title: An outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy.
abstract: OBJECTIVE
  To investigate an outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection in mechanically ventilated patients.
  
  
  METHODS
  A retrospective case-control and bacteriologic study.
  
  
  METHODS
  Veterans Affairs medical center.
  
  
  METHODS
  42 mechanically ventilated patients who developed respiratory tract colonization or infection with B. cepacia and 135 ventilator-dependent controls who were not colonized and did not develop infections.
  
  
  METHODS
  Clinical and demographic data; benzalkonium chloride concentrations and pH levels in albuterol sulfate solutions; repetitive-element polymerase chain reaction (PCR)-mediated molecular fingerprinting on eight patient isolates and three environmental B. cepacia isolates that were available for study.
  
  
  RESULTS
  42 patients had B. cepacia respiratory tract colonization or infection. Observation of intensive care unit and respiratory care personnel showed faulty infection control procedures (for example, the same multiple-dose bottle of albuterol was used for many mechanically ventilated patients). More case patients (39 [92.9%]) than controls (95 [70.4%]; P = 0.006) received nebulized albuterol, and case patients (67.5 treatments) received more treatments than controls (18 treatments; P < 0.001). In-use albuterol solutions had pH values that were unstable, and benzalkonium chloride concentrations declined over time to levels capable of supporting bacterial growth. Medication nebulizers and in-use bottles of albuterol harbored B. cepacia. Molecular fingerprints of patient isolates and environmental B. cepacia isolates were identical using repetitive-element PCR. No further isolates of B. cepacia were identified after institution of appropriate infection control procedures.
  
  
  CONCLUSIONS
  Multiple-dose medications and reliance on benzalkonium chloride as a medication preservative provide a mechanism for nosocomial spread of microorganisms, particularly if infection control procedures are not carefully followed. Repetitive-element PCR is a useful fingerprinting technique for molecular epidemiologic studies of B. cepacia.
authors.affiliation: Section of Infectious Diseases (111G), Veterans Affairs Medical Center, Houston, TX 77030, USA.
authors.forename: R J
authors.initials: RJ
authors.lastname: Hamill
authors.forename: E D
authors.initials: ED
authors.lastname: Houston
authors.forename: P R
authors.initials: PR
authors.lastname: Georghiou
authors.forename: C E
authors.initials: CE
authors.lastname: Wright
authors.forename: M A
authors.initials: MA
authors.lastname: Koza
authors.forename: R M
authors.initials: RM
authors.lastname: Cadle
authors.forename: P A
authors.initials: PA
authors.lastname: Goepfert
authors.forename: D A
authors.initials: DA
authors.lastname: Lewis
authors.forename: G J
authors.initials: GJ
authors.lastname: Zenon
authors.forename: J E
authors.initials: JE
authors.lastname: Clarridge
mesh_terms: D000368:Aged; D000420:Albuterol / Q000008:administration & dosage; D016956:Burkholderia cepacia / Q000302:isolation & purification; D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology*; D004196:Disease Outbreaks; D004340:Drug Contamination; D004866:Equipment Contamination; D006801:Humans; D008875:Middle Aged; D009330:Nebulizers and Vaporizers; D011552:Pseudomonas Infections / Q000453:epidemiology*; D012121:Respiration, Artificial / Q000009:adverse effects*; D012141:Respiratory Tract Infections / Q000453:epidemiology* / Q000382:microbiology; D012189:Retrospective Studies
chemical_list: D000420:Albuterol