title: Multi-institutional outbreak of Burkholderia cepacia complex associated with contaminated mannitol solution prepared in compounding pharmacy.
abstract: BACKGROUND
  Burkholderia cepacia complex (BCC) has been described as a cause of nosocomial outbreaks. We describe an outbreak of and identify risk factors for nosocomial BCC infections associated with intrinsically contaminated mannitol 3% solution.
  
  
  METHODS
  Urinary and bloodstream infection caused by BCC were identified in hospitalized patients who underwent urologic surgery and received intraoperative irrigation of 3% mannitol solution in February 2009. The investigation included retrospective chart review, case control study, procedural review, and culture of mannitol solution.
  
  
  RESULTS
  Seven BCC infections were identified. BCC isolates were recovered from blood and/or urine from patients and lots of mannitol in use during the outbreak period. Mannitol solution was produced by a compounding pharmacy. Receipt of larger volumes of contaminated solution was identified as a significant risk factor for infection (odds ratio, 1.5; P value < .05). BCC was also cultured in lots of mannitol in use in other hospitals.
  
  
  CONCLUSIONS
  Manipulated mannitol solution is a potential source of infection. Contamination with paraben-degrading organisms can occur at the time of manufacture. Our findings suggest that contamination of mannitol at a compounding pharmacy occurred. Prompt communication to other hospitals and implementation of infection control measures were effective in avoiding further cases of infection.
authors.affiliation: Infection Control Department, Hospital Sírio Libanês, São Paulo, Brazil. Electronic address: maria.beatriz@hsl.org.br.
authors.forename: Maria Beatriz
authors.initials: MB
authors.lastname: Souza Dias
authors.forename: Larissa G T
authors.initials: LG
authors.lastname: Cavassin
authors.forename: Valeska
authors.initials: V
authors.lastname: Stempliuk
authors.forename: Luciene S
authors.initials: LS
authors.lastname: Xavier
authors.forename: Renata D
authors.initials: RD
authors.lastname: Lobo
authors.forename: Jorge L M
authors.initials: JL
authors.lastname: Sampaio
authors.forename: Antonio Carlos
authors.initials: AC
authors.lastname: Pignatari
authors.forename: Vera L
authors.initials: VL
authors.lastname: Borrasca
authors.forename: Ana Luiza
authors.initials: AL
authors.lastname: Bierrenbach
authors.forename: Cristiana M
authors.initials: CM
authors.lastname: Toscano
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016470:Bacteremia / Q000453:epidemiology / Q000382:microbiology; D001431:Bacteriological Techniques; D019121:Burkholderia Infections / Q000453:epidemiology* / Q000382:microbiology; D042602:Burkholderia cepacia complex / Q000302:isolation & purification*; D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology; D004196:Disease Outbreaks; D004339:Drug Compounding; D004340:Drug Contamination; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008353:Mannitol; D008875:Middle Aged; D012996:Solutions; D014552:Urinary Tract Infections / Q000453:epidemiology / Q000382:microbiology
chemical_list: D012996:Solutions; D008353:Mannitol
keywords: Endoscopic urological surgery; Extrinisic contamination; Health care-associated infection; Outbreak investigation