NEW YORK (Reuters Health) - An outbreak of severe infections in ICU patients was caused by moisturizing body lotion that had been contaminated during the manufacturing process.
The culprit was found to be a bug called Burkholderia cepacia. This microbe is widespread in soil and water and is usually harmless to healthy people. However, it can be a danger to people with cystic fibrosis or whose immune systems are suppressed.
The five patients affected by the outbreak were admitted to the intensive care unit in July and August of 2006, explain Dr. Francisco Alvarez-Lerma and associates at Hospital Universitari del Mar in Barcelona, Spain.
Testing of urine and blood samples showed that the patients were infected with Burkholderia cepacia, which caused serious bloodstream infection in three cases, lower respiratory tract infection in one, and urinary tract infection in one.
The bug was then isolated from the moisturizer used for all patients in the ICU, and not from any other potential sources tested, the investigators report in the journal Critical Care. Further testing showed that the samples from the patients and the lotion were identical.
Three of the patients died, although none of the deaths was attributed to the infection, according to the report.
Burkholderia cepacia was also found in previously unopened containers of the lotion, indicating that contamination had occurred during the manufacturing process.
No new cases of Burkholderia cepacia infection in patients occurred after all containers of the lotion were thrown away.
Based on their experience, the investigators caution that ICU patients should not be exposed to "cosmetic products for which there is no guarantee of sterilization during the manufacturing process."
SOURCE: Critical Care, online January 31, 2008.
