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This Article Full Text (PDF) All Versions of this Article: chest.07-1545v1 132/6/1825    most recent Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Personal Article Archive Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kutty, P. K. Articles by McDonald, L. C. Search for Related Content PubMed PubMed Citation Articles by Kutty, P. K. Articles by McDonald, L. C.

Multi-state Outbreak of Burkholderia cenocepacia Colonization and Infection Associated with the Use of Intrinsically Contaminated Alcohol-free Mouthwash

¹Division of Healthcare Quality Promotion; National Center for Preparedness, Detection, and Control of Infectious Diseases; Centers for Disease Control and Prevention; Department for Health and Human Services, Atlanta, Georgia, USA ² Epidemic Intelligence Service; Division of Applied Public Health Training; Office of Workforce and Career Development; Centers for Disease Control and Prevention; Department of Health and Human Services, Atlanta, Georgia, USA ³Denton Regional Medical Center, Denton, Texas, USA ⁴Denton County Health Department, Denton, Texas, USA ⁵Henry Ford Hospital, Detroit, Michigan, USA ⁶Henry Ford Wyandotte Hospital, Wyandotte, Michigan, USA ⁷Florida Department of Health, Tampa, Florida, USA ⁸Tennessee Department of Health, Nashville, Tennessee, USA ⁹Virginia Department of Health, Richmond, Virginia, USA ¹⁰Oklahoma State Department of Health, Oklahoma City, Oklahoma, USA ¹¹Texas Department of State Health Services, Austin, Texas, USA ¹² Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA

PKutty{at}cdc.gov

Abstract

BackgroundNo guidelines exist for the type of mouthwash that should be used in patients at increased risk for pneumonia. In 2005, we investigated a multistate outbreak of Burkholderia cenocepacia associated with an intrinsically contaminated alcohol-free mouthwash (AFM).

MethodsWe conducted a case-series investigation. We used repetitive extragenic palindromic-PCR typing and pulsed-field gel electrophoresis (PFGE) to characterize available Burkholderia cepacia complex (Bcc) isolates from patients and implicated AFM. Seeding studies were conducted to determine the antimicrobial activity of the AFM.

ResultsOf the 116 patients with Bcc infection or colonization identified from 22 hospitals with culture dates from April 7 through August 31, 2005, 105 were due to B. cenocepacia. The median age of these 105 patients was 64 (range 6-94) years, 52% were female, 55% had evidence of infection, and two died. Of 139 patient cultures, 83 (60%) were from the respiratory tract. Among 103 Bcc patient isolates characterized, 81 (76%) had an indistinguishable PFGE pattern compared to the outbreak strain cultured from implicated lots of unopened AFM; the species was B. cenocepacia. Seeding studies showed that the contaminated AFM might have had inadequate amounts of the antimicrobial agent cetylpyridinium chloride.

ConclusionsThis intrinsically contaminated AFM led to a geographically dispersed outbreak of B. cenocepacia. AFM without therapeutic label claims is regulated by the Food and Drug Administration as a cosmetic rather than a drug and is therefore subject to limited quality control requirements. Clinicians should be aware that AFM is not sterile. Its use in intubated and other patients with increased risk of aspiration should be avoided.

Key Words: Burkholderia cepacia complex • critical care • mouthwashes • delivery of healthcare