Association for Professionals in Infection Control and Epidemiology Annual Conference
Association for Professionals in Infection Control and Epidemiology Annual Conference
June 13, 2019
1 min read

Pseudo-outbreak of B. cepacia linked to refilled ultrasound gel bottles

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PHILADELPHIA — A pseudo-outbreak of Burkholderia cepacia in a hospital ED was linked to ultrasound gel bottles that had been refilled by members of a vascular access team, according to findings presented at a conference for the Association for Professionals in Infection Control Epidemiology.

Researchers found that old bottles were being reused because of a recent product change to a bottle with a “less desirable applicator tip.”

“I definitely think that listening to your staff is important, especially when you make product changes because a lot of times what happens is they do a work-around,” Tiffany Silmon, MPH, CIC, director of infection prevention and control at Chesapeake Regional Healthcare in Virginia Beach, told Infectious Disease News. “But when you listen to them and know what they need, you can avoid an outbreak.”

In June 2018, two patients in the ED had positive blood cultures for B. cepacia and a third patient was identified a month later, according to the researchers. The ED was part of a hospital that had seen just one positive blood culture for B. cepacia in the previous 8 years.

An investigation explored commonalities between the patients, identifying two nurses from the vascular access team who had collected all cultures during ultrasound guided peripheral intravenous catheter insertion.

Of the five ultrasound gel bottles tested, two bottles tested positive for B. cepacia and they belonged to the nurses who collected the patients’ cultures. The researchers concluded that the B. cepacia strains cultured from all patient and environmental samples “possibly originated from a common source.

They said it is critical to educate staff on practices related to using ultrasound gel and to seek feedback from staff, which could have prevented this pseudo-outbreak.

“Make sure you’re educating on practices. It opens the door,” Silmon said. “I think education, listening to your staff and making sure you give them the right resources are the main things.” – by Marley Ghizzone


Silmon T and Chapman D. What’s in your bottle? Investigating a pseudo-outbreak of Burkholderia cepacia. Presented at: APIC 2019; June 12-14, 2019; Philadelphia.

Disclosures: The authors report no relevant financial disclosures.