Investigation and control of an outbreak of urinary tract infections caused by Burkholderia cepacian-contaminated anesthetic gel

Mingmei Du,Yan Wang,Bowei Liu,Jijiang Suo,Yubin Xing,Yanping Luo,Lu Li,Yunxi Liu,Yanling Bai,Lijun Xie,Linjian Song

doi:10.1186/s13756-020-00855-x

Mingmei Du, Yan Wang + Show 9 more

Open Access

https://doi.org/10.1186/s13756-020-00855-x

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Abstract

BackgroundThis report describes an outbreak of 71 patients developed B. cepacia urinary tract infection (UTI) by contaminated single-use anesthetic gel.MethodsEpidemiological investigation of patients with B. cepacia-positive urine or blood samples between March 19, 2018 and Novemeber 15, 2018 was conducted to identify the source of infection. Microbiological samples from hospital surfaces, endoscopes, disposable items, and the hands of staff were tested for B. cepacia contamination. Pulsed-field gel electrophoresis (PFGE) was used to compare homology in B. cepacia isolates.ResultsDuring the outbreak, nosocomial B. cepacia UTI was confirmed in 71 patients. Epidemiological investigation showed that 66 patients underwent invasive urological diagnosis and treatment, while the remaining five patients underwent bedside indwelling catheterization, with all patients exposed to single-use anesthetic gel. All batches of anesthetic gel were recalled and the outbreak abated. Overall, 155 samples were collected from environmental surfaces and disposable items, and B. cepacia contamination was confirmed in samples from one used cystoscope and three anesthetic gels from the same batch. PFGE showed homology between 17 out of 20 B. cepacia isolates from patients and three isolates from the contaminated anesthetic gel. All patients achieved cure.ConclusionContaminated single-use anesthetic gel was confirmed as the source of the B. cepacia outbreak, with infection occurring during invasive urological diagnostic and treatments. Thus, investigations of nosocomial outbreaks of B. cepacia infection should consider contamination of diagnostic and treatment items used in infected patients.

Highlights

This report describes an outbreak of 71 patients developed B. cepacia urinary tract infection (UTI) by contaminated single-use anesthetic gel
Epidemiological and microbiological investigations confirmed that the outbreak was caused by a batch of B. cepacia-contaminated single-use anesthetic gel, which was used for anesthesia and lubrication of the urethra during invasive diagnosis and treatment
The three cases of nosocomial B. cepacia infection occurred in three different months, indicating that they did not constitute an outbreak of nosocomial infection

Summary

Introduction

This report describes an outbreak of 71 patients developed B. cepacia urinary tract infection (UTI) by contaminated single-use anesthetic gel. Burkholderia cepacia is a Gram-negative, aerobic, nonfermentative bacterium that is widely distributed in the hospital environment. It is a opportunistic pathogen in immune-impaired patients with cystic fibrosis or chronic granulomatosis [1]. In 2012, Sutton and Jimenez published a summary of product recalls by the Food and Drug Administration involving microbial contamination [7]. They showed that between 2004 and 2011, B. cepacia contamination was associated with 34% of non-sterile product recalls.

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