Burkholderia cenocepacia outbreak linked to taps in a neonatal intensive care unit

Background: Burkholderia cenocepacia complex is an important cause of hospital acquired infections. We describe the management of an outbreak in a neonatal intensive care unit (NICU) due to tap colonisation. Methods: Microbiological testing of touch (n = 26) and non-touch taps (n = 28), sinks and drains, including genomic sequencing of selected isolates. Thermal shocking of taps with 30 min of water flush at 60 °C. Tap aerators were changed with each thermal shock. Adjuvant disinfecting measures were applied to aerator mesh at the water exit point of the tap, point-of-use water filters, drains and sinks using hospital grade chlorine-based detergent. Results: Across the 2 year outbreak, seven microbiological cultures of tap outlets were positive for B. cenocepacia. Two neonates had positive stool samples, and one neonate with gastroschisis had a bloodstream infection. Phylogenetic analysis determined the clinical and tap cultures positive for B. cenocepacia were genomically closely related. Monthly thermal shocking with adjunct disinfection measures and tap aerator changes was effective in controlling tap colonisation with longer intervals associated with positive tap B. cenocepacia cultures. Conclusions: B. cenocepacia is an important cause of hospital-acquired infection in neonates. Plumbing and tap design is an important component to consider in the build of new NICUs.