Korean J healthc assoc Infect Control Prev 2017; 22(1): 1-8
Published online June 30, 2017 https://doi.org/10.14192/kjhaicp.2017.22.1.1
Copyright © Korean Society for Healthcare-associated infection Control and Prevention
Su Hui Ko1, Hye-Sun An1, Ji Hwan Bang1,2, Sang-Won Park1,2
Infection Control Office, Boramae Medical Center1, Department of Internal Medicine, College of Medicine, Seoul National University2, Seoul, Korea
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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
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