Burkholderia cepacia Infections At A University Teaching Hospital In Lagos, Nigeria Oduyebo 0. 0., Ogunsola F. T. and Odugbemi T. 0. Department of Medical Mic,obiology and Parasitology, College of Medicine, University of Lagos, ldi·Araba Corresponding: 0.0. Oduyebo SUMMARY Twenty five isolates of B. cepacia, representing 1.4°/o of all isolates, were obtained at the M i c r o b i o I o g y Laboratory of a University Teaching Hospital in Lagos between January 1996 and December 1997. Identification of isolates was done using analytical profile index systems (Biomerieux, France) and sensitivity testing was by disc diffusion methods as recommended by the National Committee for Clinical Laboratory standards. Majority of these isolates (24 out of 25) were cultured from in-patients, with most isolates from specimens which came in from the paediatric wards. Eighteen (72%) of the 25 isolates were obtained from blood, 4 (16%) were from urine and the remaining isolates were from wound swab (1) and sputum ( 1 ). Five (27.8%) of the blood isolates were obtained from neonates with symptoms and signs of . septicaema, 8 (44.4%) from neonates without features of septicaemia while diagnosis of septicaemia was uncertain in the remaining 5 blood isolates also frorn neonates. Factors that appeared to predispose to infection included intravenous fluid administration, catheterisation and surgery. Twelve (48%) of the 25 isolates were found to produce beta-lactamase by starch paper technique. 8. cepacia showed reduced sensitivity IQ commonly used antibiotics like gentamicin (0%), and co-trlrnoxazcle (0%). Majority of the isolates were sensitive to nalidixic acid (64%), cefriaxone (56.5%) and ceftazidime (73.9%). 8. cepacia probably causes nosocomial infections in this environment. It may therefore be necessary to routinely carry out in-vitro antibiotic sensitivity testing for this organism in view ot its resistance to commonly used antibiotic agents, so that appropriate antibiotic therapy can be instituted. INTRODUCTION produces extracellular products like elastase, gelatinase haemolysin, protease and 'lipase, which are potential virulence factors8. Lipopolysaccharides and plasmids, including resistance plasmids have been isolated from the orqanlsrn" . Apart from these, 8. cepacia is ubiquitous in the environment because it is able to survive for long periods on environmental surfaces'. The ability to survive in hostile aqueous environment enables it to contaminate soaps, equipment and solutions like distilled water, disinfectants and injectable rnedicines"". It is therefore a common cause of hospital acquired infections like septicaemia/bacteremia, urinary tract infection, septic athritis and peritonitis and outbreaks ol these have been reported ,2.13. Recently, there was widespread concern over poor clinical outcome of respiratory tract infections in patients with cystic fibrosis due to resistance to antibiotics 14 • Cystic fibrosis is rare in this environment, and there has been no documentation of B.cep.acia infections. However. a preliminary report on glucose non-terrnentinq gram negative bacilli in Lagos University Teaching Hospital done between Jan. 1995 and June 1996 showed that 9% of all clinical isolates were 8. cepacia/. The isolates were obtained lrom wound swabs and urine but the study did not ascertain whether they caused infection or colonisation. Although colonisation of patients is usually more endemic in hospitals and occurs more frequently in patients with severe disease, observation have shown that 8 cepecie is transmissible indirectly between individuals, not only in hospitals and clinics, but also in social sertinqs such as conferences and camps 16• It is therefore considered necessary to 'establish the prevalence of 8. cepacia infections in our environments. Information on antibiotic susceptibility and beta lactamase production should also be useful since 8. cepacia has been found to harbour and transfer plasmids by conjugation 17• METHODOLOGY All bacteria isolated from urine, catheter tips, blood, cerebrospmal fluid, sputum, swabs pus and aspirates sent to the LUTH microbiology laboratory between January 1996 and December 1997 were subcultured on blood agar base (oxoid) supplemented with 7% human blood and MacConl, Isolation of 8. cepacia from intravenous fluid has also been previously reported in LUTH". In 1996, the contamination rates for in-use infusion in LUTH neonatal wards was iound to be 25.6% (100 of 390 infusions) and 8. cepacia accounted Jor 21.4% of the 140 organisms isolated 26 from the contaminated infusions. Other liquids or solutions, which have been implicated as sources of 8. cepacia in the hospital include 5-fluorouracil injections and ethacridine, lactate solutions". Eighteen (72%) of the isolates in this study were obtained from blood cultures which all came from the neonatal wards. Five (27 .8°/o) of the blood isolates were from patients with clinical features of septicaemia and 8. cepacia was also cultured from the intravenous fluid in two of these cases with exactly the same biotypes suggesting that the intravenous fluids were the source 9f the septicaemia12·11 • 10. The rote of B. cepacia in the disease process of another 5(27.8%) of the blood isolates was not clear because the patients had mulliple organisms, while the remaining 8 (44.4%) cases had no features of septicaemia and isolates were suspected to be contaminants. These findings are not surprising because 8. cepacia has been associated with bacteremia and pseudobacteremia 10• 12,:27,29.29•30 Four isolates were obtained from urine, three from catheterized in-patients and one from a pregnant 'Noman attending the antenatal clinic. Although 8. cepacia has been known to cause urinary tract infection10• 13, especially in patients who had genito-urinary surgery or instrumentation, Clinical features of UTI could not be confirmed in the patients in this study because they were Jost to follow up. However, despite the fact that all affected patients with UTI in this study were discharged without appropriate medication, it is likely that their infection will resolve spontaneously because previous studies have shown that once the catheter was removed (except in patients with renal calculi}, infection often subsided in patients with normal host defences". Chronic suppurative otitis media caused by 8. cepacia has been well documented"· This organism was isolated in pure culture from one patient with otitis media in this study and the inlection appeared to respond to the antibiotic to which the organism was sensitive in-vitro. The isolation of 8. cepacia in pure culture in this study from the wound swab ol a patient who had had abdominal surgery correlated with a previous report in which the organism was ultimately traced to a contaminated disinfectant". Unfortunately, the source of the infection in this study was not determined. Using API 20 NE to type all the 25 isolates, thirteen !,lgtype� were seen and the fifteen blood isolates from the same neonatal wards were distributed into ten biotypes suggesting that most isolates were probably not from the same source and therefore not epidemic strains. The few isolates that were of the same biotypes were cultured at different periods of time from specimens in different wards and probably just represented the endemic hospital strains. The most significant finding was that two isolates recovered from neonates with septicaemia had identical biotype with the two isolates from their intravenous fluid. This finding however may be confirmed by more reliable methods since phenotypic typing techniques have been proven to be less reliable and less sensitive than genotypic technlques=. The antimicrobial susceptibility pattern of 8. cepacia to various antibiotics showed resistance to the commonly used antibiotics like co-trirmoxazole and gentamicin. This is not surprising since B. cepacia, like Pseudomonas aeruginosa to which it is related, has been found to be intrinsically resistant to many antibioticsv-> including the penicillins. Nevertheless, sensitivity to ureidopenicillins like mezlocillin and piperacillin has been reported,3•35. None of the isolates was sensitive to gentamicin. This is worrisome because gentamicin is the usual drug of choice against gram negative bacilli infections in this environment. Resistance to aminoglycosides has been documented but there appears to be improved sensitivity when combined with temocillin". Co-trimoxazole is another drug used commonly in this environment as a first-line drug against infection. Even though susceptibility to co-trimoxazole has been documented both in-vivo and in-vitro'", only 2 (8°/o) isolates were sensitive in this study. Sixty four percent of the 25 isolates were sensitive to nalidixic acid. This suggests that the drug could probably be used to treat cystitis caused by 8. cepacia when in-vitro sensitivity has been confirmed. Other quinolones are however likely to be of more empiric usefulness as twenty (87%) of 23 isolates were found to be sensitive to ofloxacin. Ouinolones have been found useful in the treatment of B. cepacia infections although resistance to ciprofloxacin, which is the gold standard, has been recorded recently" . The high susceptibility rate obtained in this study is probably due to the fact that these drugs are very expensive and are not so readily prescribed in this environment. Only 23 out of 25 isolates were tested for sensitivity to the third generation cephalosporins. In this study, while 17 (73.9%) ol 23 isolates were sensitive to ceftazidime, 13 (56%) were sensitive to celtriaxone and 13 (59%) of 22 isolates to cefuroxine. The response of 8. cepacia to the third generation cephalosporins varied in different Journal of the Nigerian Infection Control Association - Vol. 3 No. 1 2000 13 Burkholdaria cepacia infections. reports. ln-vitro sensitivity was reported in some studies while clinical failures was recorded in others,3· 34. Resistance to thecephalospcrins has been associated with production of beta-lactamases= 40• 0. Twelve (48°lo) isolates were found to produce beta-lactamase using the starch paper technique in this study. These enzymes, which were reported in previous studies to be penicillinases and carbapenemases21 • 40 have been found to reduce the activities of penicillins, cephalosporins and carbapenems to which 8. cepacia have been found previously sensitive21 • "· B. cepacia should therefore not be immediately discarded as a contaminant in clinical specimens rather, it is necessary to attempt to identify to the species level as it is probably an important cause of nosocomial infection in LUTH. It is also necessary to carry out in-vitro antibiotic sensitivity testing in view of its resistance to commonly used antibiotic agents so that appropriate therapy can be instituted for infections caused by this organism. REFERENCES 1 . Burkholder WH. Sour Skin, a bacterial rot of onion bulb, Phytopathology 1950; 40: 1 1 5 - 1 1 7 . 2. Palleroni NJ, Kunisawa A, Contopoutou A, Doudoroff M. Nucleic acid homologies in the genus Psedomonas. Int J Syst Bacterial 1873; 2 3 : 333-339. 3. Gilligan PH. 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