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Multistate Outbreak of Burkholderia cepacia Complex Bloodstream Infections After Exposure to Contaminated Saline Flush Syringes — United States, 2016–2017
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July 18 2019
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Source: Clin Infect Dis. 69(3):445-449
[PDF-326.29 KB]
Details:
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Alternative Title:Clin Infect Dis
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Description:Background:
Burkholderia cepacia complex (Bcc) has caused healthcare-associated outbreaks, often in association with contaminated products. The identification of four Bcc bloodstream infections (BSIs) in patients residing at a single skilled nursing facility (SNF) within one week led to an epidemiological investigation to identify additional cases and the outbreak source.
Methods:
A case was initially defined as a blood culture yielding Bcc in a SNF resident receiving intravenous therapy after August 1, 2016. Multistate notifications were issued to identify additional cases. Public health authorities performed site visits at facilities with cases to conduct chart reviews and identify possible sources. Pulsed-field gel electrophoresis (PFGE) was performed on isolates from cases and suspect products. Facilities involved in manufacturing suspect products were inspected to assess possible root causes.
Results:
An outbreak of 162 Bcc BSIs across 59 nursing facilities in 5 states occurred during September 2016–January 2017. Isolates from patients and pre-filled saline flush syringes were closely related by PFGE, identifying contaminated flushes as the outbreak source and prompting a nationwide recall. Inspection of facilities at the saline flush manufacturer identified deficiencies which might have led to the failure to sterilize a specific case containing a partial lot of product.
Conclusions:
Communication and coordination among key stakeholders, including healthcare facilities, public health authorities, and state and federal agencies, led to the rapid identification of an outbreak source and likely prevented many additional infections. Effective processes to ensure the sterilization of injectable products are essential to prevent similar outbreaks in the future.
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Pubmed ID:30346502
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Pubmed Central ID:PMC6476681
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Volume:69
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Issue:3
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