title: Outbreak of Burkholderia cepacia bacteremia traced to contaminated hospital water used for dilution of an alcohol skin antiseptic.
abstract: OBJECTIVE
  To identify the source of an epidemic of Burkholderia cepacia bloodstream infections during 7 years (411 episodes in 361 patients).
  
  
  METHODS
  Outbreak investigation.
  
  
  METHODS
  A 250-bed university hospital in Beirut, Lebanon.
  
  
  METHODS
  Matched case-control and retrospective cohort studies, and microbiological surveillance and polymerase chain reaction-restriction fragment length ascertainment were employed. Special media and filtration techniques were used to isolate organisms from water and diluted alcohol solutions.
  
  
  RESULTS
  In a group of 50 randomly selected case-matched patients from 1999, the positive blood cultures were concomitant with fever in 98%, intravenous phlebitis in 44%, and recurrent bacteremia in 20%. Fever disappeared approximately 6 hours after intravenous catheter removal. Polymerase chain reaction-restriction fragment length polymorphism revealed strain homogeneity in patient, water, and alcohol isolates. Contaminated tap water had been used to dilute alcohol for skin antisepsis and for decontamination of the caps of heparin vials. Only sporadic cases directly attributable to breach of protocol were reported after single-use alcohol swabs were substituted.
  
  
  CONCLUSIONS
  This is potentially the largest single-source nosocomial bloodstream infection outbreak ever reported, and the first report of an alcohol skin antiseptic contaminated by tap water as a source for nosocomial bacteremia.
authors.affiliation: Department of Infection Control, Saint George Hospital, Beirut, Lebanon.
authors.forename: Rana M
authors.initials: RM
authors.lastname: Nasser
authors.forename: Amal C
authors.initials: AC
authors.lastname: Rahi
authors.forename: Mona F
authors.initials: MF
authors.lastname: Haddad
authors.forename: Ziad
authors.initials: Z
authors.lastname: Daoud
authors.forename: Noha
authors.initials: N
authors.lastname: Irani-Hakime
authors.forename: Wassim Y
authors.initials: WY
authors.lastname: Almawi
mesh_terms: D000438:Alcohols / Q000627:therapeutic use; D000891:Anti-Infective Agents, Local; D017848:Blood-Borne Pathogens; D019121:Burkholderia Infections / Q000453:epidemiology / Q000209:etiology* / Q000517:prevention & control; D016956:Burkholderia cepacia / Q000235:genetics / Q000302:isolation & purification*; D002408:Catheters, Indwelling / Q000382:microbiology*; D003428:Cross Infection / Q000453:epidemiology / Q000382:microbiology* / Q000517:prevention & control; D004196:Disease Outbreaks / Q000517:prevention & control; D004866:Equipment Contamination; D005260:Female; D006785:Hospitals, University; D006801:Humans; D017757:Infectious Disease Transmission, Professional-to-Patient; D007262:Infusions, Intravenous / Q000009:adverse effects / Q000295:instrumentation; D007861:Lebanon; D008297:Male; D008875:Middle Aged; D016133:Polymerase Chain Reaction; D012867:Skin / Q000382:microbiology; D014871:Water Microbiology
chemical_list: D000438:Alcohols; D000891:Anti-Infective Agents, Local