Burkholderia cepacia complex is a group of potential nosocomial pathogens often linked to contaminated water. We report on a cluster of 8 B.cepacia complex infections in cardiothoracic ICU patients attributed to contaminated ECMO water heaters.
In December 2020, we identified an increase in B.cepacia complex infections in the cardiothoracic ICU at Brigham and Women's Hospital. We sought commonalities, sequenced isolates, obtained environmental specimens, and enacted mitigation measures.
Whole genome sequencing of 13 B.cepacia complex clinical specimens between November 2020-February 2021 identified 6 clonally related isolates, speciated as Burkholderia contaminans. All 6 occurred in patients on ECMO. Microbiology review identified two additional B.contaminans cases from June 2020, including one ECMO patient, that may have been cluster-related as well. All 8 definite/probable cluster cases required treatment; 3 died and 3 developed recurrent infections. After ECMO was identified as the major commonality, all 9 of the hospital's ECMO water heaters were cultured; all grew B.contaminans. Air sampling adjacent to the water heaters was culture-negative. Water heater touch screens were culture-positive for B.contaminans. The sink drain in the ECMO heater reprocessing room also grew clonal B.contaminans. Observations of reprocessing revealed opportunities for cross-contamination between devices via splash from the contaminated sink. The cluster was aborted by removing all water heaters from clinical service.
We identified a cluster of 8 B.cepacia complex infections associated with contaminated ECMO water heaters. This cluster underscores the potential risks associated with water-based ECMO heaters and, more broadly, water-based care for vulnerable patients.