Abstract
BackgroundBetween November 2013 and June 2014, 56 cases of bacteremia (15 deaths) associated with the use of Total Parenteral Nutrition (TPN) and/or calcium gluconate (CG) were reported in four Brazilian states.MethodsWe analyzed 73 bacterial isolates from four states: 45 from blood, 25 from TPN and three from CG, originally identified as Acinetobacter baumannii, Rhizobium radiobacter, Pantoea sp. or Enterobacteriaceae using molecular methods.ResultsThe first two bacterial species were confirmed while the third group of species could not be identified using standard identification protocols. These isolates were subsequently identified by Multi-Locus Sequence Analysis as Phytobacter diazotrophicus, a species related to strains from similar outbreaks in the United States in the 1970’s. Within each species, TPN and blood isolates proved to be clonal, whereas the R. radiobacter isolates retrieved from CG were found to be unrelated.ConclusionThis is the first report of a three-species outbreak caused by TPN contaminated with A. baumannii, R. radiobacter and P. diazotrophicus. The concomitant presence of clonal A. baumannii and P. diazotrophicus isolates in several TPN and blood samples, as well as the case of one patient, where all three different species were isolated simultaneously, suggest that the outbreak may be ascribed to a discrete contamination of TPN. In addition, this study highlights the clinical relevance of P. diazotrophicus, which has been involved in outbreaks in the past, but was often misidentified as P. agglomerans.
Highlights
Between November 2013 and June 2014, 56 cases of bacteremia (15 deaths) associated with the use of Total Parenteral Nutrition (TPN) and/or calcium gluconate (CG) were reported in four Brazilian states
25 isolates obtained from TPN administered to the patients and three isolates from CG were included in this study (Additional file 1: Table S2)
Bacterial identification Verification of the identity of the 73 isolates at Central Public Health Laboratory of Paraná (LACEN) demonstrated that three different bacterial species were present in the analyzed samples: 22 and 26 isolates were unanimously identified as A. baumannii complex (ABC) and R. radiobacter, respectively, both using the Vitek-2® platform as well as by 16S rRNA gene analyses, largely confirming the primary identification performed by the hospital laboratories of origin (Additional file 1: Table S2, accession numbers for archetypal 16S rRNA sequences: A. baumannii isolate 4988RM - MF403059; R. radiobacter isolate 5037RM - MF403063)
Summary
Between November 2013 and June 2014, 56 cases of bacteremia (15 deaths) associated with the use of Total Parenteral Nutrition (TPN) and/or calcium gluconate (CG) were reported in four Brazilian states. Total parenteral nutrition (TPN) is an important nutritional supplement for seriously ill patients, especially those incapable of oral or enteral nutrition. TPN are Pillonetto et al BMC Infectious Diseases (2018) 18:397. Adoption of these procedures helped TPN-related outbreaks to decline, but adverse events still occur worldwide, usually resulting in severe sepses with high fatality rate, especially in vulnerable individuals [5]. Incidence of bloodstream infection within patients receiving TPN has been reported between 1.3–39% [3]. Exposure to TPN is considered an independent risk factor for blood stream infections at neonate intensive care units [6]. The relative risk has been estimated as 4.69 in neonates receiving TPN through central catheter [7]
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