Table 1.
Synthetic overview of the outbreaks of bacterial and fungal contamination of infusates in healthcare facilities in low- and middle-income countries
| Intravenous fluids (n = 37) | Intravenous medicines (n = 22) | Total articles (n = 50) | Comments | |||
|---|---|---|---|---|---|---|
| TPN (n = 10) | Saline, dextrose, other (n = 27)* | Water for Injection (n = 3) | Medicines (n = 19)** | |||
| Country income level | ||||||
| Low-income (LIC) | – | 7 | – | 2 | 4 | In total, reports originated from 17 countries, representing 2 LIC, 9 Lower-MIC and 6 Upper-MIC |
| Lower middle-income (lower-MIC) | 2 | 12 | 2 | 6 | 25 | |
| Upper middle-income (upper-MIC) | 9 | 5 | 1 | 8 | 21 | |
|
Patients–wards–duration of outbreak Median (range) duration: 8 weeks (1 day–156 weeks) (data: n = 43 articles) | ||||||
| Adults (A) and/or children (C) affected | 1A/8C | 6A/22C | 1A/2C | 8A/7C | 16A/31C |
Articles providing information about ward: n = 48 Articles providing information about duration: n = 45 Total number of patients affected: 1025 Total number of children affected: 761 Median (range) number of patients affected per outbreak: 12 [3] (3 - 185) Median (range) case fatality ratio: 21.1% (0.0–87.5%) (data: n = 33 articles) |
| Neonatal Intensive care unit | 6 | 16 | 1 | 5 | 19 | |
| Adult intensive care unit | – | 2 | – | 3 | 7 | |
| Hematology/oncology | – | 2 | 1 | 2 | 4 | |
| Other wards | 3 | 10 | 2 | 9 | 23 | |
| Duration > 1 month | 5 | 17 | 3 | 11 | 27 | |
| Duration > 3 months | 3 | 13 | 2 | 7 | 16 | |
|
Pathogens Gram-negative bacteria (n = 59 isolates) | ||||||
| Enterobacterales (n = 29 isolates) | 8 | 15 | 0 | 6 | 26 |
In 4 articles, more than 1 species was identified from the infusates [26, 35, 40, 66] Where appropriate, the original (superseded) names of the bacteria are included in the comments to reflect taxonomic changes. They include: Burkholderia cepacia—(Pseudomonas cepacia) [44] Saprochaete capitata—(Blastoschizomyces capitatus) [42] Pluralibacter gergoviae—(Enterobacter gergoviae) [54] Elizabethkingia meningoseptica—(Chryseobacterium meningosepticum) [46] Klebsiella aerogenes—(Enterobacter aerogenes) [61] Rhizobium radiobacter—(Agrobacterium tumefaciens) [66] |
| Serratia sp. | 2 | 3 | – | 2 | 7 | |
| Klebsiella sp. | 1 | 9 | – | 3 | 10 | |
| Enterobacter sp. | 2 | 1 | – | 1 | 4 | |
| Leclercia decarboxylata | 1 | – | – | – | 1 | |
| Pantoea sp. | 1 | – | – | – | 1 | |
| Phytobacter diazotrophicus | 1 | – | – | – | 1 | |
| Pluralibacter gergoviae | – | 1 | – | – | 1 | |
| Proteus mirabilis | – | 1 | – | – | 1 | |
| NFGNB (n = 30 isolates) | 2 | 11 | 5 | 11 | 25 | |
| Burkholderia cepacia complex | – | 7 | 2 | 7 | 12 | |
| Ralstonia sp. | – | 1 | 2 | 1 | 4 | |
| Acinetobacter baumannii | 2 | 1 | – | – | 3 | |
| Achromobacter sp. | – | – | – | 1 | 1 | |
| Elizabethkingia meningoseptica | – | 1 | – | – | 1 | |
| Myroides odoratus | – | – | 1 | – | 1 | |
| Pseudomonas sp. | – | 1 | – | 1 | 2 | |
| Rhizobium radiobacter | – | – | – | 1 | 1 | |
| Fungi (n = 3 isolates) | ||||||
| Candida albicans | 1 | – | – | – | 1 | |
| Saprochaete capitata | – | 1 | – | – | 1 | |
| Sarocladium kiliense | – | – | – | 1 | 1 | |
| Gram-positive bacteria (n = 1 isolate) | ||||||
| Bacillus circulans | – | – | – | 1 | 1 | |
| Contamination route | ||||||
| Intrinsic contamination | 4 | 2 | 3 | 11 | 19 |
Articles providing information about intrinsic contamination: n = 19 Articles providing information or hypothesis about extrinsic contamination: n = 30 |
| Extrinsic contamination | 6 | 23 | – | 8 | 30 | |
| Used as mSDV | – | 18 | – | 7 | 20 | |
| Used as admixture | – | 6 | – | – | 5 | |
| Unsafe or deficient IPC practices | 7 | 25 | – | 8 | 40 | |
For a total of 50 articles, 59 infusates and 63 microorganisms were described. The abbreviation mSDV refers to medicine vials designed and manufactured as SDV, which are incorrectly used more than once and/or for more than one patient and IV fluids which are used for administration of multiple doses against the instructions of the manufacturer (see Box 1)
IPC infection prevention and control; NFGNB non-fermentative gram-negative bacteria; TPN total parenteral nutrition. Data represent numbers of isolates, except if otherwise indicated
*Saline (n = 10, including 2 heparinized saline admixtures), other IV fluid admixtures (n = 3), dextrose (n = 7), IV premixtures (n = 4), Ringer’s lactate (n = 1) and unspecified IV fluids (n = 2)
**Propofol (n = 4), calcium gluconate (n = 2), diltiazem (n = 2), bromopride, caffeine citrate, fentanyl, furosemide, gentamicin, granisetron, heparin, immunoglobulin, metronidazole, ondansetron, and a steroid (1 product each)