UPDATE: LTC and HCP Notification of Recent Burkholderia Infections

​Message Details
Date Sent: 10/05/2016 01:14 PM EDT
Sender: Michigan Health Alert Network
Subject: UPDATE: LTC and HCP Notification of Recent Burkholderia Infections

Message:

Additional cases have now been identified in several other states including: Delaware, New Jersey, New York, Pennsylvania. The majority of these cases are also in patients residing at long-term care or rehabilitation facilities and were receiving IV fluids and/or antibiotics through central venous catheters.

Contaminated prefilled saline flush syringes manufactured by Nurse Assist, Haltom City, TX, have been implicated as the source. Nurse Assist is therefore performing a voluntary recall and removal of all its prefilled saline flush syringes. The PA Department of Health Bureau of Laboratories performed testing of Nurse Assist saline flush syringes that were obtained from a PA long-term care facility which reported cases; all unopened syringes tested were found to have been contaminated with B. cepacia. Additional laboratory testing of Nurse Assist flush syringes from affected facilities is ongoing. The Centers for Disease Control and Prevention and the U.S. Food and Drug Administration will be facilitating comparisons of isolates from product samples and patient isolates.

Facilities and all other users of Nurse Assist prefilled saline flush syringes are strongly encouraged to sequester and stop using any remaining product in their possession. If you identify any cases of B. cepacia bloodstream infections among patients receiving these products with onset since August 1, 2016, please notify your local or state health authority

---------------------- Original Message ----------------------
CDC recently distributed the following notification.  The Maryland Department of Health and Mental Hygiene has been notified of 7 laboratory-confirmed cases and 1 suspect case of Burkholderia cepacia bloodstream infections among patients residing at a skilled nursing facility/rehabilitation center. Earliest identification of B. cepaciafrom blood cultures occurred on September 10, 2016. All patients were receiving long-term intravenous antibiotic therapy through central venous catheters, the majority of which were PICC lines. Some of the antibiotics may have been reconstituted or compounded at a regional pharmacy that services long-term care facilities, including facilities in other states. No obvious infection control breaches were identified at the skilled nursing facility.

Additional cases have been identified in 2 other states. The majority of those cases are also in patients residing at long-term care or rehabilitation facilities and were receiving IV fluids and/or antibiotics through central venous catheters.
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Please notify Noreen Mollon (mollonn@michigan.gov or 517-284-4946) of any clusters of B. cepacia blood stream infections among patients receiving intravenous antibiotics in similar settings with onset since August 1, 2016.