Burkholderia cepacia: An Outbreak in the Peritoneal Dialysis Unit

Abstract

Burkholderia cepacia is a ubiquitous, opportunistic, environmental gram-negative bacillus which most commonly affects cystic fibrosis and immunocompromised patients. Rarely, it can cause peritoneal dialysis (PD) exit-site infection (ESI). Information relating to predisposing factors, clinical course, and treatment options for B. cepacia ESIs is limited. Although reports of B. cepacia healthcare-associated infections exist, outbreaks in PD units have not previously been reported. A recent outbreak of B. cepacia ESI in our PD unit provided a unique opportunity to study B. cepacia ESIs and to outline an approach to investigating such an outbreak. After unexpectedly identifying B. cepacia as the cause of PD catheter ESIs in 3 patients over an 11-week period, we began systematically screening our PD population for B. cepacia exit-site colonization. A further 6 patients were found to be affected, 3 with asymptomatic colonization and 3 with symptomatic B. cepacia ESI. Four of the 6 developed tunnel infections requiring multiple courses of antibiotic treatment, and 3 patients required catheter removal; 2 patients with symptomatic ESIs without tunnel involvement responded to oral and topical antibiotics. Further investigation implicated 4% chlorhexidine aqueous bodywash used by all patients as the probable source of the outbreak. This is the first reported outbreak of B. cepacia ESIs. We noted an association between diabetes mellitus and refractory/more extensive infection. Our experience suggests that isolated ESIs can be treated successfully with oral antibiotics whereas tunnel infections generally require catheter removal.

Burkholderia cepacia—A rare but important cause of refractory peritonitis in patients with continuous ambulatory peritoneal dialysis: A case report and literature review

“…However, the efficacy of the treatment should be further explored. B. cepacia 4,[9][10][11][12][13][14][15][16] (Table 1). These studies did not provide treatment options used for the cases.…”

Global burden, point sources, and outbreak management of healthcare-associatedBurkholderia cepaciainfections: An integrative review

“…Like many opportunistic pathogens, members of BCC affect immunocompromised individuals including patients affected with cystic fibrosis, 31,[42][43][44][45][46] patients with hematological diseases, 4,[47][48][49] postoperative patients, 36,50,51 and hemodialysis patients. 34,[52][53][54][55] This accounts for the predominance of reported outbreaks in adult, 12 pediatric, 29 and neonatal 25 intensive care units (ICUs), where mechanically ventilated patients are at an increased risk of HAI. 56 Additionally, because these patients are at an increased risk of infection, respiratory cultures are frequently collected to increase the chance of identifying B. cepacia colonization.…”

“…B. cepacia can successfully colonize water supplies, filter membranes, and antiseptic solutions during hemodialysis sessions, thus allowing the bacteria to move across contaminated dialysate compartments reaching the patient's bloodstream. 34,[52][53][54][55] The identified point sources of B. cepacia HAIs are diverse and involve processes from manufacturing to contamination of products at the hospital setting. 17,39,52,[57][58][59] For those 4 outbreaks pointing to an environmental source associated with the implementation of a new product for patient care, namely prefabricated moist washcloths and moisturizing body milk, this is a pivotal point if the product was developed mainly for highly vulnerable patients.…”

ISPD Catheter-related Infection Recommendations: 2023 Update

“…73 In addition to the therapeutic benefit of dressing or antiseptic agents, we should be cautious about contaminated products, especially when they are not considered to be pharmaceutical products. Suboptimal manufacturing practice or preparation could have been the cause of contaminated aqueous chlorhexidine solution, [74][75][76] leading to several Burkholderia cepacia complex PD catheter exit site infection outbreaks, as reported in New Zealand 77 and Hong Kong. 74 The optimal frequency of exit site care has not been tested by RCTs.…”