Hide and Seek with Burkholderia – The Prince Charles Hospital Experience

Ms Janice Geary1

1The Prince Charles Hospital, Chermside, Australia



In June 2017, a peri- solid organ transplant patient in intensive care grew Burkholderia cepacia (B. cepacia) from their bronchial washings.  This started an extensive game of “hide and seek “to find the source of this health care acquired B. cepacia infection


The patient journey through our facility of the index case was mapped.  An incident management team was established, during the first meeting, potential sources of infection were hypothesised for investigation and an action plan was developed.

Risk Mitigation – The first action from the incident management team was to mitigate risks to other intensive care patients.  This included micron filters, environmental cleaning and review of clinical care skills.

Environmental Screening.  A search for an environmental source was undertaken.  In total 90 samples were collected.  All positive patient and environmental B. cepacia specimens were sent for genomic mapping.

Results and Step Down of Risk Mitigation – Only one screen was positive (the sink in the patient’s cubicle in ICU) which was the same genotype as the patient.

Results –

Lessons learnt from investigation.:

  • Hand washing basins are not to be used for liquid disposal
  • Sterile water mandatory for oral cares and suctioning in ICU
  • Continuing discussion about environmental colonisation with B. cepacia.


Whilst health care associated acquisition with B. cepacia is a rare occurrence, it’s impacts can be devastating.  Our experience demonstrated environmental contamination was not the source of infection but could be a source of transmission.


Janice Geary is currently the Clinical Nurse Consultant Infection Management Service at The Prince Charles Hospital in Brisbane.  She has held this position for 13 years, but has worked in the Infection Control Speciality for 20 years.  Janice holds a Bachelor of Nursing, Graduate Diploma in Infection Control and a Graduate Certificate in Health Management.

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