The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia
Abstract Background: Burkholderia cenocepacia is an environmental Gram-negative bacterium, resistant to many antibiotics and antiseptics, that can survive in aqueous hospital environments. We investigated an outbreak of B. cenocepacia in the intensive care unit (ICU) of Ng Teng Fong General Hospi...
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| Format: | Article |
| Language: | English |
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Cambridge University Press
2025-01-01
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| Series: | Antimicrobial Stewardship & Healthcare Epidemiology |
| Online Access: | https://www.cambridge.org/core/product/identifier/S2732494X25001822/type/journal_article |
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| author | Beevifatimah Ahamed Sha Paul Anantharajah Tambyah Shi Poh Li Sarathamani Rethenam Lilibeth Silagan Alenton Ling Chee Poh Yuan Sun Yong Peng Sii Yong Gabriel Yan Zherong Lasantha Ratnayake Michelle Ang Gerald Chua Surinder Kaur Pada |
| author_facet | Beevifatimah Ahamed Sha Paul Anantharajah Tambyah Shi Poh Li Sarathamani Rethenam Lilibeth Silagan Alenton Ling Chee Poh Yuan Sun Yong Peng Sii Yong Gabriel Yan Zherong Lasantha Ratnayake Michelle Ang Gerald Chua Surinder Kaur Pada |
| author_sort | Beevifatimah Ahamed Sha |
| collection | DOAJ |
| description |
Abstract
Background:
Burkholderia cenocepacia is an environmental Gram-negative bacterium, resistant to many antibiotics and antiseptics, that can survive in aqueous hospital environments. We investigated an outbreak of B. cenocepacia in the intensive care unit (ICU) of Ng Teng Fong General Hospital, aiming to identify the source and prevent further transmission.
Methods:
The outbreak was detected after two ICU patients developed B. cenocepacia bacteremia. Environmental samples, including ultrasound gels, and disinfectants, were collected. Whole genome sequencing (WGS) was used to determine clonality between clinical and environmental isolates. Immediate actions were taken, including a recall of ultrasound gel batches and the use of sterile gel sachets for high-risk procedures.
Results:
Ultrasound gels from opened and unopened bottles from multiple hospital areas, including ICU and Radiology, were found to be contaminated with B. cenocepacia, with a specific batch (Brand A) linked to the outbreak. WGS analysis confirmed the genetic relatedness of clinical and environmental isolates. A hospital-wide recall of affected gel batches was implemented. Through our regional networks, notification of countries in our immediate region along with alerting our local health authorities for further investigation was also undertaken. Additionally, we continued surveillance of gels and identified further contaminated products.
Conclusions:
This outbreak highlights the risks of contaminated medical products, specifically ultrasound gels. Effective environmental sampling, rapid identification, and clear communication with health authorities were key to controlling the outbreak. We have since revised our protocols to mandate the use of sterile gel for invasive procedures and continue monitoring for potential contamination in ultrasound gels.
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| format | Article |
| id | doaj-art-3e89f2b19fb14327b1283a577e5be372 |
| institution | DOAJ |
| issn | 2732-494X |
| language | English |
| publishDate | 2025-01-01 |
| publisher | Cambridge University Press |
| record_format | Article |
| series | Antimicrobial Stewardship & Healthcare Epidemiology |
| spelling | doaj-art-3e89f2b19fb14327b1283a577e5be3722025-08-20T03:13:26ZengCambridge University PressAntimicrobial Stewardship & Healthcare Epidemiology2732-494X2025-01-01510.1017/ash.2025.182The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepaciaBeevifatimah Ahamed Sha0https://orcid.org/0009-0008-6575-2605Paul Anantharajah Tambyah1https://orcid.org/0000-0003-0405-771XShi Poh Li2Sarathamani Rethenam3Lilibeth Silagan Alenton4Ling Chee Poh5Yuan Sun Yong6Peng Sii Yong7https://orcid.org/0009-0009-8835-2935Gabriel Yan Zherong8https://orcid.org/0000-0003-3513-428XLasantha Ratnayake9https://orcid.org/0000-0002-1341-8452Michelle Ang10Gerald Chua11Surinder Kaur Pada12https://orcid.org/0000-0002-2384-376XInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeDepartment of Infectious Disease, National University Hospital, Singapore, SingaporeInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeInfection Control Nurse, Ng Teng Fong General Hospital, Singapore, SingaporeDepartment of Laboratory Medicine, National University of Hospital, Singapore, SingaporeDepartment of Laboratory Medicine and Pathology, Woodlands Health, Singapore, SingaporeNational Public Health Laboratory, National Centre of Infectious Diseases, Singapore, SingaporeChairman of the Medical Board, Ng Teng Fong General Hospital, Singapore, SingaporeDepartment of Infectious Disease, Ng Teng Fong General Hospital, Singapore, Singapore Abstract Background: Burkholderia cenocepacia is an environmental Gram-negative bacterium, resistant to many antibiotics and antiseptics, that can survive in aqueous hospital environments. We investigated an outbreak of B. cenocepacia in the intensive care unit (ICU) of Ng Teng Fong General Hospital, aiming to identify the source and prevent further transmission. Methods: The outbreak was detected after two ICU patients developed B. cenocepacia bacteremia. Environmental samples, including ultrasound gels, and disinfectants, were collected. Whole genome sequencing (WGS) was used to determine clonality between clinical and environmental isolates. Immediate actions were taken, including a recall of ultrasound gel batches and the use of sterile gel sachets for high-risk procedures. Results: Ultrasound gels from opened and unopened bottles from multiple hospital areas, including ICU and Radiology, were found to be contaminated with B. cenocepacia, with a specific batch (Brand A) linked to the outbreak. WGS analysis confirmed the genetic relatedness of clinical and environmental isolates. A hospital-wide recall of affected gel batches was implemented. Through our regional networks, notification of countries in our immediate region along with alerting our local health authorities for further investigation was also undertaken. Additionally, we continued surveillance of gels and identified further contaminated products. Conclusions: This outbreak highlights the risks of contaminated medical products, specifically ultrasound gels. Effective environmental sampling, rapid identification, and clear communication with health authorities were key to controlling the outbreak. We have since revised our protocols to mandate the use of sterile gel for invasive procedures and continue monitoring for potential contamination in ultrasound gels. https://www.cambridge.org/core/product/identifier/S2732494X25001822/type/journal_article |
| spellingShingle | Beevifatimah Ahamed Sha Paul Anantharajah Tambyah Shi Poh Li Sarathamani Rethenam Lilibeth Silagan Alenton Ling Chee Poh Yuan Sun Yong Peng Sii Yong Gabriel Yan Zherong Lasantha Ratnayake Michelle Ang Gerald Chua Surinder Kaur Pada The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia Antimicrobial Stewardship & Healthcare Epidemiology |
| title | The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia |
| title_full | The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia |
| title_fullStr | The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia |
| title_full_unstemmed | The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia |
| title_short | The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia |
| title_sort | risk of contaminated ultrasound gels in the intensive care unit lessons from an outbreak of burkholderia cenocepacia |
| url | https://www.cambridge.org/core/product/identifier/S2732494X25001822/type/journal_article |
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