Multistate Nosocomial Outbreak of Ralstonia pickettii Colonization Associated with an Intrinsically Contaminated Respiratory Care Solution
Jaime A. Labarca
0
2
4
5
William E. Trick
0
1
2
Carol L. Peterson
0
2
3
Loretta A. Carson
0
1
2
Stacey C. Holt
0
1
2
Matthew J. Arduino
0
1
2
Marysia Meylan
0
2
3
Laurene Mascola
0
2
3
William R. Jarvis
0
1
2
0
the medical community to this outbreak [14], 3 other hospitals in different states reported clusters of colonization by R. pick- ettii to the Centers for Disease Control and Prevention (CDC). We describe this multistate outbreak and the results of our epidemiological and laboratory investigations
1
Department of Health Services, Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention
,
Atlanta, Georgia
2
Received 17 February 1999;
revised 19 July 1999. Use of trade names and commercial sources is for identification only and does not imply endorsement by the US Public Health Service or the US Department of Health and Human Services
3
Acute Communicable Diseases Control
, Los Angeles County,
and Childrens Hospital
,
Los Angeles, California
4
Clinical Microbiology Laboratory, Department of Pathology and Laboratory Medicine, University of CaliforniaLos Angeles
5
Present affiliation: Internal Medicine Department
, Pontifica Universi- dad Cato lica de Chile,
Santiago
,
Chile
(J.A.L.). Program
, 1600 Clifton Road MS E89,
Atlanta, GA 30333
From 1 February through 30 April 1998, 4 hospitals reported a total of 34 patients colonized with Ralstonia pickettii. All but 1 had been exposed to 0.9% saline solution manufactured by 1 company (Modudose; Kendall, Mainsfield, MA), which was used during endotracheal suctioning. Culture of saline solution from previously unopened vials yielded R. pickettii. All available product and patient isolates were genotypically related by pulsed-field gel electrophoresis (PFGE) analysis. The contaminated saline solution was manufactured at the same plant that had been associated with a similar outbreak in 1983. The 1983 and 1998 R. pickettii isolates were unrelated, as determined by PFGE. In both 1983 and 1998, a 0.2-mm cartridge filter was used for terminal sterilization. The detection of R. pickettii should alert hospital personnel to the possibility of product contamination. In this outbreak, prompt notification of public health agencies resulted in rapid notification of other health care providers, which likely prevented additional outbreaks.
-
Ralstonia pickettii (formerly called Pseudomonas pickettii or
Burkholderia pickettii) [1, 2] is a nonfermentative gram-negative
bacillus that grows well in moist environments. R. pickettii has
a long history of causing nosocomial outbreaks associated with
contaminated solutions used for patient care [310] and
pseudooutbreaks associated with contaminated solutions used for
laboratory diagnosis [1113]. Although there have been several
reports of clusters of colonization or infection with R. pickettii,
it is infrequently isolated from clinical specimens.
During the period 1 February30 April 1998, 46 cultures of
respiratory specimens from 19 patients were positive for R.
pickettii in a pediatric hospital in Los Angeles County,
California (hospital A). Investigation by public health officials at
the Los Angeles County Department of Health Services and
the hospital A infection control team identified the cause of
this outbreak as intrinsically contaminated sterile 0.9%
sodium chloride solution used for respiratory therapy.
After a class I product recall was initiated and inclusion in
the Morbidity and Mortality Weekly Report (MMWR) alerted
Methods
Hospital recruitment. In the MMWR article, medical care
providers were encouraged to report all episodes of R. pickettii
colonization or infection through MedWatch, the reporting system of
the Food and Drug Administration (FDA), or to the Hospital
Infections Program of CDC. Data collection forms were distributed
to hospital personnel who reported such episodes. Isolates and data
collection forms were sent to CDC for evaluation.
Case definition and case finding. A case-patient was defined as
any patient at any United States hospital from whom a clinical
specimen yielded R. pickettii during the period 1 February30 April
1998 (i.e., the epidemic period). Case-patients were identified at
each hospital by microbiology reports and infection control
surveillance. In all hospitals, clinical information was collected by
medical-record review.
Procedure review. At hospital A, we reviewed laboratory
culture and respiratory therapy procedures. Opened and unopened
containers of various solutions used for respiratory care and for
laboratory processing of respiratory samples were collected for
microbiological evaluation.
Microbiological characterization. All R. pickettii clinical
isolates were identified with use of either the automated-method
VITEK-GNI cards (bioMerieux Vitek, Hazelwood, MO) or the
20NE API test for nonfermentors (bioMerieux). Species
identification was confirmed in a reference laboratory by means of
biochemical characterization [15 (...truncated)