25th European Congress of Clinical Microbriology and Infectious Diseases (ECCMID 2015)

Creato Sabato, 25 Aprile 2015

Dr. Di Domenico Enea Gino - Copenaghen, 25-28 aprile  2015

An outbreak of Ralstonia mannitolilytica in an oncologic day ward, September 2013 - February 2014, Rome, Italy

Claudia Lucarelli1,2, Luigi Toma3, Grazia Prignano4, Lorella Pelagalli5, Enea Gino Di DomenicoPatrizio Pezzotti2, Annalisa Pantosti2, Loredana Ingrosso2

  1. European Program for Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden.
  2. Istituto Superiore di Sanità, Rome, Italy.
  3. Department of Infectious Disease, San Gallicano Dermatology Institute, Rome, Italy.
  4. Department of Clinical Pathology and Microbiology, San Gallicano Dermatology Institute, Rome, Italy.
  5. Intensive Care Medicine, National Cancer Institute Regina Elena, Rome, Italy. 


Objective. Several cases of bacteremia in cancer outpatients, caused by Ralstonia spp, a nonfermentative Gram-negative bacteria mainly isolated from environment, were identified for the first time in an oncology hospital in Rome, Italy and prompted investigated.

Methods. We defined a case as an oncology outpatient attending the day ward during the period September 2013 - February 2014 that had blood culture and/or central venous catheter (CVC) culture

positive for Ralstonia spp. We reviewed cases’ medical records, investigated the medical procedures, obtained and analyzed environmental samples from the ward. Identification of
Ralstonia spp. was confirmed by 16S rRNA sequencing, the strains were tested for antimicrobial susceptibility and typed by Pulsed Field Gel Electrophoresis (PFGE) following restriction with SpeI.

Results. We identified 20 cases, 11 males and 9 females, median age 66, attending the day ward from the 39th week of 2013 to 9th week of 2014. The patients had different types of malignancy, different therapeutic protocols and attended the day ward in different days. The patients carried different types of CVC, inserted from few months to several years before initiation of symptoms. Sixteen patients reported fever and/or chills while or short after receiving chemotherapy through their CVC, or after CVC washing procedures. No information is available for the remaining 4 patients. Apart for 1 patient, none required antibiotic treatment and the CVC removal completely solved the clinical symptoms. All the environmental samples were negative for the presence of Ralstonia spp. The review of the medical procedures revealed that between August 2013 and September 2013, multiple-dose bottles of saline solution were in use for CVC washing but they were no longer available for testing. The strains isolated from patients were identified as Ralstonia mannitolilytica and they showed an indistinguishable PFGE profile. All the strains were resistant to ceftazidime, meropenem, ciprofloxacin, gentamicin, amikacin but susceptible to piperacillin/tazobactam.

Conclusion. Molecular typing demonstrated that a clonal outbreak of Ralstonia mannitolilytica occurred in an oncology day ward, probably due to a common source of infection. However, due to the presentation of cases along an extended period of time, a definite exposure was difficult to assess. The only common procedure was CVC washing with saline solution. It is possible that one or more contaminated multiple-dose bottles of saline solution caused CVC colonization by R.

mannitolylitica in several patients. Any subsequent procedure (chemotherapy of washing) through CVC, even after several weeks from CVC infection, may have caused detachment and
dissemination of R. mannitolylitica, followed by fever and chills in patients.

We recommend to remove any CVC that is not longer essential, and, in order to prevent other outbreaks of CVC infections, we suggest the use of single dose solutions for any injectable
treatment of cancer outpatients.

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