540. Hospital Outbreak of Burkholderia cenocepacia Infection Associated with Contaminated Chlorhexidine Solutions Prepared by the Hospital Pharmacy
Session: Poster Session: Hospital-acquired and Transplant Infections
Friday, October 30, 2009: 12:00 AM
Room: Poster Hall A
Background: From October to December 2007, the incidence of Burkholderia cepacia complex (BCC) clinical isolates markedly increased in secondary care teaching hospital, Daegu, Korea.
Methods: The infection control team investigated this outbreak. The clinical isolates of BCC from the patients and contaminated antiseptic chlorhexidine solutions was collected and analyzed by using pulsed-filed gel electrophoresis (PFGE).
Results: The isolates from patients and contaminated chlorhexidine solutions were identified as B. cenocepacia and exhibited identical PFGE profiles. Inappropriate preparation of antiseptic chlorhexidine solutions such as use of non-sterile purified water for dilution and non-sterilized container was suspicious cause of contamination. After appropriate antiseptic techniques for the preparation of disinfectants using sterile water for dilution was applied, no contaminated chlorhexidine solution was found any more and this outbreak was settled.
Conclusions: This outbreak was associated with contaminated chlorhexidine solutions prepared by the hospital pharmacy.
Seung Woo Han, MD1, Chul Lee Je, MD, PhD2, Gun Woo Kim, MD, PhD1, Ki Tae Kwon, MD, PhD, Do Young Song, MD4 and  K. Kwon, None..
D. Song, None..
C. Je, None..
S. Han, None..
G. Kim, None., (1)Department of Internal Medicine, Daegu Fatima Hospital, Daegu, Korea, Republic of, (2)Department of Microbiology, School of Medicine, Kyungpook National University, Daegu, Korea, Republic of, (3)Department of Laboratory medicine, Daegu Fatima Hospital, Daegu, Korea, Republic of