Gülendam BOZDAYI, Sidre ERGANİŞ, Fatma Nur AKSAKAL, Kayhan ÇAĞLAR, Meltem YALINAY, Özlem GÜZEL TUNÇCAN, Hasan Selçuk ÖZGER, Murat DİZBAY

Monoclonal outbreak of Ralstonia solanacearum catheter-related bloodstream infection associated with contaminated package of normal saline solution in a tertiary care hospital

Background/aim: Ralstonia solanacearum is a very rare cause of infection in humans. There is no described nosocomial outbreak due to R. solanacearum so far. We determined R. solanacearum as the source of catheter-related bloodstream infection (CRBSI) outbreak. Materials and methods: This outbreak analysis was carried out in a 1000-bed tertiary care university hospital in Turkey. The outbreak analysis included hematology, oncology, nephrology, gastroenterology wards, emergency department, and intensive care units. The first case with R. solanacearum CRBSI was detected on May 20, 2019 and R. solanacearum was isolated in catheter blood cultures in 34 patients until October 3, 2019 Results: Standard outbreak analysis procedures were applied. Culture samples were taken from the fluids administered via catheters. The cultures did not yield any bacteria. As a result of the investigation in storage area, it was found that there were leaks, air bubbles, and water drops inside the packaging of saline solutions. R. solanacearum was yielded in the cultures obtained from the surface of saline bags and the inner sides of plastic packings. To validate our hypothesis, a clonal analysis was performed using arbitrarily primed-PCR method and Sanger sequencing of the 16S rRNA gene for identification among isolates. All R. solanacearum isolates were monoclonal and identical. Conclusion: This is the first outbreak of R. solanacearum CRBSI described in a hospital setting. The source of the outbreak was a contamination in the surface of saline bags and the inner sides of plastic packings. Efficacy of an active surveillance system, accurate and rapid conduction of microbiological identification are essential for outbreak management.Key words: Ralstonia solanacearum, outbreak, nosocomial, bloodstream infection, contaminated saline

PDF

___

1. Ryan MP, Adley CC. Ralstonia spp.: emerging global opportunistic pathogens. European Journal of Clinical Microbiology and Infectious Diseases. 2014; 33: 291-304. doi: 10.1007/s10096-013-1975-9
2. Mikulska M, Durando P, Pia Molinari M, Alberti M, Del Bono V et al. Outbreak of Ralstonia pickettii bacteraemia in patients with haematological malignancies and haematopoietic stem cell transplant recipients. Journal of Hospital Infection 2009; 72: 187-188. doi: 10.1016/j.jhin.2009.02.016
3. Chen YY, Huang WT, Chen CP, Sun SM, Kuo FM et al. An outbreak of Ralstonia pickettii bloodstream infection associated with an intrinsically contaminated normal saline solution. Infection Control & Hospital Epidemiology 2017; 38: 444-448. doi: 10.1017/ice.2016.327
4. K Thet M, Pelobello MLF, Das M, Alhaji MM, Chong VH et al. Outbreak of nonfermentative gram-negative bacteria [Ralstonia pickettii and Stenotrophomonas maltophilia] in a hemodialysis center. Hemodialysis International 2019; 23: e83-e89. doi: 10.1111/hdi.12722
5. Shi X, Zhan H, Zeng Y, Zhang X, Wu B et al. A case of hemophagocytic lymphohistiocytosis secondary to Ralstonia solanacearum Infection. Clinical Laboratory 2019; 1; 65 (6). doi: 10.7754/Clin.Lab.2018.181118
6. Prashanth K, Badrinath S. Epidemiological investigation of nosocomial Acinetobacter infections using arbitrarily primed PCR & pulse field gel electrophoresis. Indian Journal of Medical Research 2005; 122: 408-418
7. Chen L, Cai Y, Zhou G, Shi X, Su J et al. Rapid Sanger sequencing of the 16S rRNA gene for identification of some common pathogens. PLoS One 2014; 9: e88886. doi: 10.1371/ journal.pone.0088886
8. Marroni M, Pasticci MB, Pantosti A, Colozza MA, Stagni G et al. Outbreak of infusion-related septicemia by Ralstonia pickettii in the oncology department. Tumori 2003; 89: 575- 576. doi: 10.1177/030089160308900528
9. Kimura AC, Calvet H, Higa JI, Pitt H, Frank C et al. Outbreak of Ralstonia pickettii bacteremia in a neonatal intensive care unit. The Pediatric Infectious Disease Journal 2005; 24: 1099- 1103. doi: 10.1097/01.inf.0000190059.54356.f3
10. Moreira BM, Leobons MB, Pellegrino FL, Santos M, Teixeira LM et al. Ralstonia pickettii and Burkholderia cepacia complex bloodstream infections related to infusion of contaminated water for injection. Journal of Hospital Infection 2005; 60: 51- 55. doi: 10.1016/j.jhin.2004.09.036
11. Lucarelli C, Di Domenico EG, Toma L, Bracco D, Prignano G et al. Ralstonia mannitolilytica infections in an oncologic day ward: description of a cluster among high-risk patients. Antimicrobial Resistance and Infection Control 2017; 6: 20. doi: 10.1186/s13756-017-0178-z
12. Liu CX, Yan C, Zhang P, Li FQ, Yang JH et al. uced septicemia and homology analysis in infected patients: 3 case reportsRalstonia mannitolilytica-ind. Jundishapur Journal of Microbiology 2016; 9: e34373. doi: 10.5812/jjm.34373
13. Kahan A, Philippon A, Paul G, Weber S, Richard C et al. Nosocomial infections by chlorhexidine solution contaminated with Pseudomonas pickettii [Biovar VA-I]. Journal of Infection 1983; 7: 256-263. doi: 10.1016/s0163-4453(83)97196-7
14. Maki DG, Klein BS, McCormick RD, Alvarado CJ, Zilz MA et al. Nosocomial Pseudomonas pickettii bacteremias traced to narcotic tampering. A case for selective drug screening of health care personnel. JAMA 1991; 265: 981-986. doi:10.1001/ jama.1991.03460080051031
15. Ryan MP, Pembroke JT, Adley CC. Ralstonia pickettii: a persistent gram-negative nosocomial infectious organism. Journal of Hospital Infection 2006; 62: 278-284. doi: 10.1016/j. jhin.2005.08.015
16. Birlutiu RM, Roman MD, Cismasiu RS, Fleaca SR, Popa CM et al. Sonication contribution to identifying prosthetic joint infection with Ralstonia pickettii: a case report and review of the literature. BMC Musculoskeletal Disorders 2017; 18: 311. doi: 10.1186/s12891-017-1678-y
17. Choudhury H, Jindal A, Pathengay A, Flynn HW Jr. An outbreak of Ralstonia pickettii endophthalmitis following intravitreal methotrexate injection. Clinical Ophthalmology 2015; 9: 1117-1120. doi: 10.2147/OPTH.S81218
18. Kulakov LA, McAlister MB, Ogden KL, Larkin MJ, O’Hanlon JF. Analysis of bacteria contaminating ultrapure water in industrial systems. Applied and Environmental Microbiology 2002; 68: 1548-1555. doi: 10.1128/aem.68.4.1548-1555.2002.
19. Szymańska J, Sitkowska J. Bacterial contamination of dental unit waterlines. Environmental Monitoring and Assessment 2013; 185: 3603-3611. doi: 10.1007/s10661-012-2812-9
20. Kendirli T, Ciftçi E, Ince E, Incesoy S, Güriz H et al. Ralstonia pickettii outbreak associated with contaminated distilled water used for respiratory care in a paediatric intensive care unit. Journal of Hospital Infection 2004; 56: 77-78. doi: 10.1016/j. jhin.2003.09.011
21. Pellegrino FL, Schirmer M, Velasco E, De Faria LM, Santos KR et al. Ralstonia pickettii bloodstream infections at a Brazilian cancer institution. Current Microbiology 2008; 56: 219-223. doi: 10.1007/s00284-007-9060-1
22. Gröbner S, Heeg P, Autenrieth IB, Schulte B. Monoclonal outbreak of catheter-related bacteraemia by Ralstonia mannitolilytica on two haemato-oncologywards. Journal of Infection 2007; 55: 539-544. doi: 10.1016/j.jinf.2007.07.021
23. Coenye T, Vandamme P, LiPuma JJ. Infection by Ralstonia species in cystic fibrosis patients: identification of R. pickettii and R. mannitolilytica by polymerase chain reaction. Emerging Infectious Diseases 2002; 8: 692-696. doi: 10.3201/ eid0807.010472
24. Ahkee S, Srinath L, Tolentino A, Scortino C, Ramirez J. Pseudomonas pickettii pneumonia in a diabetic patient. The Journal of the Kentucky Medical Association 1995; 93: 511-513
25. Ryan MP, Pembroke JT, Adley CC. Differentiating the growing nosocomial infectious threats Ralstonia pickettii and Ralstonia insidiosa. European Journal of Clinical Microbiology & Infectious Diseases 2011; 30: 1245-1247. doi: 10.1007/s10096- 011-1219-9
26. Rodríguez-Sánchez B, Cercenado E, Coste AT, Greub G. Review of the impact of MALDI-TOF MS in public health and hospital hygiene, 2018. Eurosurveillance 2019; 24 (4). doi: 10.2807/1560-7917.ES.2019.24.4.1800193