Outbreak of Burkholderia cepacia complex infection associated with intrinsically contaminated commercial 0.5% chlorhexidine solution

Abstract

Background: Burkholderia cepacia complex (BCC) is an aerobic Gram-negative bacillus commonly isolated from aqueous environments. In May 2024, we identified two cases who developed BCC infections within one month following fronto-orbital advancement (FOA) procedures in the paediatric surgery ward. Aim: To identify the source, intervene in the ongoing infections, and implement control measures. Methods: The cases were defined as individuals with laboratory-confirmed BCC isolated from December 2023 to May 2024. We reviewed medical records, interviewed healthcare workers, and verified compliance with infection control guidelines. Additionally, we aseptically collected environmental samples for microbiological analysis. Findings: Two initial cases of BCC infection were identified following FOA procedures, and one additional case occurred after wound dressing. All three cases were associated with the use of 0.5% aqueous chlorhexidine gluconate (CHG) solution. These cases exhibited similar antimicrobial susceptibility patterns. Subsequent investigation detected BCC in 10 samples of the 0.5% aqueous CHG solution. Both clinical and environmental BCC isolates were subjected to multi-locus sequence typing (MLST) analysis to determine their clonal relationship. The analysis revealed that all isolates shared an identical sequence type, consistent with Burkholderia cenocepacia. The outbreak was successfully controlled following the withdrawal of the product and re-education of staff. Conclusion: The monitoring of hospital-acquired infections by a multi-disciplinary team played a critical role in the prevention and rapid control of the outbreaks. Additionally, stricter government regulations are needed to prevent the contamination of disinfectants during manufacturing.