An Outbreak of Ralstonia pickettii Bloodstream Infection Associated with an Intrinsically Contaminated Normal Saline Solution

Abstract

OBJECTIVERalstonia pickettii has caused contamination of pharmaceutical solutions in many countries, resulting in healthcare infections or outbreak events. We determined the source of the outbreak of R. pickettii bloodstream infection (BSI).METHODSThis study was conducted in a 3,000-bed tertiary referral medical center in Taiwan with >8,500 admissions during May 2015. Patients had been treated in the injection room or chemotherapy room at outpatient departments, emergency department, or hospital wards. All patients who were culture positive for R. pickettii from May 3 to June 11, 2015, were eligible for the study. The aim of the survey was to conduct clinical epidemiological and microbiological investigations to identify possible sources of infection.RESULTSWe collected 57 R. pickettii–positive specimens from 30 case patients. We performed 24 blood cultures; 14 of these revealed >2 specimens and 6 used fluid withdrawn from Port-a-Cath implantable venous access devices. All patients received an injection of 20 mL 0.9% normal saline via catheter flushing. In addition, 2 unopened ampules of normal saline solution (20 mL) were confirmed positive for R. pickettii. The Taiwan Centers for Disease Control and Prevention performed sampling and testing of the same manufactured batch and identified the same strain of R. pickettii. Pulsed-field gel electrophoresis tests revealed that all clinical isolates had similarity of >90%, validating the outbreak of the same clone of R. pickettii.CONCLUSIONSR. pickettii can grow in saline solutions and cause bloodstream infections. Hospital monitoring mechanisms are extremely important measures in identifying and ending such outbreaks.Infect Control Hosp Epidemiol 2017;38:444–448

<p>A case of persistent bacteraemia by <em>Ralstonia mannitolilytica</em> and <em>Ralstonia pickettii</em> in an intensive care unit</p>

“…One possibility is that the infection was acquired following contamination during or after the neurosurgical clipping procedure. Indeed, Ralstonia bacteria have been associated with infections in hospital settings due to their ability to survive in liquid media (including saline and chlorhexidine with 0.05% aqueous solutions) and on hospital devices 19. In our case, environmental samples of air or from inanimate surfaces taken monthly in the operating rooms and in all areas where the patient had been treated were negative for Ralstonia spp; this is not surprising as even in cases of well documented hospital outbreaks the environmental origin was not identified 20,21.…”

Outbreak of nonfermentative Gram‐negative bacteria (Ralstonia pickettii and Stenotrophomonas maltophilia) in a hemodialysis center

“…The pathogen is now commonly recognized and implicated in septicemia in immunocompromised and debilitated hospitalized patients . Outbreaks have occurred due to contaminated solutions causing respiratory illnesses, endopthalmitis, otitis media, meningitis, prosthetic joint infections, and nonspecific bacteremic symptoms …”

“…18 Outbreaks have occurred due to contaminated solutions causing respiratory illnesses, 23 endopthalmitis, 12 otitis media, 24 meningitis, 25 prosthetic joint infections, 26 and nonspecific bacteremic symptoms. 3,4,27 A case of S. maltophilia infection in a hemodialysis patient with a tunneled central venous catheter which did not respond to ceftazidime and ciprofloxacin. Long-term daily locked-in therapy with ceftazidime was able to save both the catheter and the patient.…”

“…Nosocomial infections among susceptible individuals are more frequently reported and there has been a few documented outbreaks in the literature, particularly relating to contamination of pharmaceutical solutions and in varied settings including oncology outpatients, pediatric emergency department, hematology inpatient ward, and neonatal intensive care unit . Reports of outbreaks came from diverse countries including Taiwan, China, Italy, India, Bulgaria, Germany, and United States . Due to its heighten profile, soaring prevalence, evolving resistance, and virugenic potential, early reporting and identification of infections are necessary to curtail the serious challenges pose by the bacteria in the future.…”

Ralstonia insidiosa Neonatal Sepsis: A Case Report and Review of the Literature

“…8 Recently, several studies from multiple countries reported cases caused by pharmaceutical solutions. 9,10 In our case, we performed surveillance cultures from the hospital water sources, sterilization chemicals, water-based solutions, medication bottles, respiratory therapy equipment, and specimens from baby incubator to try to find the source of infection. Surveillance cultures were all negative; there were no additional cases of Ralstonia spp.…”