{"title":"Outbreak of Burkholderia cepacia complex infection associated with intrinsically contaminated commercial 0.5% chlorhexidine solution.","authors":"Thitirat Dilokkunanant, Kumthorn Malathum, Darunee Chotiprasitsakul, Pitak Santanirand, Thanomvong Muntajit, Chonnamet Techasaensiri","doi":"10.1016/j.jhin.2025.09.019","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Burkholderia cepacia complex (BCC) is an aerobic Gram-negative bacillus commonly isolated from aqueous environments. In May 2024, we identified two cases who developed BCC infections within one month following fronto-orbital advancement (FOA) procedures in the paediatric surgery ward.</p><p><strong>Aim: </strong>To identify the source, intervene in the ongoing infections, and implement control measures.</p><p><strong>Methods: </strong>The cases were defined as individuals with laboratory-confirmed BCC isolated from December 2023 to May 2024. We reviewed medical records, interviewed healthcare workers, and verified compliance with infection control guidelines. Additionally, we aseptically collected environmental samples for microbiological analysis.</p><p><strong>Findings: </strong>Two initial cases of BCC infection were identified following FOA procedures, and one additional case occurred after wound dressing. All three cases were associated with the use of 0.5% aqueous chlorhexidine gluconate (CHG) solution. These cases exhibited similar antimicrobial susceptibility patterns. Subsequent investigation detected BCC in ten samples of the 0.5% aqueous CHG solution. Both clinical and environmental BCC isolates were subjected to multilocus sequence typing (MLST) analysis to determine their clonal relationship. The analysis revealed that all isolates shared an identical sequence type, consistent with Burkholderia cenocepacia. The outbreak was successfully controlled following the withdrawal of the product and re-education of staff.</p><p><strong>Conclusion: </strong>The monitoring of hospital-acquired infections by a multidisciplinary team played a critical role in the prevention and rapid control of the outbreaks. Additionally, stricter government regulations are needed to prevent the contamination of disinfectants during manufacturing.</p>","PeriodicalId":54806,"journal":{"name":"Journal of Hospital Infection","volume":" ","pages":""},"PeriodicalIF":3.1000,"publicationDate":"2025-10-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Journal of Hospital Infection","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1016/j.jhin.2025.09.019","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"INFECTIOUS DISEASES","Score":null,"Total":0}
引用次数: 0
Abstract
Background: Burkholderia cepacia complex (BCC) is an aerobic Gram-negative bacillus commonly isolated from aqueous environments. In May 2024, we identified two cases who developed BCC infections within one month following fronto-orbital advancement (FOA) procedures in the paediatric surgery ward.
Aim: To identify the source, intervene in the ongoing infections, and implement control measures.
Methods: The cases were defined as individuals with laboratory-confirmed BCC isolated from December 2023 to May 2024. We reviewed medical records, interviewed healthcare workers, and verified compliance with infection control guidelines. Additionally, we aseptically collected environmental samples for microbiological analysis.
Findings: Two initial cases of BCC infection were identified following FOA procedures, and one additional case occurred after wound dressing. All three cases were associated with the use of 0.5% aqueous chlorhexidine gluconate (CHG) solution. These cases exhibited similar antimicrobial susceptibility patterns. Subsequent investigation detected BCC in ten samples of the 0.5% aqueous CHG solution. Both clinical and environmental BCC isolates were subjected to multilocus sequence typing (MLST) analysis to determine their clonal relationship. The analysis revealed that all isolates shared an identical sequence type, consistent with Burkholderia cenocepacia. The outbreak was successfully controlled following the withdrawal of the product and re-education of staff.
Conclusion: The monitoring of hospital-acquired infections by a multidisciplinary team played a critical role in the prevention and rapid control of the outbreaks. Additionally, stricter government regulations are needed to prevent the contamination of disinfectants during manufacturing.
期刊介绍：
The Journal of Hospital Infection is the editorially independent scientific publication of the Healthcare Infection Society. The aim of the Journal is to publish high quality research and information relating to infection prevention and control that is relevant to an international audience.
The Journal welcomes submissions that relate to all aspects of infection prevention and control in healthcare settings. This includes submissions that:
provide new insight into the epidemiology, surveillance, or prevention and control of healthcare-associated infections and antimicrobial resistance in healthcare settings;
provide new insight into cleaning, disinfection and decontamination;
provide new insight into the design of healthcare premises;
describe novel aspects of outbreaks of infection;
throw light on techniques for effective antimicrobial stewardship;
describe novel techniques (laboratory-based or point of care) for the detection of infection or antimicrobial resistance in the healthcare setting, particularly if these can be used to facilitate infection prevention and control;
improve understanding of the motivations of safe healthcare behaviour, or describe techniques for achieving behavioural and cultural change;
improve understanding of the use of IT systems in infection surveillance and prevention and control.
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