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This report describes the characterization of Burkholderia cenocepacia isolates belonging to sequence type (ST)-250, detected in eight patients with cystic fibrosis (CF) in Switzerland. We retrospectively analyzed 18 isolates of B. cenocepacia ST-250 isolated between 2003 and 2015 by whole-genome sequencing and evaluated clinical and epidemiological data. Single nucleotide polymorphism analysis of the B.°cenocepacia ST-250 lineage showed that the isolates from all patients cluster tightly, suggesting that this cluster has a recent common ancestor. Epidemiological investigations showed that six out of eight patients acquired B.°cenocepacia ST-250 in the years 2001-2006, where participation in CF summer camps was common. Two patients were siblings. Genomic relatedness of the B. cenocepacia ST-250 isolates supported transmission by close contact, however, a common source or nosocomial routes cannot be excluded. With respect to the fatal outcome in six patients, our study shows the importance of infection control measurements in CF patients with B.°cenocepacia., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Burkholderia cepacia complex is a ubiquitous organism with a high virulence potential. It is found most commonly in moist environments. Hospital outbreaks have been reported from diverse sources such as contaminated faucets, nebulizers, disinfectant solutions, multidose antibiotic vials, tap water, bottled water, nasal sprays, and ultrasound gels. In this article, we present our experience in investigating and successfully managing an outbreak of nosocomial transmission of Burkholderia cepacia sepsis in the neonatal intensive care unit at SGT Hospital, Haryana, India., Case Presentation: During the month of March, multiple Burkholderia cepacia complex isolates were recovered from blood cultures of Caucasian babies admitted to the neonatal intensive care unit of our hospital. The organisms were multidrug-resistant, with in vitro sensitivity to meropenem alone (minimum inhibitory concentration = 4 μg/ml). An outbreak was suspected, and the neonatal intensive care unit in-charge and hospital infection control teams were alerted. Outbreak investigation was initiated, and surveillance samples were collected. Burkholderia cepacia complex was successfully isolated from suction apparatus. The isolates were phenotypically typed (biotyping and antimicrobial susceptibility testing) and found to be identical., Conclusions: In our study, the index case might have been exposed to infection due to a physiological state of low immunity (preterm, low birth weight, and mechanical ventilation). The rest of the cases might have been exposed to this organism due to inadequate hand hygiene/improper cleaning and disinfection practices. Timely reporting and implementation of infection control measures played a significant role in curtailing this outbreak.

This report describes transmission of a Burkholderia cenocepacia ET12 strain (ET12-Bc) at the Toronto Adult Cystic Fibrosis (CF) Centre occurring from 2008 to 2017. Epidemiological and genomic data from 11 patients with CF were evaluated. Isolates were analysed using whole genome sequencing (WGS). Epidemiological investigation and WGS analysis suggested nosocomial transmission, despite enhanced infection control precautions. This was associated with subsequent deaths in 10 patients. ET12-Bc positive patients are no longer cared for on the same unit as ET12-Bc negative patients., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia., Methods: Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures., Results: The outbreak investigation identified the point source as contaminated gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of B cenocepacia with the same multilocus sequence type were identified within 4 hospitals across Australia. This typing was the same as identified in the contaminated gel isolate with single nucleotide polymorphism-based typing, demonstrating that all linked isolates clustered together., Conclusion: Arresting the national point-source outbreak within multiple jurisdictions was critically reliant on a rapid, integrated, and coordinated response and the use of informal professional networks to first identify it. All institutions where the product is used should look back at Burkholderia sp blood culture isolates for speciation to ensure this outbreak is no larger than currently recognized given likely global distribution., (Copyright © 2017 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.)

OBJECTIVE To investigate an outbreak of Burkholderia cepacia complex and describe the measures that revealed the source. SETTING A 629-bed, tertiary-care, pediatric hospital in Houston, Texas. PATIENTS Pediatric patients without cystic fibrosis (CF) hospitalized in the pediatric and cardiovascular intensive care units. METHODS We investigated an outbreak of B. cepacia complex from February through July 2016. Isolates were evaluated for molecular relatedness with repetitive extragenic palindromic polymerase chain reaction (rep-PCR); specific species identification and genotyping were performed at an independent laboratory. The investigation included a detailed review of all cases, direct observation of clinical practices, and respiratory surveillance cultures. Environmental and product cultures were performed at an accredited reference environmental microbiology laboratory. RESULTS Overall, 18 respiratory tract cultures, 5 blood cultures, 4 urine cultures, and 3 stool cultures were positive in 24 patients. Among the 24 patients, 17 had symptomatic infections and 7 were colonized. The median age of the patients was 22.5 months (range, 2-148 months). Rep-PCR typing showed that 21 of 24 cases represented the same strain, which was identified as a novel species within the B. cepacia complex. Product cultures of liquid docusate were positive with an identical strain of B. cepacia complex. Local and state health departments, as well as the CDC and FDA, were notified, prompting a multistate investigation. CONCLUSIONS Our investigation revealed an outbreak of a unique strain of B. cepacia complex isolated in clinical specimens from non-CF pediatric patients and from liquid docusate. This resulted in a national alert and voluntary recall by the manufacturer. Infect Control Hosp Epidemiol 2017;38:567-573.

Introduction: In January 2014 a possible outbreak of Burkholderia cepacia bacteremia occurred in a hemodialysis center situated in La Linea de la Concepción (Cadiz). An investigation was begun to confirm the outbreak, identify the source, and implement control measures., Methods: A descriptive analysis was performed to describe the characteristics of the patients affected with Burkholderia cepacia bacteremia from November 2013 to February 2014. Environmental samples were taken. A molecular typing study was performed using pulsed field gel electrophoresis (SpeI PFGE) and MLST analysis in order to determine the genetic similarity between the isolates., Results: The bacterium was isolated from blood cultures of 7 patients during the study period. Three of the samples (2 of which were also cases) were endoluminal fluid from catheter locks, and 4 chlorhexidine bottle samples. The patients were coincident in 2 of the 6 work shifts. The mean age of the cases was 67 years of whom 57% were women. Human samples and an environmental sample was analyzed and found to be genetically identical (ST653 clone)., Conclusions: The analysis confirmed the outbreak of Burkholderia cepacia, with 7 cases among the patients of the hemodialysis center. The outbreak was due to the same strain, probably a common source and secondary transmission from person to person., (Copyright © 2015 Elsevier España, S.L.U. y Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.)

The investigation of the bacterial populations' heterogeneity contributes to the control of natural foci, causative agents of nosocomial infections, to the analysis of the microbial evolution. Multilocus sequence typing (MLST) was employed for the analysis of the diversity and features of the distribution of polyhostal ubiquitous microorganisms of the genera Burkholderia, Leptospira, and Listeria, which belong to three bacterial phyla: Proteobacteria, Spirochaetes, and Firmicutes. According to the bacterial samples analysis microbial genotypes prevalent and unique to Russia were identified; their occurrence in different Federal Regions was investigated; their similarity with global spread genotypes was appreciated. Obtained results allowed identifying common regularities of the selection of the microorganisms capable to cause the diseases of human and animals. The formation of genotypes that are most pathogenic for the host was demonstrated for all groups of bacteria. Leptospira spp. and Listeria monocytogenes strains with these genotypes have been circulating for a long time, being supported by natural foci. The formation of a wide variety of genotypes with different pathogenicity was demonstrated in the local geographic areas. In Russia, the zonal difference in all three groups of bacteria is most clearly traced to the Far Eastern Federal Region. The results are thought to contribute to analyzing the factors of selection and the phylogeny of the taxa under study.

Burkholderia cepacia has rarely been reported in Honolulu. Its emergence as a nursing home-acquired pathogen with high mortality rate is concerning. This case report describes a local nursing home patient who was diagnosed with B. cepacia sepsis in 2012.

Background: Burkholderia cepacia complex (Bcc) is a group of common environmental bacteria that preferentially colonize and infect patients with cystic fibrosis but are also emerging as nosocomial pathogens, possibly due to their resistance to disinfectants and antimicrobials., Methods: We investigated a 3-month outbreak of Bcc bacteremia among hospitalized hematology patients. Environmental investigation and infection control measures were implemented. A retrospective, cross-sectional study was conducted to identify risk factors., Results: Bcc was repeatedly isolated from the blood of 9 patients without central venous catheter who did not easily respond to targeted antibiotic treatment and 3 died of the infection. A point source was not identified and horizontal spread was suspected. Strict infection control measures terminated the outbreak. Interestingly, diagnosis of acute myeloid leukemia but not neutropenia or prior chemotherapy was a risk factor for infection acquisition. Neutropenia was positively correlated with infection duration., Conclusions: Bcc is not only a serious threat among immunocompromized hematology patients, but is also transmissible in clinical settings. Acute myeloid leukemia appears to confer additional risk for infection acquisition., (Copyright © 2013 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.)

Burkholderia cepacia (B. cepacia) infection is rarely reported in an immunocompetent host. It is a well known occurence in patients with cystic fibrosis and chronic granulomatous disease where it increases both morbidity and mortality. It has also been included in the list of organisms causing nosocomial infections in an immunocompetent host, most of them transmitted from the immunocompromised patient in which this organism harbors. We report a rare case of isolation of B. cepacia from the bronchoalveolar lavage fluid of an immunocompetent agriculturist who presented with productive cough and fever associated with a pyopneumothorax. This is the first case of community acquired infection reported in an immunocompetent person in India.

Background: Burkholderia cepacia strains have been known to possess the capability to cause serious infections especially in neonatal intensive care units (NICUs), and their multi-drug resistances become a severe threat in hospital settings. The aim of this investigation was to evaluate the B. cepacia complex infections in the NICU in Nagano Children's Hospital, Azumino 399-8288, Japan, and to report the intervention leading to the successful cessation of the outbreak., Methodology: The incidence of isolation and antimicrobial susceptibilities of nosocomial Burkholderia cepacia complex strains during a four-year period were retrospectively examined by clinical microbiological records, and by pulsed-field gel electrophoresis analyses along with the bacteriological verification of disinfectant device itself and procedures for its maintenance routinely used in the NICU., Results: During the period surveyed between 2007 and 2009, only an isolate per respective year of B. cepacia complex was recovered from each neonate in the NICU. However, in 2010, the successive 6 B. cepacia complex isolates were recovered from different hospitalized neonates. Among them, an isolate was originated from peripheral blood of a neonate, apparently giving rise to systemic infection. In addition, the hospitalized neonate with bacteremia due to B. cepacia complex also exhibited positive cultures from repeated catheterized urine samples together with tracheal aspirate secretions. However other 5 isolates were considered as the transients or contaminants having little to do with infections. Moreover, the 5 isolates between July and October in 2010 revealed completely the same electrophoresis patterns by means of pulsed-field gel electrophoresis analyses, strongly indicating that they were infected through the same medical practices, or by transmission of the same contaminant., Conclusions: A small outbreak due to B. cepacia comlex was brought about in the NICU in 2010, which appeared to be associated with the same genomovar of B. cepacia complex. The source or the rout of infection was unknown in spite of the repeated epidemiological investigation. It is noteworthy that no outbreak due to B. cepacia complex was noted in the NICU after extensive surveillance intervention.

Forty-four of 48 Burkholderia cepacia complex strains cultured from Danish cystic fibrosis patients were Burkholderia multivorans, a distribution of species that has not been reported before. Although cases of cross infections were demonstrated, no major epidemic clone was found. The species distribution may represent the sporadic acquisition of bacteria from the environment.

Background: This study reviews the impact of changing infection control practices at the Manchester Adult Cystic Fibrosis Centre (MACFC) upon the epidemiology of Burkholderia species infections., Methods: We reviewed strain and genomovar typing of all available Burkholderia isolates at our centre between 1983-2006., Results: The incidence/prevalence of infection with Burkholderia species between 1983-1990 was below 5%/9% each year. There was a rise in incidence/prevalence of Burkholderia species between 1991 and 1994 with a peak of 16.3%/31.2% in 1992. Following complete cohort segregation, the incidence has fallen to below 3% for all but one year and the prevalence has gradually reduced to 9.3% in 2005. Currently, there is an increase in the prevalence to 10.6% for the first time since 1994, predominantly due to patients with unique infections transferring into the unit from referring centres. The presence of unique strains now exceeds transmissible strains for the first time since 1991., Conclusions: Infection control measures including patient segregation have controlled spread of transmissible B. cenocepacia strains, but not the acquisition of unique strains. Unique strains of Burkholderia species now account for the majority of new infections at the Manchester Adult Cystic Fibrosis Centre.

An outbreak of central venous catheter-associated bloodstream infections was reported in a hospital in Ecuador. Commercially produced ampoules of water for injection were found to be contaminated with Burkholderia cepacia and Myroides odoratus. Removal of these ampoules yielded a 10-fold reduction in the incidence of catheter-associated infection.

The Burkholderia cepacia complex (Bcc) is a group of significant opportunistic respiratory pathogens which affect people with cystic fibrosis. In this study, we sought to ascertain the epidemiology and geographic species distribution of 116 Bcc isolates collected from people with CF in Australia and New Zealand. We performed a combination of recA-based PCR, amplified rDNA restriction analysis (ARDRA), pulsed-field gel electrophoresis and repetitive extragenic palindromic PCR on each isolate. Each Burkholderia cenocepacia isolate was also screened by PCR for the presence of the B. cepacia epidemic strain marker. One hundred and fourteen isolates were assigned to a species using recA-based PCR and ARDRA. B. cenocepacia, B. multivorans and B. cepacia accounted for 45.7%, 29.3% and 11.2% of the isolates, respectively. Strain analysis of B. cenocepacia revealed that 85.3% of the isolates were unrelated. One related B. cenocepacia strain was identified amongst 15 people. Whilst full details of person-to-person contact was not available, all patients attended CF centres in Queensland (Qld) and New South Wales (NSW). Although person-to-person transmission of B. cenocepacia strains has occurred in Australia, the majority of CF-related Bcc infections in Australia and New Zealand are most likely acquired from the environment.

Background: An outbreak of severe nosocomial Burkholderia cepacia infections in patients admitted to intensive care unit (ICU), including investigation of the reservoir, is described., Methods: Over a period of 18 days, isolates of Burkholderia cepacia were recovered from different biological samples from five patients who were admitted to a multidisciplinary 18-bed intensive care unit. Isolation of B. cepacia was associated with bacteraemia in three cases, lower respiratory tract infection in one and urinary tract infection in one. Contact isolation measures were instituted; new samples from the index patients and adjacent patients were collected; and samples of antiseptics, eau de Cologne and moisturizing body milk available in treatment carts at that time were collected and cultured., Results: B. cepacia was isolated from three samples of the moisturizing body milk that had been applied to the patients. Three new hermetically closed units, from three different batches, were sent for culture; two of these were positive as well. All strains recovered from environmental and biological samples were identified as belonging to the same clone by pulsed-field gel electrophoresis. The cream was withdrawn from all hospitalization units and no new cases of B. cepacia infection developed., Conclusion: Moisturizing body milk is a potential source of infection. In severely ill patients, the presence of bacteria in cosmetic products, even within accepted limits, may lead to severe life-threatening infections.

Unlabelled: Burkholderia cepacia is an opportunistic gram-negative, inherently resistant to multiple antibiotics and highly transmissible bacteria found in the soil and moist environments. The bacteria is known as a cause of severe lung infections in cystic fibrosis and immunocompromised patients. The authors observed a nosocomial outbreak of B. cepacia, the strains were isolated from five patients. In one case occurred colonization of the decubitus and in the other four severe pneumonia or sepsis. Four patients developed respiratory failure and septic shock and were admitted to intensive care unit. The infections led to death of two patients. The aim of the study was to evaluate the possibility that the hospital environment or cross-infection were the source of pathogen. The authors discussed the influence of previously used antibiotics on B. cepacia selection and drug susceptibility data as well, as the influence of obtained microbiological data on therapeutic decision making process. We were not able to confirm origin of B. cepacia strains, but in our opinion the hospital environment was the most probable source of pathogen. Increasing multidrug resistance were observed during the time of outbreak. In a case of the last patient we observed only weak susceptibility to imipenem., Conclusions: B. cepacia may be an etiologic agent of severe hospital acquired pneumonia and sepsis among immunocompromised patients. Clinically infection develops picture of superinfection and usually is life-threatening condition.

Purpose of Review: The Burkholderia cepacia complex is comprised of a group of related bacterial species that are capable of causing life-threatening respiratory tract infection in persons with cystic fibrosis. This article reviews advances in our understanding of Burkholderia cepacia complex infection in cystic fibrosis, focusing on the taxonomy, clinical microbiology, and epidemiology, as well as the natural history and clinical outcomes associated with Burkholderia cepacia complex infection., Recent Findings: Each of the nine species of the Burkholderia cepacia complex has now received a formal species name. These names are the preferred nomenclature, replacing the former 'genomovar' designations. Studies from several countries reiterate that two species, Burkholderia cenocepacia and Burkholderia multivorans, account for most Burkholderia cepacia complex infection in cystic fibrosis. Bacterial genotyping studies indicate that specific Burkholderia cepacia complex strains infect multiple cystic fibrosis patients, implying that they may have an enhanced capacity for interpatient spread. Emerging clinical outcomes data suggest that at least some of these so-called transmissible or epidemic strains are also more virulent in the cystic fibrosis host. Ongoing research is aimed at gaining a better understanding of Burkholderia cepacia complex ecology, defining Burkholderia cepacia complex virulence factors and pathogenic mechanisms, and determining the relative virulence of distinct strains., Summary: Significant advances in our understanding of the Burkholderia cepacia complex serve as a critical foundation for further efforts that ultimately will enable better infection control and the development of novel therapeutics to treat Burkholderia cepacia complex infection in persons with cystic fibrosis.

The results of the study of hospital strains of the B. cepacia complex, isolated in hospitals of Moscow, with the use of phenotypical and molecular-genetic methods are presented. The phenotypical methods made it possible to differentiate Russian strains and classify them with a group of genomovars (I, III, IV). As the result the epidemic importance of the strains with epidemic markers, having specific characteristics for every clinic, was determined. The detection of the collection of genes cepI and cepR in the strains made confirmed the epidemic importance of the stains which had, due to the regulatory "quorum sensing" (QS) system, the potential capacity for inducing infection and persisting in the patient's body. The presence of gene cepR in all strains and the absence of gene cepl in 33% of strains gave evidence to suggest that in some strains the activation of the production of pathogenicity factors required the presence of other bacteria having the fully developed QS system. Thus, the new complex approach with the use of phenotypical and molecular-genetic methods permits more precise identification of the source of hospital infection induced by the bacteria of the B. cepacia complex.

To analyze national prevalence, genomovar distribution, and epidemiology of the Burkholderia cepacia complex in Italy, 225 putative B. cepacia complex isolates were obtained from 225 cystic fibrosis (CF) patients attending 18 CF centers. The genomovar status of these isolates was determined by a polyphasic approach, which included whole-cell protein electrophoresis and recA restriction fragment length polymorphism (RFLP) analysis. Two approaches were used to genotype B. cepacia complex isolates: BOX-PCR fingerprinting and pulsed-field gel electrophoresis (PFGE) of genomic macrorestriction fragments. A total of 208 (92%) of 225 isolates belonged to the B. cepacia complex, with Burkholderia cenocepacia as the most prevalent species (61.1%). Clones delineated by PFGE were predominantly linked to a single center; in contrast, BOX-PCR clones were composed of isolates collected either from the same center or from different CF centers and comprised multiple PFGE clusters. Three BOX-PCR clones appeared of special interest. One clone was composed of 17 B. cenocepacia isolates belonging to recA RFLP type H. These isolates were collected from six centers and represented three PFGE clusters. The presence of insertion sequence IS 1363 in all isolates and the comparison with PHDC reference isolates identified this clone as PHDC, an epidemic clone prominent in North American CF patients. The second clone included 22 isolates from eight centers and belonged to recA RFLP type AT. The genomovar status of strains with the latter RFLP type is not known. Most of these isolates belonged to four different PFGE clusters. Finally, a third clone comprised nine B. pyrrocinia isolates belonging to recA RFLP type Se 13. They represented three PFGE clusters and were collected in three CF centers.

Non-fermentative Gram negative rods are opportunistic pathogens responsible for nosocomial infections. Using phenotypic markers (serotypes for Pseudomonas aeruginosa and antibiotic susceptibility) allows a preliminary screening of epidemiologically-related strains. However, genotypic markers are necessary to better characterize nosocomial strains for the investigation of outbreaks or cross-transmissions in the hospital setting. Infections due to P. aeruginosa, Burkholderia. cepacia or Stenotrophomonas. maltophilia are usually hospital-acquired and responsible for a high mortality rate as illustrated by the lethality of nosocomial pneumonia due to P. aeruginosa. The severity of these infections is due to the virulence factors of the bacteria and to their occurrence in debilitated patients in whom invasives devices are used. The hospital environment can act as a reservoir with a rate of exogeneous transmission of these bacteria as high as 50% in some studies. To better prevent nosocomial infections related to Gram negative non fermentative rods, the control of the aqueous hospital environment, the strict application of hand disinfection and the investigation of potential cross-transmission in the hospital setting are needed.

We report on a pseudooutbreak of Burkholderia cepacia because of the use of a contaminated disinfectant during quality controls in a university blood bank. No septic reactions associated with transfusions had been reported in patients over the last 6 months. Analysis of the individual quality control procedures showed that a disinfectant based on a quaternary ammonium compound (QAC) had been used in order to disinfect the rubber stopper of the blood culture bottle. B. cepacia was found in a sample taken from this disinfectant, which was prepared with concentrate and tap water according to the manufacturer's instructions. The four isolates (one in disinfectant and three in blood components) were found to be identical in their biochemical reactions and resistance patterns. QAC-based disinfectants are not efficacious against a part of the spectrum of gram-negatives and are therefore inadequate. After introduction of an alcohol-based preparation, no more cases of B. cepacia contamination have been identified.

The Burkholderia cepacia complex (Bcc) is a collection of genetically distinct but phenotypically similar bacteria that are divided into at least nine species. Bcc bacteria are found throughout the environment, where they can have both beneficial and detrimental effects on plants and some members can also degrade natural and man-made pollutants. Bcc bacteria are now recognized as important opportunistic pathogens that can cause variable lung infections in cystic fibrosis patients, which result in asymptomatic carriage, chronic infection or 'cepacia syndrome', which is characterized by a rapid decline in lung function that can include invasive disease. Here we highlight the unique characteristics of the Bcc, focusing on the factors that determine virulence.

Burkholderia cenocepacia is an opportunistic bacterium that infects patients with cystic fibrosis. B. cenocepacia strains J2315, K56-2, C5424, and BC7 belong to the ET12 epidemic clone, which is transmissible among patients. We have previously shown that transposon mutants with insertions within the O antigen cluster of strain K56-2 are attenuated for survival in a rat model of lung infection. From the genomic DNA sequence of the O antigen-deficient strain J2315, we have identified an O antigen lipopolysaccharide (LPS) biosynthesis gene cluster that has an IS402 interrupting a predicted glycosyltransferase gene. A comparison with the other clonal isolates revealed that only strain K56-2, which produced O antigen and displayed serum resistance, lacked the insertion element inserted within the putative glycosyltransferase gene. We cloned the uninterrupted gene and additional flanking sequences from K56-2 and conjugated this plasmid into strains J2315, C5424, and BC7. All the exconjugants recovered the ability to form LPS O antigen. We also determined that the structure of the strain K56-2 O antigen repeat, which was absent from the LPS of strain J2315, consisted of a trisaccharide unit made of rhamnose and two N-acetylgalactosamine residues. The complexity of the gene organization of the K56-2 O antigen cluster was also investigated by reverse transcription-PCR, revealing several transcriptional units, one of which also contains genes involved in lipid A-core oligosaccharide biosynthesis.

We have performed a 4-year prospective surveillance for Pseudomonas aeruginosa cross-infection at a large regional adult cystic fibrosis center. Despite purpose-built facilities in a new building and the practice of strict hygiene, P. aeruginosa cross-infection has continued. In contrast, individuals segregated from the cohort of patients with chronic P. aeruginosa infection but who attend the same center have not acquired infection with transmissible P. aeruginosa strains. Simple infection control measures alone do not prevent the spread of transmissible P. aeruginosa strains between individuals with cystic fibrosis. However, in our clinic patient segregation effectively controlled spread of such strains.

Studies of the prevalence of Burkholderia cepacia complex species amongst cystic fibrosis (CF) patients in different geographical regions, and the association between cross-infection and putative transmissibility markers, will further our understanding of these organisms and help to address infection-control issues. In this study, B. cepacia complex isolates from CF patients in different regions of Europe were analysed. Isolates were examined for B. cepacia complex species and putative transmissibility markers [cable pilin subunit gene (cblA) and the B. cepacia epidemic strain marker (BCESM)]. Sporadic and cross-infective strains were identified by random amplification of polymorphic DNA (RAPD). In total, 79% of patients were infected with Burkholderia cenocepacia (genomovar III), 18% with Burkholderia multivorans (genomovar II) and less than 5% of patients with B. cepacia (genomovar I), Burkholderia stabilis (genomovar IV) or Burkholderia vietnamiensis (genomovar V). The cblA and BCESM transmissibility markers were only detected in strains of B. cenocepacia. The BCESM was a more sensitive marker for transmissible B. cenocepacia strains than cblA, although sporadic B. cenocepacia strains containing the BCESM, but lacking cblA, were also observed. Furthermore, clusters of cross-infection with transmissibility marker-negative strains of B. multivorans were identified. In conclusion, B. cenocepacia was the greatest cause of cross-infection, and the most widely distributed B. cepacia complex species, within these CF populations. However, cross-infection was not exclusive to B. cenocepacia and cblA and the BCESM were not absolute markers for transmissible B. cenocepacia, or other B. cepacia complex strains. It is therefore suggested that CF centres cohort patients based on the presence or absence of B. cepacia complex infection and not on the basis of transmissibility marker-positive B. cenocepacia as previously suggested.

Burkholderia cepacia is a Gram-negative bacillus that is widely distributed in nature; it is isolated from the ground, water, plants and vegetables. Generally, it produces nosocomial infection due to contamination of disinfectants, medical equipment, prosthetic material and drugs, such as anesthetics or liquids used in urological irrigation. The most probable mechanism of transmission is through hospital material or through fomites among people after contact for several weeks or months. Recently, it has been considered as an important pathogen in immunocompromised patients, or in those with significant underlying diseases, such as chronic granulomastosis or cystic fibrosis. We present a case of pharyngitis due to B. cepacia and its transmission within a few days in two immunocompetent twin siblings without previous underlying diseases. The infection disappeared after specific treatment for this microorganism was started. We believe that samples should be taken from the pharynx and nasal pits in patients with acute upper respiratory tract processes that do not respond to empiric antibiotic treatment, before classifying them as viral infection without etiologic diagnosis.

Objective: To describe an outbreak of serious nosocomial Burkholderia cepacia infections occurring after transrectal prostate biopsy associated with ultrasound gel intrinsically contaminated with paraben-degrading microorganisms., Methods: A retrospective chart review prompted by a blood culture isolate of B. cepacia. Identification of microorganisms in ultrasound gel in two Canadian centers and characterization by pulsed-field gel electrophoresis and assays for paraben degradation., Setting: Two Canadian university-affiliated, tertiary-care centers in Newfoundland and Alberta., Results: Six serious B. cepacia infections were identified at the two centers. Isolates of B. cepacia recovered from the blood of patients from both centers and the ultrasound gel used during the procedures were identical, confirming intrinsic contamination. Strains of Enterobacter cloacae isolated from ultrasound gel at the two centers were also identical. The ability to degrade parabens was proven for both B. cepacia and E. cloacae strains recovered from the ultrasound gel., Conclusions: Ultrasound gel is a potential source of infection. Contamination occurs at the time of manufacture, with organisms that degrade parabens, which are commonly used as stabilizing agents. There are far-reaching implications for the infection control community.

Within a few years bacteriological knowledge on Burkholderia cepacia species has progressed considerably. Within bacterial classification (taxonomy), B. cepacia gathers eight species and one species on standby of nomenclature (genomovar VI); the whole of these species constitutes the "B. cepacia complex" or B. cepacia "sensu lato" and the denomination B. cepacia "sensu stricto" is attributed to the genomovar I. These new data call into question the knowledge on the clinic and the epidemiology of B. cepacia "sensu lato" infection in the course of cystic fibrosis. Among these newly described species, B. cenocepacia (formerly genomovar III) and B. multivorans (formerly genomovar II) are the most frequent species and together they represent more than 90% of infections associated to "B. cepacia complex" in the course of cystic fibrosis. B. cenocepacia is often associated to the "cepacia syndrome" which is characterized as a fatal necrotizing pneumonia with bacteremia. The progress of molecular epidemiology allowed the description of bacterial clones of which some are highly transmissible from person-to-person. Their distribution varies according to the species and the geography. The identification of these new species appears particularly difficult and, by the fact, the data on taxonomy and molecular epidemiology can be provided only by highly specialized reference centers.

Burkholderia multivorans strains from 47 cystic fibrosis (CF) patients in 28 hospitals were compared by pulsed-field gel electrophoresis (PFGE) and flagellin (fliC) PCR-restriction fragment length polymorphism (PCR-RFLP) analysis. A considerable degree of genetic variation was evident, with each patient harboring a strain with a unique PFGE profile. Four sizes of fliC amplicons were produced, and these amplicons gave 13 RFLP types with restriction enzyme MspI. B. multivorans did not appear to spread between patients, suggesting that most CF patients acquire the organism from the natural environment.

Previous studies have identified specific Burkholderia cepacia complex strains that are common to multiple persons with cystic fibrosis (CF). Such so-called epidemic strains have an apparent enhanced capacity for inter-patient spread and reside primarily in Burkholderia cenocepacia (formerly B. cepacia complex genomovar III). We sought to identify strains from B. cepacia complex species other than B. cenocepacia that are similarly shared by multiple CF patients. We performed genotype analysis of 360 recent sputum culture isolates from 360 persons residing in 29 cities by using repetitive extragenic palendromic polymerase chain reaction (rep-PCR) and pulsed field gel electrophoresis. The results indicate that sharing of a common Burkholderia multivorans strain occurs relatively infrequently; however, several small clusters of patients infected with the same strain were identified. A cluster of seven patients infected with the same B. cepacia (genomovar I) strain was found. We also identified a large group of 28 patients receiving care in the same treatment center and infected with the same Burkholderia dolosa strain. These observations suggest that B. cepacia complex strains in species other than B. cenocepacia may be spread among CF patients.

Background: We report an outbreak of Burkholderia cepacia respiratory tract infection and colonization in an intensive pediatric care unit.P PATIENTS AND METHODS: Between February and December 1999, B. cepacia was isolated from five children hospitalized in this unit. We reviewed the charts of the patients, evaluated the antiseptics use and the disinfection practices for reusable patient care equipment. An environmental study was conducted and comparison of B. cepacia was performed with genotypic method (RAPD)., Results: All patients were mechanically ventilated and had received large spectrum antibiotics. The disinfection procedure for reusable equipment was not respected and some single-dose of antiseptics solutions were used for several patients. B. cepacia was not found in 34 environmental samples. The RAPD assay revealed that all five isolates had identical DNA profiles., Conclusion: Despite the investigation the source of the B. cepacia clone in this nosocomial outbreak remained unknown, but antiseptics use and disinfection practices were revised. No new B. cepacia infections were identified after control measures were implemented.

Objectives: To investigate and describe an outbreak of Burkholderia cepacia in a neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU), and to report the interventions leading to the cessation of the outbreak., Design: We conducted an epidemiologic investigation of an outbreak of B. cepacia colonization or infection in two clinical wards during a 35-month period (December 1998 to October 2001)., Setting: A 500-bed, university hospital-affiliated, tertiary-care pediatric institution in Paris, France, with a 22-bed PICU and 31-bed NICU., Methods: Ribotyping was used to determine the genotypes of B. cepacia isolates. Procedures for the maintenance and disinfection of respiratory therapy devices were reviewed., Results: Thirty-two children were colonized (n = 14) or infected (n = 18) by B. cepacia in 2 wards (28 in the PICU and 4 in the NICU). In the PICU, a single ribotype was found among the isolates obtained from all of the patients except 1, and from the 6 isolates obtained from respiratory therapy devices (ie, heated humidifier water). In the NICU, the isolates obtained from the patients harbored a single ribotype unrelated to that of the epidemic strain isolated in the PICU; no environmental source of infection was found., Conclusion: Two different outbreaks appeared to be associated with 2 ribotypes, 1 of which was linked to patient-to-patient transmission via respiratory therapy devices. Complete elimination of the outbreak was achieved only when disposable, sterilizable, or easy-to-disinfect materials were used in the PICU. The source of infection in the NICU was not found.

There was concern that nosocomial person-to-person transmission of Burkholderia cepacia had occurred when two patients with cystic fibrosis shared a bathroom. Pulsed-field gel electrophoresis demonstrated that the two isolates were unrelated. Subsequent testing of 34 stored isolates of B. cepacia demonstrated that no particular clone predominated in our hospital.

Burkholderia cepacia isolates of genomovar III are highly transmissible amongst patients with cystic fibrosis (CF) and express a 97 kDa putative haem-binding protein (HBP) [Smalley, J. W., Charalabous, P., Birss, A. J. & Hart, C. A. (2001). Clin Diagn Lab Immunol 8, 509-514]. An investigation of the interactions of iron(III) protoporphyrin IX with epidemic and non-epidemic strains of B. cepacia to determine the role of the above protein in haem acquisition and binding is reported herein. Spectrophotometric titrations of cell suspensions of genomovar IIIa strains BC7 and C5424 with iron(III) protoporphyrin IX, at pH 7.0, resulted in the depletion of Fe(III)PPIX.OH monomers and formation of the micro -oxo oligomeric species, [Fe(III)PPIX](2)O. Difference spectroscopy indicated a continuous conversion of the monomeric iron(III) protoporphyrin IX into micro -oxo oligomers. Incubations with Fe(III)PPIX.OH monomers at pH 6.5 also showed that cells could shift the equilibrium to generate the micro -oxo oligomeric form. Genomovar I strains ATCC 25416 and LMG 17997 were unable to mediate this conversion. SDS-PAGE of genomovar IIIa strains exposed to Fe(III)PPIX.OH at pH 6.5 followed by tetramethylbenzidine/H(2)O(2) staining revealed, in addition to the 97 kDa HBP, two proteins of 77 and 149 kDa located in the outer membrane which bound Fe(III)PPIX.OH monomers. These proteins were absent from the genomovar I strains. Genomovar IIIa strains BC7 and C5424 showed increased cellular binding of [Fe(III)PPIX](2)O, and as a consequence, displayed increased catalase activities compared to cells of the genomovar I isolates. It is concluded that, in addition to the putative 97 kDa HBP, B. cepacia genomovar IIIa strains express two outer-membrane proteins which function to bind and convert Fe(III)PPIX.OH monomers into the micro -oxo oligomeric form, [Fe(III)PPIX](2)O. The ability to perform this conversion at both neutral and slightly acidic pHs may enable epidemic strains to withstand attack from neutrophil-derived H(2)O(2) in the inflamed CF lung.

Burkholderia cepacia is an important opportunistic pathogen in certain compromised hosts, particularly those with either cystic fibrosis (CF) or chronic granulomatous disease. The "family" of bacteria known as B. cepacia is highly heterogeneous and is composed of at least nine discrete species or genomovars, constituting the B. cepacia complex. Bacteria from the B. cepacia complex are particularly virulent in susceptible hosts, often causing necrotising invasive infection and death. Whereas the microbial determinants of virulence in B. cepacia complex are currently not defined, the bacteria appear to have features facilitating survival within host cells. Burkholderia cepacia is highly resistant to antibiotics and to neutrophil-mediated non-oxidative killing; infection should be treated with combination antimicrobial therapy. Burkholderia cepacia can spread from one CF patient to another. Transmission appears to be facilitated by close personal contact and by certain bacterial factors., (Copyright 2002 Elsevier Science Ltd.)

Infection with Burkholderia cepacia complex in patients with cystic fibrosis (CF) results in highly variable clinical outcomes. The purpose of this study was to determine if there are genomovar-specific disparities in transmission and disease severity. B. cepacia complex was recovered from 62 patients with CF on > or =1 occasions (genomovar III, 46 patients; genomovar II [B. multivorans], 19 patients; genomovar IV [B. stabilis], 1 patient; genomovar V [B. vietnamiensis], 1 patient; and an unclassified B. cepacia complex strain, 1 patient). Patient-to-patient spread was observed with B. cepacia genomovar III, but not with B. multivorans. Genomovar III strains replaced B. multivorans in 6 patients. Genomovar III strains were also associated with a poor clinical course and high mortality. Infection control practices should be designed with knowledge about B. cepacia complex genomovar status; patients infected with transmissible genomovar III strains should not be cohorted with patients infected with B. multivorans and other B. cepacia genomovars.

Objectives: We sought to determine whether the same Burkholderia cepacia complex strain has persisted as the dominant clonal lineage among patients in a large cystic fibrosis (CF) treatment center during the past 2 decades., Study Design: The inter-city spread of B cepacia through transfer of a colonized patient and the impact of infection control measures in containing inter-patient transmission were investigated. We analyzed all available B cepacia complex isolates recovered from 1981 to 1987 and from 1996 to 2000 at one large CF treatment center (Center A) and from 1997 to 2000 at another center (Center B). Incidence of B cepacia complex infection and infection control measures in both centers were assessed., Results: Seventeen (81%) of 21 Center A patients from whom B cepacia complex bacteria were recovered between 1981 and 1987 and 40 (97%) of 41 patients culture-positive between 1996 and 2000 were infected with the same genomovar III strain. Transfer of a colonized patient from Center A to Center B was associated with an increase in B cepacia complex infection in Center B, all of which was with the Center A dominant strain. This strain, designated PHDC, lacks both B cepacia epidemic strain and cblA markers., Conclusions: B cepacia complex strains may remain endemic in CF treatment centers for many years. Responsible bacterial and host factors and optimal infection control measures to prevent inter-patient spread remain to be identified.

Objective: To investigate an outbreak of Burkholderia cepacia., Design: Observational study and chart review., Patients: Adult non-cystic fibrosis (CF) patients., Setting: Intensive care units (ICUs) at a university-affiliated teaching hospital., Methods: As part of the epidemiological investigation, we conducted a chart review and collected environmental samples. A review of work schedules of healthcare workers also was performed. We used B. cepacia selective agar for preliminary screening for all isolates, which subsequently were confirmed as members of the B. cepacia complex by polyphasic analysis employing conventional biochemical reactions and genus- and species-specific polymerase chain reaction assays. Pulsed-field gel electrophoresis, randomly amplified polymorphic DNA typing, and automated ribotyping were used to genotype the isolates. As part of the intervention, contact isolation precautions were initiated for all patients identified as having had a culture positive for B. cepacia., Results: Between September 1997 and September 1999, B. cepacia was isolated from 31 adult patients without CF in ICUs at a university-affiliated teaching hospital. Based on geographic clustering and genotypic analysis, three distinct clusters were observed involving 20 patients. Isolates from 17 of these patients were available for testing and were found to be of the same strain (outbreak strain). Further taxonomic analysis indicated that the outbreak strain was B. cepacia complex genomovar III. Twelve (71%) of the 17 patients were judged to be infected, and 5 (29%) were colonized with this strain. Six of 200 environmental cultures from multiple sources in the hospital's ICUs yielded B. cepacia. Two of these isolates, both recovered from rooms of colonized patients, were the same genotype as the outbreak strain recovered from patients., Conclusion: Despite an extensive investigation, the source of the B. cepacia clone involved in this outbreak remains unknown. The spatial and temporal pattern of cases suggests that cross-transmission of a genetically related strain contributed to clustering among patients. The initiation of contact isolation may have limited the extent of this transmission. Additional studies are needed to elucidate better the epidemiology of nosocomial B. cepacia infection among non-CF adult patients.

Several distinct species (genomovars) comprise bacteria previously identified merely as Burkholderia cepacia. Understanding how these species, collectively referred to as the B. cepacia complex, differ in their epidemiology and pathogenic potential in cystic fibrosis (CF) is important in efforts to refine management strategies. B. cepacia isolates recovered from 606 CF patients receiving care at 132 treatment centers in 105 cities in the United States were assessed to determine species within the B. cepacia complex and examined for the presence of putative transmissibility markers (B. cepacia epidemic strain marker [BCESM] and cable pilin subunit gene [cblA]). Fifty percent of patients were infected with B. cepacia complex genomovar III, 38% with B. multivorans (formerly genomovar II), and 5% with B. vietnamiensis (formerly genomovar V); fewer than 5% of patients were infected with either genomovar I, B. stabilis (formerly genomovar IV), genomovar VI, or genomovar VII. BCESM was found in 46% of genomovar III isolates and not in any other species. Only one isolate, from a patient infected with the ET12 epidemic lineage, contained the complete cblA pilin subunit gene. Our data indicate a differential capacity for human infection among the phylogenetically closely related species of the B. cepacia complex. The low frequency of BCESM and cblA suggests that they are not sufficient markers of B. cepacia virulence or transmissibility.

Objective: To investigate and control a nosocomial outbreak of Burkholderia cepacia lower respiratory tract infection., Design: Outbreak investigation and case-control study., Setting: A 260-bed community hospital., Patients: Participants were mechanically ventilated intensive care patients without cystic fibrosis. A case was defined as a hospitalized patient with a sputum culture positive for B. cepacia between January 1 and November 6, 1998., Methods: Respiratory therapy infection control policies and practices were reviewed; laboratory and environmental studies and a retrospective case-control study were conducted. Case-patients were matched with control-patients on age, gender, diagnosis, and type of intensive care unit., Results: Nine case-patients were identified; B. cepacia likely caused pneumonia in seven and colonization in two. Two respiratory therapy practices probably contributed to the transmission of B. cepacia: multidose albuterol vials were used among several patients, and nebulizer assemblies often were not dried between uses. B. cepacia was grown from cultures of three previously opened multidose vials; pulsed-field gel electrophoresis patterns of B. cepacia from seven case-patients and two multidose vials were indistinguishable. Case-patients had longer durations of heated humidified mechanical ventilation (mean, 9.8 days vs 4.4 days; P=.03) and were more likely to have exposure to one particular respiratory therapist than controls (odds ratio, undefined; 95% confidence interval, 4.7-infinity; P=.001). The association with the respiratory therapist, a temporary employee, persisted after controlling for duration of heated humidified ventilation. No new B. cepacia infections were identified after control measures were implemented., Conclusions: B. cepacia probably was transmitted among patients through use of extrinsically contaminated multidose albuterol vials. Respiratory therapy departments must pay close attention to infection control practices, particularly among new or temporary staff.

Burkholderia cepacia is a plant phytogen and is known as a hardy and versatile organism. Over the past two decades it has emerged as a pathogen in the cystic fibrosis (CF) community, with devastating effects. Pulmonary colonisation can lead to an accelerated decline in lung function. In some cases, it causes a rapid and progressive pneumonic illness termed "cepacia syndrome", which is untreatable and fatal. B. cepacia is inherently resistant to multiple antibiotics and highly transmissible and virulent strains have been identified. CF patients colonised with the organism have to be segregated from their peers to try to prevent cross-infection. However, the pathogenicity of B. cepacia is not limited to CF. Other groups, such as individuals with chronic granulomatous disease and immunocompromised patients are vulnerable and it has caused disease in healthy individuals. However, the agricultural and petrochemical industries are attempting to exploit properties of B. cepacia for use as a biopesticide and biodegradation agent. This article provides an up to date review of clinically based literature on the Burkholderia cepacia complex, highlighting clinical management issues for both cystic fibrosis and non-cystic fibrosis patients. The article also addresses the potential conflict between medicine and agriculture on plans to reintroduce strains of Burkholderia cepacia back into the environment.

From August 1996 through June 1998, 69 ventilated, intensive care unit patients at two Arizona hospitals had nosocomial respiratory tract cultures positive for Burkholderia cepacia. Intrinsically contaminated alcohol-free mouthwash was identified by pulsed-field gel electrophoresis as the source of the outbreak.