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Molecular Investigation of Isolates from a Multistate Polymicrobial Pillonetto et al. BMC Infectious Diseases (2018) 18:397 https://doi.org/10.1186/s12879-018-3287-2 RESEARCHARTICLE Open Access Molecular investigation of isolates from a multistate polymicrobial outbreak associated with contaminated total parenteral nutrition in Brazil Marcelo Pillonetto1,2*, Lavinia Arend2, Suzie M. T. Gomes3, Marluce A. A. Oliveira4, Loeci N. Timm5, Andreza F. Martins6, Afonso L. Barth6, Alana Mazzetti1, Lena Hersemann7,8, Theo H. M. Smits7 , Marcelo T. Mira1† and Fabio Rezzonico7† Abstract Background: Between November 2013 and June 2014, 56 cases of bacteremia (15 deaths) associated with the use of Total Parenteral Nutrition (TPN) and/or calcium gluconate (CG) were reported in four Brazilian states. Methods: We analyzed 73 bacterial isolates from four states: 45 from blood, 25 from TPN and three from CG, originally identified as Acinetobacter baumannii, Rhizobium radiobacter, Pantoea sp. or Enterobacteriaceae using molecular methods. Results: The first two bacterial species were confirmed while the third group of species could not be identified using standard identification protocols. These isolates were subsequently identified by Multi-Locus Sequence Analysis as Phytobacter diazotrophicus, a species related to strains from similar outbreaks in the United States in the 1970’s. Within each species, TPN and blood isolates proved to be clonal, whereas the R. radiobacter isolates retrieved from CG were found to be unrelated. Conclusion: This is the first report of a three-species outbreak caused by TPN contaminated with A. baumannii, R. radiobacter and P. diazotrophicus. The concomitant presence of clonal A. baumannii and P. diazotrophicus isolates in several TPN and blood samples, as well as the case of one patient, where all three different species were isolated simultaneously, suggest that the outbreak may be ascribed to a discrete contamination of TPN. In addition, this study highlights the clinical relevance of P. diazotrophicus, which has been involved in outbreaks in the past, but was often misidentified as P. agglomerans. Keywords: Acinetobacter baumannii, Rhizobium radiobacter, Phytobacter diazotrophicus, Pantoea,TPN,Rep-PCR, Bacterial identification Background nutritionally rich mixtures and probably the most com- Total parenteral nutrition (TPN) is an important nutri- plex pharmaceutical dosage forms compounded by phar- tional supplement for seriously ill patients, especially macists. These infusions, composed by 50 or more those incapable of oral or enteral nutrition. TPN are constituents, including electrolytes, amino acids, dextrose, lipids and calcium gluconate (CG) [1], are also a favorable * Correspondence: [email protected] growth media for microorganisms [2]. In addition, mul- † Marcelo T. Mira and Fabio Rezzonico contributed equally to this work. tiple transfer steps into the same container during prepar- 1Core for Advanced Molecular Investigation, Graduate Program in Health Sciences, School of Medicine, Pontifícia Universidade Católica do Paraná, ation increase the risk for microbial contamination [3]. To Curitiba, PR, Brazil avoid this, strictly sterile manipulation conditions and 2Central Public Health Laboratory – State of Paraná – LACEN/PR, Molecular total compliance to good manufacturing practices and Bacteriology Division, São José dos Pinhais, PR, Brazil Full list of author information is available at the end of the article quality control rules are of paramount importance [1, 4]. © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Pillonetto et al. BMC Infectious Diseases (2018) 18:397 Page 2 of 11 Adoption of these procedures helped TPN-related out- hospitals where the cases were detected, resulted in the breaks to decline, but adverse events still occur worldwide, identification of mainly three species –“P. agglomer- usually resulting in severe sepses with high fatality rate, es- ans”/“Pantoea sp.”, A. baumannii, and R. radiobacter pecially in vulnerable individuals [5]. (Additional file 1: Table S2). Alongside, there were In nine outbreaks reviewed from 1990 to 2006, the mor- sporadic reports of different Enterobacteriaceae species tality following TPN contamination was 48.9% (19/39) [5]. such as Citrobacter amalonaticus, Citrobacter diversus, Incidence of bloodstream infection within patients receiv- Kluyvera intermedia, Kluyvera sp. and Enterobacteria- ing TPN has been reported between 1.3–39% [3]. Expos- ceae spp. Later, in June 2014, R. radiobacter was de- ure to TPN is considered an independent risk factor for tected in three lots of CG by a private laboratory in Rio blood stream infections at neonate intensive care units Grande do Sul. [6]. The relative risk has been estimated as 4.69 in neo- Throughout this investigation, a subset of 73 bacterial nates receiving TPN through central catheter [7]. isolates from blood, TPN and CG were directed to the Several species of microorganisms have been involved reference Central Public Health Laboratory of Paraná – in TPN-related outbreaks, including bacteria belonging LACEN for molecular analysis. This subset was com- to the Erwinia herbicola-Enterobacter agglomerans posed of all available isolates recovered during the out- complex (EEC), as well as glucose non-fermenting break and some TPN bags that were only partially Gram-negative bacteria, such as Acinetobacter spp. [8–11] administered to the patients. Here, we report the results and, less frequently, also Rhizobium radiobacter [12]. of the microbiological and molecular investigation of In November 2013, the municipal autorithies of the this outbreak, with emphasis on the identification of the City of Curitiba, capital of the state of Paraná, southern bacterial species involved and the tracking of the prob- Brazil, reported a contamination of TPN bags. The batch able sources of contamination. was immediately recalled and a retrospective statewide survey was launched, resulting in the identification of 30 Methods cases of TPN-related bacteremia (Additional file 1: Table Epidemiological description of the outbreak S1). Case definition was: patient receveing Total Paren- Demographic and epidemiological data of the cases were teral Nutrition at Hospitals receiving TPN bags from the obtained from three different sources: epidemiological suspected producers. The finding led the Brazilian reports from municipal and state health autorithies at Health Surveillance Agency (ANVISA) to trigger a Paraná, Minas Gerais and Rio Grande do Sul; official nation-wide epidemiological, sanitary and microbio- reports published by ANVISA; and the Laboratory Infor- logical investigation, leading to immediate withdraw of mation System at LACEN. the TPN solutions from the suspected manufacturers and closing of the involved TPN pharmaceutical indus- Origin of isolates try for a three-month period. At the same time, 16 add- Within this study, no clinical samples were handled dir- itional cases were detected in the southeastern state of ectly, as we only obtained bacterial isolates from the in- Minas Gerais and were linked to a different pharmaceut- volved hospitals. All isolates originated from the blood ical industry and one compound pharmacy based on that stream of case patients, from TPN bags involved in the state, whereby the same precautions were taken by local treatment of the patients, or from CG vials. These isolates health autorithies. Additionally, an extensive epidemio- were sent to LACEN in adequate transport containers, logical investigation was conducted, tracing the use of together with the microbiological reports produced at the raw material used to manufacture the compound so- the hospitals where the cases were ascertained. From lutions in Paraná and Minas Gerais production plants. November 2013 through June 2014, a total of 45 isolates The use of the same lot of calcium gluconate in mixtures from 27 patients were evaluated. Another 25 isolates were from both Paraná and Minas Gerais was investigated. recovered directly from TPN (four different manufac- The sole calcium gluconate manufacturer industrial turers from four states), while the last three came from plant in Brazil was shut down and sterility tests were three different lots of CG from one single compounding launched. In March 2014, one single case of bacteremia industry (Table 1 and Additional file 1: Table S2). was detected in Mogi Mirim, a municipality located A microbiological investigation of the pharmaceutical southeastern state of São Paulo. From February to June components sterility (such as CG, vitamins, electrolytes, 2014, further nine cases of bacteremia involving use of amino acids, and dextrose) used to produce TPN in Paraná TPN and/or CG produced in one additional in-house was conducted using USP Pharmacopeia Methods (1995). pharmacy (IP) were detected in the southern state of Rio In addition, different equipment parts such as bags, con- Grande do Sul (Additional file 1: Table S1). nectors, elastomers and others were also submitted to Initial investigation, as performed
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