Ralstonia mannitolilytica infections in an oncologic day ward: Description of a cluster among high-risk patients

C. Lucarelli, E.G. Di Domenico, L. Toma, D. Bracco, G. Prignano, M. Fortunati, L. Pelagalli, F. Ensoli, P. Pezzotti, A. Garc�a-Fern�ndez, A. Pantosti, L. Ingrosso

Research output: Contribution to journalArticle

Abstract

Background: Ralstonia spp, an environmental microorganism, has been occasionally associated with healthcare infections. The aim of this study was to investigate an outbreak caused by Ralstonia mannitolilytica in oncology patients. Methods: Case definition: Oncology outpatients attending a day ward, with positive blood and/or central venous catheter (CVC) culture for Ralstonia spp from September 2013 - June 2014. We analysed medical records, procedures and environmental samples. R. mannitolilytica was identified by 16S rRNA sequencing, and typed by Pulsed Field Gel Electrophoresis (PFGE); resistance to carbapenemes was investigated by phenotypic and molecular methods. Results: The patients (N=22) had different malignancies and received different therapy; all had a CVC and 16 patients presented chills and/or fever. R. mannitolilytica was isolated from both blood and CVC (n=12) or only blood (n=6) or CVC tips (n=4). The isolates had indistinguishable PFGE profile, and showed resistance to carbapenems. All the isolates were negative for carbapenemase genes while phenotypic tests suggests the presence of an AmpC β-lactamase activity,responsible for carbapenem resistance. All patients had had CVC flushed with saline to keep the venous access pervious or before receiving chemotherapy at various times before the onset of symptoms. After the first four cases occurred, the multi-dose saline bottles used for CVC flushing were replaced with single-dose vials; environmental samples were negative for R. mannitolilytica. Conclusions: Although the source of R. mannitolilytica remains unidentified, CVC flushing with contaminated saline solution seems to be the most likely origin of R. mannitolilytica CVC colonization and subsequent infections. In order to prevent similar outbreaks we recommend removal of any CVC that is no longer necessary and the use of single-dose solutions for any parenteral treatment of oncology patients. � 2017 The Author(s).
Original languageEnglish
JournalAntimicrobial Resistance and Infection Control
Volume6
Issue number1
DOIs
Publication statusPublished - 2017

Fingerprint

Ralstonia
Central Venous Catheters
Infection
Carbapenems
Pulsed Field Gel Electrophoresis
Disease Outbreaks
Chills
Cross Infection
Sodium Chloride
Medical Records
Fever
Outpatients

Keywords

  • Carbapenem resistance
  • Central venous catheter
  • Oncologic patients
  • Outbreak
  • Ralstonia mannitolilytica
  • beta lactamase AmpC
  • carbapenem
  • RNA 16S
  • adult
  • aged
  • antibiotic resistance
  • Article
  • bacterial colonization
  • bacterium identification
  • bacterium isolation
  • chill
  • clinical article
  • controlled study
  • enzyme activity
  • female
  • fever
  • Gram negative infection
  • high risk patient
  • human
  • male
  • middle aged
  • nonhuman
  • oncology
  • phenotype
  • pulsed field gel electrophoresis
  • Ralstonia
  • Ralstonia mannitolilytica infection
  • RNA sequence
  • very elderly
  • ward

Cite this

@article{496fadcca6b843b189d8be84c0828a79,
title = "Ralstonia mannitolilytica infections in an oncologic day ward: Description of a cluster among high-risk patients",
abstract = "Background: Ralstonia spp, an environmental microorganism, has been occasionally associated with healthcare infections. The aim of this study was to investigate an outbreak caused by Ralstonia mannitolilytica in oncology patients. Methods: Case definition: Oncology outpatients attending a day ward, with positive blood and/or central venous catheter (CVC) culture for Ralstonia spp from September 2013 - June 2014. We analysed medical records, procedures and environmental samples. R. mannitolilytica was identified by 16S rRNA sequencing, and typed by Pulsed Field Gel Electrophoresis (PFGE); resistance to carbapenemes was investigated by phenotypic and molecular methods. Results: The patients (N=22) had different malignancies and received different therapy; all had a CVC and 16 patients presented chills and/or fever. R. mannitolilytica was isolated from both blood and CVC (n=12) or only blood (n=6) or CVC tips (n=4). The isolates had indistinguishable PFGE profile, and showed resistance to carbapenems. All the isolates were negative for carbapenemase genes while phenotypic tests suggests the presence of an AmpC β-lactamase activity,responsible for carbapenem resistance. All patients had had CVC flushed with saline to keep the venous access pervious or before receiving chemotherapy at various times before the onset of symptoms. After the first four cases occurred, the multi-dose saline bottles used for CVC flushing were replaced with single-dose vials; environmental samples were negative for R. mannitolilytica. Conclusions: Although the source of R. mannitolilytica remains unidentified, CVC flushing with contaminated saline solution seems to be the most likely origin of R. mannitolilytica CVC colonization and subsequent infections. In order to prevent similar outbreaks we recommend removal of any CVC that is no longer necessary and the use of single-dose solutions for any parenteral treatment of oncology patients. {\"i}¿½ 2017 The Author(s).",
keywords = "Carbapenem resistance, Central venous catheter, Oncologic patients, Outbreak, Ralstonia mannitolilytica, beta lactamase AmpC, carbapenem, RNA 16S, adult, aged, antibiotic resistance, Article, bacterial colonization, bacterium identification, bacterium isolation, chill, clinical article, controlled study, enzyme activity, female, fever, Gram negative infection, high risk patient, human, male, middle aged, nonhuman, oncology, phenotype, pulsed field gel electrophoresis, Ralstonia, Ralstonia mannitolilytica infection, RNA sequence, very elderly, ward",
author = "C. Lucarelli and {Di Domenico}, E.G. and L. Toma and D. Bracco and G. Prignano and M. Fortunati and L. Pelagalli and F. Ensoli and P. Pezzotti and A. Garc{\"i}¿½a-Fern{\"i}¿½ndez and A. Pantosti and L. Ingrosso",
note = "Export Date: 10 April 2018 Correspondence Address: Lucarelli, C.; European Centre for Disease Prevention and Control, (ECDC), European Program for Public Health Microbiology Training (EUPHEM)Sweden; email: claudia.lucarelli@iss.it Chemicals/CAS: carbapenem, 83200-96-8 References: Ryan, M.P., Adley, C.C., Ralstonia spp.: emerging global opportunistic pathogens (2014) Eur J Clin Microbiol Infect Dis, 33 (3), pp. 291-304; Gr{\"i}¿½bner, S., Heeg, P., Autenrieth, I.B., Schulte, B., Monoclonal outbreak of catheter-related bacteraemia by Ralstonia mannitolilytica on two haemato-oncology wards (2007) J Infect, 55 (6), pp. 539-544; Mikulska, M., Durando, P., Molinari, M.P., Alberti, M., Del Bono, V., Dominietto, A., Outbreak of Ralstonia pickettii bacteraemia in patients with haematological malignancies and haematopoietic stem cell transplant recipients (2009) J Hosp Infect, 72 (2), pp. 187-188; Daxboeck, F., Stadler, M., Assadian, O., Marko, E., Hirschl, A.M., Koller, W., Characterization of clinically isolated Ralstonia mannitolilytica strains using random amplification of polymorphic DNA (RAPD) typing and antimicrobial sensitivity, and comparison of the classification efficacy of phenotypic and genotypic assays (2005) J Med Microbiol, 54, pp. 55-61; Ann, H.M., An unusual case of bacterial meningitis caused by Burkholderia pickettii (1998) Clin Microbiol Newsl, pp. 102-103; Bonatti, H., Stelzmueller, I., Laimer, I., Obwegeser, A., Ralstonia pickettii meningitis in a child with hydrocephalus (2009) Eur J Pediatr Surg, 19 (5), pp. 341-342; Marroni, M., Pasticci, M.B., Pantosti, A., Colozza, M.A., Stagni, G., Tonato, M., Outbreak of infusion-related septicemia by Ralstonia pickettii in the Oncology Department (2003) Tumori, 89 (5), pp. 575-576; Weist, K., Stolze, H., Sohr, D., Wickmann, L., Liebeskind, A.K., R{\"i}¿½den, H., P14.03 Ralstonia pickettii septicemia in pediatric oncology patients associated with the use of contaminated heparin-saline-solution (2006) J Hosp Infect, 64, p. 74; Pasticci, M.B., Baldelli, F., Camilli, R., Cardinali, G., Colozza, A., Marroni, M., Pulsed field gel electrophoresis and random amplified polymorphic DNA molecular characterization of Ralstonia pickettii isolates from patients with nosocomial central venous catheter related bacteremia (2005) New Microbiol, 28 (2), pp. 145-149; Enoch, D.A., Birkett, C.I., Ludlam, H.A., Non-fermentative Gram-negative bacteria (2007) Int J Antimicrob Agents, 29, pp. 33-41; McGowan, J.E., Resistance in nonfermenting gram-negative bacteria: multidrug resistance to the maximum (2006) Am J Med, 119 (6), pp. 29-36; Ryan, M.P., Pembroke, J.T., Adley, C.C., Differentiating the growing nosocomial infectious threats Ralstonia pickettii and Ralstonia insidiosa (2011) Eur J Clin Microbiol Infect Dis, 30 (10), pp. 1245-1247; De Baere, T., Steyaert, S., Wauters, G., Des Vos, P., Goris, J., Coenye, T., Classification of Ralstonia pickettii biovar 3/'thomasii' strains (Pickett 1994) and of new isolates related to nosocomial recurrent meningitis as Ralstonia mannitolytica sp. nov (2001) Int J Syst Evol Microbiol, 51, pp. 547-558; Moreira, B.M., Leobons, M.B., Pellegrino, F.L., Santos, M., Teixeira, L.M., de Andrade, M.E., Sampaio, J.L., Pessoa-Silva, C.L., Ralstonia pickettii and Burkholderia cepacia complex bloodstream infections related to infusion of contaminated water for injection (2005) J Hosp Infect, 60 (1), pp. 51-55; Zhang, L., Morrison, M., Rickard, C.M., Draft Genome Sequence of Ralstonia pickettii AU12-08 (2014) Isolated from an Intravascular Catheter in Australia, 2 (1). , vGenome Announc; Eilmus, S., Heil, M., Bacterial associates of arboreal ants and their putative functions in an obligate ant-plant mutualism (2009) Appl Environ Microbiol, 75 (13), pp. 4324-4332; Suzuki, M., Nishio, H., Asagoe, K., Kida, K., Suzuki, S., Matsui, M., Genome Sequence of a Carbapenem-Resistant Strain of Ralstonia mannitolilytica (2015) Genome Announc, 3 (3); Poirel, L., Walsh, T.R., Cuvillier, V., Nordmann, P., Multiplex PCR for detection of acquired carbapenemase genes (2011) Diagn Microbiol Infect Dis, 70 (1), pp. 119-123; Raveh, D., Simhon, A., Gimmon, Z., Sacks, T., Shapiro, M., Infections caused by Pseudomonas pickettii in association with permanent indwelling intravenous devices: four cases and a review (1993) Clin Infect Dis, 17 (5), pp. 877-880; Donlan, R.M., Biofilms and device-associated infections (2001) Emerg Infect Dis, 7 (2), pp. 277-281; Hu, J.Y., Fan, Y., Lin, Y.H., Zhang, H.B., Ong, S.L., Dong, N., Microbial diversity and prevalence of virulent pathogens in biofilms developed in a water reclamation system (2003) Res Microbiol, 154 (9), pp. 623-629; Kang, Y., Liu, H., Genin, S., Schell, M.A., Denny, T.P., Ralstonia solanacearum requires type 4 pili to adhere to multiple surfaces and for natural transformation and virulence (2002) Mol Microbiol, 46 (2), pp. 427-437; Zhang, L., Gowardman, J., Morrison, M., Krause, L., Playford, E.G., Rickard, C.M., Molecular investigation of bacterial communities on intravascular catheters: no longer just Staphylococcus (2014) Eur J Clin Microbiol Infect Dis, 33 (7), pp. 1189-1198; Di Domenico, E.G., Toma, L., Christian, C., Ascenzioni, F., Sperduti, I., Prignano, G., Development of an in vitro Assay, Based on the BioFilm Ring Test{\"i}¿½, for Rapid Profiling of Biofilm-Growing Bacteria (2016) Front Microbiol, 7, p. 1429; Block, C., Ergaz-Shaltiel, Z., Valinsky, L., Temper, V., Hidalgo-Grass, C., Minster, N., D{\"i}¿½j{\"i}¿½ vu: Ralstonia mannitolilytica infection associated with a humidifying respiratory therapy device, Israel, June to July 2011 (2013) Euro Surveill, 18 (18), p. 20471; Jhung, M.A., Sunenshine, R.H., Noble-Wang, J., Coffin, S.E., St John, K., Lewis, F.M., A national outbreak of Ralstonia mannitolilytica associated with use of a contaminated oxygen-delivery device among pediatric patients (2007) Pediatrics, 119 (6), pp. 1061-1068; Pan, A., Dolcetti, L., Barosi, C., Catenazzi, P., Ceruti, T., Ferrari, L., Magri, S., An outbreak of Serratia marcescens bloodstream infections associated with misuse of drug vials in a surgical ward (2006) Infect Control Hosp Epidemiol, 27 (1), pp. 79-82; Nakashima, A.K., Highsmith, A.K., Martone, W.J., Survival of Serratia marcescens in benzalkonium chloride and in multiple-dose medication vials: relationship to epidemic septic arthritis (1987) J Clin Microbiol, 25 (6), pp. 1019-1021; Harbarth, S., Sudre, P., Dharan, S., Cadenas, M., Pittet, D., Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices (1999) Infect Control Hosp Epidemiol, 20 (9), pp. 598-603; Muller, A.E., Huisman, I., Roos, P.J., Rietveld, A.P., Klein, J., Harbers, J.B., Dorresteijn, J.J., Outbreak of severe sepsis due to contaminated propofol: lessons to learn (2010) J Hosp Infect, 76 (3), pp. 225-230; (2014) The Joint Commission, (52). , https://www.jointcommission.org/assets/1/6/SEA_52.pdf, June 16 Accessed 9 Jan 2017; (2017), https://www.cdc.gov/injectionsafety/cdcposition-singleusevial.html, Accessed 9 Jan; Dotis, J., Printza, N., Orfanou, A., Papathanasiou, E., Papachristou, F., Peritonitis due to Ralstonia mannitolilytica in a pediatric peritoneal dialysis patient (2012) New Microbiol, 35 (4), pp. 503-506; Maroye, P., Doermann, H.P., Rogues, A.M., Gachie, J.P., M{\"i}¿½graud, F., Investigation of an outbreak of Ralstonia pickettii in a paediatric hospital by RAPD (2000) J Hosp Infect, 44 (4), pp. 267-272; Vaneechoutte, M., De Baere, T., Wauters, G., Steyaert, S., Claeys, G., Vogelaers, D., One case each of recurrent meningitis and hemoperitoneum infection with Ralstonia mannitolilytica (2001) J Clin Microbiol, 39 (12), pp. 4588-4590; Nordmann, P., Poirel, L., Kubina, M., Casetta, A., Naas, T., Biochemical-genetic characterization and distribution of OXA-22, a chromosomal and inducible class D beta-lactamase from Ralstonia (Pseudomonas) pickettii (2000) Antimicrob Agents Chemother, 44 (8), pp. 2201-2204; Girlich, D., Naas, T., Nordmann, P., OXA-60, a chromosomal, inducible, and imipenem-hydrolyzing class D beta-lactamase from Ralstonia pickettii (2004) Antimicrob Agents Chemother, 48 (11), pp. 4217-4225; Wozniak, A., Villagra, N.A., Undabarrena, A., Gallardo, N., Keller, N., Moraga, M., Porin alterations present in non-carbapenemase-producing Enterobacteriaceae with high and intermediate levels of carbapenem resistance in Chile (2012) J Med Microbiol, 61, pp. 1270-1279",
year = "2017",
doi = "10.1186/s13756-017-0178-z",
language = "English",
volume = "6",
journal = "Antimicrobial Resistance and Infection Control",
issn = "2047-2994",
publisher = "BioMed Central Ltd.",
number = "1",

}

TY - JOUR

T1 - Ralstonia mannitolilytica infections in an oncologic day ward: Description of a cluster among high-risk patients

AU - Lucarelli, C.

AU - Di Domenico, E.G.

AU - Toma, L.

AU - Bracco, D.

AU - Prignano, G.

AU - Fortunati, M.

AU - Pelagalli, L.

AU - Ensoli, F.

AU - Pezzotti, P.

AU - Garc�a-Fern�ndez, A.

AU - Pantosti, A.

AU - Ingrosso, L.

N1 - Export Date: 10 April 2018 Correspondence Address: Lucarelli, C.; European Centre for Disease Prevention and Control, (ECDC), European Program for Public Health Microbiology Training (EUPHEM)Sweden; email: claudia.lucarelli@iss.it Chemicals/CAS: carbapenem, 83200-96-8 References: Ryan, M.P., Adley, C.C., Ralstonia spp.: emerging global opportunistic pathogens (2014) Eur J Clin Microbiol Infect Dis, 33 (3), pp. 291-304; Gr�bner, S., Heeg, P., Autenrieth, I.B., Schulte, B., Monoclonal outbreak of catheter-related bacteraemia by Ralstonia mannitolilytica on two haemato-oncology wards (2007) J Infect, 55 (6), pp. 539-544; Mikulska, M., Durando, P., Molinari, M.P., Alberti, M., Del Bono, V., Dominietto, A., Outbreak of Ralstonia pickettii bacteraemia in patients with haematological malignancies and haematopoietic stem cell transplant recipients (2009) J Hosp Infect, 72 (2), pp. 187-188; Daxboeck, F., Stadler, M., Assadian, O., Marko, E., Hirschl, A.M., Koller, W., Characterization of clinically isolated Ralstonia mannitolilytica strains using random amplification of polymorphic DNA (RAPD) typing and antimicrobial sensitivity, and comparison of the classification efficacy of phenotypic and genotypic assays (2005) J Med Microbiol, 54, pp. 55-61; Ann, H.M., An unusual case of bacterial meningitis caused by Burkholderia pickettii (1998) Clin Microbiol Newsl, pp. 102-103; Bonatti, H., Stelzmueller, I., Laimer, I., Obwegeser, A., Ralstonia pickettii meningitis in a child with hydrocephalus (2009) Eur J Pediatr Surg, 19 (5), pp. 341-342; Marroni, M., Pasticci, M.B., Pantosti, A., Colozza, M.A., Stagni, G., Tonato, M., Outbreak of infusion-related septicemia by Ralstonia pickettii in the Oncology Department (2003) Tumori, 89 (5), pp. 575-576; Weist, K., Stolze, H., Sohr, D., Wickmann, L., Liebeskind, A.K., R�den, H., P14.03 Ralstonia pickettii septicemia in pediatric oncology patients associated with the use of contaminated heparin-saline-solution (2006) J Hosp Infect, 64, p. 74; Pasticci, M.B., Baldelli, F., Camilli, R., Cardinali, G., Colozza, A., Marroni, M., Pulsed field gel electrophoresis and random amplified polymorphic DNA molecular characterization of Ralstonia pickettii isolates from patients with nosocomial central venous catheter related bacteremia (2005) New Microbiol, 28 (2), pp. 145-149; Enoch, D.A., Birkett, C.I., Ludlam, H.A., Non-fermentative Gram-negative bacteria (2007) Int J Antimicrob Agents, 29, pp. 33-41; McGowan, J.E., Resistance in nonfermenting gram-negative bacteria: multidrug resistance to the maximum (2006) Am J Med, 119 (6), pp. 29-36; Ryan, M.P., Pembroke, J.T., Adley, C.C., Differentiating the growing nosocomial infectious threats Ralstonia pickettii and Ralstonia insidiosa (2011) Eur J Clin Microbiol Infect Dis, 30 (10), pp. 1245-1247; De Baere, T., Steyaert, S., Wauters, G., Des Vos, P., Goris, J., Coenye, T., Classification of Ralstonia pickettii biovar 3/'thomasii' strains (Pickett 1994) and of new isolates related to nosocomial recurrent meningitis as Ralstonia mannitolytica sp. nov (2001) Int J Syst Evol Microbiol, 51, pp. 547-558; Moreira, B.M., Leobons, M.B., Pellegrino, F.L., Santos, M., Teixeira, L.M., de Andrade, M.E., Sampaio, J.L., Pessoa-Silva, C.L., Ralstonia pickettii and Burkholderia cepacia complex bloodstream infections related to infusion of contaminated water for injection (2005) J Hosp Infect, 60 (1), pp. 51-55; Zhang, L., Morrison, M., Rickard, C.M., Draft Genome Sequence of Ralstonia pickettii AU12-08 (2014) Isolated from an Intravascular Catheter in Australia, 2 (1). , vGenome Announc; Eilmus, S., Heil, M., Bacterial associates of arboreal ants and their putative functions in an obligate ant-plant mutualism (2009) Appl Environ Microbiol, 75 (13), pp. 4324-4332; Suzuki, M., Nishio, H., Asagoe, K., Kida, K., Suzuki, S., Matsui, M., Genome Sequence of a Carbapenem-Resistant Strain of Ralstonia mannitolilytica (2015) Genome Announc, 3 (3); Poirel, L., Walsh, T.R., Cuvillier, V., Nordmann, P., Multiplex PCR for detection of acquired carbapenemase genes (2011) Diagn Microbiol Infect Dis, 70 (1), pp. 119-123; Raveh, D., Simhon, A., Gimmon, Z., Sacks, T., Shapiro, M., Infections caused by Pseudomonas pickettii in association with permanent indwelling intravenous devices: four cases and a review (1993) Clin Infect Dis, 17 (5), pp. 877-880; Donlan, R.M., Biofilms and device-associated infections (2001) Emerg Infect Dis, 7 (2), pp. 277-281; Hu, J.Y., Fan, Y., Lin, Y.H., Zhang, H.B., Ong, S.L., Dong, N., Microbial diversity and prevalence of virulent pathogens in biofilms developed in a water reclamation system (2003) Res Microbiol, 154 (9), pp. 623-629; Kang, Y., Liu, H., Genin, S., Schell, M.A., Denny, T.P., Ralstonia solanacearum requires type 4 pili to adhere to multiple surfaces and for natural transformation and virulence (2002) Mol Microbiol, 46 (2), pp. 427-437; Zhang, L., Gowardman, J., Morrison, M., Krause, L., Playford, E.G., Rickard, C.M., Molecular investigation of bacterial communities on intravascular catheters: no longer just Staphylococcus (2014) Eur J Clin Microbiol Infect Dis, 33 (7), pp. 1189-1198; Di Domenico, E.G., Toma, L., Christian, C., Ascenzioni, F., Sperduti, I., Prignano, G., Development of an in vitro Assay, Based on the BioFilm Ring Test�, for Rapid Profiling of Biofilm-Growing Bacteria (2016) Front Microbiol, 7, p. 1429; Block, C., Ergaz-Shaltiel, Z., Valinsky, L., Temper, V., Hidalgo-Grass, C., Minster, N., D�j� vu: Ralstonia mannitolilytica infection associated with a humidifying respiratory therapy device, Israel, June to July 2011 (2013) Euro Surveill, 18 (18), p. 20471; Jhung, M.A., Sunenshine, R.H., Noble-Wang, J., Coffin, S.E., St John, K., Lewis, F.M., A national outbreak of Ralstonia mannitolilytica associated with use of a contaminated oxygen-delivery device among pediatric patients (2007) Pediatrics, 119 (6), pp. 1061-1068; Pan, A., Dolcetti, L., Barosi, C., Catenazzi, P., Ceruti, T., Ferrari, L., Magri, S., An outbreak of Serratia marcescens bloodstream infections associated with misuse of drug vials in a surgical ward (2006) Infect Control Hosp Epidemiol, 27 (1), pp. 79-82; Nakashima, A.K., Highsmith, A.K., Martone, W.J., Survival of Serratia marcescens in benzalkonium chloride and in multiple-dose medication vials: relationship to epidemic septic arthritis (1987) J Clin Microbiol, 25 (6), pp. 1019-1021; Harbarth, S., Sudre, P., Dharan, S., Cadenas, M., Pittet, D., Outbreak of Enterobacter cloacae related to understaffing, overcrowding, and poor hygiene practices (1999) Infect Control Hosp Epidemiol, 20 (9), pp. 598-603; Muller, A.E., Huisman, I., Roos, P.J., Rietveld, A.P., Klein, J., Harbers, J.B., Dorresteijn, J.J., Outbreak of severe sepsis due to contaminated propofol: lessons to learn (2010) J Hosp Infect, 76 (3), pp. 225-230; (2014) The Joint Commission, (52). , https://www.jointcommission.org/assets/1/6/SEA_52.pdf, June 16 Accessed 9 Jan 2017; (2017), https://www.cdc.gov/injectionsafety/cdcposition-singleusevial.html, Accessed 9 Jan; Dotis, J., Printza, N., Orfanou, A., Papathanasiou, E., Papachristou, F., Peritonitis due to Ralstonia mannitolilytica in a pediatric peritoneal dialysis patient (2012) New Microbiol, 35 (4), pp. 503-506; Maroye, P., Doermann, H.P., Rogues, A.M., Gachie, J.P., M�graud, F., Investigation of an outbreak of Ralstonia pickettii in a paediatric hospital by RAPD (2000) J Hosp Infect, 44 (4), pp. 267-272; Vaneechoutte, M., De Baere, T., Wauters, G., Steyaert, S., Claeys, G., Vogelaers, D., One case each of recurrent meningitis and hemoperitoneum infection with Ralstonia mannitolilytica (2001) J Clin Microbiol, 39 (12), pp. 4588-4590; Nordmann, P., Poirel, L., Kubina, M., Casetta, A., Naas, T., Biochemical-genetic characterization and distribution of OXA-22, a chromosomal and inducible class D beta-lactamase from Ralstonia (Pseudomonas) pickettii (2000) Antimicrob Agents Chemother, 44 (8), pp. 2201-2204; Girlich, D., Naas, T., Nordmann, P., OXA-60, a chromosomal, inducible, and imipenem-hydrolyzing class D beta-lactamase from Ralstonia pickettii (2004) Antimicrob Agents Chemother, 48 (11), pp. 4217-4225; Wozniak, A., Villagra, N.A., Undabarrena, A., Gallardo, N., Keller, N., Moraga, M., Porin alterations present in non-carbapenemase-producing Enterobacteriaceae with high and intermediate levels of carbapenem resistance in Chile (2012) J Med Microbiol, 61, pp. 1270-1279

PY - 2017

Y1 - 2017

N2 - Background: Ralstonia spp, an environmental microorganism, has been occasionally associated with healthcare infections. The aim of this study was to investigate an outbreak caused by Ralstonia mannitolilytica in oncology patients. Methods: Case definition: Oncology outpatients attending a day ward, with positive blood and/or central venous catheter (CVC) culture for Ralstonia spp from September 2013 - June 2014. We analysed medical records, procedures and environmental samples. R. mannitolilytica was identified by 16S rRNA sequencing, and typed by Pulsed Field Gel Electrophoresis (PFGE); resistance to carbapenemes was investigated by phenotypic and molecular methods. Results: The patients (N=22) had different malignancies and received different therapy; all had a CVC and 16 patients presented chills and/or fever. R. mannitolilytica was isolated from both blood and CVC (n=12) or only blood (n=6) or CVC tips (n=4). The isolates had indistinguishable PFGE profile, and showed resistance to carbapenems. All the isolates were negative for carbapenemase genes while phenotypic tests suggests the presence of an AmpC β-lactamase activity,responsible for carbapenem resistance. All patients had had CVC flushed with saline to keep the venous access pervious or before receiving chemotherapy at various times before the onset of symptoms. After the first four cases occurred, the multi-dose saline bottles used for CVC flushing were replaced with single-dose vials; environmental samples were negative for R. mannitolilytica. Conclusions: Although the source of R. mannitolilytica remains unidentified, CVC flushing with contaminated saline solution seems to be the most likely origin of R. mannitolilytica CVC colonization and subsequent infections. In order to prevent similar outbreaks we recommend removal of any CVC that is no longer necessary and the use of single-dose solutions for any parenteral treatment of oncology patients. � 2017 The Author(s).

AB - Background: Ralstonia spp, an environmental microorganism, has been occasionally associated with healthcare infections. The aim of this study was to investigate an outbreak caused by Ralstonia mannitolilytica in oncology patients. Methods: Case definition: Oncology outpatients attending a day ward, with positive blood and/or central venous catheter (CVC) culture for Ralstonia spp from September 2013 - June 2014. We analysed medical records, procedures and environmental samples. R. mannitolilytica was identified by 16S rRNA sequencing, and typed by Pulsed Field Gel Electrophoresis (PFGE); resistance to carbapenemes was investigated by phenotypic and molecular methods. Results: The patients (N=22) had different malignancies and received different therapy; all had a CVC and 16 patients presented chills and/or fever. R. mannitolilytica was isolated from both blood and CVC (n=12) or only blood (n=6) or CVC tips (n=4). The isolates had indistinguishable PFGE profile, and showed resistance to carbapenems. All the isolates were negative for carbapenemase genes while phenotypic tests suggests the presence of an AmpC β-lactamase activity,responsible for carbapenem resistance. All patients had had CVC flushed with saline to keep the venous access pervious or before receiving chemotherapy at various times before the onset of symptoms. After the first four cases occurred, the multi-dose saline bottles used for CVC flushing were replaced with single-dose vials; environmental samples were negative for R. mannitolilytica. Conclusions: Although the source of R. mannitolilytica remains unidentified, CVC flushing with contaminated saline solution seems to be the most likely origin of R. mannitolilytica CVC colonization and subsequent infections. In order to prevent similar outbreaks we recommend removal of any CVC that is no longer necessary and the use of single-dose solutions for any parenteral treatment of oncology patients. � 2017 The Author(s).

KW - Carbapenem resistance

KW - Central venous catheter

KW - Oncologic patients

KW - Outbreak

KW - Ralstonia mannitolilytica

KW - beta lactamase AmpC

KW - carbapenem

KW - RNA 16S

KW - adult

KW - aged

KW - antibiotic resistance

KW - Article

KW - bacterial colonization

KW - bacterium identification

KW - bacterium isolation

KW - chill

KW - clinical article

KW - controlled study

KW - enzyme activity

KW - female

KW - fever

KW - Gram negative infection

KW - high risk patient

KW - human

KW - male

KW - middle aged

KW - nonhuman

KW - oncology

KW - phenotype

KW - pulsed field gel electrophoresis

KW - Ralstonia

KW - Ralstonia mannitolilytica infection

KW - RNA sequence

KW - very elderly

KW - ward

U2 - 10.1186/s13756-017-0178-z

DO - 10.1186/s13756-017-0178-z

M3 - Article

VL - 6

JO - Antimicrobial Resistance and Infection Control

JF - Antimicrobial Resistance and Infection Control

SN - 2047-2994

IS - 1

ER -