Collaboration and enhanced surveillance help find the source for an outbreak at Johns Hopkins Health System.
The 2018 annual meeting for the Association for Professionals in Infection Control and Epidemiology (APIC) is underway and many of the presentation topics will surely hit close to home for many of us in the health care field.
One of these topics is the growing presence of Burkholderia cepacia. These bacteria are a common cause of infections in those with compromised immune systems or certain medical conditions like cystic fibrosis. Typically soil and water bacteria, B cepacia commonly carry resistance to several antibiotics and have an alarming capacity to contaminate medical supplies and medicines. Within the past 15 years, there have been outbreak clusters associated with contaminated mouthwash, nasal spray, and more, and contaminated medical supplies and medicines have been associated with health care-associated infections and pose a serious health risk for patients in intensive care units and those who are immunocompromised.
A presentation at the 2018 APIC conference underscored the challenges of identifying sources for health care-associated outbreaks, especially in patients without weakened immune systems or cystic fibrosis. Presenters detailed the plight of the infection prevention team from Johns Hopkins Health System and their unique experience identifying and investigating a B cepacia outbreak among patients in their pediatric intensive care unit (PICU). The affected patients did not have cystic fibrosis.
The Johns Hopkins team noted that in May 2017, 3 infants in the PICU test positive for B cepacia. The positive isolates were from tracheal aspirates and blood. After the identification, the patients were placed in contact isolation, as B cepacia can spread among susceptible individuals. All 3 infants were on mechanical ventilation, and so the team started their investigation by looking at their respiratory medications and equipment.
Pharmacy personnel confirmed that the hospital was not utilizing any of the liquid docusate that was involved in the 2016 recall. By July 2017, 4 additional cases were identified, and the infection prevention team began working with the US Centers for Disease Control and Prevention (CDC) and other medical facilities to identify additional cases and potential sources.
During the investigation, the team found that all cases had received 1 medication with “the same National Drug Code (NDC) of the previously implicated liquid docusate.” This medication was sent to the CDC for additional testing. By August 2017, the manufacturer had issued a voluntary recall of liquid docusate and the CDC laboratory testing had confirmed it to be the source of the B cepacia.
Interestingly, the strain implicated in this outbreak was different than that of the 2016 B cepacia outbreak.
Although this outbreak will likely not be the last involving B cepacia in health care and medical supplies, it gives insight into the importance of considering medications. B cepacia is a hardy organism that can easily live on surfaces and in water, not to mention that it is often resistant to preservatives. A natural inclination towards aqueous environments mixed with the capacity to resist preservatives makes these bacteria particularly worrisome. The presentation underscored the importance of utilizing and working with outside sources, like the CDC and other health care facilities, to help identify potential sources. Health care can easily be siloed, which makes this presentation a good reminder that no matter what part of patient care we are responsible for, the universal goal is patient safety and this can be better achieved through collaboration.