, Volume 38, Issue 3, pp 187–194 | Cite as

An outbreak of Burkholderia cenocepacia bacteremia in immunocompromised oncology patients

  • T. Mann
  • D. Ben-David
  • A. Zlotkin
  • D. Shachar
  • N. Keller
  • A. Toren
  • A. Nagler
  • G. Smollan
  • A. Barzilai
  • G. RahavEmail author
Clinical and Epidemiological Study



Burkholderia cepacia is a common environmental bacterium that is resistant to disinfectants, and therefore is often encountered as a hospital-acquired pathogen. We describe an outbreak of B. cenocepacia bacteremia among hospitalized oncology patients.


A matched case–control study and an extensive environmental investigation were conducted. Species were identified by RFLP of the amplified recA gene. DNA was fingerprinted by pulsed-field gel electrophoresis (PFGE).


Between November 2005 and September 2006, B. cenocepacia bacteremia developed in 17 patients with underlying malignancy of whom 14 had tunneled central venous catheters. All patients had fever and chills which subsided following removal of the central catheter and administration of ceftazidime. Extensive epidemiological investigation could not find a common source for the outbreak. Patients were hospitalized in three different buildings with different health care personnel. Medications were prepared in different sites by different personnel. A multivariate analysis demonstrated that the independent risk factors for developing nosocomial B. cenocepacia bacteremia were hospitalization at the center for long-term support (OR 28.8; 95% CI 1.83–453.4) and reduced use of antibiotics during the last month (OR 0.07; 95% CI 0.01–0.40). All isolates had identical antimicrobial susceptibility; PFGE indicated that a complex of closely related strains was involved in the outbreak. All isolates were identified as B. cenocepacia, known to infect cystic fibrosis patients. Strict infection control measures terminated the outbreak.


B. cenocepacia is an emerging nosocomial pathogen among oncology patients.


Burkholderia cenocepacia Immunocompromised patients Bacteremia 


Conflict of interest statement



  1. 1.
    Mortensen JE, Fischer MC, LiPuma JJ. Recovery of Pseudomonas cepacia and other Pseudomonas species from the environment. Infect Control Hosp Epidemiol. 1995;16:30–2.CrossRefPubMedGoogle Scholar
  2. 2.
    Mahenthiralingam E, Baldwin A, Vandamme P. Burkholderia cepacia complex infection in patients with cystic fibrosis. J Med Microbiol. 2002;51:533–8.PubMedGoogle Scholar
  3. 3.
    Pegues DA, Carson LA, Anderson RL, Norgard MJ, Argent TA, Jarvis WR, et al. Outbreak of Pseudomonas cepacia bacteremia in oncology patients. Clin Infect Dis. 1993;16:407–11.PubMedGoogle Scholar
  4. 4.
    Gravel-Tropper D, Sample ML, Oxley C, Toye B, Woods DE, Garber GE. Three year outbreak of pseudobacteremia with Burkholderia cepacia traced to a contaminated blood gas analyzer. Infect Control Hosp Epidemiol. 1996;17:737–40.CrossRefPubMedGoogle Scholar
  5. 5.
    Reboli AC, Koshinski R, Arias K, Marks-Austin K, Stieritz D, Stull TL. An outbreak of Burkholderia cepacia lower respiratory tract infection associated with contaminated albuterol nebulization solution. Infect Control Hosp Epidemiol. 1996;17:741–3.CrossRefPubMedGoogle Scholar
  6. 6.
    van Laer F, Raes D, Vandamme P, Lammens C, Sion JP, Vrints C, et al. An outbreak of Burkholderia cepacia with septicemia on a cardiology ward. Infect Control Hosp Epidemiol. 1998;19:112–3.CrossRefPubMedGoogle Scholar
  7. 7.
    Kaitwatcharachai C, Silpapojakul K, Jitsurong S, Kalnauwakul S. An outbreak of Burkholderia cepacia bacteremia in hemodialysis patients: an epidemiologic and molecular study. Am J Kidney Dis. 2000;36:199–204.PubMedCrossRefGoogle Scholar
  8. 8.
    Matrician L, Ange G, Burns S, Fanning WL, Kioski C, Cage GD, et al. Outbreak of nosocomial Burkholderia cepacia infection and colonization associated with intrinsically contaminated mouthwash. Infect Control Hosp Epidemiol. 2000;21:739–41.CrossRefPubMedGoogle Scholar
  9. 9.
    Siddiqui AH, Mulligan ME, Mahenthiralingam E, Hebden J, Brewrink J, Qaiyumi S, et al. An episodic outbreak of genetically related Burkholderia cepacia among non CF patients at a university hospital. Infect Control Hosp Epidemiol. 2001;22:419–22.CrossRefPubMedGoogle Scholar
  10. 10.
    Doit C, Loukil C, Simon AM, Ferroni A, Fontan JE, Bonacorsi S, et al. Outbreak of Burkholderia cepacia bacteremia in a pediatric hospital due to contamination of lipid emulsion stoppers. J Clin Microbiol. 2004;42:2227–30.CrossRefPubMedGoogle Scholar
  11. 11.
    Nasser RM, Rahi AC, Haddad MF, Daoud Z, Irani-Hakime N, Almawi WY. Outbreak of Burkholderia cepacia bacteremia traced to contaminated hospital water used for dilution of an alcohol skin antiseptic. Infect Control Hosp Epidemiol. 2004;25:231–9.CrossRefPubMedGoogle Scholar
  12. 12.
    Shehabi AA, Abu Al Soud W, Mahafzah A, Khuri-Bulos N, Abu Khader I, Ouis IS, et al. Investigation of Burkholderia cepacia nosocomial outbreak with high fatality in patients suffering from diseases other than CF. Scand J Infect Dis. 2004;36:174–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Souza AV, Moreira CR, Pasternak J, Hirata Mde L, Saltini DA, Caetano VC, et al. Characterizing uncommon Burkholderia cepacia complex isolates from an outbreak in a haemodialysis unit. J Med Microbiol. 2004;53:999–1005.CrossRefPubMedGoogle Scholar
  14. 14.
    Otağ F, Ersöz G, Salcioğlu M, Bal C, Schneider I, Bauernfeind A. Nosocomial bloodstream infections with Burkholderia stabilis. J Hosp Infect. 2005;59:46–52.CrossRefPubMedGoogle Scholar
  15. 15.
    Estivariz CF, Bhatti LI, Pati R, Jensen B, Arduino MJ, Jernigan D, et al. An outbreak of Burkholderia cepacia associated with contamination of albuterol and nasal spray. Chest. 2006;130:1346–53.CrossRefPubMedGoogle Scholar
  16. 16.
    Held MR, Begier EM, Beardsley DS, Browne FA, Martinello RA, Baltimore RS, et al. Life threatening sepsis caused by Burkholderia cepacia from contaminated intravenous flush solutions prepared by a compounding pharmacy in another state. Pediatrics. 2006;118:e212–5.CrossRefPubMedGoogle Scholar
  17. 17.
    Lo Cascio G, Bonora MG, Zorazi A, Mortani E, Tessitore N, Loschiavo C, et al. A napkin associated outbreak of Burkholderia cenocepacia bacteremia in hemodialysis patients. J Hosp Infect. 2006;64:56–62.CrossRefPubMedGoogle Scholar
  18. 18.
    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.CrossRefPubMedGoogle Scholar
  19. 19.
    Heo ST, Kim S, Jeong YG, Bae IG, Jin JS, Lee JC. Hospital outbreak of Burkholderia stabilis bacteraemia related to contaminated chlorhexidine in haematological malignancy patients with indwelling catheters. J Hosp Infect. 2008;70:241–5.CrossRefPubMedGoogle Scholar
  20. 20.
    Romero-Gómez MP, Quiles-Melero MI, Peña García P, Gutiérrez Altes A, García de Miguel MA, Jiménez C, et al. Outbreak of Burkholderia cepacia bacteremia caused by contaminated chlorhexidine in a hemodialysis unit. Infect Control Hosp Epidemiol. 2008;29:377–8.CrossRefPubMedGoogle Scholar
  21. 21.
    Yu WL, Wang DY, Lin CW, Tsou MF. Endemic Burkholderia cepacia bacteremia: clinical features and antimicrobial susceptibilities of isolates. Scand J Infect Dis. 1999;31:293–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Huang CH, Jang TN, Liu CY, Fung CP, Yu KW, Wong WW. Characteristics of patients with Burkholderia cepacia bacteremia. J Microbiol Immunol Infect. 2001;34:215–9.PubMedGoogle Scholar
  23. 23.
    Bressler AM, Kaye KS, LiPuma JJ, Alexander BD, Moore CM, Reller LB, et al. Risk factors for Burkholderia cepacia complex bacteremia among intensive care unit patients without cystic fibrosis: a case-control study. Infect Control Hosp Epidemiol. 2007;28:951–8.CrossRefPubMedGoogle Scholar
  24. 24.
    Dizbay M, Tunccan OG, Sezer BE, Aktas F, Arman D. Nosocomial Burkholderia cepacia infections in a Turkish university hospital: a five-year surveillance. J Infect Dev Ctries. 2009;3:273–7.PubMedGoogle Scholar
  25. 25.
    Levy I, Grisaru-Soen G, Lerner-Geva L, Kerem E, Blau H, Bentur L, et al. Multicenter cross-sectional study of nontuberculous mycobacterial infections among cystic fibrosis patients, Israel. Emerg Infect Dis. 2008;14:378–84.CrossRefPubMedGoogle Scholar
  26. 26.
    Mahenthiralingam E, Bischof J, Byrne SK, Radomski C, Davies JE, Av-Gay Y, et al. DNA-based diagnostic approaches for identification of Burkholderia cepacia complex, Burkholderia vietnamiensis, Burkholderia multivorans, Burkholderia stabilis, and Burkholderia cepacia genomovars I and III. J Clin Microbiol. 2000;38:3165–73.PubMedGoogle Scholar
  27. 27.
    Coenye T, Vandamme P, Govan JR, LiPuma JJ. Taxonomy and identification of the Burkholderia cepacia complex. J Clin Microbiol. 2001;39:3427–36.CrossRefPubMedGoogle Scholar
  28. 28.
    LiPuma JJ, Spilker T, Gill L, Campbell PW, Liu L, Mahenthiralingam E. Disproportionate distribution of Burkholderia cepacia complex species and transmissibility markers in cystic fibrosis. Am J Respir Crit Care Med. 2001;164:92–6.PubMedGoogle Scholar
  29. 29.
    Reik R, Spilker T, LiPuma JJ. Distribution of Burkholderia cepacia complex species recovered from persons with or without cystic fibrosis. J Clin Microbiol. 2005;43:2926–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Rhee JY, Kwon KT, Ki HK, Shin SY, Jung DS, Chung DR, et al. Scoring systems for prediction of mortality in patients with intensive care unit-acquired sepsis: a comparison of the Pitt bacteremia score and the Acute Physiology and Chronic Health Evaluation II scoring systems. Shock. 2009;31:146–50.CrossRefPubMedGoogle Scholar
  31. 31.
    Isenberg HD, editor. Clinical microbiology procedures handbook. Epidemiologic and infection control microbiology. Vol. 3, sect. 13.10.1, 2nd ed. ASM Press, Washington, D.C., 2004.Google Scholar
  32. 32.
    Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing. In: Sixteenth informational supplement M100-S16. 2006.Google Scholar
  33. 33.
    Mahenthiralingam E, Coenye T, Chung J, Speert DP, Govan JRW, Taylor P, et al. Diagnostically and experimentally useful panel of strains from the Burkholderia cepacia complex. J Clin Microbiol. 2000;38:910–3.PubMedGoogle Scholar
  34. 34.
    Tenover FC, Arbeit RD, Goering RV, Mickelsen PA, Murray BE, Persing DH, et al. Interpreting chromosomal DNA restriction patterns produced by pulsed-field gel electrophoresis: criteria for bacterial strain typing. J Clin Microbiol. 1995;33:2233–9.PubMedGoogle Scholar
  35. 35.
    Millar-Jones L, Paull A, Saunders Z, Goodchild MC. Transmission of Pseudomonas cepacia among cystic fibrosis patients. Lancet. 1992;340:491.CrossRefPubMedGoogle Scholar
  36. 36.
    Pegues DA, Carson LA, Tablan OC, FitzSimmons SC, Roman SB, Miller JM, et al. Acquisition of Pseudomonas cepacia at summer camps for patients with cystic fibrosis. Summer Camp Study Group. J Pediatr. 1994;124:694–702.CrossRefPubMedGoogle Scholar
  37. 37.
    Vermis K, Brachkova M, Vandamme P, Nelis H. Isolation of Burkholderia cepacia complex genomovars from waters. Syst Appl Microbiol. 2003;26:595–600.CrossRefPubMedGoogle Scholar
  38. 38.
    Mahenthiralingam E, Campbell ME, Henry DA, Speert DP. Epidemiology of Burkholderia cepacia infection in patients with cystic fibrosis: analysis by random amplified polymorphic DNA (RAPD) fingerprinting. J Clin Microbiol. 1996;34:2914–20.PubMedGoogle Scholar
  39. 39.
    Vermis K, Coenye T, Mahenthiralingam E, Nelis HJ, Vandamme P. Evaluation of species-specific recA-based PCR tests for genomovar level identification within the Burkholderia cepacia complex. J Med Microbiol. 2002;51:937–40.PubMedGoogle Scholar
  40. 40.
    Payne GW, Vandamme P, Morgan SH, Lipuma JJ, Coenye T, Weightman AJ, et al. Development of a recA gene-based identification approach for the entire Burkholderia genus. Appl Environ Microbiol. 2005;71:3917–27.CrossRefPubMedGoogle Scholar
  41. 41.
    Baldwin A, Mahenthiralingam E, Thickett KM, Honeybourne D, Maiden MC, Govan JR, et al. Multilocus sequence typing scheme that provides both species and strain differentiation for the Burkholderia cepacia complex. J Clin Microbiol. 2005;43:4665–73.CrossRefPubMedGoogle Scholar
  42. 42.
    Cesarini S, Bevivino A, Tabacchioni S, Chiarini L, Dalmastri C. RecA gene sequence and multilocus sequence typing for species-level resolution of Burkholderia cepacia complex isolates. Lett Appl Microbiol. 2009;49:580–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Turton JF, Arif N, Hennessy D, Kaufmann ME, Pitt TL. Revised approach for identification of isolates within the Burkholderia cepacia complex and description of clinical isolates not assigned to any of the known genomovars. J Clin Microbiol. 2007;45:3105–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Graindorge A, Menard A, Neto M, Bouvet C, Miollan R, Gaillard S, et al. Epidemiology and molecular characterization of a clone of Burkholderia cenocepacia responsible for nosocomial pulmonary tract infections in a French intensive care unit. Diagn Microbiol Infect Dis. 2010;66:29–40.CrossRefPubMedGoogle Scholar
  45. 45.
    LiPuma JJ. Update on the Burkholderia cepacia complex. Curr Opin Pulm Med. 2005;11:528–33.CrossRefPubMedGoogle Scholar
  46. 46.
    LiPuma JJ. Burkholderia cepacia epidemiology and pathogenesis: implications for infection control. Curr Opin Pulm Med. 1998;4:337–41.CrossRefPubMedGoogle Scholar
  47. 47.
    Garner JS. Guideline for isolation precautions in hospitals. The Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1996;17:53–80.CrossRefPubMedGoogle Scholar
  48. 48.
    Thomassen MJ, Demko CA, Doershuk CF, Stern RC, Klinger JD. Pseudomonas cepacia: decrease in colonization in patients with cystic fibrosis. Am Rev Respir Dis. 1986;134:669–71.PubMedGoogle Scholar

Copyright information

© Urban & Vogel 2010

Authors and Affiliations

  • T. Mann
    • 1
    • 2
  • D. Ben-David
    • 1
  • A. Zlotkin
    • 1
  • D. Shachar
    • 1
  • N. Keller
    • 3
  • A. Toren
    • 4
  • A. Nagler
    • 5
  • G. Smollan
    • 3
  • A. Barzilai
    • 4
  • G. Rahav
    • 1
    Email author
  1. 1.Infectious Diseases UnitSheba Medical CenterTel-HashomerIsrael
  2. 2.Internal MedicineAssaf HarofeZrifinIsrael
  3. 3.Department of Clinical MicrobiologySheba Medical CenterTel-HashomerIsrael
  4. 4.Department of PediatricsSheba Medical CenterTel-HashomerIsrael
  5. 5.Division of Hematology and Bone Marrow TransplantationSheba Medical CenterTel-HashomerIsrael

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