control of the aqueous hospital environment, the strict application of hand disinfection and the investigation of potential cross-transmission in the hospital setting are needed.

Prevention of hospital-associated pneumonia and ventilator-associated pneumonia

OBJECTIVE

To synthesize the available clinical data for the prevention of hospital-associated pneumonia (HAP) and ventilator-associated pneumonia (VAP) into a practical guideline for clinicians.

DATA SOURCE

A Medline database and references from identified articles were used to perform a literature search relating to the prevention of HAP/VAP.

CONCLUSIONS

There is convincing evidence to suggest that specific interventions can be employed to prevent HAP/VAP. The evidence-based interventions focus on the prevention of aerodigestive tract colonization (avoidance of unnecessary antibiotics and stress ulcer prophylaxis, use of sucralfate for stress ulcer prophylaxis, chlorhexidine oral rinse, selective digestive decontamination, short-course parenteral prophylactic antibiotics in high-risk patients) and the prevention of aspiration of contaminated secretions (preferred oral intubation, appropriate intensive care unit staffing, avoidance of tracheal intubation with the use of mask ventilation, application of weaning protocols and optimal use of sedation to shorten the duration of mechanical ventilation, semirecumbent positioning, minimization of gastric distension, subglottic suctioning, avoidance of ventilator circuit changes/manipulation, routine drainage of ventilator circuit condensate). Clinicians caring for patients at risk for HAP/VAP should promote the development and application of local programs encompassing these interventions based on local resource availability, occurrence rates of HAP/VAP, and the prevalence of infection due to antibiotic-resistant bacteria (Pseudomonas aeruginosa, Acinetobacter species, and methicillin-resistant Staphylococcus aureus).

Virulence Associated with Outbreak-Related Strains of Burkholderia cepacia Complex among a Cohort of Patients with Bacteremia

The Burkholderia cepacia complex includes 9 genomovars. The relative virulence of each is unknown. Host and pathogen features associated with mortality were evaluated among patients with B. cepacia complex bacteremia. Cases were ascertained through review of blood culture results for the period of May 1996 through May 2002. Isolates were identified to species level with 16S rDNA and recA-based species-specific polymerase chain reaction analyses and recA restriction fragment-length polymorphism. Strain typing was performed with pulsed-field gel electrophoresis. Fifty-three patients with B. cepacia complex bacteremia were identified; only 9 (17%) had cystic fibrosis. Twenty-five patients (47%) died within 14 days of bacteremia. After controlling for comorbid conditions and therapeutic interventions, 2 outbreak-related strains of Burkholderia cenocepacia (genomovar III) were associated with 14-day mortality (odds ratio, 5.5; 95% confidence interval, 1.20-25.02). B. cenocepacia is an emerging nosocomial pathogen. Certain strains are associated with an enhanced capacity for interpatient spread and poor outcome.

Infection control in cystic fibrosis

Over the past 20 years there has been a greater interest in infection control in cystic fibrosis (CF) as patient-to-patient transmission of pathogens has been increasingly demonstrated in this unique patient population. The CF Foundation sponsored a consensus conference to craft recommendations for infection control practices for CF care providers. This review provides a summary of the literature addressing infection control in CF. Burkholderia cepacia complex, Pseudomonas aeruginosa, and Staphylococcus aureus have all been shown to spread between patients with CF. Standard precautions, transmission-based precautions including contact and droplet precautions, appropriate hand hygiene for health care workers, patients, and their families, and care of respiratory tract equipment to prevent the transmission of infectious agents serve as the foundations of infection control and prevent the acquisition of potential pathogens by patients with CF. The respiratory secretions of all CF patients potentially harbor clinically and epidemiologically important microorganisms, even if they have not yet been detected in cultures from the respiratory tract. CF patients should be educated to contain their secretions and maintain a distance of >3 ft from other CF patients to avoid the transmission of potential pathogens, even if culture results are unavailable or negative. To prevent the acquisition of pathogens from respiratory therapy equipment used in health care settings as well as in the home, such equipment should be cleaned and disinfected. It will be critical to measure the dissemination, implementation, and potential impact of these guidelines to monitor changes in practice and reduction in infections.

Épidémie nosocomiale à Burkholderia cepacia dans une unité de réanimation infantile

BACKGROUND

We report an outbreak of Burkholderia cepacia respiratory tract infection and colonization in an intensive pediatric care unit.P PATIENTS AND METHODS: Between February and December 1999, B. cepacia was isolated from five children hospitalized in this unit. We reviewed the charts of the patients, evaluated the antiseptics use and the disinfection practices for reusable patient care equipment. An environmental study was conducted and comparison of B. cepacia was performed with genotypic method (RAPD).

RESULTS

All patients were mechanically ventilated and had received large spectrum antibiotics. The disinfection procedure for reusable equipment was not respected and some single-dose of antiseptics solutions were used for several patients. B. cepacia was not found in 34 environmental samples. The RAPD assay revealed that all five isolates had identical DNA profiles.

CONCLUSION

Despite the investigation the source of the B. cepacia clone in this nosocomial outbreak remained unknown, but antiseptics use and disinfection practices were revised. No new B. cepacia infections were identified after control measures were implemented.

Polyclonal outbreak of Burkholderia cepacia complex bacteraemia in haemodialysis patients

We report a polyclonal outbreak of bacteraemia involving 24 patients at a haemodialysis facility in Recife (Brazil). During the outbreak period (4 June to 11 July, 2001), three Burkholderia cepacia complex strains were isolated from human blood and from various water samples collected at different sites in the haemodialysis unit and from dialysate fluids. Out of 14 patients with positive blood cultures, six were infected by Burkholderia cepacia complex bacteria: three with Burkholderia cepacia genomovar III, two with a first strain of Burkholderia vietnamiensis, and one with the Burkholderia cepacia genomovar III strain and a second B. vietnamiensis strain.

Infection control recommendations for patients with cystic fibrosis: microbiology, important pathogens, and infection control practices to prevent patient-to-patient transmission

Infection Control Recommendations for Patients With Cystic Fibrosis: Microbiology, Important Pathogens, and Infection Control Practices to Prevent Patient-to-Patient Transmissionupdates, expands, and replaces the consensus statement,Microbiology and Infectious Disease in Cystic Fibrosispublished in 1994. This consensus document presents background data and evidence-based recommendations for practices that are intended to decrease the risk of transmission of respiratory pathogens among CF patients from contaminated respiratory therapy equipment or the contaminated environment and thereby reduce the burden of respiratory illness. Included are recommendations applicable in the acute care hospital, ambulatory, home care, and selected non-healthcare settings. The target audience includes all healthcare workers who provide care to CF patients. Antimicrobial management is beyond the scope of this document.

Contamination of trypan blue with Burkholderia cepacia in a cornea bank

OBJECTIVE

To describe Burkholderia cepacia contamination of a cornea bank and the measures taken to identify and eliminate the source of infection.

METHODS

Cultures were performed to assess the extent and source of contamination, and pulsed-field gel electrophoresis was used for molecular typing.

RESULTS

Routine surveillance cultures identified 5 contaminated corneas during a 10-day period. Additional cultures showed that 28 of 88 samples were positive for this organism. Environmental investigation showed that an open bottle of trypan blue used to assess corneal morphology was contaminated with the epidemic strain.

CONCLUSION

Trypan blue played a major role in this contamination of corneas. This episode shows that microbial contamination can affect transplanted corneas despite ongoing culture surveillance and suggests that new methods may be needed to avoid this risk.

Nosocomial pneumonia: emerging concepts in diagnosis, management, and prophylaxis

Nosocomial pneumonia is a dynamic disease with multiple etiologic agents and a changing natural history. The highest attack rates and mortality occur in patients with ventilator-associated pneumonia. Diagnosis of nosocomial pneumonia is often made by clinical criteria that are sensitive but lack specificity. The use of quantitative endotracheal aspirates or bronchoscopy with bronchoalveolar lavage and protected specimen brush clearly improve diagnostic specificity and outcome in patients who are mechanically ventilated. The rapid spread of multidrug-resistant, spp, and has made initial empiric therapy more difficult. Management principles include the use of techniques for more accurate diagnosis and early antimicrobial therapy with appropriate agents along with careful analysis of culture results, clinical response, and potential complications of pneumonia and therapy. Strategies for prophylaxis are of critical importance for risk reduction, improvement in patient outcome, and reduction of hospital costs.