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

Global burden, point sources, and outbreak management of healthcare-associatedBurkholderia cepaciainfections: An integrative review

“…It is critical, when using ultrasound gel for the placement of both central and peripheral cannulas, to ensure both the sterility of the coupling gel and the ultrasound probe and that an aseptic cannula insertion technique is used at all times, especially when dealing with high-risk patients. 18 In terms of effective infection prevention and control measures that managed to cease the rising number of cases associated with each reported outbreak, the most effective approaches used a combination of environmental-, staff-and patient-related measures. For instance, those outbreaks in which a combination of actions, such as equipment maintenance, routine education programs for staff and patient confinement were reported, were shorter.…”

“…For instance, those outbreaks in which a combination of actions, such as equipment maintenance, routine education programs for staff and patient confinement were reported, were shorter. 18,47,[62][63][64] Findings from the review suggest that the point sources for B. cepacia HAIs were often contaminated fluids, which in some instances were contaminated during manufacture. Substandard manufacturing of products distributed globally undermines the efficiency of implemented control measures and may boost the trend of outbreak-related cases worldwide.…”

“…[8][9][10][11] Confirmed point sources included contaminated solutions and medications such as mouthwashes, 12 respiratory equipment and ventilators, 13 disinfectants, 14 hemodialysis machines, 15 intravenous catheters, 16 medication vials 17 and ultrasound gels. 18 The published evidence describing B. cepacia HAIs worldwide is disparate and may present challenges for infection control professionals (ICPs) attempting to source current evidence to plan intervention strategies. In this integrative review, we present our analysis of a series of published outbreak reports to determine the global burden, associated point sources, and successful outbreak prevention and control measures described for B. cepacia HAIs worldwide.…”

Ultrasound probe use and reprocessing: Results from a national survey among U.S. infection preventionists

“…Recently reported outbreaks resulted in patient death and bacteremia associated with contaminated gel used during CVC placements. 8,9 These studies described pathogen transmission during ultrasound procedures, and demonstrate that the probe contacts the puncture site because typically gel is moved around by the probe to visualize the anatomy. Because probe sheaths break (reviewed in the CDC guidelines) and may become contaminated during application to the probe, the probe still needs a minimum of HLD before use in these procedures.…”

“…7 Numerous outbreaks implicating contaminated ultrasound gel have also occurred, including cases where bacteremia and death resulted. 8,9 These outbreaks demonstrate the risks associated with surface ultrasound-guided procedures and suggest the probe and gel can contaminate the puncture site during imaging. Appropriate use of sterile gel and adequate ultrasound probe reprocessing play key roles in preventing these adverse events.…”