Systematic review of ultrasound gel associated Burkholderia cepacia complex outbreaks: Clinical presentation, sources and control of outbreak

Burkholderia cepacia Complex Infections in Urgently Referred Neonates from Syrian Border Regions to a Hospital in Turkey: A Cross-Border Cluster

“…Cross-transmission, frequent pulmonary procedures, surgeries, and instrumentation, including central venous access, facilitate this organism’s nosocomial spread [ 5 , 12 ]. BCC can lead to outbreaks through different sources that include contaminated intravenous medications/fluids, medical devices, ultrasound probe gels, lipid emulsion stoppers, mouthwash, nebulizer solutions, or skin disinfectants [ 4 , 6 , 10 , 12 , 13 , 14 , 15 ]. In a systematic review of healthcare-associated BCC outbreaks, medical products are found to be the most frequent source of the outbreaks, representing over half of the identified sources, with 12% of the outbreaks caused by disinfectant products [ 16 ].…”

Clinical Issues — August 2023

“…5 The National Institute for Occupational Health and Safety illustrates how engineering control strategies fit within the hierarchy of controls as physical changes in the workplace environment to minimize exposure by isolating the hazard to prevent contact; these controls should follow the use of elimination and substitution strategies. 6 The AORN "Guideline for surgical smoke safety" 2 describes how the hierarchy of controls applies to the surgical setting with LEV (ie, surgical smoke evacuation) as a type of engineering control to help prevent health care personnel from being exposed to surgical smoke (Figure 1).…”

“…7,8 However, there have been outbreaks of B cepacia complex bacterial infections caused by contaminated gel in both nonsterile multidose containers and sterile, single-use packages that were determined to have been intrinsically contaminated by the manufacturer. 4,6 In a multistate outbreak involving 119 patients who developed B stabilis infections, public health officials identified the source of the outbreak as nonsterile ultrasound transmission gel that was intrinsically contaminated by the manufacturer. 4 Investigators observed personnel using nonsterile ultrasound gel for percutaneous procedures and recommended using sterile, single-use packages of gel for ultrasound examinations being performed before and during invasive percutaneous procedures.…”

“…There have been many reports of outbreaks related to contaminated ultrasound transmission gel. Contaminated ultrasound transmission gels have caused Burkholderia cepacia complex infections and bacteremia, 6,7 Staphylococcus aureus pyoderma, Mycobacterium massiliense surgical site infections, and P aeruginosa pneumonia 7 . Some of these outbreaks may have been caused by health care personnel using extrinsically contaminated nonsterile ultrasound transmission gel in multidose containers 7,8 .…”

“…Some of these outbreaks may have been caused by health care personnel using extrinsically contaminated nonsterile ultrasound transmission gel in multidose containers 7,8 . However, there have been outbreaks of B cepacia complex bacterial infections caused by contaminated gel in both nonsterile multidose containers and sterile, single‐use packages that were determined to have been intrinsically contaminated by the manufacturer 4,6 …”