Highlights
- •Burkholderia cepacia outbreaks/pseudo-outbreaks have significant healthcare impact
- •Investigation of pseudo-outbreaks can improve quality and safety of patient care
- •A breach in culture preparation protocol resulted in contamination of specimens
- •Pseudo-outbreak investigation identified several process gaps requiring remediation
- •Infection control training is important for staff in all patient impact areas
Abstract
A cluster of Burkholderia cepacia complex cases from January to October 2020 among outpatients undergoing urologic
procedures within a Kentucky hospital's operating rooms was investigated. This investigation
included a laboratory look-back, chart reviews, exposure tracing, staff interviews,
and direct observation of infection prevention and control practices. A significant
protocol breach in a laboratory procedure led to contamination of surgical specimens
submitted for culture with nonsterile saline. Pseudo-outbreaks often highlight gaps
in infection control processes. Healthcare facilities can make substantial improvements
in patient care quality and safety as they respond to identified gaps and improve
systems and protocols.
Key words
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References
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Article info
Publication history
Published online: November 03, 2021
Footnotes
Conflicts of interest: None to report.
Identification
Copyright
© 2021 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
