title: A National Guard outbreak of Burkholderia cepacia infection and colonization secondary to intrinsic contamination of albuterol nebulization solution.
abstract: BACKGROUND
  Burkholderia cepacia, a gram-negative pathogen, has been a known cause of hospital outbreaks because of a contaminated common source such as multidose medications. We describe an outbreak with Burkholderia cepacia infection in 2 major hospitals affiliated to the National Guard, related to an intrinsic contamination of a locally manufactured, multidose Albuterol nebulization solution (Tabouk Pharmaceutical Company, Tabouk, Saudi Arabia) and we report the interventions taken to interrupt this outbreak.
  
  
  METHODS
  During the outbreak period between May 2003 and March 2004, a combined prospective surveillance and a retrospective chart and microbiologic data review were conducted in 4 major hospitals affiliated to the National Guard. Microbiologic cultures were also performed on environmental objects of concern, as well as certain medications. In addition, a questionnaire was distributed to the respiratory therapy staff to evaluate the process of administering respiratory medications and their adherence to sound infection control practices.
  
  
  RESULTS
  An intrinsic contamination of a locally manufactured brand of multidose Albuterol nebulization with B cepacia was identified. Two of the 4 hospitals were found to be involved: hospital A a 700-bed tertiary care center and Hospital B a 150-bed hospital. A total of 2121 patients were exposed to Albuterol nebulization as inpatients at hospital A and 318 as outpatients. For hospital B, a total of 283 inpatients and 34 outpatients were exposed to the Albuterol nebulization. Forty and 12 patients, from hospital A and hospital B, respectively, were found to have at least 1 positive culture for B cepacia. From hospital A, most samples were respiratory, and, from hospital B, most were from blood. Molecular typing of 34 available isolates showed that 23 cases were of a single strain of B cepacia that matched the strain isolated from the 3 different batches of multidose Albuterol nebulization. Three culture-positive patients never received Albuterol nebulization of that brand but were in the same room of a patient who had been receiving the medication.
  
  
  CONCLUSIONS
  We identified a large outbreak of B cepacia in 2 major hospitals affiliated with the National Guard, linked to an intrinsic contamination of a multidose Albuterol nebulization solution. During the period of prospective surveillance, only a few cases were identified as a result of nosocomial transmission. Immediate notification of the Ministry of Health and withdrawal of the medication and revisiting the respiratory therapy practices were necessary to halt this outbreak.
authors.affiliation: Department of Infection Prevention and Control, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
authors.forename: Hanan H
authors.initials: HH
authors.lastname: Balkhy
authors.forename: Gwen
authors.initials: G
authors.lastname: Cunningham
authors.forename: Christine
authors.initials: C
authors.lastname: Francis
authors.forename: Maha A
authors.initials: MA
authors.lastname: Almuneef
authors.forename: Gwen
authors.initials: G
authors.lastname: Stevens
authors.forename: Nadia
authors.initials: N
authors.lastname: Akkad
authors.forename: Ayman
authors.initials: A
authors.lastname: Elgammal
authors.forename: Abdullah
authors.initials: A
authors.lastname: Alassiri
authors.forename: Elaine
authors.initials: E
authors.lastname: Furukawa
authors.forename: Fong Khew
authors.initials: FK
authors.lastname: Chew
authors.forename: Mazen
authors.initials: M
authors.lastname: Sobh
authors.forename: Diane
authors.initials: D
authors.lastname: Daniel
authors.forename: Gregory
authors.initials: G
authors.lastname: Poff
authors.forename: Ziad A
authors.initials: ZA
authors.lastname: Memish
mesh_terms: D000293:Adolescent; D000328:Adult; D000336:Aerosols; D000368:Aged; D000420:Albuterol; D019121:Burkholderia Infections / Q000453:epidemiology*; D016956:Burkholderia cepacia / Q000302:isolation & purification*; D002353:Carrier State; D002648:Child; D004196:Disease Outbreaks; D004340:Drug Contamination; D004349:Drug Packaging; D005260:Female; D006772:Hospitals, Military; D006801:Humans; D007223:Infant; D017053:Infection Control / Q000379:methods; D008297:Male; D008875:Middle Aged; D009330:Nebulizers and Vaporizers; D012529:Saudi Arabia / Q000453:epidemiology; D011795:Surveys and Questionnaires
chemical_list: D000336:Aerosols; D000420:Albuterol