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An Outbreak of Burkholderia (Formerly Pseudomonas) cepacia Respiratory Tract Colonization and Infection Associated with Nebulized Albuterol Therapy
- Richard J. Hamill, MD;
- Eric D. Houston, BS;
- Paul R. Georghiou, MBBS;
- Charles E. Wright, PhD;
- Maureen A. Koza, RN, CIC;
- Richard M. Cadle, PharmD;
- Paul A. Goepfert, PhD;
- Debra A. Lewis, MD;
- Golden J. Zenon, MD; and
- Jill E. Clarridge, MD
- From the Veterans Affairs Medical Center, Baylor College of Medicine, and Texas Southern University, Houston, Texas. Requests for Reprints: Richard J. Hamill, MD, Section of Infectious Diseases (111G), Veterans Affairs Medical Center, 2002 Holcombe Boulevard, Houston, TX 77030. Acknowledgments: The authors thank Ann M. Doggett BS, ASCP, David Y. Graham, MD, and Loretta Carson, MS, for provision of bacterial strains; the employees of the Respiratory Therapy Department at the Houston Veterans Affairs Medical Center for their cooperation during this investigation; and Daniel M. Musher, MD, for his review of the manuscript. Grant Support: By funds provided by the Department of Veterans Affairs.
Abstract
Objective: To investigate an outbreak of Burkholderia (formerly (Pseudomonas) cepacia respiratory tract colonization and infection in mechanically ventilated patients.
Design: A retrospective case–control and bacteriologic study.
Setting: Veterans Affairs medical center.
Patients: 42 mechanically ventilated patients who developed respiratory tract colonization or infection with B. cepacia and 135 ventilator-dependent controls who were not colonized and did not develop infections.
Measurements: Clinical and demographic data; benzalkonium chloride concentrations and pH levels in albuterol sulfate solutions; repetitive-element polymerase chain reaction (PCR)-mediated molecular fingerprinting on eight patient isolates and three environmental B. cepacia isolates that were available for study.
Results: 42 patients had B. cepacia respiratory tract colonization or infection. Observation of intensive care unit and respiratory care personnel showed faulty infection control procedures (for example, the same multiple-dose bottle of albuterol was used for many mechanically ventilated patients). More case patients (39 [92.9%]) than controls (95 [70.4%]; P = 0.006) received nebulized albuterol, and case patients (67.5 treatments) received more treatments than controls (18 treatments; P < 0.001). In-use albuterol solutions had pH values that were unstable, and benzalkonium chloride concentrations declined over time to levels capable of supporting bacterial growth. Medication nebulizers and in-use bottles of albuterol harbored B. cepacia. Molecular fingerprints of patient isolates and environmental B. cepacia isolates were identical using repetitive-element PCR. No further isolates of B. cepacia were identified after institution of appropriate infection control procedures.
Conclusions: Multiple-dose medications and reliance on benzalkonium chloride as a medication preservative provide a mechanism for nosocomial spread of microorganisms, particularly if infection control procedures are not carefully followed. Repetitive-element PCR is a useful fingerprinting technique for molecular epidemiologic studies of B. cepacia.
- Copyright ©2004 by the American College of Physicians
