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A pseudo-outbreak of Burkholderia cepacia complex in a Kentucky hospital

  • Chad C. Eldridge
    Correspondence
    Address correspondence to: Chad C. Eldridge, DNP, RN, Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, 275 East Main Street, Frankfort, KY 40621.
    Affiliations
    Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY
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  • Andrea H. Flinchum
    Affiliations
    Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY
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  • Doug Thoroughman
    Affiliations
    Division of Epidemiology and Health Planning, Kentucky Department for Public Health

    Career Epidemiology Field Officer Program, Division of State and Local Readiness, Center for Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA
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  • Kevin B. Spicer
    Affiliations
    Healthcare-Associated Infection/Antibiotic Resistance Prevention Program, Division of Epidemiology and Health Planning, Kentucky Department for Public Health, Frankfort, KY

    Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA
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Published:November 03, 2021DOI:https://doi.org/10.1016/j.ajic.2021.10.028

      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.

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