Burkholderia cepacia 

Updated: Oct 25, 2018
Author: Syed Faisal Mahmood, MBBS; Chief Editor: Michael Stuart Bronze, MD 

Overview

Background

Burkholderia cepacia is an aerobic gram-negative bacillus found in various aquatic environments. B cepacia is an organism of low virulence and is a frequent colonizer of fluids used in the hospital (eg, irrigation solutions, intravenous fluids). B cepacia rarely causes infection in healthy hosts. Based on phenotypic and genotypic analyses, B cepacia is divided into 9 genomovars that constitute the B cepacia complex (BCC).

Pathophysiology

B cepacia is almost always a colonizing organism rather than an infecting organism, but it may be important when isolated from body fluids that are ordinarily sterile. The pathophysiology of B cepacia infection mirrors that of other nonfermentative aerobic gram-negative bacilli.

Epidemiology

Frequency

United States

B cepacia is ordinarily not a pathogen in the ambulatory setting, but it may colonize and/or infect the respiratory tract of patients with cystic fibrosis or bronchiectasis. B cepacia may also cause central venous catheter–related infections in patients with cancer and in those on hemodialysis. B cepacianosocomial pneumonia has rarely been reported, usually in patients treated with fluoroquinolones and ceftazidime. Skin and soft-tissue infections, surgical-wound infections, and genitourinary tract infections with B cepacia have also been reported.

According to the US Cystic Fibrosis Foundation’s 2016 National Patient Registry, 3% percent of all persons with cystic fibrosis were infected with B cepacia complex compared to 2.6% in 2012.[1]

International

B cepacia is generally not a pathogen in the ambulatory setting, but it may colonize and/or infect the respiratory tract of patients with cystic fibrosis or bronchiectasis.

Mortality/Morbidity

If an intravenous infusate contains high numbers of B cepacia, direct injection into the bloodstream may result in gram-negative bacteremia.

Mortality and morbidity is highest in those with impaired pulmonary function (eg, cystic fibrosis, bronchiectasis, chronic granulomatosis disease).

Disease severity (defined by the Simplified Acute Physiology Score II) and age are independent predictors of mortality.[2]

Malignancy and a higher SOFA score at onset of bacteremia are associated with high mortality rates.[3]

Race

Burkholderia has no racial predisposition.

Age

Burkholderia has no age predisposition.

Prognosis

Signs and symptoms of B cepacia infections are related to the organ system involved and are indistinguishable from infections with other pathogens.

 

Presentation

History

A history of the use of irrigant solutions that may have contained B cepacia is epidemiologically important.

Physical

Physical examination is referable to the organ system involved.

Causes

B cepacia is a nonfermentative, aerobic, gram-negative bacillus formerly classified as Pseudomonas. Unlike Pseudomonas aeruginosa, B cepacia is an organism of low virulence with a limited ability to cause infection in humans.

B cepacia survives and multiplies in aqueous hospital environments, where it may persist for long periods.[4]

Sources of B cepacia colonization include the following:

  • Personnel - Hands, antiseptic soaps, hand lotion[5]

  • Respiratory equipment and/or fluids - Respirator tubing condensate, ultrasonic nebulizers, inhalation medications

  • Intravenous lines and/or fluids - Intravenous solutions, central venous catheters

  • Pressure-monitoring devices - Pressure transducer fluids

  • Urine and/or fluids - Indwelling Foley catheters, urometers, irrigation solutions

Complications

Because B cepacia is normally a colonizer, no complications are expected.

 

DDx

Diagnostic Considerations

B cepacia recovered from blood cultures may represent infection, pseudoinfection, or actual infection from contaminated intravenous fluids (infusate-related).

Regard the recovery of B cepacia from the respiratory secretions or urine of catheterized patients as colonization until proven otherwise.

B cepacia is a common cause of catheter-associated bacteriuria in hospitalized patients. B cepacia commonly colonizes the urine and is potentially pathogenic only in individuals with impaired host defenses (eg, patients on steroids or those with diabetes, systemic lupus erythematosus [SLE], multiple myeloma, cirrhosis, or chronic granulomatous disease).

B cepacia is an extremely rare cause of nosocomial pneumonia. In ventilated patients with presumed nosocomial pneumonia who have fever, pulmonary infiltrates, and leukocytosis, B cepacia cultured from respiratory secretions generally represents colonization rather than infection.

Nosocomial infections caused by B cepacia include the following:

  • Catheter-associated bacteriuria - Indwelling urinary catheters
  • Intravenous line infections - Central venous catheters (CVCs)
  • Urosepsis - Following urinary tract instrumentation
  • Secondary bacteremia - Arterial monitoring devices
  • Pseudobacteremia - Contamination of blood during collection and/or processing of blood cultures

There have also been reports of B cepacia as a cause of endocarditis in individuals with drug addiction or prosthetic heart valves, endophthalmitis and subdural empyema, brain abscesses, and meningitis.[6, 7, 8, 9, 10, 11, 12]

 

Workup

Laboratory Studies

Culture B cepacia from body fluids.

Although B cepacia–positive cultures from nonsterile sites (eg, respiratory secretions, urine in the setting of Foley catheters) nearly always represent colonization, presence in sterile body fluids such as blood or CSF mandates consultation with an infectious disease specialist.

 

Treatment

Medical Care

Patient-to-patient spread of B cepacia may be minimized and/or prevented with effective infection-control measures.

Use Foley catheters only as long as necessary. If possible, avoid their use in compromised hosts predisposed to urinary tract infections (eg, patients with diabetes, SLE, multiple myeloma).

Preventing B cepacia colonization of respiratory secretions in intubated patients who are in ICUs and on broad-spectrum antibiotics is difficult.

Consultations

Consultation with an infectious disease specialist helps to differentiate B cepacia colonization from infection.

Prevention

Effective infection-control measures can minimize or limit the spread of B cepacia and other organisms in the ICU.

Recovered B cepacia should be considered a nonpathogen unless proven otherwise.

If B cepacia is recovered from several patients in the same area, sections of an ICU or ward can become the focus for further B cepacia colonizations within the hospital setting.

Appropriate isolation procedures rather than antimicrobial therapy should be used to control the spread of B cepacia colonization among patients.

 

Medication

Medication Summary

Because B cepacia is almost always a colonizer, antimicrobial treatment is unnecessary and may be harmful unless infection is proven.

B cepacia, as a non-aeruginosa pseudomonad, is usually resistant to aminoglycosides, antipseudomonal penicillins, and antipseudomonal third-generation cephalosporins and polymyxin B.[13]

B cepacia is often susceptible to trimethoprim plus sulfamethoxazole (TMP-SMX), cefepime, meropenem, minocycline, and tigecycline and has varying susceptibility to fluoroquinolones.

Antibiotics

Class Summary

Empiric antimicrobial therapy should cover the most likely pathogens in the context of the clinical setting.

Trimethoprim/sulfamethoxazole (Bactrim DS, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity includes common urinary tract pathogens, except P aeruginosa.

Cefepime (Maxipime)

Fourth-generation cephalosporin with good gram-negative coverage; similar to ceftazidime, but with better gram-positive coverage.

Tigecycline (Tygacil)

A glycylcycline antibiotic that is structurally similar to tetracycline antibiotics. Inhibits bacterial protein translation by binding to 30S ribosomal subunit and blocks entry of amino-acyl tRNA molecules in ribosome A site. Indicated for complicated skin and skin-structure infections caused by E coli, E faecalis (vancomycin-susceptible isolates only), S aureus (methicillin-susceptible and -resistant isolates), S agalactiae, S anginosus group (includes S anginosus, S intermedius, S constellatus), S pyogenes, and B fragilis.

Meropenem (Merrem IV)

Semisynthetic carbapenem antibiotic that inhibits bacterial cell wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram-negative bacteria and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Minocycline (Dynacin, Minocin)

Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma. Was found to be effective in some non-tuberculotic mycobacterial infections.