Suspicious outbreak of ventilator-associated pneumonia caused by Burkholderia cepacia in a surgical intensive care unit

•Patients on mechanical ventilation are at risk for ventilator-associated pneumonia.•An outbreak of ventilator-associated pneumonia occurred in our surgical intensive care unit.•Burkholderia cepacia was confirmed as the causative pathogen.•Immediate ventilator cleaning and treatment after use was instituted.•The highest standards of hygiene are required in the health care environment.

BackgroundWe reviewed Burkholderia cepacia infections in a hospital from 2013-2016 to report a suspicious outbreak that occurred in a surgical intensive care unit in 2015, and to outline the infection control measures adopted thereafter.MethodsReview of the health care-associated infection data regarding B cepacia via the surveillance system, hospital information system, electronic medical records, and laboratory information system together with the outbreak investigation was managed by the health care-associated infection control team.ResultsDuring June 1-14, 2015, 4 cases of ventilator-associated pneumonia (VAP) were identified; B cepacia was isolated from endotracheal aspirate samples. On June 16, 120 environmental samples were collected and analyzed for microbiologic differentiation. Thirteen strains of B cepacia were prominently found in the expiratory blocks of ventilators, revealing the biocontamination source. After chemical disinfection without damaging ventilator components, repeat microbiologic testing of random ventilator samples yielded negative results until July 30, 2015. Retrospective data showed that isolation rates of B cepacia strains had increased since 2014. Although the resistance phenotype of these strains varied slightly, they exhibited similar patterns of antibiotic susceptibility.ConclusionsRoutine cleaning and disinfection of ventilators, in addition to an intervention bundle, should form part of an integrated VAP prevention and management approach.