CDC's Annual Epidemic Intelligence Service Conference

CDC's Annual Epidemic Intelligence Service Conference

May 02, 2017
2 min read

B. cepacia outbreak in nursing facilities traced to saline flushes

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ATLANTA — An outbreak of Burkholderia cepacia spanning five states was traced to contaminated saline flushes, according to researchers.

The findings, presented at the CDC’s annual Epidemic Intelligence Service (EIS) Conference, highlight the need to thoroughly document medical products used at facilities.

Photo of Richard B. Brooks
Richard B. Brooks

“This investigation demonstrates the need for us to be able to better track compounded medications and medical devices, including saline flush syringes, throughout the manufacturing and distribution process, up to the point at which they are given to individual patients,” study researcher Richard B. Brooks, MD, MPH, a CDC Epidemic Intelligence Service officer assigned to the Maryland Department of Health and Mental Hygiene, told Infectious Disease News.

The outbreak was discovered on Sept. 22, 2016, when four B. cepacia bloodstream infections were found in patients receiving IV therapy at a Maryland skilled nursing facility (SNF). Officials notified colleagues across state lines, and clusters of B. cepacia infection were discovered in other SNFs.

Investigators abstracted patient records and visited SNFs affected by the outbreak in two states in the hope of finding the source. They cultured suspect products and typed patient and product isolates with pulsed-field gel electrophoresis (PFGE).

The investigators found that all the infected patients were staying at SNFs supplied by a certain pharmacy that on Sept. 1 began distributing saline flushes from a specific manufacturer. They then focused on SNFs using flushes from that manufacturer.

The investigators found 162 cases of B. cepacia infection at 59 facilities in five states, with first positive blood cultures identified between Sept. 6, 2016, and Jan. 20.

On Oct. 3, they isolated B. cepacia from unopened saline flushes produced at one of the manufacturer’s facilities. PFGE patterns were indistinguishable in 111 of 127 (87.4%) patient isolates from all five states and in six of seven (85.7%) product isolates.

Investigators found that another PFGE pattern in one of seven product isolates (14.3%) and eight of 127 (6.3%) patient isolates differed by only one band. The saline flushes were recalled on Oct. 4.

They said epidemiologic and laboratory evidence indicates the contamination of saline flushes produced by the manufacturer was the source of the outbreak, but their investigation and surveillance for more cases of B. cepacia are ongoing.

However, this is not the only recent outbreak of B. cepacia linked to contaminated medical products. A 2016 multistate B. cepacia outbreak was traced to syringes of liquid docusate, a stool softener. That outbreak was discovered in a Texas children’s hospital and sickened 60 patients at facilities in eight states. The docusate manufacturer, PharmaTech, voluntarily recalled its Diocto brand docusate. – by Joe Green


Brooks RB, et al. Burkholderia cepacia Bloodstream Infections Among Skilled Nursing Facility Residents — United States, 2016. Presented at: Annual Epidemic Intelligence Service Conference; April 24-27, 2017; Atlanta.

CDC. Multistate Outbreak of Burkholderia cepacia Bloodstream Infections Associated with Contaminated Prefilled Saline Flush Syringes. Accessed May 2, 2017.

Marquez L, et al. Infect Control Hosp Epidemiol. 2017;doi: 10.1017/ice.2017.11.

Disclosure: The researchers report no relevant financial disclosures.