Ralstonia pickettii outbreak associated with contaminated distilled water used for respiratory care in a paediatric intensive care unit

Ralstonia pickettii bacteremia in a cardiac surgery patient in Belgrade, Serbia

Ralstonia pickettii is an opportunistic bacterium found in the water environment with an increasing incidence as a nosocomial pathogen. The objectives of this study were to describe R. pickettii bacteremia in a cardiac surgery patient and to evaluate its ability to grow in a saline solution and to form biofilm. The patient in this study underwent mitral and aortic valve replacement surgery with two aortocoronary bypasses. She developed signs of respiratory and renal failure, therefore hemodialysis was started. After 25 days in an intensive care unit, the patient had recurrent episodes of fever with signs of bacteremia. R. pickettii was identified from blood cultures by MALDI-TOF MS. Antimicrobial susceptibility testing was performed using disc diffusion and broth microdilution methods in accordance with EUCAST methodology and results were interpreted following clinical breakpoints for Pseudomonas spp. The isolate was susceptible to all tested antimicrobial agents except aminoglycosides and colistin. Survival of R. pickettii was analyzed in saline solution with four different starting concentrations at 25 °C and 37 °C for six days. Biofilm capacity was tested using the microtiter plate method. R. pickettii showed substantial growth in saline solution, with starting concentration of 2 CFU ml-1 reaching 107 CFU ml-1 after six days. There was no significant difference between growth at 25 °C and 37 °C. This indicates that storage of contaminated solutions at room temperature can enhance the count of R. pickettii. Our strain did not show the capacity to form biofilm. The patient responded well to adequate treatment with ceftazidime, and after 48 days in ICU she was discharged to convalesce.

The Role of a Rapid Prevention of Ralstonia pickettii Growth during Dialysis in a Frail Patient

Ralstonia pickettii is an opportunistic bacillus found in Pseudomonas species, with the ability to induce systemic infections. We report the case of a 69-year-old man, with a clinical history of myeloma, Type IIdiabetes, renal failure (grade IV), and colon cancer, that developed a severe bacterial infection, with acute asthenia and a fever, that appeared at the end of dialysis. Using theMALDI-TOF technology, the bacillus Ralstonia pickettii was identified, and an antimicrobial treatment was quickly started with a rapid microbiological remission.

Monoclonal outbreak of Ralstonia solanacearum catheter-related bloodstream infection associated with contaminated package of normal saline solution in a tertiary care hospital

Background/aim

Ralstonia solanacearum is a very rare cause of infection in humans. There is no described nosocomial outbreak due to R. solanacearum so far. We determined R. solanacearum as the source of catheter-related bloodstream infection (CRBSI) outbreak.

Materials and methods

This outbreak analysis was carried out in a 1000-bed tertiary care university hospital in Turkey. The outbreak analysis included hematology, oncology, nephrology, gastroenterology wards, emergency department, and intensive care units. The first case with R. solanacearum CRBSI was detected on May 20, 2019 and R. solanacearum was isolated in catheter blood cultures in 34 patients until October 3, 2019

Results

Standard outbreak analysis procedures were applied. Culture samples were taken from the fluids administered via catheters. The cultures did not yield any bacteria. As a result of the investigation in storage area, it was found that there were leaks, air bubbles, and water drops inside the packaging of saline solutions. R. solanacearum was yielded in the cultures obtained from the surface of saline bags and the inner sides of plastic packings. To validate our hypothesis, a clonal analysis was performed using arbitrarily primed-PCR method and Sanger sequencing of the 16S rRNA gene for identification among isolates. All R. solanacearum isolates were monoclonal and identical.

Conclusion

This is the first outbreak of R. solanacearum CRBSI described in a hospital setting. The source of the outbreak was a contamination in the surface of saline bags and the inner sides of plastic packings. Efficacy of an active surveillance system, accurate and rapid conduction of microbiological identification are essential for outbreak management.

Outbreaks of healthcare-associated infections linked to water-containing hospital equipment: a literature review

BACKGROUND

Healthcare-associated infections (HAIs) are a significant cause of morbidity and mortality in hospitalized patients. Water in the environment can be a source of infection linked to outbreaks and environmental transmission in hospitals. Water safety in hospitals remains a challenge. This article has summarized available scientific literature to obtain an overview of outbreaks linked to water-containing hospital equipment and strategies to prevent such outbreaks.

METHODS

We made a list of water-containing hospital equipment and devices in which water is being used in a semi-closed circuit. A literature search was performed in PubMed with a search strategy containing the names of these medical devices and one or more of the following words: outbreak, environmental contamination, transmission, infection. For each medical device, we summarized the following information: the function of the medical device, causes of contamination, the described outbreaks and possible prevention strategies.

RESULTS

The following water-containing medical equipment  or devices were identified: heater-cooler units, hemodialysis equipment, neonatal incubators, dental unit waterlines, fluid warmers, nebulizers, water traps, water baths, blanketrol, scalp cooling, and thermic stimulators. Of the latter three, no literature could be found. Of all other devices, one or more outbreaks associated with these devices were reported in the literature.

CONCLUSIONS

The water reservoirs in water-containing medical devices can be a source of microbial growth and transmissions to patients, despite the semi-closed water circuit. Proper handling and proper cleaning and disinfection can help to reduce the microbial burden and, consequently, transmission to patients. However, these devices are often difficult to clean and disinfect because they cannot be adequately opened or disassembled, and the manufacturer's cleaning guidelines are often not feasible to execute. The development of equipment without water or fluid containers should be stimulated. Precise cleaning and disinfection guidelines and instructions are essential for instructing healthcare workers and hospital cleaning staff to prevent potential transmission to patients.

An outbreak of Ralstonia pickettii bloodstream infection among pediatric leukemia patients

BACKGROUND

Ralstonia pickettii is an opportunistic waterborne microbe which can survive in many kinds of solutions. Contamination of these solutions may result as outbreaks, which can be mortal for immuncompromised patients. Herein we report an outbreak of R. pickettii related to contaminated saline infusion in our center.

METHODS

This study was conducted in Ankara Pediatric City Hospital. An outbreak occured in Pediatric Hematology and Oncology Unit between August 28, 2019 and September 13, 2019. When the outbreak occured, infection control team began an investigation. Environmental samples were collected in order to find the source of the outbreak.

RESULTS

A total of 11 patients with catheter related blood stream infection caused by R. pickettii who were diagnosed with leukemia were affected. None of the patients infected with R. pickettii died during the outbreak. A total of seventy environmental samples were cultured with the purpose of finding the source of outbreak. R. pickettii grew in normal saline solution culture and all isolates had the same clone of R. pickettii. The outbreak lasted two weeks and was controlled by stopping the usage and sending back the saline solutions belonging to the same manufacturing batch.

CONCLUSIONS

We reported an outbreak of R. pickettii BSIs in highly immunocompromised patients due to contaminated intravascular solution, which was rapidly controlled by infection control measures. Vigilant surveillance by hospital infection control teams and prompt investigation to identify the source of nosocomial infections are crucial to stop an outbreak.

Characterization of the Bacterial Biofilm Communities Present in Reverse-Osmosis Water Systems for Haemodialysis

Biofilm in reverse osmosis (RO) membranes is a common problem in water treatment at haemodialysis facilities. Bacteria adhere and proliferate on RO membranes, forming biofilms, obstructing and damaging the membranes and allowing the transfer of bacteria and/or cellular components potentially harmful to the health of haemodialysis patients. Our aim was to characterize the bacterial community associated to biofilm of RO membranes and to identify potentially pathogenic bacteria present in the haemodialysis systems of two dialysis centres in Chile. The diversity of the bacterial communities present on RO membranes and potable and osmosed water samples was evaluated using Illumina sequencing. Additionally, bacteria from potable water, osmosed water and RO membrane samples were isolated, characterized and identified by Sanger’s sequencing. The molecular analyses of metagenomics showed that the phyla having a greater relative abundance in both dialysis centres were Proteobacteria and Planctomycetes. Pseudomonas, Stenotrophomonas, Agrobacterium, Pigmentiphaga, Ralstonia, Arthrobacter, Bacteroides and Staphylococcus were bacterial genera isolated from the different samples obtained at both haemodialysis centres. Pseudomonas spp. was a bacterial genus with greater frequency in all samples. Pseudomonas and Staphylococcus showed higher levels of resistance to the antibiotics tested. Results demonstrated the presence of potentially pathogenic bacteria, showing resistance to antimicrobials on RO membranes and in osmosed water in both dialysis centres studied.

Gastric microbes associated with gastric inflammation, atrophy and intestinal metaplasia 1 year after Helicobacter pylori eradication

OBJECTIVE

Helicobacter pylori is associated with gastric inflammation, precancerous gastric atrophy (GA) and intestinal metaplasia (IM). We aimed to identify microbes that are associated with progressive inflammation, GA and IM 1 year after H. pylori eradication.

DESIGN

A total of 587 H. pylori-positive patients were randomised to receive H. pylori eradication therapy (295 patients) or placebo (292 patients). Bacterial taxonomy was analysed on 404 gastric biopsy samples comprising 102 pairs before and after 1 year H. pylori eradication and 100 pairs before and after 1 year placebo by 16S rRNA sequencing.

RESULTS

Analysis of microbial sequences confirmed the eradication of H. pylori in treated group after 1 year. Principal component analysis revealed distinct microbial clusters reflected by increase in bacterial diversity (p<0.00001) after H. pylori eradication. While microbial interactions remained largely unchanged after placebo treatment, microbial co-occurrence was less in treated group. Acinetobacter lwoffii, Streptococcus anginosus and Ralstonia were enriched while Roseburia and Sphingomonas were depleted in patients with persistent inflammation 1 year after H. pylori eradication. A distinct cluster of oral bacteria comprising Peptostreptococcus, Streptococcus, Parvimonas, Prevotella, Rothia and Granulicatella were associated with emergence and persistence of GA and IM. Probiotic Faecalibacterium praustznii was depleted in subjects who developed GA following H. pylori eradication. Functional pathways including amino acid metabolism and inositol phosphate metabolism were enriched while folate biosynthesis and NOD-like receptor signalling decreased in atrophy/IM-associated gastric microbiota.

CONCLUSION

This study identified that gastric microbes contribute to the progression of gastric carcinogenesis after H. pylori eradication.

A case of persistent bacteraemia by Ralstonia mannitolilytica and Ralstonia pickettii in an intensive care unit

The Ralstonia spp. genus is a group of non-fermentative, Gram-negative bacteria often resistant to many antibiotics, which are emerging as opportunistic pathogens frequently associated with infections in hospital settings. We present herein a case of combined R. pickettii and R. mannitolilytica persisting and relapsing bacteraemia, possibly caused by a septic arterial thrombosis secondary to the rupture of an internal carotid artery aneurysm. Microbiology studies showed that both Ralstonia isolates produced biofilm and carried class D oxacillinase genes. When confronted with infections caused by members of the Ralstonia genus, identification to the species level is crucial for correct clinical management, as the two species show different antibiotic susceptibility patterns.

Outbreak of nonfermentative Gram-negative bacteria (Ralstonia pickettii and Stenotrophomonas maltophilia) in a hemodialysis center

We report a case series of seven patients with nonfermentative Gram-negative bacteria infections in a single dialysis center; four patients with Ralstonia pickettii and three patients with Stenotrophomonas maltophilia. Two of the seven patients were admitted to hospital for intravenous antibiotic treatment, while the rest were treated with oral antibiotics at home. Both the admitted patients had temporary vascular catheter infections from the aforementioned pathogens. We conclude that the outbreak is due to colonization of treated reverse osmosis water, presumably through contamination via polluted filters and compounded by the usage of reprocessed dialysers in the dialysis center. This is especially relevant because contaminated treated water is directly introduced into the blood compartment of the dialysers during reprocessing. In addition, there seems to be a propensity for both organisms to cause prolonged febrile reactions in patients with temporary vascular catheters, likely through the early development of biofilm. Intensification of general sterilization procedures, servicing and replacement of old decrepit components of the water treatment system and temporary cessation of dialyser reuse practice seem to have halted the outbreak. Due to the virulent nature and difficult resistant profile of nonfermentative Gram-negative bacteria, we strongly recommend meticulous vigilance in the surveillance of culture isolates in routine microbiological specimens from dialysis centers, especially if there is a senescent water treatment system and a practice of reprocessing dialysers.

Draft Genome Sequence and Annotation of the Phytopathogenic Ralstonia pickettii (Previously Burkholderia glumae) Strain ICMP-8657

Strain ICMP-8657 was formerly taxonomically classified as Burkholderia glumae and reported to be the producer of an antibacterial pyrazole derivative. Here, we report the draft genome sequence of ICMP-8657, which failed to demonstrate the biosynthetic capacity to produce the stated antibacterial compound, leading to its taxonomic reclassification as Ralstonia pickettii ICMP-8657.

Ralstonia species - do these bacteria matter in cystic fibrosis?

Ralstonia species, often regarded as an environmental organism of low pathogenicity, can cause significant disease in certain at-risk patient groups, including those with cystic fibrosis. Difficulties with its identification in the clinical laboratory mean that it may be misidentified and therefore under recognised as a cause of disease. A number of outbreaks have been associated with the use of devices for inhaled respiratory therapy, putting those with chronic respiratory conditions at risk. Antimicrobial treatment of infection is challenging and limited due to frequent antimicrobial resistance. This review highlights issues regarding the identification, treatment and prevention of infection due to Ralstonia spp. in children with cystic fibrosis.

An Outbreak of Ralstonia pickettii Bloodstream Infection Associated with an Intrinsically Contaminated Normal Saline Solution

OBJECTIVE Ralstonia pickettii has caused contamination of pharmaceutical solutions in many countries, resulting in healthcare infections or outbreak events. We determined the source of the outbreak of R. pickettii bloodstream infection (BSI). METHODS This study was conducted in a 3,000-bed tertiary referral medical center in Taiwan with >8,500 admissions during May 2015. Patients had been treated in the injection room or chemotherapy room at outpatient departments, emergency department, or hospital wards. All patients who were culture positive for R. pickettii from May 3 to June 11, 2015, were eligible for the study. The aim of the survey was to conduct clinical epidemiological and microbiological investigations to identify possible sources of infection. RESULTS We collected 57 R. pickettii-positive specimens from 30 case patients. We performed 24 blood cultures; 14 of these revealed >2 specimens and 6 used fluid withdrawn from Port-a-Cath implantable venous access devices. All patients received an injection of 20 mL 0.9% normal saline via catheter flushing. In addition, 2 unopened ampules of normal saline solution (20 mL) were confirmed positive for R. pickettii. The Taiwan Centers for Disease Control and Prevention performed sampling and testing of the same manufactured batch and identified the same strain of R. pickettii. Pulsed-field gel electrophoresis tests revealed that all clinical isolates had similarity of >90%, validating the outbreak of the same clone of R. pickettii. CONCLUSIONS R. pickettii can grow in saline solutions and cause bloodstream infections. Hospital monitoring mechanisms are extremely important measures in identifying and ending such outbreaks. Infect Control Hosp Epidemiol 2017;38:444-448.

Native Valve Endocarditis due to Ralstonia pickettii: A Case Report and Literature Review

Ralstonia pickettii is a rare pathogen and even more rare in healthy individuals. Here we report a case of R. pickettii bacteremia leading to aortic valve abscess and complete heart block. To our knowledge this is the first case report of Ralstonia species causing infective endocarditis with perivalvular abscess.

Aetiology, source and prevention of waterborne healthcare-associated infections: a review

The purpose of this review is to discuss the scientific literature on waterborne healthcare-associated infections (HCAIs) published from 1990 to 2012. The review focuses on aquatic bacteria and describes both outbreaks and single cases in relation to patient characteristics, the settings and contaminated sources. An overview of diagnostic methods and environmental investigations is summarized in order to provide guidance for future case investigations. Lastly, on the basis of the prevention and control measures adopted, information and recommendations are given. A total of 125 reports were included, 41 describing hospitalized children. All cases were sustained by opportunistic pathogens, mainly Legionellaceae, Pseudomonadaceae and Burkholderiaceae. Hot-water distribution systems were the primary source of legionnaires’ disease, bottled water was mainly colonized by Pseudomonaceae, and Burkholderiaceae were the leading cause of distilled and sterile water contamination. The intensive care unit was the most frequently involved setting, but patient characteristics were the main risk factor, independent of the ward. As it is difficult to avoid water contamination by microbes and disinfection treatments may be insufficient to control the risk of infection, a proactive preventive plan should be put in place. Nursing staff should pay special attention to children and immunosuppressed patients in terms of tap-water exposure and also their personal hygiene, and should regularly use sterile water for rinsing/cleaning devices.

Draft Genome Sequences of Ralstonia pickettii Strains SSH4 and CW2, Isolated from Space Equipment

Ralstonia pickettii SSH4 and CW2 were isolated from space equipment. Here, we report their draft genome sequences with the aim of gaining insight into their potential to adapt to these environments.

The antibiotic susceptibility of water-based bacteria Ralstonia pickettii and Ralstonia insidiosa

Ralstonia pickettii and Ralstonia insidiosa are waterborne bacteria that can survive and grow in various water sources, and that are emerging pathogens in hospital settings. Not much is known about the antibiotic resistance of these bacteria. Previous reports of antimicrobial susceptibility have been largely limited to a few clinical strains with no accounting for genotypic or phenotypic diversity or that these species could vary from the set breakpoints. Etests and disc diffusion tests were carried out to compare the antimicrobial susceptibilities to 12 different antibiotics of 68 different isolates of R. pickettii (53) and R. insidiosa (15) from varying environments, which have previously been well characterized both phenotypically and genetically. The majority of the R. pickettii and R. insidiosa isolates showed susceptibility to most of the antibiotics tested in this study. The most effective were found to be the quinolones and sulfamethoxazole/trimethoprim. Antibiotic susceptibility was also found not to vary between environmental niches for R. pickettii and R. insidiosa isolates.

Bacteria from drinking water supply and their fate in gastrointestinal tracts of germ-free mice: a phylogenetic comparison study

Microorganisms in drinking water sources may colonize in gastrointestinal (GI) tracts and this phenomenon may pose a potential health risk especially to immunocompromised population. The microbial community diversity of the drinking water was compared with the GI tracts of the mice using phylogenetic and statistical analyses of 16S rRNA gene sequences. A group of germ-free mice were fed with drinking water from public water supply that passed through an automated watering system with documented biofilm accumulation. From drinking water and GI tracts of the germ-free mice, 179 bacteria were isolated and 75 unique 16S rRNA gene phylotypes were sequenced as operational taxonomic unit (OTU, >97% similarity). Three major groups of the genus Acidovorax (21%), Variovorax (42%) and Sphingopyxis (15%) were found in drinking water. Three major groups of the genus Ralstonia (24%), Staphylococcus (20%) and Bosea (22%) were found in GI tracts. Ralstonia (6%, 24%), Sphingopyxis (15%, 2%), Bacillus (3%, 5%), Escherichia coli (3%, 2%) and Mesorhizobium (3%, 5%) were found in both sources - drinking water and GI tract. A lineage-per-time plot shows that the both bacterial communities have convex shape lines, suggesting an excess of closely related ecotypes. A significant F(ST) test (0.00000-0.00901) coupled with an insignificant P test (0.07-0.46) implies that the tree contained several clades of closely related bacteria. Both phylogenetic and statistical results suggest a correlation between the bacterial communities originating in the drinking water and those associated with the GI tracts. The GI tract showed a higher genetic diversity than the drinking water, but a similar lineage-per-time plot was obtained overall. It means a sudden evolutionary transformation and colonization occurred with high selective forces.

A national outbreak of Ralstonia mannitolilytica associated with use of a contaminated oxygen-delivery device among pediatric patients

OBJECTIVES

In August 2005, the Centers for Disease Control and Prevention was notified of a Ralstonia species outbreak among pediatric patients receiving supplemental oxygen therapy with the Vapotherm 2000i (Vapotherm, Inc, Stevensville, MD). The Vapotherm 2000i is a reusable medical device that was used in >900 hospitals in the United States in 2005. Ralstonia are waterborne bacilli that have been implicated in hospital-acquired infections. We initiated an investigation to determine the source of the outbreak and implement infection control and prevention measures.

PATIENTS AND METHODS

We performed a case-control study at 1 hospital and conducted national case findings to obtain clinical and environmental samples for laboratory analysis. Case-patients had health care-acquired Ralstonia colonization or infection. Isolates were compared by using pulsed-field gel electrophoresis. We tested manufacturer-recommended disinfection protocols for the Vapotherm 2000i under simulated-use conditions.

RESULTS

Case-patients at the hospital (n = 5) were more likely to have received Vapotherm therapy than controls. Nationally, Ralstonia mannitolilytica was confirmed in 38 patients (aged 5 days to 7 years); 35 (92%) of the patients were exposed to the Vapotherm 2000i before recovery of the organism. Pulsed-field gel electrophoresis showed related R. mannitolilytica strains from isolates sent from 18 hospitals in 12 states. A Vapotherm machine reprocessed with a protocol proposed by the manufacturer grew Ralstonia spp after 7 days of simulated use. In December 2005, Vapotherm recalled the 2000i.

CONCLUSIONS

Our findings suggest intrinsic contamination of Vapotherm devices with Ralstonia spp. New medical devices may provide therapy equivalent to current devices yet pose novel reprocessing challenges.

Ostéite du trapèze à Ralstonia pickettii : à propos d'un cas et revue de la littérature

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.

Two cases of Ralstonia pickettii bacteremias in a pediatric oncology unit requiring removal of the Port-A-Caths

Ralstonia pickettii is an aerobic, gram-negative bacterium causing bacteremia following the use of contaminated saline vials, respiratory therapy solutions, skin disinfectants, blood culture mediums, and water supplies. It is rarely associated with human infections. The authors report two cases of R. pickettii bacteremia in patients with Port-A-Caths that could be treated only by removal of the ports.