Burkholderia cepacia infection in the neonatal unit: a cautionary tale of contaminated EEG skin preparation

I-Ly Joanna ChuaPathWest Laboratory Medicine, Western Australia

Chris BlythPathWest Laboratory Medicine, Western Australia; and Perth Children’s Hospital, Western Australia

Michelle PorterPathWest Laboratory Medicine, Western Australia; and King Edward Memorial Hospital, Western Australia

Cara Minney-SmithPathWest Laboratory Medicine, Western Australia

Adam MerrittPathWest Laboratory Medicine, Western Australia

Brittany BrennanPathWest Laboratory Medicine, Western Australia

Cristina FarrarPathWest Laboratory Medicine, Western Australia

Linda PelumboPerth Children’s Hospital, Western Australia

Danielle EngelbrechtKing Edward Memorial Hospital, Western Australia

Lisa NicolaouKing Edward Memorial Hospital, Western Australia

DOI:

https://doi.org/10.3396/ijic.v20.23528

Abstract

Burkholderia cepacia isolated from a scalp wound of a neonate prompted investigation to identify potential sources. The same organism was isolated from numerous batches of gel used to prepare skin prior to electroencephalography (EEG), prompting a recall of this product. This case highlights the potential for contamination of equipment and products used for EEG.

 

How to Cite:

Chua, I.-L. J., Blyth, C., Porter, M., Minney-Smith, C., Merritt, A., Brennan, B., … Nicolaou, L. (2024). Burkholderia cepacia infection in the neonatal unit: a cautionary tale of contaminated EEG skin preparation. International Journal of Infection Control, 20. https://doi.org/10.3396/ijic.v20.23528

References

  1. Vandamme P, Dawyndt P. Classification and identification of the Burkholderia cepacia complex: past, present and future. Syst Appl Microbiol. 2011 Apr 1; 34(2): 87–95. doi: 10.1016/j.syapm.2010.10.002

  2. Häfliger E, Atkinson A, Marschall J. Systematic review of healthcare-associated Burkholderia cepacia complex outbreaks: presentation, causes and outbreak control. Infect Prevent Pract. 2020 Sep 1; 2(3): 100082. doi: 10.1016/j.infpip.2020.100082

  3. Shaban RZ, Sotomayor-Castillo C, Nahidi S, Li C, Macbeth D, Mitchell BG, et al. Global burden, point sources, and outbreak management of healthcare-associated Burkholderia cepacia infections: an integrative review. Infect Control Hosp Epidemiol. 2020 Jul; 41(7): 777–83. doi: 10.1017/ice.2020.184

  4. Cunningham-Oakes E, Weiser R, Pointon T, Mahenthiralingam E. Understanding the challenges of non-food industrial product contamination. FEMS Microbiol Lett. 2019 Dec; 366(23): fnaa010. doi: 10.1093/femsle/fnaa010

  5. Dao H, Lakhani P, Police A, Kallakunta V, Ajjarapu SS, Wu KW, et al. Microbial stability of pharmaceutical and cosmetic products. Aaps Pharmscitech. 2018 Jan 1; 19(1): 60–78. doi: 10.1208/s12249-017-0875-1

  6. Lee JK. Two outbreaks of Burkholderia cepacia nosocomial infection in a neonatal intensive care unit. J Paediatr Child Health. 2008 Jan; 44(1–2): 62–6. doi: 10.1111/j.1440-1754.2007.01173.x

  7. Paul LM, Hegde A, Pai T, Shetty S, Baliga S, Shenoy S. An outbreak of Burkholderia cepacia bacteremia in a neonatal intensive care unit. Indian J Pediatr. 2016 Apr 1; 83(4): 285–8. doi: 10.1007/s12098-015-1855-7

  8. 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 May 1; 42(5): 2227–30. doi: 10.1128/JCM.42.5.2227-2230.2004

  9. Depoorter E, De Canck E, Peeters C, Wieme AD, Cnockaert M, Zlosnik JE, et al. Burkholderia cepacia complex taxon K: where to split? Front Microbiol. 2020 Jul 14; 11: 1594. doi: 10.3389/fmicb.2020.01594

  10. FDA. Mavidon issues voluntary worldwide recall of LemonPrep tubes and single use cups. 2019. 2020 Dec 28;10-12: Available from: https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/mavidon-issues-voluntary-worldwide-recall-lemonprepr-tubes-and-single-use-cups [cited 28 December 2020].

  11. FDA. Mavidon issues voluntary worldwide recall of manufactured products including Lemonprep tubes and single use cups Pediaprep tubes and single use cups Wave Prep tubes and single use cups Cardio prep single use cups due To Burkholderia cepacia contamination. 2019. Available from: https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/mavidon-issues-voluntary-worldwide-recall-manufactured-products-including-lemonprepr-tubes-and [cited 28 December 2020].

  12. Mavidon Medical Products. LemonPrep. 2016. Available from: https://www.mavidon.com/upload/product/files/52/LemonPrep_Spec_Sheet.pdf [cited 28 December 2020].

 

Copyright (c) 2023 Joanna Chua

This work is licensed under a Creative Commons Attribution 4.0 International License.

Authors retain copyright of their work, with first publication rights granted to IJIC. Read the full Copyright- and Licensing Statement.

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