Infect Control Hosp Epidemiol. 2025 Sep 4:1-7. doi: 10.1017/ice.2025.10232. Online ahead of print.
ABSTRACT
BACKGROUND: Species of the Burkholderia (B.) cepacia complex (Bcc) have been implicated in multiple nosocomial outbreaks linked to contaminated water-based products, including liquid soaps, mouthwash, and other non-alcoholic aqueous solutions.
OBJECTIVE: We describe two substantial healthcare-associated outbreaks of Bcc (B. cepacia and B. contaminans) in the United Kingdom and Ireland associated with contaminated products. We highlight the challenges during investigation and mitigation, and provide recommendations.
METHODS: A multidisciplinary, multi-stakeholder investigation across both outbreaks was adopted, involving interviews, trawling questionnaires, and targeted product sampling.
RESULTS: There were 153 and 66 confirmed cases in the B. cepacia and B. contaminans outbreaks, respectively. Cases predominantly comprised hospitalized individuals, and 70% of isolates were recovered from an invasive site. The outbreak strain of B. cepacia was isolated from non-sterile ultrasound gel. An analytical study suggested the B. contaminans cluster was also linked to ultrasound gel; however, a disinfectant wipe product was subsequently identified as the source (0-3 single nucleotide polymorphism differences between case and wipe isolates).
OUTBREAK CONTROL MEASURES: The affected disinfectant wipes were withdrawn. The ultrasound gel was not recalled but health system procurement was suspended, rapid clinical guidance was produced and a National Patient Safety Alert was issued. Inter-organizational partnership was required to mitigate risks.
CONCLUSION: Identifying the source of outbreaks associated with contaminated products can be challenging, requiring complex multi-stakeholder interventions. We recommend a low threshold for investigation of Bcc clusters, adopting a multidisciplinary approach to investigation and mitigation, implementing interventions focusing on practice, and prompt product removal to protect patients.
PMID:40905274 | DOI:10.1017/ice.2025.10232
