Dive Deeper Than the Water

Abstract

BACKGROUND Burkholderia cepacia (B. cepacia) complex is an opportunistic pathogen found in soil or water. The bacteria are often resistant to antibiotics. A cluster of B. cepacia was identified over a five month period. The bacteria resulted in various culture types including sputum, urine, pelvic and foot cultures. An investigation was performed to identify a source. METHODS Cases were defined as patients with a positive culture. B. cepacia is not an organism routinely observed in the facility. Sixty percent of patients were identified during readmission to the facility. The investigation consisted of review of medical records, ongoing meetings with perioperative services, the wound care team and the microbiology department. The state epidemiology division was notified to assist in the investigation. There were no specific findings as to the source except the water system. Isolates were being forwarded to the state laboratory. RESULTS During the investigation period, B. cepacia resulted in only ten specimens. State findings revealed gaps in hand hygiene, wound care and the water management program. Common factors included surgery and wound care. Infection prevention performed environmental cultures. A skin cleansing foam was contaminated with B. cepacia. Patient isolates forwarded to the state laboratory were DNA identical to product isolates. The FDA was notified. Findings resulted in a multistate investigation and outbreak. The manufacturer issued a multistate recall of product. CONCLUSIONS The outbreak of B. cepacia isolates was caused by a contaminated skin care foaming agent. The product was manufactured at one facility which allowed for quick identification and remediation by the manufacturer. As soon as the product was isolated for B. cepacia and removed from the facility, no other cases were identified. Prompt reporting to the state division of epidemiology allowed an openness to continue to investigate and determine a cause.