Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Centers for Disease Control and Prevention, Atlanta, Georgia.
Maryland Department of Health, Baltimore.
Clin Infect Dis. 2019 Jul 18;69(3):445-449. doi: 10.1093/cid/ciy910.
Burkholderia cepacia complex (Bcc) has caused healthcare-associated outbreaks, often in association with contaminated products. The identification of 4 Bcc bloodstream infections in patients residing at a single skilled nursing facility (SNF) within 1 week led to an epidemiological investigation to identify additional cases and the outbreak source.
A case was initially defined via a blood culture yielding Bcc in a SNF resident receiving intravenous therapy after 1 August 2016. Multistate notifications were issued to identify additional cases. Public health authorities performed site visits at facilities with cases to conduct chart reviews and identify possible sources. Pulsed-field gel electrophoresis (PFGE) was performed on isolates from cases and suspect products. Facilities involved in manufacturing suspect products were inspected to assess possible root causes.
An outbreak of 162 Bcc bloodstream infections across 59 nursing facilities in 5 states occurred during September 2016-January 2017. Isolates from patients and pre-filled saline flush syringes were closely related by PFGE, identifying contaminated flushes as the outbreak source and prompting a nationwide recall. Inspections of facilities at the saline flush manufacturer identified deficiencies that might have led to the failure to sterilize a specific case containing a partial lot of the product.
Communication and coordination among key stakeholders, including healthcare facilities, public health authorities, and state and federal agencies, led to the rapid identification of an outbreak source and likely prevented many additional infections. Effective processes to ensure the sterilization of injectable products are essential to prevent similar outbreaks in the future.
洋葱伯克霍尔德菌复合群（Bcc）已导致与医疗保健相关的暴发，这些暴发通常与受污染的产品有关。在一个单一的熟练护理机构（SNF）内，一周内有 4 例 Bcc 血流感染患者，导致进行了流行病学调查以确定其他病例和暴发源。
最初通过在 2016 年 8 月 1 日后接受静脉治疗的 SNF 居民的血液培养中获得 Bcc 来定义病例。发出了多州通知以确定其他病例。公共卫生当局对有病例的机构进行了现场访问，以进行病历审查并确定可能的来源。对来自病例和疑似产品的分离物进行脉冲场凝胶电泳（PFGE）。对涉及制造疑似产品的设施进行了检查，以评估可能的根本原因。
2016 年 9 月至 2017 年 1 月期间，在 5 个州的 59 个护理机构中发生了 162 例 Bcc 血流感染暴发。患者和预填充生理盐水冲洗注射器的分离物通过 PFGE 密切相关，确定受污染的冲洗液为暴发源，并促使全国范围内召回。对生理盐水冲洗制造商设施的检查发现了可能导致未能对含有特定批次产品的特定病例进行消毒的缺陷。
包括医疗机构、公共卫生当局以及州和联邦机构在内的关键利益攸关方之间的沟通和协调，迅速确定了暴发源，并可能防止了许多其他感染。确保注射产品消毒的有效流程对于防止未来发生类似的暴发至关重要。
