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Abstract
Introduction
Subjects and Methods
Results
Discussion
Conclusion
References
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ORIGINAL ARTICLE
Year : 2018  |  Volume : 19  |  Issue : 1  |  Page : 1-5
 

Outbreak of Burkholderia cepacia catheter-related bloodstream infection in cancer patients with long-term central venous devices at a tertiary cancer centre in India


Department of Anaesthesia, Pathology and Medical Oncology, Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan, India

Date of Submission31-Oct-2017
Date of Acceptance28-Dec-2017
Date of Web Publication22-May-2018

Correspondence Address:
Dr. Vinita Jain
Bhagwan Mahaveer Cancer Hospital and Research Centre, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_38_17

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  Abstract 


Background: Different central venous devices are required in cancer patients for long duration, especially in hematological malignancies. In this new era of highly developed long-term central venous devices such as port and peripherally inserted central catheter line, incidence of catheter-related bloodstream infection (CRBSI) is low. However, immunocompromised cancer patients may acquire catheter-related opportunistic infections frequently including Burkholderia cepacia. B.cepacia can cause various bloodstream infections, pneumonias, and wound infections etc.
Methodology and Result: We analyzed an outbreak of 14 cases of B. cepacia infection in patients with long-term central venous lines at a tertiary oncology care center. Febrile neutropenia was the only clinical presentation at the time of detection of infection in almost all patients, and the catheter had to be removed in 10 patients owing to partial response to susceptible antibiotic therapy. The source of infection that led to the outbreak could not be identified. Nevertheless, all possible measures to prevent cross-contamination including training of the staff to maintain hand hygiene and aseptic precautions were taken. Although resecuring central venous access is difficult in these patients due to bleeding diathesis, timely decision to remove the catheter based on standard guidelines can prevent complications. To the best of our knowledge, this is the first outbreak of B. cepacia-positive CRBSI reported in this specific subgroup of patients in North India.
Conclusion: The opportunistic infection (B. cepacia) of central venous devices during chemotherapy being resistant to commonly used antibiotics could be an important factor in increasing morbidity and mortality in cancer patients.


Keywords: Burkholderia cepacia, catheter-related bloodstream infection, central venous devices, hematological malignancies, outbreak, peripherally inserted central catheter


How to cite this article:
Gupta P, Jain V, Hemrajani M, Gupta A, Sharma U. Outbreak of Burkholderia cepacia catheter-related bloodstream infection in cancer patients with long-term central venous devices at a tertiary cancer centre in India. Indian Anaesth Forum 2018;19:1-5

How to cite this URL:
Gupta P, Jain V, Hemrajani M, Gupta A, Sharma U. Outbreak of Burkholderia cepacia catheter-related bloodstream infection in cancer patients with long-term central venous devices at a tertiary cancer centre in India. Indian Anaesth Forum [serial online] 2018 [cited 2019 Aug 25];19:1-5. Available from: http://www.theiaforum.org/text.asp?2018/19/1/1/232906





  Introduction Top


Central venous catheters (CVCs) are commonly used in cancer patients on short-term as well as long-term basis and therefore the incidence of catheter-related bloodstream infections (CRBSI) is quite high in this subgroup, specifically in hematological malignancies ranging from 20.3 to 22.0/1000 neutropenia days.[1] The major causative organisms are Gram-positive bacteria. Isolation of Gram-negative bacilli is rare. However, Burkholderia spp. infection in immunocompromised patients is not uncommon and indeed quite alarming due to its tendency to sustain adverse environmental conditions and grow in commonly used disinfectants and antiseptic solutions. In addition, long-term indwelling catheters provide a favorable environment for their propagation.

We report an outbreak of Burkholderia cepacia-positive CRBSI in oncology group of patients. Although outbreaks of B. cepacia infection are reported worldwide, only few incidences has been reported in India.[2] To the best of our knowledge, this is the first B. cepacia outbreak of CRBSI reported in cancer patients with long-term central venous devices in North India.

The idea behind reporting this outbreak is to highlight the potential risk of serious opportunistic infection with rampant spread in immunocompromised cancer patients with indwelling catheters. Timely diagnosis and infection source identification can avoid a major outbreak and reduce the morbidity and mortality due to these multiresistant bacteria.

Burkholderia species are being recognized with increasing frequency as nosocomial pathogens. Due to their wide distribution in the natural environment, nutritional adaptability, and ability to form biofilms, outbreaks of infection in hospitals are frequent. However, the source of infection is seldom identified. Several recent reports suggested a variety of infection vehicles, including ultrasound gel, nebulized medications, nasal spray, hospital water, and lipid emulsion.[3]

Decision regarding removal of CVCs with persistent B. cepacia bacteremia is a big dilemma as it is sometimes very difficult to secure intravenous (IV) access in pediatric patients and those on long-standing chemotherapy.

IDSA guidelines recommend removal of long-term catheters if Gram-negative bacillary CRBSI is associated with severe sepsis or persistent bacteremia even after 72 h of susceptible antimicrobial therapy.[4]


  Subjects and Methods Top


It is an analytical study conducted in September 2016 and October at a 200-bedded tertiary care oncology center.

The incidence of CRBSI was initially 2/1000 central line days in August that rose to 3.79/1000 central line days in September and further increased drastically to 11.43/1000 central line days in October. Most common pathogen detected was B. cepacia.

A possibility of an outbreak was considered and a prompt workout for epidemiological and environmental outbreak investigation was initiated to identify the source of pathogen and limit its spread [Table 1].
Table 1: Steps for outbreak investigation of Burkholderia cepacia

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By the end of October 2016, control on B. cepacia infection was achieved as there was a significant decline in number of cases being reported to a single case in Novomber 2016 which was recurrent/resistant case of CRBSI.

The test used to confirm the diagnosis of CRBSI was differential time to positivity in which paired CVC and peripheral blood culture samples were used. Blood samples were drawn before the start of any antibiotics. After confirmation of B. cepacia-positive CRBSI, antibiotics according to culture and sensitivity were started and clinical response was observed. Catheter was removed if the blood cultures were still positive for B. cepacia despite susceptible systemic antibiotic therapy for 5 days as per our hospital antibiotic policy. The patient-related data including age, sex, ward, duration and type of CVC, type of dressing used, underlying malignancy, risk factors such as neutropenia, clinical presentation, response to antibiotics, and outcome (catheter removal) were recorded. Moreover, relevant microbiological information regarding antibiotic sensitivity pattern of isolated B. cepacia was also collected.

Samples were collected from various suspected sources of infection such as hand and nasal swab of all doctors and nursing staff, antiseptic solutions, IV fluids, commonly used drugs, belongings of central line care, chemotherapeutic drugs, and kitchen and food samples. Reinforcement of hand hygiene and intensive training of the nursing staff on CVC handling was done to limit its further spread.


  Results Top


A total of 14 cancer patients harboring CVCs were diagnosed for CRBSI over 2 months period with blood cultures showing growth for B. cepacia. It was found that blood culture positivity from a catheter was 4–11 h ahead of blood cultures obtained from peripheral vein.

Majority of patients were under 18 years, 3 patients being <5 years of age. The most common central venous device used was peripherally inserted central catheter line. One pediatric patient had Hickman catheter and 3 patients had port in situ. Most of the cases were reported from neutropenia and pediatric ward. All patients were known case of acute leukemia except three patients who had breast cancer and Ewing's sarcoma.

The most common clinical presentation was recurrent fever on hospitalization. Only one patient had local signs of catheter infection. Moderate-to-severe neutropenia was the most consistent finding associated with the isolation of B. cepacia, probably under the influence of ongoing chemotherapy. All patients presented with CVC-related infection during the same period regardless of date of cannulation, suggesting a common source of infection. The B. cepacia strain isolated was only sensitive to ceftazidime and meropenem and resistant to all other commonly used antibiotics.

Causes for catheter removal in most of the cases include persistent bacteremia despite antibiotic therapy for 5 days and recurrence of B. cepacia infection in neutropenia phase in patients who have been previously treated. Ten patients showed partial clinical response with persistent bacteremia even after 5 days of susceptible antibiotic therapy, and therefore, the catheter was removed. Within 24 h of catheter removal, patients became asymptomatic.

The rest 4 patients showed good clinical response to meropenem within 24–48 h showing no growth on microbiological cultures done on the 5th day of antibiotic therapy and hence the catheter was retained. Two among these four patients presented with recurrent fever after 1 month, i.e., October and November during their second cycle of chemotherapy with severe neutropenia, and the blood cultures were again found to be positive for B. cepacia. One of them also developed pneumonitis with isolation of Klebsiella in sputum and B. cepacia in blood. Therefore, the catheter was removed and susceptible antibiotics were restarted. All possible sources of infection were analyzed, but none of the environmental samples grew B. cepacia except water sample from kitchen.


  Discussion Top


B. cepacia is an aerobic Gram-negative bacillus, widely distributed in environment. It is a known opportunistic pathogen, which can cause broadspectrum of clinical manifestations ranging from uncomplicated fever to disseminated infection and septicemia in immunocompromised patients. Its multidrug-resistant nature adds onto the overall morbidity and hospital stay in cancer patients with indwelling long-term catheters.[5] Although outbreaks of B. cepacia infection have been reported worldwide, isolated B. cepacia infection has been mostly described in patients with cystic fibrosis.[6]

In India, case reports of diseases due to these organisms are rare and it has been reported from few tertiary care centers in North India.[2] Little is known about virulence of B. cepacia.[7]

The clinical presentation in all the patients during this outbreak was high-grade fever with chills under the background of chemotherapy-induced moderate-to-severe neutropenia. None of the patients developed sepsis or any other complication. One of the patients developed pneumonitis. However, it was a superimposed Klebsiella infection confirmed by sputum cultures.

Irrespective of date of cannulation as shown in [Table 2], all patients developed B. cepacia infection in September and October, suggesting hospital-acquired infection. Despite extensive search, we could not find any possible source of infection during this period except one sample of water from kitchen. Nevertheless, specific control measures were reinforced, namely strict hand hygiene, intensification of environmental cleaning, adherence to aseptic protocols, and strengthening of disinfection and sterilization. Oyesina and Anthony and Patra et al. also could not isolate source of infection in their case reports.[8],[9]
Table 2: Clinical and demographic presentation of patients with Burkholderia cepacia

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On confirmation of the diagnosis of B. cepacia-positive CRBSI, all patients were given injectable meropenem as antibiogram showed sensitivity for meropenem and ceftazidime.[10]

The gravity of Burkholderia species infections amplifies due to its intrinsic resistance to most available antimicrobial agents. It is resistant to aminoglycosides, Polymyxin B, and colistin, which are usually considered the last-resort antibiotics.[11]

Long-term catheters should be removed from patients with complicated CRBSI associated with severe sepsis, suppurative thrombophlebitis, endocarditis, or bloodstream infection that continues despite 72 h of susceptible antimicrobial therapy as suggested by IDSA guidelines.[3] Although securing venous access was difficult in pediatric group, we did not take any risk in these neutropenia patients and removed the catheter if there was persistent bacteremia after 5th day of antibiotic therapy according to culture and sensitivity.


  Conclusion Top


B. cepacia opportunistic infection of CVC during chemotherapy-induced neutropenia could be an important factor in increasing the morbidity and mortality in cancer patients and an outbreak in such patients should be promptly investigated to curb the spread of infection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hentrich M, Schalk E, Schmidt-Hieber M, Chaberny I, Mousset S, Buchheidt D, et al. Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the infectious diseases working party of the German Society of Hematology and Medical Oncology. Ann Oncol 2014;25:936-47.  Back to cited text no. 1
[PUBMED]    
2.
Gautam V, Singhal L, Ray P. Burkholderia cepacia complex: Beyond pseudomonas and acinetobacter. Indian J Med Microbiol 2011;29:4-12.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Bhise SM, Rahangdale VA, Qazi MS. Burkholderia Cepacia an emerging cause of septicemia- an outbreak in a neonatal Intensive Care Unit from a tertiary care hospital of central India. IOSR J Dent Med Sci 2013;10:41-3.  Back to cited text no. 3
    
4.
Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O'Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the infectious diseases society of America. Clin Infect Dis 2009;49:1-45.  Back to cited text no. 4
    
5.
Abe K, D'Angelo MT, Sunenshine R, Noble-Wang J, Cope J, Jensen B, et al. Outbreak of Burkholderia cepacia bloodstream infection at an outpatient hematology and oncology practice. Infect Control Hosp Epidemiol 2007;28:1311-3.  Back to cited text no. 5
    
6.
Jones AM, Dodd ME, Webb AK. Burkholderia cepacia: Current clinical issues, environmental controversies and ethical dilemmas. Eur Respir J 2001;17:295-301.  Back to cited text no. 6
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7.
Fung SK, Dick H, Devlin H, Tullis E. Transmissibility and infection control implications of Burkholderia cepacia in cystic fibrosis. Can J Infect Dis 1998;9:177-82.  Back to cited text no. 7
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8.
Oyesina O, Anthony WC. Burkholderia Cepacia: A case report. J Med Cases 2014;5:9-10.  Back to cited text no. 8
    
9.
Patra S, Bhat YR, Lewis LE, Purakayastha J, Sivaramaraju VV, Kalwaje EV, et al. Burkholderia cepacia sepsis among neonates. Indian J Pediatr 2014;81:1233-6.  Back to cited text no. 9
    
10.
Zhou J, Chen Y, Tabibi S, Alba L, Garber E, Saiman L, et al. Antimicrobial susceptibility and synergy studies of Burkholderia cepacia complex isolated from patients with cystic fibrosis. Antimicrob Agents Chemother 2007;51:1085-8.  Back to cited text no. 10
    
11.
Jacquier H, Le Monnier A, Carbonnelle E, Corvec S, Illiaquer M, Bille E, et al. In vitro antimicrobial activity of “last-resort” antibiotics against unusual nonfermenting gram-negative bacilli clinical isolates. Microb Drug Resist 2012;18:396-401.  Back to cited text no. 11
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  [Table 1], [Table 2]



 

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