348. Outbreak of Burkholderia cepacia bacteremia associated with contaminated ondasetron
Session: Poster Abstract Session: HAI: Outbreaks
Thursday, October 8, 2015
Room: Poster Hall

Burkholderia cepacia complex (BCC) is a nosocomial pathogen that causes bacteremia, urinary tract infection, septic arthritis, peritonitis and respiratory tract infection. Due high intrinsic resistance, outbreaks and pseudo-outbreaks of BCC bacteremia have been documented in intensive care units, oncology and renal failure patient.

Methods: Cases were defined as patients with positive blood cultures for BCC during march and april. Patient files were reviewed and environmental sampling was performed.


During the 2 months’ outbreak, 17 patients with central venous catheter had BCC bacteremia. The mean age was 47 ± 22 years; 12 (70.6%) were females. Study population included: 16 (94%) oncological patients [8 (48%) women with breast cancer, 2 (12%) colonic cancers, 2 (12%) gynecological cancers and 2 (12%) hematologic malignancies] and 1 (6%) geriatric patient. The median between catheter insertion and bacteremia development was 78 days (IQR 34-172). All the isolates were sensitive to carbapenems and cothrimoxasole. Removal of the catheter was done in 15 (88%) patients. The median period between culture positivity and removal of catheter was 3 days (IQR 2- 4). The tips of 14 (93%) implanted catheters grew BCC with antimicrobial sensitivity identical to that isolated from the blood.

Cultures from water and disinfectants (2% alcoholic chlorhexidine and 10% aqueous povidone iodine) were negative, cultures from the environmental surfaces grew Staphylococuus spp. Intravenous fluid bags, heparin and chemotherapy medication were sterile, ondasetron vials grew Burkholderia cepacia. The antibiotic susceptibility was identical to those from patients. The median days between ondasetron administration and development of bacteremia was 10 days (IQ range 5-28).

This indicates that this outbreak was due to intrinsic contamination of the antiemetic drug. The results were communicated to the manufacturer with no further cases. Patients received appropriate treatment, 100% survived.


Immediate notification of the Ministry of Health and withdrawal of the medication were necessary. Regulatory actions are needed to ensure sterility of medications.

Claudia Lopez Enriquez, DR1, Jose Juan Donis-Hernandez, DR1, Pilar Escamilla-Llano, DR2, Lucia Martinez-Hernandez, DR1, Margarita Virgen-Cuevas, MD1, Jesus Alfaro, Chemical3, Carlos Villalpando, Chemical3, Gabriel Galvan-Salazar, ONCOLOGY4, Lizbett Vanessa Garcia-Montes, ONCOLOGY5, Blanca Sosa-Sanchez, NURSERY1 and Veronica Rivera-Milo, NURSERY1, (1)Unit Infect Diseases, Hospital Espaņol, Mexico City, Mexico, (2)Microbiology, HOSPITAL ESPAŅOL, MEXico City, Mexico, (3)Microbiology, Hospital Espaņol, Mexico City, Mexico, (4)Oncology, HOSPITAL ESPAŅOL, Mexico City, Mexico, (5)Oncology, Hospital Espaņol, Mexico City, Mexico


C. Lopez Enriquez, None

J. J. Donis-Hernandez, None

P. Escamilla-Llano, None

L. Martinez-Hernandez, None

M. Virgen-Cuevas, None

J. Alfaro, None

C. Villalpando, None

G. Galvan-Salazar, None

L. V. Garcia-Montes, None

B. Sosa-Sanchez, None

V. Rivera-Milo, None

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