Burkholderia cenocepacia bacteremia attributed to sterile gel in ultrasound guided central line insertions
Outbreak of health care-associated Burkholderia cenocepacia bacteremia and infection attributed to
contaminated sterile gel used for central line insertion under ultrasound guidance and other procedures
Ramon Z. Shaban PhD, PGDipPH&TM, GradCertInfCon, Med, MCHPrac(Hons), BSc(Med), BN, RN, CICP-E, RACM. FFCEMAa,*, Samuel Maloney MMBBS,
BMedSc(Hons), FRCPAb, John Gerrard MSc (Microbiology), MBBS, BSc(Med), DLSHTM, DTM&H (Lon), FRACPc, Peter Collignon MBBS, BMedSc, FRACP, FRCPA, FASMd, Deborough Macbeth PhD, RN CICP-Ee, Marilyn Cruickshank PhD, RN, CICP-E, FACNf, Anna Hume MBBS, BBiomedScg, Amy V. Jennison PhD, BSc,(Hons)h, Rikki M.A. Graham PhD, BSc(Hons)h, Haakon Bergh BSc, AssDip(Medsc)i, Heather L. Wilson PhD, MBBS, FRACP, FRCPAj, Petra Derrington MBBS, FRACPk, 1Infection Control Department, Division of Infectious Diseases and Immunology, Gold Coast Hospital and Health Service and Griffith University, Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia, 2Infectious Diseases and Immunology, Gold Coast Hospital and Health Service, Pathology Queensland, Health Support Queensland, Department of Health, Queensland Government, Gold Coast University Hospital, Southport, Queensland, Australia, 3Infecious Diseases and Immunology, Gold Coast University Hospital, Gold Coast Hospital and Health Service, Southport, Queensland, Australia, 4ACT Pathology, The Canberra Hospital, Australian National University School of Medicine, Canberra, Australia, 5Infection Control Department, Infectious Diseases and Immunology, Gold Coast Hospital and Health Service, Southport, Queensland, Australia, 6Australasian College for Infection Prevention and Control, School of Nursing and Midwifery, Griffith University, Southport, Queensland, Australia, 7Medical Microbiology, Gold Coast Hospital and Health Service, Pathology Queensland, Health Support Queensland, Department of Health, Queensland Government, Southport, Queensland, Australia, 8Molecular Epidemiology, Public Health Microbiology, Forensic and Scientific Services, Health Support Queensland, Department of Health, Queensland Government, Southport, Queensland, Australia, 9Central Microbiology, Molecular Bacteriology/Quality, Pathology Queensland, Health Support Queensland, Department of Health, Queensland Government, Southport, Queensland, Australia, 10Microbiology and Antimicrobial Stewardship, Department of Infectious Diseases and Microbiology, Canberra Hospital and Health Services, Garran, Australian Capital Territory, Australia, 11Pathology Queensland, Health Support Queensland, Department of Health, Queensland Government, Southport, Queensland, Australia
The American Journal of Infectious Control, 45 (2017) 954-8
SUMMARY & METHODS
The authors describe an outbreak of Burkholderia cenocepacia bacteremia in 4 hospitals across Australia between the dates of March 2017 and May 2017. Eleven patients were infected, predominately in intensive care units. A collaborative outbreak response team was formed to investigate sources of the contamination. Intravenous fluids were cultured and testing of multiple potential sources were performed. The source of the infection was traced back to contaminated sterile ultrasound gel sachets within kits used in central line insertion and sterile procedures.
DISCUSSION & RESULTS
Four hospitals across Australia were involved in an effort to find the source of a Berkholderia cenocepacia bacteremia outbreak in the spring of 2017. Through aseptic microbiological testing, the point source was isolated and proven to be gel sachets from sterile ultrasound probe cover kits, manufactured from
a company in China. All patients with bacteremia identified had central line placements using ultrasound guidance. These sterile gel sachets yielded heavy contamination with B cenocepacia. Genomic sequencing analysis was preformed and demonstrated that the isolates from patients linked to the use of the ultrasound gel and the isolate grown from the gel were highly genetically related to each other and demonstrated far more genetic distance from other isolates taken from patients that were referenced.
The gel sachets were a component of sterile probe cover kits which included an expiration date, however
the gel packets themselves did not poses an expiration date. Another observance noted was that the
gel packets were not consistent and varied in packaging. All gel was enclosed in foil packing. It is likely that the gel was contaminated while being packed and that the ethylene oxide used during the sterilization process could not penetrate the foil enclosure. All gel kits were removed from the associated hospitals and the distributor was contacted and ordered a recall which was classified as a life-threatening event. From isolation of the source to the recall, the time span was 36 hours. All patients recovered from the apparent infections.
“This recent outbreak of health care-associated infection, in particular bacteremia due to B cenocepacia contamination of ultrasound gel, highlights again the important role that medical equipment and its cleanliness plays in the delivery of quality health care.” In a well-orchestrated effort to isolate the contaminant, the source was proven, and a recall was issued within 36 hours. All patients recovered from the infection caused by central line placement procedures using contaminated ultrasound gel.