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B. cepacia outbreak yields pointers for multi-institutional response

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February 21, 2017

A 2016 outbreak of Burkholderia cepacia has left clinicians with lessons on an effective response, including sharing information among facilities and the value of a national laboratory identifying species, researchers reported.

The study published in Infection Control and Hospital Epidemiology reviewed steps taken when patients at Texas Children’s Hospital in Houston were among at least 60 nationwide to contract B. cepacia. The investigation by hospital officials and others identified a brand of liquid docusate, a stool softener, as the disease source.

“Using a multidisciplinary approach and by sharing information with other institutions, our detailed investigation stopped short a national outbreak of B. cepacia,” study researcher Lucila Marquez, MD, MPH, said in a news release.

“This work also provided our team an opportunity to improve our infection prevention practices for the care of all patients.”

B. cepacia commonly infects patients with cystic fibrosis and rarely affects healthy hosts. Yet, none of the 24 patients infected at the Houston hospital between February 8 and July 4 had cystic fibrosis, the researchers said.

Seventeen of those patients had symptomatic infections, whereas seven were colonized. The median patient age was 22.5 months, with a range of 2 to 148 months, and all patients had chronic conditions.

Twenty-one of the patients had the same strain of B. cepacian, and the bacteria in the other three patients showed unique molecular patterns.

The early response included audits of safety and hygiene practices, among other measures. “After B. cepacia complex was identified in a stool specimen from a case, we expanded the investigation to include potential sources of transmission including oral care products, feedings and medications,” researchers wrote.

Investigators tested specimens at the Houston hospital and sent isolates to the University of Michigan Burkholderia cepacia Research Laboratory and Repository, where the outbreak strain was identified as a novel species.

On May 3, staff of the Michigan laboratory reported that another pediatric facility had found isolates of the bacteria matching the Houston hospital’s outbreak strain.

“The best explanation for a shared novel strain among two pediatric institutions that are geographically separated would be an intrinsically contaminated product used at both sites,” the researchers concluded.

The hospital notified city and state health officials, along with the CDC. On June 22, they learned that B. cepacia matching the outbreak strain had been found in unopened syringes of liquid docusate from manufacturer PharmaTech.

That day, they took steps to prevent further use of liquid docusate in the hospital, including a quarantine of the product.

The FDA in July announced PharmaTech had issued a voluntary nationwide recall of its Diocto brand docusate, which had been distributed by Rugby Laboratories.

By Aug. 10, the CDC had identified 60 cases of B. cepacia in eight states.

“This number is likely a gross underestimate because many facilities may not have saved isolates for confirmatory typing,” the researchers wrote.

Among other takeaways, they learned that “a multidisciplinary approach to outbreak investigation is essential in identifying a source and successful interventions … and nonsterile products, medications or others should be used with great caution in vulnerable patient populations.” – by Joe Green

Disclosure: The researchers report no relevant financial disclosures.

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L. Silvia Munoz-Price
L. Silvia Munoz-Price

This article reminds me of the reason I got interested in hospital epidemiology in the first place — investigative work, answering the question, “Why are we observing such an unusual situation?”

The capacity to answer the “why” question is truly what brings value to the role of a hospital epidemiologist.

Many times during our careers, we will experience sporadic cases of B. cepacia. This article reminds us that we should always consider typing to ensure the problem we are experiencing is not clonal.

Additionally, the paper provides a nice summary list of all the liquids that we should consider culturing. This is a cautionary tale reminding us that we should never assume that sterile liquids are truly sterile and that we should always retain our critical thinking and healthy skepticism.

L. Silvia Munoz-Price, MD, PhD

Associate professor of clinical medicine, Medical College of Wisconsin

Disclosure: Munoz-Price reports no relevant financial disclosures.