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Outbreak of Burkholderia Cepacia Bacteremia Traced to Contaminated Hospital Water Used for Dilution of an Alcohol Skin Antiseptic

Published online by Cambridge University Press:  02 January 2015

Rana M. Nasser ,
Amal C. Rahi ,
Mona F. Haddad ,
Ziad Daoud ,
Noha Irani-Hakime  and
Wassim Y. Almawi
Rana M. Nasser*
Affiliation:
Department of Infection Control, Saint George Hospital, Beirut, Lebanon
Amal C. Rahi
Affiliation:
Department of Epidemiology and Biostatistics, American University of Beirut, Beirut, Lebanon
Mona F. Haddad
Affiliation:
Department of Infection Control, Saint George Hospital, Beirut, Lebanon Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon
Ziad Daoud
Affiliation:
Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon Faculty of Health Sciences, Balamand University, Beirut, Lebanon
Noha Irani-Hakime
Affiliation:
Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon Department of Pathology, Saint George Hospital, Beirut, Lebanon
Wassim Y. Almawi
Affiliation:
Department of Laboratory Medicine, Saint George Hospital, Beirut, Lebanon
*
Department of Infectious Diseases, Marshfield Clinic, 1000 North Oak Avenue, Marshfield, WI 54449
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Abstract

Objective:

To identify the source of an epidemic of Burkholderia cepacia bloodstream infections during 7 years (411 episodes in 361 patients).

Design:

Outbreak investigation.

Setting:

A 250-bed university hospital in Beirut, Lebanon.

Methods:

Matched case-control and retrospective cohort studies, and microbiological surveillance and polymerase chain reaction–restriction fragment length ascertainment were employed. Special media and filtration techniques were used to isolate organisms from water and diluted alcohol solutions.

Results:

In a group of 50 randomly selected case-matched patients from 1999, the positive blood cultures were concomitant with fever in 98%, intravenous phlebitis in 44%, and recurrent bacteremia in 20%. Fever disappeared approximately 6 hours after intravenous catheter removal. Polymerase chain reaction–restriction fragment length polymorphism revealed strain homogeneity in patient, water, and alcohol isolates. Contaminated tap water had been used to dilute alcohol for skin antisepsis and for decontamination of the caps of heparin vials. Only sporadic cases directly attributable to breach of protocol were reported after single-use alcohol swabs were substituted.

Conclusion:

This is potentially the largest single-source nosocomial bloodstream infection outbreak ever reported, and the first report of an alcohol skin antiseptic contaminated by tap water as a source for nosocomial bacteremia.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 25 , Issue 3 , March 2004 , pp. 231 - 239
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2004

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