title: An outbreak of Burkholderia cepacia complex pseudobacteremia associated with intrinsically contaminated commercial 0.5% chlorhexidine solution.
abstract: BACKGROUND
  Burkholderia cepacia complex (Bcc) is well-known for intrinsic resistance to certain antiseptics. We experienced a sudden rise in Bcc bloodstream infections in a 786-bed hospital. An investigation was conducted to identify the source and to intervene in the ongoing infections.
  
  
  METHODS
  The cases were defined as patients with positive blood cultures for Bcc from October 10, 2013-December 16, 2013. We reviewed medical records, interviewed health care workers, and audited the clinical laboratory. A microbiologic culture for a suspected antiseptic was performed, and interventions were instituted.
  
  
  RESULTS
  During the outbreak period, Bcc were isolated from 46 blood cultures from 40 patients. The temporal and spatial distributions did not reveal common factors. The clinical features of the case patients suggested pseudobacteremia. A 0.5% chlorhexidine solution product was found to be contaminated with Bcc and had been misused as a skin antiseptic during blood culture. After withdrawal of the product and staff education, the outbreak was terminated.
  
  
  CONCLUSIONS
  The pseudobacteremia was caused by contaminated 0.5% chlorhexidine from a single company. This contamination was permitted by multiple breaches of infection control principles that could have caused significant outbreaks of true infections. Regulatory actions at the government level are needed to ensure the sterility of antiseptics.
authors.affiliation: Infection Control Office, Boramae Medical Center, Seoul, Republic of Korea.
authors.forename: Suhui
authors.initials: S
authors.lastname: Ko
authors.affiliation: Infection Control Office, Boramae Medical Center, Seoul, Republic of Korea.
authors.forename: Hye-Sun
authors.initials: HS
authors.lastname: An
authors.affiliation: Department of Internal Medicine, Boramae Medical Center and Seoul National University College of Medicine, Seoul, Republic of Korea.
authors.forename: Ji Hwan
authors.initials: JH
authors.lastname: Bang
authors.affiliation: Infection Control Office, Boramae Medical Center, Seoul, Republic of Korea; Department of Internal Medicine, Boramae Medical Center and Seoul National University College of Medicine, Seoul, Republic of Korea. Electronic address: hswon1@snu.ac.kr.
authors.forename: Sang-Won
authors.initials: SW
authors.lastname: Park
mesh_terms: D016470:Bacteremia / Q000175:diagnosis / Q000453:epidemiology* / Q000382:microbiology; D019121:Burkholderia Infections / Q000175:diagnosis / Q000453:epidemiology* / Q000382:microbiology; D042602:Burkholderia cepacia complex / Q000302:isolation & purification*; D016022:Case-Control Studies; D002710:Chlorhexidine; D004196:Disease Outbreaks; D004340:Drug Contamination; D006801:Humans
chemical_list: D002710:Chlorhexidine
keywords: Antiseptic; Burkholderia; Chlorhexidine; Outbreak; Pseudobacteremia