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infection control and hospital epidemiology july 2010, vol. 31, no.

concise communication

Cluster of Pseudoinfections sterile saline was flushed through the distal (or biopsy) port
of the instrument into a sterile cup. Swab samples of the
with Burkholderia cepacia Associated automated washer-disinfector basin surface, along with asep-
with a Contaminated Washer-Disinfector tically collected samples of feed water and rinse water used
in a Bronchoscopy Unit in the washer-disinfector, were sent for bacterial culture. Swab
samples were cultured on blood agar, MacConkey agar, and
Dror Rosengarten, MD; Colin Block, MBBCh, PhD; B. cepaciaselective agar. Fluid samples were processed by
Carlos Hidalgo-Grass, MD, PhD; Violeta Temper, MD; initial surface plating of 10-mL or 100-mL aliquots on tryptic
Ilana Gross, RN, MPH; Anna Budin-Mizrahi, RN; soy agar and inoculation of 1-mL aliquots into tryptic soy
Neville Berkman, MBBCh, FRCP; Shmuel Benenson, MD broth and supplemented thioglycollate broth (Novamed). All
positive cultures were subcultured onto B. cepaciaselective
agar. Yellow-pigmented, oxidase-positive, colistin-resistant,
In December 2008, bronchoalveolar lavage fluid samples obtained gram-negative bacilli were identified presumptively by use of
from 3 patients were positive for Burkholderia cepacia complex on the API 20NE kit (bioMerieux).
culture. Samples obtained from bronchoscopes and rinse-water sam- Isolates were assessed for genus and species identification
ples obtained from the washer-disinfector were found to be positive by use of polymerase chain reaction (PCR) with full-length
for B. cepacia complex. The cause of this pseudo-outbreak was that
16S ribosomal RNA (rRNA) and the recA gene, as described
the washer-disinfector was installed without the required antibac-
elsewhere.2,3 Nucleic acid sequence manipulation and anno-
terial filter.
tation were performed by use of dedicated software (Geneious
Infect Control Hosp Epidemiol 2010; 31(7):769-771 Pro 4.6; Biomatters). Pulsed-field gel electrophoresis (PFGE)
was performed on available isolates. DNA was digested with
XbaI (New England Biolabs) at 37C for 4 hours, and gels
Although infectious complications resulting from flexible
were analyzed by use of Molecular Analyst Fingerprinting
bronchoscopy are considered to be relatively uncommon, the
Plus software (CHEF Mapper; Bio-Rad). PFGE patterns were
potential for bronchoscopy-associated infections is high.
interpreted using accepted criteria.4
There are reports of more than 800 patients who had infec-
tious complications after bronchoscopy, including instances
in which fatalities might have been related to the infection.1
In our report, we describe a cluster of pseudoinfections in results
patients in a bronchoscopy unit who had Burkholderia cepacia
complex isolated from bronchoalveolar lavage fluid samples, The 3 patients had been examined with the same broncho-
the clinical and microbiological investigation that led us to scope, and use of this particular bronchoscope was stopped.
the source of the organism, and the successful intervention. Samples obtained from 8 of the 10 bronchoscopes in the unit
tested positive for B. cepacia complex on culture, a finding
that pointed to probable contamination in the cleaning and
disinfection process. Routine bronchoscopies were suspended,
methods and the healthcare workers in the bronchoscopy unit were
HadassahHebrew University Medical Center is a 750-bed instructed to perform emergency procedures only, using bron-
tertiary care hospital, Jerusalems largest. The Institute of Pul- choscopes that had been carefully disinfected manually. Spu-
monology operates a bronchoscopy unit that performs ap- tum samples for culture were not obtained from the 3 patients.
proximately 900 bronchoscopies annually. A bronchoscope is Samples obtained from reverse osmosis water at the inlet
cleaned by placing it in an automated endoscope reprocessor to the washer-disinfector yielded no growth on culture, but
(MediVator, SSD-102; Olympus America). B. cepacia complex those obtained from rinse water from the basin and those
is rarely found in the hospital; 53 isolates were identified in obtained from the basin surface grew B. cepacia complex on
the past decade, mostly recovered from children with cystic culture. The reprocessing procedure was observed, but no
fibrosis. In December 2008, bronchoalveolar lavage fluid sam- substantial breach in technique was found. Examination of
ples obtained from 3 adult patients on 3 consecutive days the automated endoscope washer-disinfector demonstrated
grew organisms identified as B. cepacia complex on culture that the 0.2-mm bacteriaretentive filter on the water supply
(Table 1). No clinical manifestations were attributed to these line was missing and that this missing filter was the probable
isolates. cause of the cluster of pseudoinfections. The washer-disin-
Samples were obtained from bronchoscopes for culture in fector was thoroughly manually cleaned and disinfected, and
a standard anterograde manner.1 Approximately 50 mL of a 0.2-mm bacteriaretentive filter on the water supply line
770 infection control and hospital epidemiology july 2010, vol. 31, no. 7

table 1. Main Features of 3 Male Patients in the Bronchoscopy Unit Who Had Burkholderia cepacia Isolated from Bronchoalveolar
Lavage (BAL) Fluid Samples, HadassahHebrew University Medical Center, Jerusalem, Israel, December 2008
Age, Indication Microbiology
Case years Medical history for bronchoscopy of BAL fluid sample
1 56 Lymphoma, 9 months after allogeneic bone Dyspnea and fever; bilateral B. cepacia
marrow transplantation pulmonary infiltrates
2 51 AIDS Dyspnea and fever; bilateral B. cepacia and Pneumocystis jirovecii
pulmonary infiltrates
3 60 Nonsmall cell carcinoma on left upper lobe Preoperative evaluation B. cepacia

was installed. The subsequent samples obtained from the en- contaminating organism is isolated from samples obtained
doscope washer-disinfector and the bronchoscopes were all from bronchoscopes used in patients with no clinical evidence
negative for B. cepacia complex on culture, and the bron- of disease attributable to that organism. In our report, no
choscopy unit resumed routine activity. clinical manifestations were attributed to infection with B.
Organisms identified as B. cepacia complex had an API cepacia. Despite the fact that additional culture samples were
20NE profile index of 1077577. The alignment of the con- not obtained from these patients, we assume that the cluster
sensus sequences obtained from the rRNA (size, 1,611 bp) of infections was actually a cluster of pseudoinfections.
and alignment of the consensus sequences obtained from the Multiple avenues for contamination in the bronchoscopy
recA gene (size, 680 bp) were 100% identical among isolates suite have been described, including ineffective bronchoscope
recovered from the 3 patients and the bronchoscope cleaning, problems with disinfectants, and contaminated re-
(GenBank accession numbers GQ359110 and GQ359109, re- processing equipment.6 Although the use of automated en-
spectively). Comparing the rRNA sequences generated by use doscope reprocessors has helped healthcare workers to main-
of the Basic Local Alignment Search Tool with those stored tain standards of disinfection, these reprocessors may also be
in the GenBank (99% identity), we were unable to differ- the source of bronchoscope contamination. Although the in-
entiate between B. cepacia and 6 other B. cepacia complex sides of these devices are periodically disinfected, their water
species, whereas we found that the recA gene gave 100% query supply tanks, tubing, and pumps are not always in contact
coverage and 99% identity with B. cepacia. All the isolates with disinfectants, and these areas may serve as reservoirs for
had identical PFGE profiles. contaminating pathogens.7 Biofilm on the surfaces of the ba-
sin may protect organisms during disinfection cycles.8 De-
tailed recommendations for preventing contamination dur-
discussion ing bronchoscope reprocessing have been published, but still
We report on a pseudo-outbreak of B. cepacia in a bron- it appears that this problem is underrecognized and under-
choscopy unit resulting from a contaminated washer-disin- reported.1,6,9 In the present study, the lack of an antibacterial
fector. All of the isolates recovered from bronchoalveolar lav- filter made formation of a biofilm possible, leading to this
age fluid, the bronchoscopes, and the washer-disinfector were particular cluster of pseudoinfections. Proper implementation
identified as B. cepacia complex by use of conventional mi- of installation protocols is necessary in reprocessing systems
crobiological methods and 16S rRNA gene sequencing and to prevent contamination and transmission of true infection.
as B. cepacia by use of recA species-specific polymerase chain Although the use of periodic surveillance cultures in the
reaction. The isolates were found to be identical by use of bronchoscopy suite remains controversial and is not rec-
PFGE. This outbreak was attributable to the incorrect in- ommended in guidelines,6,10 bronchoscopists and their as-
stallation of the washer-disinfector. Failure to adhere to the sociated microbiology laboratories should routinely re-
manufacturers installation instructions by not installing the view pathogenic isolates to identify unexpected clusters or
0.2-mm bacteriaretentive filter enabled bacteria to enter the trends. Specific approaches to improve infection control
machine and to contaminate it and the bronchoscopes. practices include the formalized institutional monitoring
B. cepacia has the ability to survive in the hospital setting of patterns in isolates (to detect trends early) and the es-
because of its resistance to many disinfectants and antiseptic tablishment of quality-control monitoring for all steps in
solutions.5 Outbreaks of infection with B. cepacia complex device reprocessing.
have been reported elsewhere; most were linked to contam- Our report emphasizes the importance of microbiology
ination of water and aqueous solutions. Patients with cystic laboratorybased surveillance for unusual clusters of pseu-
fibrosis or chronic granulomatous disease are especially pre- doinfections to identify outbreaks early and to prevent sub-
disposed to B. cepaciaassociated pneumonia. sequent human infection. Moreover, our report highlights
True infections resulting from bronchoscopy have been the central importance of adhering closely to installation in-
rare; most apparent infections resulting from bronchoscopy structions for washer-disinfectors and to infection control
are pseudoinfections. These pseudoinfections occur when a practice procedures in the bronchoscopy unit.
cluster of b. cepacia pseudoinfections 771

acknowledgments 2. Gee JE, Sacchi CT, Glass MB, et al. Use of 16S rRNA gene sequencing
for rapid identification and differentiation of Burkholderia pseudomallei
Potential conflicts of interest. All authors report no conflicts of interest rel- and B. mallei. J Clin Microbiol 2003;41:46474654.
evant to this article. 3. Payne GW, Vandamme P, Morgan SH, et al. Development of a recA gene-
based identification approach for the entire Burkholderia genus. Appl
Environ Microbiol 2005;71:39173927.
4. Tenover FC, Arbeit RD, Goering RV, et al. Interpreting chromosomal
From the Institute of Pulmonology (D.R., A.B.-M., N.B.) and the De- DNA restriction patterns produced by pulsed-field gel electrophoresis:
partment of Clinical Microbiology and Infectious Diseases (C.B., C.H.-G., criteria for bacterial strain typing. J Clin Microbiol 1995;33:22332239.
V.T., I.G., S.B.), HadassahHebrew University Medical Center, Jerusalem, 5. Maschmeyer G, Gobel UB. Stenotrophompnas maltophilia and Burkhold-
Israel.
eria cepacia. In: Mandell GL, Bennett JE, Dolin R, eds. Principles and
Address reprint requests to Shmuel Benenson, MD, Department of Clinical
Practice of Infectious Diseases. Philadelphia, PA: Churchill Livingstone,
Microbiology and Infectious Diseases, HadassahHebrew University Medical
2005:26152622.
Center, PO Box 12000, Jerusalem 91120, Israel (Benenson@hadassah.org.il).
6. Culver DA, Gordon SM, Mehta AC. Infection control in the bronchos-
Received October 14, 2009; accepted January 5, 2010; electronically pub-
copy suite: a review of outbreaks and guidelines for prevention. Am J
lished May 14, 2010.
Respir Crit Care Med 2003;167:10501056.
Presented in part: 49th Interscience Conference on Antimicrobial Agents
7. Centers for Disease Control (CDC). Nosocomial infection and pseu-
and Chemotherapy; San Francisco, California; September 1215, 2009 (Ab-
stract K-2109). doinfection from contaminated endoscopes and bronchoscopesWis-
2010 by The Society for Healthcare Epidemiology of America. All rights consin and Missouri. MMWR Morb Mortal Wkly Rep 1991;40(39):675
reserved. 0899-823X/2010/3107-0018$15.00. DOI: 10.1086/653611 678.
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