Treatment of Burkholderia cepacia Infections

Antimicrobial Selection

The American College of Physicians and Infectious Diseases Society recommends trimethoprim-sulfamethoxazole (TMP-SMX) as the first-line agent for Burkholderia cepacia complex infections when susceptible, with ceftazidime, meropenem, or ceftazidime-avibactam as preferred alternatives based on susceptibility testing, typically used in combination for severe infections 1

The Centers for Disease Control and Prevention recommends implementing contact precautions with gown and gloves for all patient encounters, cohorting B. cepacia-infected patients in designated areas, communicating B. cepacia status when transferring patients to other facilities, and performing environmental screening of surfaces in contact with colonized patients 2

The Cystic Fibrosis Foundation recommends inhaled antibiotics be administered twice daily using breath-enhanced open vent nebulizers with flow rates of 6 L/min, and separate nebulizer equipment must be used for patients colonized with B. cepacia versus Pseudomonas aeruginosa to prevent cross-contamination 3

B. cepacia is intrinsically resistant to carbapenems due to ubiquitous metallo-β-lactamase, though paradoxically meropenem shows clinical efficacy in some cases, as noted by the American Thoracic Society 4, 5

The American Thoracic Society notes that B. cepacia tends to colonize the respiratory tract rather than cause invasive disease, which should inform treatment duration decisions 4, 5
For catheter-related bloodstream infections with B. cepacia, catheter removal reduces treatment failure rates and improves survival, as recommended by the Infectious Diseases Society of America 6

The European Respiratory Journal recommends that inhaled tobramycin should not be used for maintenance therapy in B. cepacia colonized patients, as there is no evidence of increased selection for intrinsically tobramycin-resistant pathogens like B. cepacia 7
The American Journal of Respiratory and Critical Care Medicine suggests that generalizing recommendations to cystic fibrosis patients with B. cepacia is reasonable, despite their exclusion from many antibiotic trials 8

The Clinical Microbiology and Infection journal recommends that contact precautions with gown and gloves are required for all patient encounters with B. cepacia colonized or infected patients, and that cohorting B. cepacia patients in designated areas can help prevent transmission 9
The Clinical Microbiology and Infection journal also recommends communicating B. cepacia status when transferring patients to other healthcare facilities, performing environmental screening of surfaces, and implementing intensive environmental cleaning with audit and feedback mechanisms 9

The Thorax journal suggests that baseline and interval testing for drug toxicity is essential when using aminoglycosides, carbapenems, or other potentially toxic agents 10, 11

The Cystic Fibrosis Foundation recommends discontinuing macrolides, such as azithromycin, immediately following isolation of B. cepacia complex, as they should never be prescribed without two appropriate companion antibiotics 12
Patients with B. cepacia were excluded from azithromycin trials in CF, and the Cystic Fibrosis Foundation recommendation for chronic azithromycin specifically applies only to patients with Pseudomonas aeruginosa, not B. cepacia 13

The Infectious Diseases Society of America recommends tailoring treatment duration to infection severity and source control, with bloodstream infections requiring 10-14 days of treatment, complicated urinary tract infections requiring 5-7 days, hospital-acquired or ventilator-associated pneumonia requiring 10-14 days minimum, and deep-seated infections requiring 4-6 weeks of treatment 14, 15
The Centers for Disease Control and Prevention suggests implementing strict contact precautions with gown and gloves for all patient encounters with B. cepacia colonized or infected patients, and cohorting B. cepacia patients in designated areas separate from other patients to prevent cross-contamination 16
The World Health Organization recommends communicating B. cepacia status when transferring patients to any healthcare facility, and using separate nebulizer equipment for B. cepacia patients versus those with P. aeruginosa colonization 16