2025/09/04 by Jason Doran, Clare Foster, M.I. Saunders +20 · 1 voice
Immunology and Microbiology · Medicine · #Infection Control in Healthcare #Medical Device Sterilization and Disinfection #Nosocomial Infections in ICU
paper · doi:10.1017/ice.2025.10232
openalex publication_date 2025/09/04 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/14
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 Outbreak control measures: The affected disinfectant wipes were withdrawn.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.