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Original Research: CRITICAL CARE MEDICINE |

Multistate Outbreak of Burkholderia cenocepacia Colonization and Infection Associated With the Use of Intrinsically Contaminated Alcohol-Free Mouthwash* FREE TO VIEW

Preeta K. Kutty, MD, MPH; Barbara Moody, RN, CIC; Jessica Smartt Gullion, PhD; Marcus Zervos, MD; Marie Ajluni, MT (ASCP), MPH, CIC; Rebecca Washburn, RN, BSN; Roger Sanderson, MA, BSN; Marion A. Kainer, MD, MPH; Timothy A. Powell, MPH; Carmen F. Clarke, MPH; Renee J. Powell, MPH; Neil Pascoe, RN, BSN, CIC; Alicia Shams, MPH; John J. LiPuma, MD; Bette Jensen, MMSc; Judith Noble-Wang, PhD; Matthew J. Arduino, DrPH; L. Clifford McDonald, MD
Author and Funding Information

*From the Division of Healthcare Quality Promotion (Drs. Kutty, Noble-Wang, Arduino, and McDonald, and Ms. Shams and Ms. Jensen), National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA; Denton Regional Medical Center (Ms. Moody), Denton, TX; Denton County Health Department (Dr. Gullion), Denton, TX; Henry Ford Hospital (Dr. Zervos and Ms. Ajluni), Detroit, MI; Henry Ford Wyandotte Hospital (Ms. Washburn), Wyandotte, MI; Florida Department of Health (Mr. Sanderson), Tampa, FL; Tennessee Department of Health (Dr. Kainer), Nashville, TN; Virginia Department of Health (Mr. Powell), Richmond, VA; Oklahoma State Department of Health (Ms. Clarke and Ms. Powell), Oklahoma City, OK; Texas Department of State Health Services (Mr. Pascoe), Austin, TX; and the Department of Pediatrics (Dr. LiPuma), University of Michigan Medical School, Ann Arbor, MI.

Correspondence to: Preeta K. Kutty, MD, MPH, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS-A47, Atlanta, GA 30333; e-mail: PKutty@cdc.gov



Chest. 2007;132(6):1825-1831. doi:10.1378/chest.07-1545
Text Size: A A A
Published online

Background: No 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).

Methods: We conducted a case-series investigation. We used repetitive extragenic palindromic- polymerase chain reaction 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.

Results: Of the 116 patients with Bcc infection or colonization identified from 22 hospitals with culture dates from April 7 through August 31, 2005, 105 had infections or colonizations that were due to B cenocepacia. The median age of these 105 patients was 64 years (range, 6 to 94 years), 52% were women, 55% had evidence of infection, and 2 patients died. Of 139 patient culture specimens, 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.

Conclusions: This intrinsically contaminated AFM led to a geographically dispersed outbreak of B cenocepacia. AFM without therapeutic label claims is regulated by the US 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.

Figures in this Article

Some studies14 have suggested a potentially important role for oral disinfection in preventing ventilator-associated pneumonia. There is increasing understanding of the importance of general oral hygiene in patients who either are intubated or have a tracheostomy as a means to reduce the risk of health-care-associated pneumonia.5However, current guidelines6do not provide recommendations concerning which oral care products are either beneficial or safe to use in reducing the risk of pneumonia. A product commonly used to provide oral care to ventilated patients is mouthwash. Mouthwashes containing alcohol at a concentration of > 20% are believed to have reliable antimicrobial activity.78 However, some health-care providers use alcohol-free mouthwash (AFM) preferentially to reduce mucosal irritation.

Organisms of the Burkholderia cepacia complex (Bcc), including Burkholderia cenocepacia and Burkholderia multivorans, are a common cause of respiratory tract infection in patients with cystic fibrosis, but a rare (0.6%) cause of ventilator-associated pneumonia.912 Because Bcc requires few nutrients for growth and are relatively resistant to the action of some chemical antiseptics and disinfectants, they have been implicated in several health-care-associated outbreaks resulting from intrinsic contamination of commercial medications, ultrasound gels, and skin antiseptics.1317 In addition, Bcc has been traced to at least three previously reported outbreaks of respiratory tract colonization and infection, and two other US Food and Drug Administration (FDA) recalls resulting from intrinsically contaminated AFM.12,1821

During August 2005, a Texas health-care facility reported the presence of Bcc respiratory tract infection or colonization among three patients without cystic fibrosis to the Centers for Disease Control and Prevention (CDC); all three patients received AFM from a national distributor Y.22Cultures performed at the facility on unopened lots of the AFM yielded approximately 100,000 colonies per milliliter of Bcc. On August 26, 2005, distributor Y issued a voluntary recall of the implicated lots of AFM.23 We describe the results of a multistate investigation to identify patients affected by this mouthwash, determine the cause of the outbreak, and offer recommendations to prevent similar outbreaks in the future.

AFM Manufacture and Distribution

Through discussions between CDC, FDA, and distributor Y, the manufacturer of the implicated AFM was identified, along with the dates and distribution of the affected product. Distributor Y was the primary distributor of the product to inpatient facilities in the southern United States. They informed hospitals, medical centers, and long-term care facilities nationwide that had received the implicated product. In addition to being supplied as individual bottles, the product was part of certain personal hygiene hospital admission kits.

Definitions and Case Finding

A case patient was defined as a patient with a Bcc-positive clinical culture between March 1 (when the manufacture of AFM was initiated) and August 31, 2005 (5 days after the recall),24 who had either known or suspected exposure to an implicated lot of AFM in the 7 days before culture collection. Infection was defined by Bcc recovery from a normally sterile body site, or, if recovered from a nonsterile body, physician diagnosis of Bcc infection. Colonization was defined by Bcc recovery from a nonsterile body site and no physician-diagnosed Bcc infection. Based on isolate relatedness to the strain recovered from an unopened AFM bottle, case patients were further categorized into confirmed (typing results indistinguishable from mouthwash isolates) and possible (no available isolate). Case patients were excluded if they had a typing result that was distinguishable from mouthwash isolates.

A case finding was undertaken by a request sent to state and local public health officials and professional organizations via e-mail notification on August 26, 2005.24 A standardized data-collection form was used. The information collected included demographics, hospital admission diagnosis, location at the time of diagnosis (eg, ICU or ward), comorbid conditions, culture sites and dates, the presence of indwelling medical devices (ie, urinary catheters, ventilators, and central venous catheters), treatment, and outcomes.

Laboratory Studies
Organism Characterization:

Mouthwash and clinical isolates were sent to the Burkholderia cepacia Research Laboratory and Repository at the University of Michigan and were assessed for species identification by using 16S ribosomal RNA, and recA-targeted, species-specific polymerase chain reaction (PCR) and restriction fragment length polymorphism assays, as previously described.2526 Repetitive extragenic palindromic-PCR genotyping using a BOX A1R primer was performed as described.27Mouthwash and clinical isolates sent to the CDC were compared by pulsed-field gel electrophoresis (PFGE) following the digestion of chromosomal DNA with the restriction endonuclease Spe I. The PFGE method was previously described by the FDA, Denver District Office, for Pseudomonas (Dexter et al28) and was adapted by the CDC for Bcc. PFGE was performed using a mapper (CHEF Mapper; Bio-Rad; Hercules, CA). The running parameters were as follows: 200 V (6 V/cm); temperature, 14°C; initial switch time, 2 s; final switch time, 50 s; and run time, 22 h. Gels were photographed (MP-4 Land camera; Polaroid Corp; Cambridge, MA) using ultraviolet illumination. Photographs were saved as a TIFF file for analysis (BioNumerics software; Applied Maths; Kortrijk, Belgium). The percentage of similarities of the test isolates were identified on a dendrogram derived from the unweighted pair-group method using arithmetic averages and based on Dice coefficients. Band position tolerance and optimization were set at 1.25% and 0.5%, respectively. A similarity coefficient of 80% was selected to define the pulsed-field type clusters. These criteria have been used previously in outbreak investigations and correlate broadly with differences of three bands or less between isolates.2931

Seeding Studies:

To determine the preservative efficacy of AFM, both implicated and nonimplicated (control) AFM were challenged with Bcc. The method used was adapted from the American Society for Testing and Materials method No. E640-7832 and consisted of inoculating the outbreak strain of Bcc (106 cfu/mL) in lots of previously unopened AFM. The control, or nonimplicated, AFM was from a second manufacturer that also had supplied distributor Y with AFM. The exact formulations of the AFM from each manufacturer were proprietary. Although the list of ingredients was not identical, both formulations utilized cetylpyridinium chloride (CPC) as the main antibacterial agent, the concentration of which was unknown.

Recovery was quantified and compared to a control suspension in sterile water at time 0 (time of inoculation) and the following exposure intervals: 1, 4, 8, and 24 h, and 2, 4, 7, 14, 21, and 28 days. The inoculated test product and control samples were stored at ambient room temperature. At each time point, Bcc, from the inoculated product and control samples, was quantified by performing a 1:10 dilution of 1 mL of test samples in 9 mL (10−1, 10−2, and 10−3) of Letheen neutralizing broth (Difco; BD Diagnostic Systems; Sparks, MD) and spreading 0.1 mL on Letheen neutralizing agar (BD Diagnostic Systems) plates (10−2, 10−3, and 10−4). The neutralizer was qualified by testing for preservative carryover. Negative growth plates (10−2) were rechallenged with a single streak of a fresh culture of Bcc. The recovery of Bcc was determined by performing plate counts at each specified dilution and calculating the concentration from plates yielding 25 to 250 cfu. The concentration (in colony-forming units per milliliter) was log10-transformed and plotted against time.

Statistical Analysis

The data were entered into a database (EXCEL 2003; Microsoft; Redmond, WA). For univariate analysis, a statistical software package (SAS, version 9.1; SAS Institute; Cary, NC) was used.

A total of 116 patients with clinical cultures positive for Bcc were reported from 22 hospitals in nine states with positive culture dates from April 7 through August 31, 2005 (Fig 1 ). Because case report forms and isolates were often received independently from hospitals or state health departments, isolates were available from several patients for whom case report forms were not received and vice versa. Isolates were received for 79 of the 116 patients (68%). The remaining 37 patients (32%) were classified as possible case patients because either they could not be matched or did not have isolates. Of the 79 patients with available isolates, 68 (86%) were confirmed patients and 11 (14%) were excluded based on PFGE results. An additional four patients, who were not included in the patient count detailed in the previous section, had cultures positive for the outbreak strain, but were not exposed to the implicated AFM over the 7 days prior to the date of the positive culture, suggesting that secondary transmission may have been responsible.

Case characteristics are shown in Table 1 for 105 patients for whom adequate data were received. Among 84 patients for whom a physician interpretation of the Bcc-positive culture was available, 46 (55%) were thought to represent infection. Two deaths were attributable to the organism, with the site of infection being the lungs. Of 139 clinical cultures that were positive for Bcc among the patients, 83 (60%) were from the respiratory tract, 33 (24%) were from urine, 20 (14%) were from blood, and 3 (2%) were from tissue. Of the 75 patients for whom we have information on both invasive devices and culture sites, 26 of 27 patients with positive respiratory culture findings were intubated, all 29 patients with a positive urine culture finding had a urinary catheter in place, and 11 of 12 patients with a positive blood culture finding had a central venous catheter in place.

A total of 103 Bcc patient isolates were available to the CDC for characterization. Species identification and repetitive extragenic palindromic PCR genotyping during the initial investigation identified the outbreak strain as B cenocepacia. Ultimately, 81 of the 103 available isolates (76%) from seven states were found by PFGE to have a pattern (Fig 2 ) that was indistinguishable from the strain cultured from implicated lots of unopened and opened AFM.

No significant difference was found in the recovery of B cenocepacia from inoculated test products at times of < 24 h (ie, log reduction, < 1.0) [Fig 3 ]. In the implicated AFM, B cenocepacia concentration was reduced by an average of 1.5 logs at 24 h, and the concentration decreased another 0.8 logs by day 2. However, an increase in B cenocepacia concentration to 6.2 log10 cfu/mL was noted by day 7. The concentration reached the stationary phase at approximately 6.0 log10 cfu/mL for the remaining observation points up to 28 days. At no point after time 0 was B cenocepacia recovered from the nonimplicated AFM.

We present the fourth and largest reported outbreak of Bcc infection and colonization associated with AFM. Based on isolate typing results, at least 68 patients in seven states were colonized with B cenocepacia. At least 48 patients were thought to be infected and, in two patients, death was thought to be either directly or indirectly attributable to B cenocepacia infection. Although only four cases of secondary transmission were identified serendipitously, it is likely there were many more instances of such transmission. As in previous outbreaks of Bcc associated with AFM, mechanically ventilated patients appeared to be at increased risk. The results of laboratory testing indicated that, in addition to intrinsic contamination that likely occurred during manufacture, the implicated AFM, when compared to control AFM, did not have sufficient antibacterial activity.

Prior reported outbreaks of Bcc infection and colonization associated with AFM include a 1995 outbreak in Wisconsin in which 12 patients without predisposing factors were affected.18 From 1996 to 1998, Bcc due to an intrinsically contaminated mouthwash that contained CPC and was later recalled was diagnosed in 69 ventilated patients without cystic fibrosis (age range, 17 to 87 years; median age, 73 years).12 Most recently, an outbreak in Spain occurred from 2004 to 2005 in which 37 patients (age range, 16 to 77 years; mean age, 49.9 years) were colonized or infected with Bcc following the use of an AFM in which the active ingredient was hexetidine 0.1%.19Although the attributable mortality was not determined, 11 patients died. In addition to these outbreaks, there have been two additional recalls by the FDA of AFMs that were intrinsically contaminated by Bcc.2021

This is the first report of a multistate outbreak and reveals the broad impact that intrinsically contaminated AFM can have on patient safety. The product was mainly distributed to southern and southeastern states in the United States. However, a secondary distributor, distributor V, distributed this product in northern midwestern states, including Michigan. This could explain the presence of the large number of cases in this outbreak that occurred in this state. Positive culture findings from a variety of body sites at this and other institutions may have been related to reports of AFM being added as a fragrance to patient bath water at some institutions. Alternatively, there may have been widespread contamination of the patient care environment or of the hands of health-care workers.

The American Society for Testing and Materials criteria of preservation is defined as a ≥ 99.9% decrease in organism load within 7 days following challenge and no significant increase thereafter for the remainder of the test. Based on this criterion, the implicated lots of AFM did not possess adequate antimicrobial properties and allowed the survival of B cenocepacia for up to 28 days of storage. In contrast, the nonimplicated lot of AFM appeared bactericidal, generating a hypothesis that nonimplicated lots contained a higher concentration of CPC, a quaternary ammonium compound that is the main antibacterial agent in many brands of AFM.

Although details of an onsite investigation at the manufacturing plant are not available, contamination appears to have occurred during the manufacturing process. No repackaging or other manipulation of the product was performed after the AFM left the manufacturing facility, and there were no reports suggesting package deterioration or tampering. One resulting hypothesis is that this outbreak occurred because of inadequate antibacterial properties coupled with intrinsic contamination of the AFM by Bcc during the production process. Due to the absence of therapeutic label claims, this AFM, as well as others regulated by the FDA, are classified as cosmetics rather than as drugs. Hence, this and similar products are subject to limited requirements under the Cosmetic Act.

The major role of ventilated patients in this and previous outbreaks is due to several factors. Ventilated patients are at a higher risk of infection due to their decreased ability to maintain mucociliary clearance and cough mechanisms that normally protect the lower respiratory tract.6 In addition, because of the increased risk of infection in these patients, respiratory cultures are more frequently collected; thus, patients are more likely to be identified as having been colonized with a bacterium such as B cenocepacia. The results of this and previous similar investigations suggest that caution be exercised when using nonsterile compounds in intubated patients and other patients with increased risk of aspiration, especially as no recommendations exist for formulations of oral care products that are considered to be safe for use in such patients. Although there were other culture specimens obtained from sites other than the respiratory tract, pneumonia is the most well-defined infection described in the literature in association with B cepacia.

This investigation was subject to several limitations. Only passive case finding was employed. In addition, because many bottles of implicated AFM were in home care packages, the case finding at many hospitals was probably incomplete. Because of the large number of patients, many of whom had complicated clinical histories, following up on these case patients in some hospitals or states was substantial, leading to incomplete data collection. As this investigation was descriptive in nature, based on existing clinical records, the exact estimates of patient morbidity and mortality attributable to B cenocepacia colonization or infection as well as the excess costs caused by this outbreak could not be determined.

In summary, we have described an outbreak of B cenocepacia colonization and infection caused by intrinsic contamination of AFM in which at least 68 patients from seven states were affected, at least 48 patients were infected, and 2 patients died. However, it is likely that these figures underestimate the full impact of this outbreak on patient morbidity and mortality. Although we were unable to estimate the excess health-care costs associated with this outbreak, they are likely to be substantial. This outbreak was caused by inadequate quality control in the manufacture of a product regulated as a cosmetic but used in health care for the oral care of patients who were at high risk for pneumonia. Given that this is the latest of four such outbreaks reported in the literature over the past 12 years, we recommend that, at least until the manufacturers of alcohol-free products can provide assurance of sterility, only alcohol-containing mouthwashes be used in intubated patients and other patients with increased risk of aspiration.

Abbreviations: AFM = alcohol-free mouthwash; Bcc = Burkholderia cepacia complex; CDC = Centers for Disease Control and Prevention; CPC = cetylpyridinium chloride; FDA = US Food and Drug Administration; PCR = polymerase chain reaction; PFGE = pulse-field gel electrophoresis

The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Dr. LiPuma is supported by the Cystic Fibrosis Foundation.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Figure Jump LinkFigure 1. The patients with Bcc colonization or infection associated with contaminated AFM, by state, from March through August 2005.Grahic Jump Location
Table Graphic Jump Location
Table 1. Demographics and Clinical Characteristics of Patients With B cenocepacia-Positive Cultures, March Through August 31, 2005 (n = 105)*
* 

Values are given as No. (%).

 

Includes neurologic, musculoskeletal, cardiovascular surgery, fistula drainage, and graft thrombosis.

 

Includes patients with rheumatic heat disease, cervical spondylosis, Crohn disease, hepatitis C, and paraplegia.

Figure Jump LinkFigure 2. PFGE following the digestion of chromosomal DNA with the restriction endonuclease Spe I. The percentage of similarities of the test isolates were identified using arithmetic averages and based on Dice coefficients. Band position tolerance and optimization were set at 1.25% and 0.5%, respectively. A similarity coefficient of 80% was selected to define the pulsed-field-type clusters. Outbreak clusters are highlighted in the box.Grahic Jump Location
Figure Jump LinkFigure 3. Efficacy of AFM against B cenocepacia. The treatment of an outbreak isolate of B cenocepacia in implicated lots of alcohol-free mouthwash (n = 5). Different lots of one container each of AFM were tested. The recovery of B cenocepacia from the mouthwash was compared to the recovery of cells suspended in sterile water (control; n = 5) from the time of inoculation at zero hour to 28 days of treatment.Grahic Jump Location

We thank Shelley Stonecipher, DVM, MPH, from the Texas Department of State Health Services; the Texas Department of State Health Services laboratory; and the Infection Control Practitioner of the hospitals for their cooperation and assistance in making this investigation possible.

Bergmans, DC, Bonten, MJ, Gaillard, CA, et al (2001) Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double blind, placebo-controlled study.Am J Respir Crit Care Med164,382-388. [PubMed]
 
Grap, MJ, Munro, CL Preventing ventilator-associated pneumonia: evidence-based care.Crit Care Nurs Clin North Am2004;16,349-358. [PubMed] [CrossRef]
 
Crnich, CJ, Safdar, N, Maki, D The role of the intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia.Respir Care2005;50,813-838. [PubMed]
 
Koeman, M, van der Ven, AJ, Hak, E, et al Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia.Am J Respir Crit Care Med2006;173,1348-1355. [PubMed]
 
Munro, CL, Grap, MJ, Elswick, RK Oral health status and development of ventilator-associated pneumonia: a descriptive study.Am J Crit Care2006;15,453-460. [PubMed]
 
Tablan, OC, Anderson, LJ, Besser, R, et al Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.MMWR Recomm Rep2004;53,1-36
 
Sox, TE Mechanisms of action of cosmetic preservatives. Brannen, DK eds.Cosmetic microbiology: a practical handbook1997,163-176 CRC Press. Boca Raton FL:
 
Fassiti, RA Preservation and microbiological attributes of nonsterile pharmaceutical product. Block, SS eds.Disinfection, sterilization, and preservation 5th ed.2001,529-541 Lippincott Williams & Wilkins. Philadelphia, PA:
 
LiPuma, JJ Update on theBurkholderia cepaciacomplex.Curr Opin Pulm Med2005;11,528-533. [PubMed]
 
Mahenthiralingam, E, Simpson, DA, Speert, DP Identification and characterization of a novel DNA marker associated with epidemicBurkholderia cepaciastrains recovered from patients with cystic fibrosis.J Clin Microbiol1997;35,808-816. [PubMed]
 
McCloskey, M, McCaughern, J, Redmond, AOB, et al Clinical outcome after acquisition ofBurkholderia cepaciain patients with cystic fibrosis.Ir J Med Sci2001;170,28-31. [PubMed]
 
Centers for Disease Control and Prevention.. NosocomialBurkholderia cepaciainfection and colonization associated with intrinsically contaminated mouthwash: Arizona, 1998.MMWR Morb Mortal Wkly Rep1998;47,926-928. [PubMed]
 
Panlilio, AL, Beck-Sague, CM, Siegel, JD, et al Infections and pseudo-infections due to povidone-iodine solution contaminated withPseudomonas cepacia.Clin Infect Dis1992;14,1078-1083. [PubMed]
 
Balkhy, HH, Cunningham, G, Francis, C, et al A National Guard outbreak ofBurkholderia cepaciainfection and colonization secondary to intrinsic contamination of albuterol nebulization solution.Am J Infect Control2005;33,182-188. [PubMed]
 
Hutchinson, J, Runge, W, Mulvey, M, et al Burkholderia cepaciainfections associated with intrinsically contaminated ultrasound gel: the role of microbial degradation of parabens.Infect Control Hosp Epidemiol2004;25,291-296. [PubMed]
 
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Centers for Disease Control and Prevention. CDC health advisory: nosocomial.Burkholderia cepacia pneumonia associated with contaminated alcohol-free mouthwash. Available at: http://www2a.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00230. Accessed October 19, 2007.
 
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Figures

Figure Jump LinkFigure 1. The patients with Bcc colonization or infection associated with contaminated AFM, by state, from March through August 2005.Grahic Jump Location
Figure Jump LinkFigure 2. PFGE following the digestion of chromosomal DNA with the restriction endonuclease Spe I. The percentage of similarities of the test isolates were identified using arithmetic averages and based on Dice coefficients. Band position tolerance and optimization were set at 1.25% and 0.5%, respectively. A similarity coefficient of 80% was selected to define the pulsed-field-type clusters. Outbreak clusters are highlighted in the box.Grahic Jump Location
Figure Jump LinkFigure 3. Efficacy of AFM against B cenocepacia. The treatment of an outbreak isolate of B cenocepacia in implicated lots of alcohol-free mouthwash (n = 5). Different lots of one container each of AFM were tested. The recovery of B cenocepacia from the mouthwash was compared to the recovery of cells suspended in sterile water (control; n = 5) from the time of inoculation at zero hour to 28 days of treatment.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Demographics and Clinical Characteristics of Patients With B cenocepacia-Positive Cultures, March Through August 31, 2005 (n = 105)*
* 

Values are given as No. (%).

 

Includes neurologic, musculoskeletal, cardiovascular surgery, fistula drainage, and graft thrombosis.

 

Includes patients with rheumatic heat disease, cervical spondylosis, Crohn disease, hepatitis C, and paraplegia.

References

Bergmans, DC, Bonten, MJ, Gaillard, CA, et al (2001) Prevention of ventilator-associated pneumonia by oral decontamination: a prospective, randomized, double blind, placebo-controlled study.Am J Respir Crit Care Med164,382-388. [PubMed]
 
Grap, MJ, Munro, CL Preventing ventilator-associated pneumonia: evidence-based care.Crit Care Nurs Clin North Am2004;16,349-358. [PubMed] [CrossRef]
 
Crnich, CJ, Safdar, N, Maki, D The role of the intensive care unit environment in the pathogenesis and prevention of ventilator-associated pneumonia.Respir Care2005;50,813-838. [PubMed]
 
Koeman, M, van der Ven, AJ, Hak, E, et al Oral decontamination with chlorhexidine reduces the incidence of ventilator-associated pneumonia.Am J Respir Crit Care Med2006;173,1348-1355. [PubMed]
 
Munro, CL, Grap, MJ, Elswick, RK Oral health status and development of ventilator-associated pneumonia: a descriptive study.Am J Crit Care2006;15,453-460. [PubMed]
 
Tablan, OC, Anderson, LJ, Besser, R, et al Guidelines for preventing health-care–associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee.MMWR Recomm Rep2004;53,1-36
 
Sox, TE Mechanisms of action of cosmetic preservatives. Brannen, DK eds.Cosmetic microbiology: a practical handbook1997,163-176 CRC Press. Boca Raton FL:
 
Fassiti, RA Preservation and microbiological attributes of nonsterile pharmaceutical product. Block, SS eds.Disinfection, sterilization, and preservation 5th ed.2001,529-541 Lippincott Williams & Wilkins. Philadelphia, PA:
 
LiPuma, JJ Update on theBurkholderia cepaciacomplex.Curr Opin Pulm Med2005;11,528-533. [PubMed]
 
Mahenthiralingam, E, Simpson, DA, Speert, DP Identification and characterization of a novel DNA marker associated with epidemicBurkholderia cepaciastrains recovered from patients with cystic fibrosis.J Clin Microbiol1997;35,808-816. [PubMed]
 
McCloskey, M, McCaughern, J, Redmond, AOB, et al Clinical outcome after acquisition ofBurkholderia cepaciain patients with cystic fibrosis.Ir J Med Sci2001;170,28-31. [PubMed]
 
Centers for Disease Control and Prevention.. NosocomialBurkholderia cepaciainfection and colonization associated with intrinsically contaminated mouthwash: Arizona, 1998.MMWR Morb Mortal Wkly Rep1998;47,926-928. [PubMed]
 
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