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- Title
Multistate Outbreak of Burkholderia cepacia Complex Bloodstream Infections After Exposure to Contaminated Saline Flush Syringes: United States, 2016–2017.
- Authors
Brooks, Richard B; Mitchell, Patrick K; Miller, Jeffrey R; Vasquez, Amber M; Havlicek, Jessica; Lee, Hannah; Quinn, Monica; Adams, Eleanor; Baker, Deborah; Greeley, Rebecca; Ross, Kathleen; Daskalaki, Irini; Walrath, Judy; Moulton-Meissner, Heather; Crist, Matthew B; Workgroup, Burkholderia cepacia
- Abstract
Background Burkholderia cepacia complex (Bcc) has caused healthcare-associated outbreaks, often in association with contaminated products. The identification of 4 Bcc bloodstream infections in patients residing at a single skilled nursing facility (SNF) within 1 week led to an epidemiological investigation to identify additional cases and the outbreak source. Methods A case was initially defined via a blood culture yielding Bcc in a SNF resident receiving intravenous therapy after 1 August 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 bloodstream infections 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. Inspections of facilities at the saline flush manufacturer identified deficiencies that might have led to the failure to sterilize a specific case containing a partial lot of the 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.
- Subjects
UNITED States; PREVENTION of bloodborne infections; BLOOD; BLOODBORNE infections; CELL culture; COMMUNICATION; DISEASE outbreaks; FEDERAL government; INTRAVENOUS therapy; IRRIGATION (Medicine); MEDICAL appointments; MEDICAL records; NURSING care facilities; PUBLIC health; PULSED-field gel electrophoresis; STATE governments; SYRINGES; BURKHOLDERIA infections; VASCULAR catheters; CATHETER-related infections; MEDICAL equipment contamination; ACQUISITION of data methodology; DISEASE risk factors; INFECTION prevention
- Publication
Clinical Infectious Diseases, 2019, Vol 69, Issue 3, p445
- ISSN
1058-4838
- Publication type
Article
- DOI
10.1093/cid/ciy910