BACKGROUND: On September 22, 2016, Maryland Department of Health and Mental Hygiene was notified of 4 Burkholderia cepacia bloodstream infections among skilled nursing facility (SNF) residents receiving intravenous therapy. Multistate notification occurred on September 28; clusters were reported in 4 additional states. We sought to determine outbreak scope, identify source, and prevent additional cases.
METHODS: Cases were initially defined as blood cultures yielding B. cepacia in SNF residents receiving intravenous therapy after August 1. Jurisdictional health alerts were disseminated to aid case finding. We abstracted patient medical records and visited affected SNFs in 2 states in late September to identify possible infection sources. Suspect products were cultured; patient and product isolates were typed by using pulsed-field gel electrophoresis (PFGE).
RESULTS: All patients resided at SNFs supplied by Pharmacy A, which began distributing saline flushes from Manufacturer X on September 1. By using an updated case definition requiring residence at an SNF using Manufacturer X flushes, we identified 153 cases from 57 facilities in 5 states with first positive blood cultures during September 10–November 11. On October 3, B. cepacia was isolated from unopened Manufacturer X saline flushes obtained from an affected facility. PFGE patterns were indistinguishable in 111/127 (87.4%) patient isolates from all 5 states and 6/7 (85.7%) product isolates. A second PFGE pattern from 1/7 (14.3%) product isolates and 8/127 (6.3%) patient isolates differed by 1 band. Implicated products were recalled on October 4.
CONCLUSIONS: Epidemiologic and laboratory evidence indicates contamination of saline flushes produced by Manufacturer X was the outbreak source. Investigation into the cause of contamination and surveillance for additional cases is ongoing.