Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2018 Aug 13;18(1):397.
doi: 10.1186/s12879-018-3287-2.

Molecular investigation of isolates from a multistate polymicrobial outbreak associated with contaminated total parenteral nutrition in Brazil

Marcelo Pillonetto  1   2 , Lavinia Arend  3 , Suzie M T Gomes  4 , Marluce A A Oliveira  5 , Loeci N Timm  6 , Andreza F Martins  7 , Afonso L Barth  7 , Alana Mazzetti  8 , Lena Hersemann  9   10 , Theo H M Smits  9 , Marcelo T Mira  8 , Fabio Rezzonico  9
Affiliations

Molecular investigation of isolates from a multistate polymicrobial outbreak associated with contaminated total parenteral nutrition in Brazil

Marcelo Pillonetto et al. BMC Infect Dis. .

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; Bacterial identification; Pantoea; Phytobacter diazotrophicus; Rep-PCR; Rhizobium radiobacter; TPN.

PubMed Disclaimer

Conflict of interest statement

As in this study, we only handled bacterial isolates obtained from the involved hospitals, an ethical approval for work with clinical samples was not required.

Not applicable.

The authors declare that they have no competing interests.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Rep-PCR based molecular typing and percentage of similarity within Phytobacter diazotrophicus outbreak isolates and outliers. Location: H1 to H7- hospitals numbered sequentially; I1-I2 – industries 1 and 2, respectively; MG – Minas Gerais State, PR – Paraná State; CC- capital city; CS – country-side. Source: ANS – ankle secretion; BSI – blood isolates; TPN – total parenteral nutrition; RSW – rectal swab. Shaded area: isolates recovered from the outbreak. The couloured boxes states the percentage of similarity between the two strains. The red boxes indicate higher similarity (above 95%) between strains meaning isolates are clonal. The orange boxes indicate high similarities (90–95%) meaning isolates are related –i.e: belong to the same clonal group. Yellow boxes indicate intermediate similarities (70–80%). The grey boxes indicate similarity is low (50–70%)
Fig. 2
Fig. 2
Rep-PCR based molecular typing and percentage of similarity within Acinetobacter baumannii outbreak isolates and outliers. Location: H1 to H3- hospitals numbered sequentially; I1-I2 – industries 1 and 2, respectively; PR – Paraná State; CC- capital city; CS – country-side. Source: BAL – bronchoalveolar lavage; BPS – Biopsy; BSI – blood isolates; CSI – Cirurgic Site Infection; TPN – total parenteral nutrition; RSW – rectal swab. Shaded area: clonal groups from the outbreak. The couloured boxes states the percentage of similarity between the two strains. The red boxes indicate higher similarity (above 95%) between strains meaning isolates are clonal. The orange boxes indicate high similarities (90–95%) meaning isolates are related –i.e: belong to the same clonal group. Yellow boxes indicate intermediate similarities (70–80%). The grey boxes indicate similarity is low (50–70%)
Fig. 3
Fig. 3
Rep-PCR based molecular typing and percentage of similarity within Rhizobium radiobacter outbreak isolates and outliers. Location: H1 to H13- hospitals numbered sequentially; IP-In house pharmacy; PR – Paraná State; RS – Rio Grande do Sul State; SP – São Paulo state; CC- capital city; CS – country-side. Source: BSI – blood isolates; CGL – Calcium gluconate vial; TPN – total parenteral nutrition. Shaded area: isolates belonging to the same clone or clonal group. The couloured boxes states the percentage of similarity between the two strains. The red boxes indicate higher similarity (above 95%) between strains meaning isolates are clonal. The orange boxes indicate high similarities (90–95%) meaning isolates are related –i.e: belong to the same clonal group. Yellow boxes indicate intermediate similarities (70–80%). The grey boxes indicate similarity is low (50–70%)
Fig. 4
Fig. 4
Position of outbreak isolates 5110RM and 5020RM as well as of post-outbreak isolate 10289RM within P. diazotrophicus as determined by MLSA using concatenated sequences of housekeeping genes atpD, gyrB, infB and rpoB (Brady et al., 2008). The tree was was inferred using the Neighbor-Joining method. Numbers at branching points are bootstrap percentage values (> 50%) based on 1000 replications. Kosakonia oryzae LMG 24251T as used as outgroup. The scale bar represents 1% nucleotide substitutions
Fig. 5
Fig. 5
Venn diagram depicting the affiliation to the three different species involved in the outbreak of all the isolates analyzed at LACEN. Isolates obtained from the same patient, TPN bag or CG vial are regrouped by grey circles. Codes indicate individual patient or sample
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Driscoll D. Compounding TPN admixtures: then and now. J Parenter Enter Nutr. 2003;27:433–438. doi: 10.1177/0148607103027006433. - DOI - PubMed
    1. Kuwahara T, Kaneda S, Shimono K, Inoue Y. Growth of microorganisms in total parenteral nutrition solutions without lipid. Int J Med Sci. 2010;7:43–47. doi: 10.7150/ijms.7.43. - DOI - PMC - PubMed
    1. Turpin RS, Canada T, Rosenthal V, Nitzki-George D, Liu FX, Mercaldi CJ, et al. Bloodstream infections associated with parenteral nutrition preparation methods in the United States: a retrospective, large database analysis. J Parenter Enter Nutr. 2012;36:169–176. doi: 10.1177/0148607111414714. - DOI - PubMed
    1. Gupta N, Hocevar SN, Moulton-Meissner HA, Stevens KM, McIntyre MG, Jensen B, et al. Outbreak of Serratia marcescens bloodstream infections in patients receiving parenteral nutrition prepared by a compounding pharmacy. Clin Infect Dis. 2014;59:1–8. doi: 10.1093/cid/ciu218. - DOI - PMC - PubMed
    1. Vonberg RP, Gastmeier P. Hospital-acquired infections related to contaminated substances. J Hosp Infect. 2007;65:15–23. doi: 10.1016/j.jhin.2006.09.018. - DOI - PubMed

MeSH terms