Title : Burkholderia cepacia infection outbreak in an oncology set up: Investigation and infection control response
Abstract:
Background: Burkholderia cepacia complex (BCC) is a non-fermenting Gram-negative bacillus known for its ability to survive in aqueous environments, disinfectants, and medical solutions. It is an opportunistic pathogen that poses significant risk to immunocompromised patients, particularly those in oncology and bone marrow transplant (BMT) units. Bloodstream infections caused by BCC are associated with contaminated medical products and invasive devices. In March 2026, a cluster of BCC bloodstream infections was detected in patients admitted to the Hematolymphoid (HL) ward and BMT unit of our hospital, prompting an urgent outbreak investigation.
Problem: Within one week, three patients developed bloodstream infections due to Burkholderia cepacia. The first case, identified on 14 March 2026 in the BMT ward, yielded BCC from both Hickman catheter lumens and peripheral blood. On 16 March, a second patient grew the same organism from central venous catheter (CVC) and peripheral samples. A third patient, reported on 19 March, also tested positive for BCC. All patients had undergone recent invasive procedures involving ultrasound (USG) guidance, during which USG gel had been used. The temporal clustering and microbiological similarity suggested a common source outbreak, necessitating immediate epidemiological and microbiological investigation.
Work-up and Action Taken: An outbreak investigation was promptly initiated. Environmental surveillance samples were collected from the BMT ward, ICU, and operating theatre. These included water samples; potential fomites, disinfectant solutions; ECG and USG gel bottles (opened and unopened); and USG probe surfaces. All samples were cultured in the in-house microbiology laboratory.
Burkholderia cepacia was isolated from multiple ECG and USG gel bottles across different clinical areas, including unopened containers. Other environmental samples did not yield the organism. This strongly implicated contaminated gel as the outbreak source, possibly due to intrinsic contamination during manufacturing or contamination during bulk storage and handling.
Immediate corrective measures were implemented. All suspected gel products were withdrawn and replaced with sterile, single-use gels. An advisory was circulated hospital-wide, discontinuing the use of non-sterile gel for invasive procedures. Infection control practices were reinforced, emphasizing sterile technique, avoidance of multi-use gel bottles, and strengthened surveillance.
Patient management included removal of infected lines and antibiotic therapy, resulting in negative follow-up blood cultures.
