Lessons Learned from a Health System's Pseudo-Outbreak of Burkholderia Cepacia

Session Description: This session will recount the steps taken to investigate an uptick in Burkholderia cepacia isolates across a health system. Through a narrative presentation, we will explore the epidemiological methods used to identify the source. These methods included creating a line list that assessed multiple variables, including patient location, past procedures, and whether any endoscopes were utilized.

As the investigation unfolded, we interviewed staff, traced endoscope cleaning processes, and completed multiple rounds of environmental culturing. Interestingly, we discovered that all isolates were received in the microbiology lab after 4 PM. This led us to follow the culturing process from specimen collection to plating. Through conversations with laboratory leadership and microbiology technicians, we identified that a bottle of sterile saline—left open and reused over time—was being used to dilute viscous specimens.

Culturing the saline confirmed that Burkholderia cepacia had been inadvertently introduced into the respiratory and tissue cultures. This finding confirmed that the suspected outbreak was, truly, a pseudo-outbreak.

The session will also examine the immediate and downstream impact of pseudo-outbreaks in the acute care setting. These include unnecessary antibiotic treatment, prolonged hospital stays, and extensive patient notification efforts. We also plan to share our lessons learned along the way to emphasize the importance of close collaboration with laboratory partners during outbreak investigations.

This topic is highly relevant, as Infection Preventionists frequently encounter suspected outbreaks. The insights shared in this session aim to empower attendees with practical tools and strategies to navigate complex outbreak investigations with confidence.

The target audience for this session includes Infection Preventionists, Infection Prevention Leaders, and Microbiologists.

Kevin Smith

Director of Infection Prevention and Control, Temple Health

Kevin has served as the Director of Infection Prevention and Control at Temple Health since 2022. He was previously an Infection Preventionist at Temple University Hospital after completing his Master of Public Health in Epidemilogy at Drexel University. In his free time, Kevin enjoys travelling and discovering all of the best restaurant offerings wherever he goes.

Dan Popkin

Director of Infection Prevention & Control, Temple Health

Dan Popkin, MPH, CIC, CHEP, is Director of Infection Prevention and Control at Temple Health in Philadelphia, PA. With a background in epidemiology and experience at the CDC and the Georgia Emerging Infections Program, he works to apply data-driven approaches that strengthen infection prevention practices and improve patient safety. Dan is committed to advancing strategies that support healthcare teams and enhance outcomes across diverse care settings. In his free time, Dan enjoys exploring new places, playing volleyball, and spending time with his dog, Layla.

Maria Whitaker

Infection Preventionist, Infection, Prevention and Control Consulting Services

Maria Whitaker, BS,MT,CIC, is an Independent Infection Prevention and Control Consultant. She worked as a Clinical Microbiologist for 18 years before pursuing her career in Infection Prevention. For the next 22 years, Maria worked as the manager for the Infection Prevention and Control Program in both the acute and long-term care settings at Guthrie Cortland Medical Center in Cortland, New York. Maria is very active in APIC. She has served as President and Chair of the Education Committee for her local Chapter, and has served on several committees at the National level; including Practice Guidance Committee, Communications Committee and is currently a member of the Annual Conference Committee.