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CORRESPONDENCE
Year : 2012  |  Volume : 136  |  Issue : 5  |  Page : 882-883

Burkholderia cepacia complex in Indian cystic fibrosis patients


1 Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
2 Department of Paediatrics, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
3 Hospital Administration, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India

Date of Web Publication2-Jan-2013

Correspondence Address:
Vikas Gautam
Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012
India
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Source of Support: None, Conflict of Interest: None


PMID: 23287140

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How to cite this article:
Gautam V, Singh M, Singhal L, Kaur M, Kumar A, Ray P. Burkholderia cepacia complex in Indian cystic fibrosis patients. Indian J Med Res 2012;136:882-3

How to cite this URL:
Gautam V, Singh M, Singhal L, Kaur M, Kumar A, Ray P. Burkholderia cepacia complex in Indian cystic fibrosis patients. Indian J Med Res [serial online] 2012 [cited 2020 Nov 28];136:882-3. Available from: https://www.ijmr.org.in/text.asp?2012/136/5/882/105420

Sir,

In India, there are no precise reports of the prevalence of Burkholderia cepacia complex (BCC) infections due to the lack of awareness and difficulty in identification by routine clinical laboratories. In most cases, BCC has been ambiguously reported as non-fermentative Gram-negative bacilli (NFGNB) or simply Pseudomonas spp. [1],[2] . For this reason, reports of disease due to BCC are rare and BCC has been reported from only a few tertiary care centres in north India [2],[3],[4],[5],[6] . BCC is an established pathogen in two patient populations with genetic diseases viz. cystic fibrosis (CF) and chronic granulomatous disease, where it causes increased morbidity and mortality [7] . Moreover, BCC has become an increasingly common nosocomial pathogen due to its high intrinsic and acquired antimicrobial resistance, lack of effective antibiotics, and survival ability in the environment for prolonged periods of time.

BCC has been observed in non CF-septicaemic patients of Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh during 2005-2010. However, though known to be associated frequently, there are no reports of isolation of BCC from Indian cystic fibrosis patients. CF itself was thought to be rare in India but published reports indicate that CF is probably far more common in people of Indian origin than previously thought but is underdiagnosed or missed in the majority of cases [8] . In 1968, six CF cases were reported from PGIMER [9] . At present, there are approximately 60 CF patients on regular follow up in Advanced Paediatric Centre (APC). We hereby report isolation of BCC from six CF cases admitted in PGIMER between April 2009 and March, 2010. The ethics committee of PGIMER, Chandigarh, approved the study protocol.

Blood culture was performed using BACTEC 9240 (Becton Dickinson, USA). Specimens were inoculated onto sheep blood agar and MacConkey agar, incubated aerobically at 37°C for up to 48 h. BCSA (B. cepacia selective agar) was used in addition for the recovery of B. cepacia from respiratory specimens [expectorated sputum, induced sputum, bronchoalveolar lavage (BAL), endotracheal aspirates] of CF patients (diagnosed as per the guidelines of CF Foundation) [10] . In positive cases, isolates were identified using standard biochemical tests and confirmed using recA PCR based RFLP (restriction fragment length polymorphism) to identify BCC isolates to the species level [2],[11] . Genomic DNA was isolated using the Avgene system as per the protocol recommended by the manufacturer (Avgene, Taiwan). Antibiotic susceptibility testing was done on Mueller-Hinton agar by Kirby Bauer's disk diffusion method according to CLSI guidelines [12] . BCC susceptibility was performed for ceftazidime, tetracycline, co-trimoxazole, meropenem and levofloxacin (Oxoid) [12] .

Amongst the six CF infants (five male and one female), a total of 12 BCC isolates were obtained. A four month old male infant with history of bronchopneumonia, presented with fever, cough and respiratory distress of 4 wk duration. B. cenocepacia was isolated twice from BAL and the RFLP types (G and I) were obtained in this child. He was treated with intravenous ceftazidime followed by meropenem. However, the patient deteriorated, his blood culture also grew BCC twice and he died of septic shock. In another two month old infant, BCC was isolated twice each from BAL specimens and blood cultures, with three isolates having the same RFLP types (type G - B. cenocepacia IIIA). First isolate from blood specimen gave faint band on recA PCR and RFLP pattern could not be obtained though repeated thrice. The other four infants diagnosed with CF presented with fever, cough and respiratory distress. B. cenocepacia (RFLP types G and I) was isolated from BAL in two of these cases. B. cenocepacia is genetically highly heterogeneous, being composed of at least four phylogenetic lineages (IIIA, IIIB, IIIC, and IIID) based on the polymorphism of the recA gene. In our cases, B. cenocepacia IIIA (recA RFLP types G) and IIIB (recA RFLP types I) were isolated. Though recA lineage IIIA has very limited environmental reservoir, recA lineage IIIB has been found in both clinical specimens and natural habitats [13] . All BCC isolates were found to be susceptible to ceftazidime, meropenem and co-trimoxazole. Appropriate antimicrobial therapy was initiated based on the susceptibility pattern. All infants except one responded well with improvement in condition.

Since BCC is difficult to eradicate after colonization, initial screening plays a pivotal role and patients may be segregated accordingly. B. cenocepacia and B. multivorans are more predominant amongst CF patients than non-CF patients as reported from United States, Canada, Italy and Australia [14],[15],[16] . Other than B. cenocepacia and B. multivorans, the remaining formally named species account for less than 10 per cent of all CF infections caused by the complex [13] . Isolation of B. cenocepacia from all our CF patients is a cause of concern, as these patients suffer from high mortality and have higher rate of transmission [2],[3],[4],[5] .


   Acknowledgment Top


Authors acknowledge the Indian Council of Medical Research (ICMR), New Delhi, for financial support.

 
   References Top

1.Calderon YA CL, Lemoine VR, Pru EP. Antibiotic resistance patterns and SDS-PAGE protein profiles of Burkholderia cepacia complex isolates from nosocomial and environmental sources in Venezuela. Med Sci Monit 2008; 14 : BR49-55.  Back to cited text no. 1
    
2.Gautam V, Ray P, Vandamme P, Chatterjee SS, Das A, Sharma K, et al. Identification of lysine positive non-fermenting gram negative bacilli (Stenotrophomonas maltophilia and Burkholderia cepacia complex). Indian J Med Microbiol 2009; 27 : 128-33.  Back to cited text no. 2
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3.Gautam V, Arora A, Madhup SK, Das A, Vandamme P, Sharma K, et al. Burkholderia cepacia complex in septicaemic non-cystic fibrosis cases from two tertiary care hospitals in north India. Indian J Med Res 2010; 131 : 829-32.  Back to cited text no. 3
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4.Gautam V, Ray P, Das A, Vandamme P, Malhotra P, Varma S, et al. Two cases of Burkholderia cenocepacia in septicemic patients. Jpn J Infect Dis 2008; 61 : 133-4.  Back to cited text no. 4
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5.Gautam V, Ray P, Puri GD, Sharma K, Vandamme P, Madhup SK, et al. Investigation of Burkholderia cepacia complex in septicaemic patients in a tertiary care hospital, India. Nepal Med Coll J 2009; 11 : 222-4.  Back to cited text no. 5
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6.Mukhopadhyay C, Bhargava A, Ayyagari A. Two novel clinical presentations of Burkholderia cepacia infection. J Clin Microbiol 2004; 42 : 3904-5.  Back to cited text no. 6
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7.The nonfermentative Gram-negative bacilli. In: Winn WAS, Jande W, Koneman E, Procop G, Schrekernbenger P, Woods G, editors. Koneman's color atlas and textbook of diagnostic microbiology, 6 th ed. Baltimore, USA: Lippincott Williams and Wilkins Publishers; 2006. p. 303-91.  Back to cited text no. 7
    
8.Ahuja AS, Kabra SK. Cystic fibrosis: Indian experience. Indian Pediatr 2002; 39 : 813-8.  Back to cited text no. 8
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9.Mehta S, Wadhwa UN, Mehta SK, Chhuttani PN. Fibrocystic disease of pancreas in India. Indian Pediatr 1968; 5 : 185-91.  Back to cited text no. 9
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10.Farrell PM, Rosenstein BJ, White TB, Accurso FJ, Castellani C, Cutting GR, et al. Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. J Pediatr 2008; 153 : S4-S14.  Back to cited text no. 10
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11.Mahenthiralingam E, Bischof J, Byrne SK, Radomski C, Davies JE, Av-Gay Y, et al. DNA-Based diagnostic approaches for identification of Burkholderia cepacia complex, Burkholderia vietnamiensis, Burkholderia multivorans, Burkholderia stabilis, and Burkholderia cepacia genomovars I and III. J Clin Microbiol 2000; 38 : 3165-73.  Back to cited text no. 11
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12.Performance standards for antimicrobial susceptibility testing; 20 th informational supplement. Wayne, PA: Clinical and Laboratory Standards Institute (CLSI); 2010.  Back to cited text no. 12
    
13.Mahenthiralingam E, Baldwin A, Dowson CG. Burkholderia cepacia complex bacteria: opportunistic pathogens with important natural biology. J Appl Microbiol 2008; 104 : 1539-51.  Back to cited text no. 13
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14.Coenye T, Mahenthiralingam E, Henry D, LiPuma JJ, Laevens S, Gillis M, et al. Burkholderia ambifaria sp. nov., a novel member of the Burkholderia cepacia complex including biocontrol and cystic fibrosis-related isolates. Int J Syst Evol Microbiol 2001; 51 : 1481-90.  Back to cited text no. 14
    
15.Mahenthiralingam E, Urban TA, Goldberg JB. The multifarious, multireplicon Burkholderia cepacia complex. Nat Rev Microbiol 2005; 3 : 144-56.  Back to cited text no. 15
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16.Reik R, Spilker T, Lipuma JJ. Distribution of Burkholderia cepacia complex species among isolates recovered from persons with or without cystic fibrosis. J Clin Microbiol 2005; 43 : 2926-8.  Back to cited text no. 16
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