Introduction

Burkholderia cepacia is an aerobic, glucose non-fermenting gram negative bacillus (NFGNB) which is not considered as part of normal human flora [1]. They are commonly found in moist environments such as intravenous fluids, nebuliser solutions, contaminated disinfectants, medical devices [1, 2] as well as skin of health care workers. In recent years, B. cepacia infections have increased due to indiscriminate use of antibiotics, longer duration of hospital stay and indwelling catheter related infections [1–5]. It rarely causes sepsis in neonates in the absence of predisposing factors [1, 2], but infections are usually severe [3]. The authors aimed to analyse the disease spectrum, source of infection, antibiotic sensitivity pattern, complications and outcome of B. cepacia infections in neonates.

Material and Methods

This retrospective study was conducted in a level III Neonatal intensive care unit of Kasturba Hospital, Manipal which is a tertiary care referral hospital. Blood culture proven B. cepacia infections between May 2011 and April 2012 were analysed by retrieving data from patient records and computerised database. The data included gestational age, birth weight, gender, presenting complaints, risk factors, source of infection, antibiotic sensitivity, response to antibiotics, complications and outcome. Neonatal sepsis was categorised as early onset (≤72 h after birth) or late onset (>72 h after birth).

BacT/ALERT PF Pediatric FAN (bioMérieux, France) bottles were used for blood culture. Blood samples for routine investigations and culture were obtained concurrently at admission. Oxidase positive, glucose NFGNB grown in blood cultures were further characterized by standard microbiological methods. Antimicrobial susceptibility was determined by disc diffusion method according to CLSI guidelines [6]. Cerebrospinal fluid (CSF) analysis and culture were performed in all.

Results

Of 594 neonates suspected of sepsis, 61 (10.3 %) were blood culture positive, 12 were identified with B. cepacia. In these 12 patients, B. cepacia was the sole organism isolated. All 12 neonates were outborn referrals with male to female ratio of 2:1. Gestation ranged from 29–41 wk. Four neonates had low birth weight and two had very low birth weight. Early onset sepsis (EOS) was observed in 8 and late onset sepsis in 4. Major presenting complaints were lethargy (41.7 %) and tachypnea (41.7 %) followed by refusal of feeds (25 %). Bleeding from gut, seizures and apnea were the other complaints (Table 1). Five (41.7 %) newborns required mechanical ventilation for 3–7 d. B. cepacia was simultaneously isolated from CSF in three neonates. The antibiotic sensitivity pattern is shown in Fig. 1. Neonates were treated with piperacillin-tazobactam, ciprofloxacin and cotrimoxazole either singly or in combination for 14–21 d depending on associated meningitis. Repeat blood cultures were sterile in all. Average duration of nursery stay was 21.2 (range, 5–60) d.

Table 1 Demographic characteristics, clinical features, risk factors and outcome of 12 neonates with Burkholderia cepacia infections
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Fig. 1
figure 1

Antimicrobial susceptibility pattern of B. cepacia isolates CSL Cefoperazone-sulbactam; Pip-tazo Piperacillin-tazobactam; SXT Sulfamethoxazole-trimethoprim

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Normal outcome until discharge was observed in 11 (91.7 %) neonates. One neonate developed hydrocephalus and had multiple seizures. He needed multiple anticonvulsants and ventriculoperitoneal shunt. Hearing evaluation in 3 neonates with meningitis was normal. There was no mortality. At 6 mo follow up visit 8 infants were neurologically normal and 1 had hydrocephalus. Three infants were lost to follow up.

Discussion

B. cepacia is a bacillus of low virulence but can cause serious infection in people with weakened immune system and chronic lung disease [1, 2]. B. cepacia most commonly presents with respiratory tract, urinary tract and blood stream infections [1, 2]. In the present study, neonates with relatively weaker immune system had infections with respiratory distress (41.67 %) and poor feeding (25 %) as common presentations. About 66.7 % neonates had EOS which agrees with reports by Sundaram et al. [5]. They observed 75 % of NFGNB neonatal infections as EOS.

B. cepacia are usually multidrug resistant organisms [1]. Resistance is common to aminoglycosides, polymyxins B and colistin [7–9]. Jacquier et al. reported 100 % resistance to colistin-a “last resort antibiotic” [10]. Co-trimoxazole has been reported as a drug of choice [2, 9] but intravenous cotrimoxazole is not available in most places of India. Avgeri et al. reported ceftazidime, meropenem and piperacillin, either alone or in combination as an effective alternative [9]. The authors used piperacillin-tazobactam, ciprofloxacin or cotrimoxazole either singly or in combination depending on the sensitivity reports, with good results. All B. cepacia isolates were resistant to ampicillin, amikacin and colistin.

B. cepacia can survive in moist environment including disinfectants and frequently colonise various medical solutions. Direct person-to-person spread is also known. In an attempt to find out the source, the authors cultured tap water, humidifier water, nebuliser solution, disinfectants at both their hospital and referring hospital but found negative results.

The most dreaded complication of B. cepacia infection is meningitis, leading to mortality and long term sequelae. Complete recovery was observed in most of the case with no mortality.

Conclusions

B. cepacia is an upcoming pathogen causing neonatal sepsis. Intrinsic resistance to aminoglycosides and colistin is a potential problem to effective therapy and demands a relook into aminoglycoside containing regimen for empirical therapy. Appropriate infection control measures in high risk neonatal care areas are needed to prevent this infection.