Korean J healthc assoc Infect Control Prev.  2017 Jun;22(1):1-8. 10.14192/kjhaicp.2017.22.1.1.

Recurrent Burkholderia cepacia Pseudo-bacteremia Related to Contaminated Commercial Product of 0.5% Chlorhexidine Solution

• Ko SH
• An HS
• Bang JH
• Park SW

• KMID: 2416033
• DOI: http://doi.org/10.14192/kjhaicp.2017.22.1.1

Abstract

BACKGROUND
Burkholderia cepacia is one of the key pathogens involved in the nosocomial outbreaks via contaminated supplies. We describe here an experience of recurrent B. cepacia pseudo-bacteremia caused by the contaminated commercial product of 0.5% chlorhexidine solution in a hospital.
METHODS
B. cepacia bacteremias detected from 30 November to 17 December 2014 were defined as cases. Epidemiological data were collected by reviewing the medical records and interviews with the healthcare workers. Suspected antiseptics were cultured using blood culture media.
RESULTS
Using regular active surveillance of microbiological results, 15 B. cepacia isolates were found in 13 patients. Pseudo-bacteremia was suspected in all of the cases based on the clinical analysis of individual patients. Misuse of 0.5% chlorhexidine in its solution rather than its tincture form as a skin antiseptic prior to drawing blood for blood culture procedures was the only identifiable risk factor for B. cepacia pseudo-bacteremia. Culture of 0.5% chlorhexidine solution was negative. Suspending the use of 0.5% chlorhexidine solution and educating healthcare workers on the proper use of the antiseptic ended the outbreak.
CONCLUSION
Regular surveillance of unusual pathogens may lead to early detection of nosocomial outbreaks. Epidemiological analysis is a strong indicator for the source of outbreak even when there is no microbiological evidence of contamination source.

Keyword

Burkholderia cepacia; Chlorhexidine; Infection control; Outbreak; Pseudo-bacteremia

MeSH Terms

Anti-Infective Agents, Local
Bacteremia
Burkholderia cepacia*
Burkholderia*
Chlorhexidine*
Culture Media
Delivery of Health Care
Disease Outbreaks
Equipment and Supplies
Humans
Infection Control
Medical Records
Risk Factors
Skin
Anti-Infective Agents, Local
Chlorhexidine
Culture Media

Figure

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  Fig. 1 Epidemic curve of positive blood cultures for Burkholderia cepacia. Wd: ward.

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  Fig. 2 Length of hospital stay until the first blood culture sampling in cases positive for Burkholderia cepacia. Wd: ward.

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