An outbreak of Burkholderia cepacia complex pseudobacteremia associated with intrinsically contaminated commercial 0.5% chlorhexidine solution

Suhui Ko, Hye Sun An, Ji Hwan Bang, Sang Won Park

Research output: Contribution to journalArticle

20 Citations (Scopus)

Abstract

Background: Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections. Methods: The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted. Results: During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5% chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated. Conclusion: The pseudobacteremia was caused by contaminated 0.5% chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics.

Original languageEnglish
Pages (from-to)266-268
Number of pages3
JournalAmerican Journal of Infection Control
Volume43
Issue number3
DOIs
StatePublished - 1 Mar 2015

Fingerprint

Burkholderia cepacia complex
Chlorhexidine
Local Anti-Infective Agents
Disease Outbreaks
Product Recalls and Withdrawals
Infection
Infection Control
Infertility
Medical Records
Delivery of Health Care
Education
Skin
Blood Culture

Keywords

  • Antiseptic
  • Burkholderia
  • Chlorhexidine
  • Outbreak
  • Pseudobacteremia

Cite this

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title = "An outbreak of Burkholderia cepacia complex pseudobacteremia associated with intrinsically contaminated commercial 0.5{\%} chlorhexidine solution",
abstract = "Background: Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections. Methods: The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted. Results: During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5{\%} chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated. Conclusion: The pseudobacteremia was caused by contaminated 0.5{\%} chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics.",
keywords = "Antiseptic, Burkholderia, Chlorhexidine, Outbreak, Pseudobacteremia",
author = "Suhui Ko and An, {Hye Sun} and Bang, {Ji Hwan} and Park, {Sang Won}",
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AU - An, Hye Sun

AU - Bang, Ji Hwan

AU - Park, Sang Won

PY - 2015/3/1

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AB - Background: Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections. Methods: The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted. Results: During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5% chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated. Conclusion: The pseudobacteremia was caused by contaminated 0.5% chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics.

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