Recurrent Burkholderia cepacia Pseudo-bacteremia Related to Contaminated Commercial Product of 0.5% Chlorhexidine Solution

Su Hui Ko; Hye-Sun An; Ji Hwan Bang; Sang-Won Park

doi:10.14192/kjhaicp.2017.22.1.1

Journal List > Korean J Healthc Assoc Infect Control Prev > v.22(1) > 1098365

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Ko, An, Bang, and Park: Recurrent Burkholderia cepacia Pseudo-bacteremia Related to Contaminated Commercial Product of 0.5% Chlorhexidine Solution

Original Article

Korean Journal of Healthcare-Associated Infection Control and Prevention 2017; 22(1): 1-8.

Published online: 30 June 2017

DOI: https://doi.org/10.14192/kjhaicp.2017.22.1.1

Recurrent Burkholderia cepacia Pseudo-bacteremia Related to Contaminated Commercial Product of 0.5% Chlorhexidine Solution

Su Hui Ko¹, Hye-Sun An¹, Ji Hwan Bang^1,², Sang-Won Park^1,²

¹Infection Control Office, Boramae Medical Center, Seoul, Korea.

²Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea.

Correspondence to: Sang-Won Park, Infection Control Office, Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea Tel: 02-870-2224, Fax: 02-870-3863, hswon1@snu.ac.kr

Received 9 October 2016 Revised 30 December 2016 Accepted 10 January 2017

Abstract

Background

Burkholderia cepacia is one of the key pathogens involved in the nosocomial outbreaks via contaminated supplies. We describe here an experience of recurrent B. cepacia pseudo-bacteremia caused by the contaminated commercial product of 0.5% chlorhexidine solution in a hospital.

Methods

B. cepacia bacteremias detected from 30 November to 17 December 2014 were defined as cases. Epidemiological data were collected by reviewing the medical records and interviews with the healthcare workers. Suspected antiseptics were cultured using blood culture media.

Results

Using regular active surveillance of microbiological results, 15 B. cepacia isolates were found in 13 patients. Pseudo-bacteremia was suspected in all of the cases based on the clinical analysis of individual patients. Misuse of 0.5% chlorhexidine in its solution rather than its tincture form as a skin antiseptic prior to drawing blood for blood culture procedures was the only identifiable risk factor for B. cepacia pseudo-bacteremia. Culture of 0.5% chlorhexidine solution was negative. Suspending the use of 0.5% chlorhexidine solution and educating healthcare workers on the proper use of the antiseptic ended the outbreak.

Conclusion

Regular surveillance of unusual pathogens may lead to early detection of nosocomial outbreaks. Epidemiological analysis is a strong indicator for the source of outbreak even when there is no microbiological evidence of contamination source.

Keywords: Burkholderia cepacia, Chlorhexidine, Infection control, Outbreak, Pseudo-bacteremia

Figures and Tables

Fig. 1

Epidemic curve of positive blood cultures for Burkholderia cepacia. Wd: ward.

Fig. 2

Length of hospital stay until the first blood culture sampling in cases positive for Burkholderia cepacia. Wd: ward.

Table 1

Characteristics of cases having positive blood culture for Burkholderia cepacia

^a(Positive blood culture)/(pairs of blood culture performed). ^bFU: 2^nd blood cultures. ^cAll 3^rd blood cultures became negative. ^dTACE: transarterial chemoembolization, ^eMSSA: methicillin-sensitive Staphylococcus aureus.

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