title: Efficient management and maintenance of ultrasonic nebulizers to prevent microbial contamination.
abstract: OBJECTIVE
  To seek the cause of Burkholderia cepacia complex (Bcc) infection outbreak and evaluate the efficacy of new methods for nebulizer maintenance.
  
  
  METHODS
  We investigated the annual number of Bcc isolates recovered from clinical samples in our hospital between 1999 and 2013. Swab samples were randomly collected for bacterial culture before patient use from 10 each of the two machine types in August 2001; these included 20 samples from each of the following: Drain tubes, operating water chambers, oscillators, and nebulizing chambers. In addition, 10 samples each of nebulizer solutions before and after use were cultured. For environmental investigation, 10 samples were collected from sinks in the nurse stations of the wards where patients positive for Bcc were hospitalized. Numbers of Bcc isolates were compared before and after introduction of new methods for nebulizer maintenance in October 2001. In addition, randomly amplified polymorphic DNA (RAPD) assay was applied to find the genetic divergence of the Bcc isolates obtained from clinical samples and nebulizers.
  
  
  RESULTS
  From January 1999 to December 2013, a total of 487 Bcc isolates were obtained from clinical specimens from 181 patients. Notably, 322 (66.1%) Bcc isolates were obtained from clinical specimens from 1999 to 2001, including 244 (115 patients) from sputum and 34 (11 patients) from blood. During this period, 14 isolates were obtained from nebulizer components. Among these, six were derived from nebulizer drain tubes, five from operating water chambers, and one from the oscillator before patient use, and two from nebulizer solutions after patient use. When Bcc was isolated from the nebulizer solution after patient use, Bcc was simultaneously detected in other parts of the nebulizer. Bcc was not isolated from any nebulizer solution before use. RAPD assays revealed similar DNA profiles in isolates obtained from patients and nebulizers. Investigation revealed damaged diaphragms in many nebulizers. The new maintenance methods for nebulizers, including restriction of the usage period, thorough disinfection, and routine check for diaphragm breakage, remarkably reduced Bcc isolation (165 isolates from patients in 12 years and 0 isolate from nebulizers in periodical sampling). In particular, Bcc has been isolated from blood from only one patient since the new methods were introduced.
  
  
  CONCLUSIONS
  Appropriate maintenance of ultrasonic nebulizers is crucial for preventing Bcc contamination of nebulizers and subsequent respiratory tract and blood infections.
authors.affiliation: Yoko Ida, Hiroaki Ohnishi, Kouji Araki, Takashi Watanabe, Clinical Laboratory, Kyorin University Hospital, Tokyo 181-8611, Japan.
authors.forename: Yoko
authors.initials: Y
authors.lastname: Ida
authors.affiliation: Yoko Ida, Hiroaki Ohnishi, Kouji Araki, Takashi Watanabe, Clinical Laboratory, Kyorin University Hospital, Tokyo 181-8611, Japan.
authors.forename: Hiroaki
authors.initials: H
authors.lastname: Ohnishi
authors.affiliation: Yoko Ida, Hiroaki Ohnishi, Kouji Araki, Takashi Watanabe, Clinical Laboratory, Kyorin University Hospital, Tokyo 181-8611, Japan.
authors.forename: Kouji
authors.initials: K
authors.lastname: Araki
authors.affiliation: Yoko Ida, Hiroaki Ohnishi, Kouji Araki, Takashi Watanabe, Clinical Laboratory, Kyorin University Hospital, Tokyo 181-8611, Japan.
authors.forename: Ryoichi
authors.initials: R
authors.lastname: Saito
authors.affiliation: Yoko Ida, Hiroaki Ohnishi, Kouji Araki, Takashi Watanabe, Clinical Laboratory, Kyorin University Hospital, Tokyo 181-8611, Japan.
authors.forename: Shin
authors.initials: S
authors.lastname: Kawai
authors.affiliation: Yoko Ida, Hiroaki Ohnishi, Kouji Araki, Takashi Watanabe, Clinical Laboratory, Kyorin University Hospital, Tokyo 181-8611, Japan.
authors.forename: Takashi
authors.initials: T
authors.lastname: Watanabe
keywords: Burkholderia cepacia; Contamination; Prevention; Randomly amplified polymorphic DNA assay; Ultrasonic nebulizer