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BRIEF COMMUNICATION  
Year : 2016  |  Volume : 59  |  Issue : 2  |  Page : 197-199
A sporadic outbreak of Burkholderia cepacia complex bacteremia in pediatric intensive care unit of a tertiary care hospital in coastal Karnataka, South India


1 Department of Microbiology, Father Muller Medical College, Mangalore, Dakshina Kannada, Karnataka, India
2 Department of Paediatrics, Father Muller Medical College, Mangalore, Dakshina Kannada, Karnataka, India

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Date of Web Publication9-May-2016
 

   Abstract 

Burkholderia cepacia complex (BCC) is a significant opportunistic pathogen in hospitalized and immunocompromised patients, particularly in cystic fibrosis. It is widely distributed in natural habitats such as soil and water and frequently encountered in nosocomial outbreaks due to contaminated disinfectants and medical devices. However reports on outbreaks due to this organism are lacking from the Indian subcontinent. We report here a sporadic outbreak due to BCC which occurred in the pediatric Intensive Care Unit of our institute, the probable source being contaminated distilled water. The isolate from three babies and environmental sources including distilled water were identical and confirmed as BCC. Strict infection control measures were instituted to prevent the spread of infection. This report highlights the potential role of B.cepacia in causing sporadic outbreaks especially in ICUs, associated with water.

Keywords: Bacteremia, Burkholderia cepacia complex, outbreak, pediatric ICU

How to cite this article:
Antony B, Cherian EV, Boloor R, Shenoy K V. A sporadic outbreak of Burkholderia cepacia complex bacteremia in pediatric intensive care unit of a tertiary care hospital in coastal Karnataka, South India. Indian J Pathol Microbiol 2016;59:197-9

How to cite this URL:
Antony B, Cherian EV, Boloor R, Shenoy K V. A sporadic outbreak of Burkholderia cepacia complex bacteremia in pediatric intensive care unit of a tertiary care hospital in coastal Karnataka, South India. Indian J Pathol Microbiol [serial online] 2016 [cited 2019 Feb 22];59:197-9. Available from: http://www.ijpmonline.org/text.asp?2016/59/2/197/182010



   Introduction Top


Burkholderia cepacia complex (BCC) is a well documented opportunistic pathogen in hospitalized and immunocompromised patients, particularly those with broad spectrum antibiotic therapy.[1] This organism is reported to colonize the lungs of patients with cystic fibrosis. A variety of human infections caused by BCC include bacteremia, septic arthritis, urinary tract infections, peritonitis and respiratory tract infections.[1],[2] The high level of intrinsic resistance in this organism, coupled with the lack of newer or effective antibiotics, make treatment options very difficult.[2] In spite of the infections in humans, these are labeled as animal and plant pathogens. It is widely distributed in natural habitats such as soil, water [3] and nutrient poor water.[4] As BCC is employed in the commercial industry for bio- control, bioremediation in toxic agents and as plant growth promoting agents, environment can be a reservoir for the acquisition of BCC infection.[5]

B.cepacia was frequently encountered in nosocomial outbreaks due to contaminated disinfectants,[6],[7] nebulizer solutions,[8] mouth wash,[9] medical devices,[10],[11] intravenous solutions due to contamination of lipid emulsion stoppers.[12] A recent outbreak in an ICU was attributed to unopened containers of moisturizing body milk.[13] Reports of pseudo- bacteremia due to BCC has also appeared in the literature.[14] However, reports on outbreaks due to this organism from the Indian subcontinent is lacking.

We report a sporadic outbreak due to BCC which has occurred in the pediatric ICU of our institute, probable source being contaminated distilled water.


   Case Reports Top


Case report 1

A term male baby born to a primigravida with no adverse antenatal events was admitted on the day 26 of life with lethargy, poor suck and scanty urine output. The baby had tachycardia, respiratory distress, facial puffiness, epigastric pulsations, cardiomegaly, grade 2 systolic murmurs at the left lower sternal border and hepatomegaly suggestive of congestive cardiac failure with sepsis. Laboratory results showed polymorphoneutrophilic leukocytosis and elevated C-reactive protein (CRP). The diagnosis was confirmed when echocardiography revealed a large subaortic ventricular septal defect. Blood culture grew Acinetobacter species sensitive to aminoglycosides, meropenem and cefotaxime. Digoxin, spironolactone and humidified oxygen were commenced with ampicillin and cefotaxime. There was clinical improvement and white blood cell counts and CRP levels normalized. After a week he again became lethargic with increased oxygen requirements. This time blood culture grew B.cepacia. Commenced on piperacillin as per antibiogram, he improved and was discharged.

Case report 2

A 10 year old girl with rhabdomyosarcoma, on chemotherapy was evaluated for fever. Clinical evidence for sepsis or metastasis was absent. Laboratory investigations revealed anemia, leukopenia with neutropenia. Urine culture and microscopy were normal. Abdominal ultrasound revealed a hydroureteronephrosis secondary to the tumor mass. Blood culture grew B.cepacia and she was commenced on cefotaxime as per antibiogram and fever subsided.

Case report 3

An 18 month old toddler was admitted with fever and shortness of breath for 2 days. He was tachypneic with respiratory distress and diminished breath sounds on the right side. Chest radiograph revealed right upper lobe pneumonia and pneumothorax. Laboratory investigations revealed polymorphoneutrophilic leukocytosis and elevated Erythrocyte Sedimentation Rate. Mantoux test was negative. Blood culture grew B.cepacia. Treated with cefotaxime and gentamicin and was found to be well on follow- up.

Microbiological analysis

In the pediatric ICU, on consecutive days, non fermenting, motile, gram negative bacilli were isolated from the first two cases suspected of septicemia. Both the isolates were morphologically and biochemically identical. On blood agar, both grew as opaque, glistening colonies, non pigmented initially, later developed yellowish pigmentation and non lactose fermenting colonies on MacConkey agar. They were catalase and oxidase positive, oxidative acid production was observed with glucose, mannitol, lactose, sucrose, maltose, decarboxylated lysine and ornithine, resistant to polymyxin B and colistin. The isolates presumed as BCC were confirmed by VITEK 2 system (BioMerieux) by enzyme profile analysis. Meanwhile the same organism was isolated from another baby with sepsis.

An outbreak was suspected and strict infection control measures were instituted to prevent the spread of infection. Environmental sampling was done to identify the source and route of infection. B.cepacia was isolated from the door handle and oxygen flow meter. Further investigations proved that the source was the distilled water used in the ICU, which had been stored for more than 24-48 hours.


   Discussion Top


B.cepacia, formerly known as Pseudomonas cepacia was assigned to a new genus Burkholderia in 1992, in honor of its discoverer. Currently BCC comprises seventeen closely related species (formerly genomovars), belonging to the phylum Proteobacteria. BCC is a saprophyte commonly distributed in soil, water, fruits and vegetables as well as contaminants of pharmaceutical preparations, medical equipments etc. In our case series, identical isolates obtained from the door handle and oxygen flow meter, aroused suspicion of another original and common source. Detailed investigations were conducted in the ICU and the source of infection was traced to the distilled water used in the ICUs. These water samples were dispatched from the central water treatment plants in large containers to the ICU and used in procedures such as nebulizations, humidification of oxygen and flushing orogastric tubes etc.

Regular periodical environmental sampling of ICUs in our institute, had not isolated B.cepacia in the past. All the isolates from patients and the environmental samples belonged to the same biotype and exhibited the same antibiogram. The first neonate and the second child on chemotherapy might have predisposed to infections due to BCC with their physiological state of low immunity. The third child could have been exposed to the same bacterium while receiving oxygen and nebulizations with the contaminated water. This sporadic outbreak due to this bacterium in our ICU was controlled by the timely information given to the clinician, implementation of infection control measures such as fumigation, thorough hand washing techniques, screening of the staff in ICU, disinfecting thermometers and cohorting infected children. After the outbreak, the shelf life of distilled water used from large containers in the ICU was restricted to not more than 24 hours.

BCC is intrinsically resistant to aminoglycosides, polymyxins and variable resistance to β-lactams, chloramphenicol, fluoroquinolones and trimethoprim. Minimum Inhibitory Concentration determination of our isolates revealed multidrug resistance. Though BCC species are highly resistant, antibiotic combinations have exhibited a reasonable response as shown in some studies. According to the Clinical and Laboratory Standards Institute guidelines, the drugs of choice against BCC include ceftazidime, minocycline, meropenem and cotrimoxazole. Drug combinations such as meropenem with ciprofloxacin and tobramycin as well as ceftazidime -tobramycin were reported in successful treatments.[2]

The present study report highlights the potential role of B.cepacia in causing sporadic outbreaks especially in ICUs. It also emphasizes the clinicians to be vigilant about the possible sources of infection, their surveillance and management. Assurance of the quality of water, the essential component of many procedures in hospitals and periodical environmental sampling can reduce the hospital acquired infections associated with water that in turn can reduce the hospital stay and the increased financial burden to the patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
The nonfermentative gram negative bacilli. In Winn Was, Jande W, Koneman E, Procop G, Schrekernbenger P, Woods G, editors. Koneman's colour Atlas and Text book of Diagnostic Microbiology. Batlimore USA: Lippincott William & Wilkins Publishers; 2006, p. 303-91.  Back to cited text no. 1
    
2.
Gautam V, Singhal L, Ray P. Burkholderia cepacia complex: Beyond Pseudomonas and Acinetobacter. Indian J Med Microbiol2011;29:4-12.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.
Sousa SA, Ramos CG, Leitão JH. Burkholderia cepacia Complex: Emerging Multihost Pathogens Equipped with a Wide Range of Virulence Factors and Determinants. Int J Microbiol 2011; doi: 10.1155/2011/607575.1-10.  Back to cited text no. 3
    
4.
Goldmann DA, Klinger JD. Goldmann DA, Klinger JD. Pseudomonas cepacia: Biology, mechanisms of virulence, epidemiology. J Pediatr 1986;108:806-12.  Back to cited text no. 4
    
5.
Souza AV, Moreira CR, Pasternak J, Hirata Mde L, Saltini DA, Caetano VC, et al. Characterizing uncommon Burkholderia cepacia complex isolates from an outbreak in a haemodialysis unit. J Med Microbiol2004;53:999-1005.  Back to cited text no. 5
    
6.
Panlilio AL, Beck-Sague CM, Siegel JD, Anderson RL, Yetts SY, Clark NC, et al. Infections and Pseudoinfections due to povidone iodine solution contaminated with Pseudomonas cepacia. Clin Infect Dis 1992;14:1078-83.  Back to cited text no. 6
    
7.
Hamill RJ, Houston ED, Georghiou PR, Wright CE, Koza MA, Cadle RM, et al. An outbreak of Burkholderia cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy. Ann Intern Med 1995;122:762-6.  Back to cited text no. 7
    
8.
Centers for Disease Control and Prevention (CDC). Nosocomial Burkholderia cepacia infection and colonization associated with intrinsically contaminated mouthwash- Arizona. MMWR Morb Mortal Wkly Rep. 1998;47:926-8.  Back to cited text no. 8
    
9.
Loukil C, Saizou C, Doit C, Bidet P, Mariani-Kurkdjian P, Aujard Y, et al. Epidemiologic investigation of Burkholderia cepacia acquisition in two pediatric intensive care units. Infect Control Hosp Epidemiol 2003;24:707-10.  Back to cited text no. 9
    
10.
Weems JJ. Jr. Nosocomial outbreak of Pseudomonas cepacia associated with contamination of reusable electronic ventilator temperature probes. Infect Control Hosp Epidemiol 1993;14:583-6.  Back to cited text no. 10
    
11.
Gravel-Tropper D, Sample ML, Oxley C, Toye B, Woods DE, Garber GE. Three-year outbreak of pseudobacteremia with Burkholderia cepacia traced to a contaminated blood gas analyzer. Infect Control Hosp Epidemiol 1996;17:737-40.  Back to cited text no. 11
    
12.
Van Laer F, Raes D, Vandamme P, Lammens C, Sion JP, Vrints C, et al. An outbreak of Burkholderia cepacia with septicemia on a cardiology ward. Infect Control Hosp Epidemiol 1998;19:112-3.  Back to cited text no. 12
    
13.
Doit C, Loukil C, Simon AM, Ferroni A, Fontan JE, Bonacorsi S, et al. Outbreak of Burkholderia cepacia bacteremia in a pediatric hospital due to contamination of lipid emulsion stoppers. J Clin Microbiol 2004;42:2227-30.  Back to cited text no. 13
    
14.
Alvarez-Lerma F, Maull E, Terradas R, Segura C, Planells I, Coll P, et al. Moisturizing body milk as a reservoir of Burkholderia cepacia: Outbreak of nosocomial infection in a multidisciplinary intensive care unit. Crit Care. 2008;12:R10.  Back to cited text no. 14
    

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Correspondence Address:
Beena Antony
Department of Microbiology, Father Muller Medical College, Kankanaday, Mangalore - 575 000, Dakshina Kannada, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.182010

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