Polyclonal outbreak of bacteremia caused by Burkholderia cepacia complex and the presumptive role of ultrasound gel

braz j infect dis.2015;19(5):543–545

ww w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Brief

communication

Polyclonal

outbreak

of

bacteremia

caused

by

Burkholderia

cepacia

complex

and

the

presumptive

role

of

ultrasound

gel

Esteban

C.

Nannini

_,

_Adriana

_Ponessa

_,

_Rosa

_Muratori

_,

_Patricia

_Marchiaro

_,

Viviana

Ballerini

_,

_Luis

_Flynn

_,

_Adriana

_S.

_Limansky

a_{DivisionofInfectiousDiseases,SanatorioBritánico,Rosario,Argentina} b_{DepartmentofMicrobiology,SanatorioBritánico,Rosario,Argentina}

c_{DivisionofInfectiousDiseases,SchoolofMedicine,UniversidadNacionaldeRosario,Rosario,Argentina}

d_{InstitutodeBiologíaMolecularyCelulardeRosario–CONICET,FacultaddeCienciasBioquímicasyFarmacéuticas,Universidad}

NacionaldeRosario,Rosario,Argentina

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Received25March2015 Accepted30June2015

Availableonline29August2015

Keywords:

Burkholderiacepaciacomplex Outbreak

Bacteremia Polyclonal

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AnosocomialpolyclonaloutbreakassociatedtobacteremiacausedbydifferentBurkholderia cepaciacomplex(BCC)speciesandclonesisreported.Molecularcharacterizationidentified

Burkholderiastabilis,Burkholderiacontaminans,andBurkholderiaambifariaamongBCCisolates obtainedfrompatientsinneonatalandadultintensivecareunits.BCCwasalsoisolated fromanintrinsicallycontaminatedultrasoundgel,whichconstitutedthepresumptiveBCC source.PriorBCCoutbreakrelatedtocontaminatedultrasoundgelshavebeendescribedin thesettingoftransrectalprostatebiopsy.Outbreakcausedstrainsand/orclonesofBCChave beenreported,probablybecauseBCCarecommonlyfoundinthenaturalenvironment;most BCCspeciesarebiofilmproducers,anddifferentspeciesmaycontaminateanenvironmental source.ThefindingofmultiplespeciesorclonesduringtheanalysisofnosocomialBCCcases mightnotbeenoughtorejectanoutbreakfromacommonsource.

©2015ElsevierEditoraLtda.Allrightsreserved.

TheBurkholderiacepaciacomplex(BCC)encompassesatleast 17relatedGram-Negativebacillispeciesasjudgedby differ-entphenotypicandgenotypicanalyses.1 _{BCCmemberscan}

causeinfectionsincysticfibrosis,chronicgranulomatous dis-ease, and hospitalizedpatients.2 _{BCC members are among}

themost frequentsourcesofnosocomial outbreaksdue to

∗ _{Correspondingauthorat:DivisionofInfectiousDiseases,SanatorioBritánico,Paraguay40,Rosario(2000),SantaFe,Argentina.}

E-mailaddress:esteban.nannini@sanbritanico.com.ar(E.C.Nannini).

intrinsically contaminated substances other than blood products.2_{Here,wedescribeanoutbreakofbacteremiacaused}

byBCCstrainsbetweenAprilandJuly2013.Subject’sclinical charts were reviewed and microbiological testing of sub-stances andsolutionsrepresentingpotentialsourcesofthe outbreakwasperformed.Eightysamplesfromdifferentwards

http://dx.doi.org/10.1016/j.bjid.2015.06.009

544

Table1–Descriptionofthe12Burkholderiacepaciacomplexstrainsisolatedfrombloodculturesandfromultrasound lubricantgel.

Dateofpositiveculture Origin Patient(P)orgelsample (G)number BCCspeciesbyrecA sequencing Cloneby DO-PCR 04/05/2013 NU P1 B.ambifaria A 04/09/2013 NU P2 B.ambifaria A 04/13/2013 ICU P3 B.stabilis B 04/14/2013 ICU P3 B.stabilis B 04/27/2013 ICU P4 B.ambifaria C 04/30/2013 ICU P4 B.ambifaria C 05/04/2013 ICU P5 B.stabilis B 05/04/2013 ICU P4 B.ambifaria C 05/08/2013 NU P6 B.contaminans D 06/05/2013 UO G1 B.contaminans E 06/05/2013 OW G2 B.contaminans E

06/12/2013 Gelcontainer G3 B.contaminans E

NU,NeonatalUnit;ICU,IntensiveCareUnit;UO,UltrasoundOffice;OW,ObstetricWard,DO-PCR,degenerateoligonucleotide-PCR.

and commercial productscommonly used inthe Neonatal Unit(NU)andIntensiveCareUnit(ICU)weretestedforBCC presence using selective culturemedia (Burkholderia agar, BioMerieuxInc,MercyL ´etoil,France).Allsuspectedisolates werephenotypicallyidentifiedasbelongingtotheBCCby oxi-dase, OF-glucose,sculin hydrolysis,lysine decarboxylation, andDNAhydrolysistests,aswellasbythesemi-automatized API-20NE (BioMerieux Inc, Mercy L ´etoil, France) method. Regrettably,onlynineBCCisolateswereavailablefor molecu-laranalysis(sixfrombloodculturesandthreefromultrasound gels). These strains were identified to the species level by

recAgenesequencecomparisons3_{andanalyzedforgenomic}

relatednessbybothdegenerateoligonucleotide-primedPCR4 andrepetitiveextragenicpalindromic-PCR.5

Theoutbreak involved 11 patientswith 17 BCC isolates recoveredfrombloodcultures;sevenofthese11subjectswere hospitalizedinthe NU,all ofthemwere preterm neonates with respiratory distress, three other patients were in the ICU,twoofwhichhadrecentcardiovascularsurgery,andone patientwasintheGeneralWard.Themean(range)timeof hospitalizationofthesepatientsuntilthedevelopmentthe bacteremiawas5.55(0–15)days;oneneonatedevelopedBCC bacteremiathe dateofbirth,probablyreflecting horizontal transmission. In seven patients, BCC strains were recov-eredonly from baselineblood cultures;two morepatients had positivesurveillance bloodcultures onday2, and two otherpatientshadbacteremiaalsoina3rdsetofblood cul-tures. Three of the 11 patients died (two adults and one neonate)duringthehospitalization,althoughnoneofthese deathswereattributedtotheBCCbacteremicepisode.Itwas notedthat the sevenneonatesand the fouradultpatients underwentamean(range)of5(1–10)ultrasounds,including transthoracicandtransfontanellarones,and2(1–3), respec-tively.

Eighty environmental samples were taken for culture, including several solutions of antiseptics (iodopovidone, hydrogen peroxide, cholorhexidine, and alcohol-gel),drugs (fentanylcitrate,morphine,tobramycindrops),multiple sur-facesinthesurgicalroom,ICUandNU,andothercommonly

usedmaterialssuchasgelsforultrasound,liquidsoap,and vaseline; BCC strains were isolated only from ultrasound scanninggels(Table1).Aquantitativeculturedonefroman unopened5-L containerultrasoundgeldisplayedgrowthof 4.66log10CFU/mL(meanoftwosamples)ofBCCcells.

Molec-ular analysesbasedonrecAgenesequenceofnineisolates obtainedfrom six patientsinNU andICU wards indicated the presenceofthreedifferentspeciesofthe BCCcomplex (Table1):Burkholderiaambifariawasidentifiedinpatients1and 2(NU)andpatient4(ICU),Burkholderiastabilisinpatient3and 5(ICU),andBurkholderiacontaminansinpatient6(NU).AllBCC isolatesweresusceptibletoceftazidime,meropenem, minocy-cline, andtrimethoprim-sulfamethoxazolebydiskdiffusion methods.

Among the clinical isolates, genotypic characterization revealed two different clones of B. ambifaria and a single clone of both, B. stabilis and B. contaminans (Table 1). Two different BCCspeciescoexistedintheNU(B.ambifaria and

B. contaminans) and the ICU (B. stabilisand B. ambifaria). In addition, two different B. ambifaria clones were detected, bothfrom differentwards(Table1).B.contaminanswas iso-lated indifferentsamplesofultrasoundgel asitwas from patient6althoughthisisolatewasadifferentclone(Table1). Repetitive extragenicpalindromic-PCRconfirmedtheclonal distinctness of the BCC isolates analyzed above (data not shown).TheseresultssupportthepolyclonaloutbreakofBCC strains caused by multiple species (B. ambifaria, B. stabilis,

and B.contaminans) and clones(e.g.B. ambifaria,B. contami-nans).

Interesting,BCCmemberscanhydrolyzeparabens,which arep-hydroxybenzoicacidesterswithantimicrobial proper-tiescommonlyaddedasstabilizerstoultrasoundgels6_;BCC

strains canthereforesurviveandproliferate inthesegels.6

Eventhoughthesterilityofsubstancesincontactwithintact skinsuchasultrasoundgelsisgenerallynotrequired,theUS FoodandDrugAdministrationhadtorecallcommercial ultra-sound gels contaminated with Pseudomonas aeruginosa and

Klebsiellaoxytoca,recommendingtheuseofsterileultrasound gel for invasive procedures, leaving the use of non-sterile

brazj infect dis.2015;19(5):543–545

545

(open)containersforproceduresperformedonintactskinand forlowriskpatients.7_{Ofnote,BCCinvasiveinfectionsrelated}

tocontaminated ultrasound gelshave been onlydescribed inthesettingoftransrectalprostatebiopsy.6,8_{Currentreport}

representsthethirdoutbreakofBCCpresumablyassociated toultrasoundgel.Wespeculatethattheinvasiveprocedures doneinneonatehostsandpatientsundergoingcardiovascular surgerymighthavepredisposedthemtodevelopbacteremia aftersignificantBCCskincolonizationfromcontaminatedgel. The striking feature of this outbreak is the presence of multiple BCC species and clones since most BCC out-breaks have been associated to a single clone. However, outbreakscausedbydifferentstrainsand/orcloneshavebeen reported,9–11_{includingBCCcontaminationofhospitalwater,}9

intravenousbromopridevials,10_{andnon-identified}

environ-mentalsources.11SinceBCCbacteriaarecommonlyfoundin thenaturalenvironment andmostBCCspeciesare biofilm producers, different species may contaminate an environ-mental source (as it has been described in cystic fibrosis patients12_{),eventuallyleadingtoapolyclonalnosocomial}

out-break.Unfortunately,wecouldnotconfirmthishypothesisas weonlyrecovered oneB.contaminans clonefromthe ultra-soundgelsamples.

In summary, the sudden appearance of BCC invasive cases,theisolationofBCCfromultrasoundgelsincludingan unopenedcontainer,andtheabruptinterruptionofnewcases afterremovalofultrasoundgelstocksledustospeculatethat thissubstancemighthavebeenthesourceofthenosocomial BCCoutbreak.Thefindingofmultiplespeciesorclonesduring theanalysisofnosocomialBCCcasesmightnotbeenoughto rejectanoutbreakfromacommonsource.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgments

WeareindebtedtoDr.AlejandroM.Vialeforcriticalreading ofthemanuscript.

ThisworkwaspartiallysupportedbygrantstoASLfrom theMinisteriodeSalud,ProvinciadeSantaFeandSecretaría deCienciayTécnica,UniversidadNacionaldeRosario.

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