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  • 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

    Author(s)
    Shaban, Ramon Z
    Maloney, Samuel
    Gerrard, John
    Collignon, Peter
    Macbeth, Deborough
    Cruickshank, Marilyn
    Hume, Anna
    Jennison, Amy V
    Graham, Rikki MA
    Bergh, Haakon
    Wilson, Heather L
    Derrington, Petra
    Griffith University Author(s)
    Shaban, Ramon Z.
    Cruickshank, Marilyn A.
    Year published
    2017
    Metadata
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    Abstract
    Background: We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia. Methods: Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures. Results: The outbreak investigation identified the point source as ...
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    Background: We report an outbreak of Burkholderia cenocepacia bacteremia and infection in 11 patients predominately in intensive care units caused by contaminated ultrasound gel used in central line insertion and sterile procedures within 4 hospitals across Australia. Methods: Burkholderia cenocepacia was first identified in the blood culture of a patient from the intensive care unit at the Gold Coast University Hospital on March 26, 2017, with 3 subsequent cases identified by April 7, 2017. The outbreak response team commenced investigative measures. Results: The outbreak investigation identified the point source as contaminated gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of B cenocepacia with the same multilocus sequence type were identified within 4 hospitals across Australia. This typing was the same as identified in the contaminated gel isolate with single nucleotide polymorphism-based typing, demonstrating that all linked isolates clustered together. Conclusion: Arresting the national point-source outbreak within multiple jurisdictions was critically reliant on a rapid, integrated, and coordinated response and the use of informal professional networks to first identify it. All institutions where the product is used should look back at Burkholderia sp blood culture isolates for speciation to ensure this outbreak is no larger than currently recognized given likely global distribution
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    Journal Title
    American Journal of Infection Control
    Volume
    45
    Issue
    9
    DOI
    https://doi.org/10.1016/j.ajic.2017.06.025
    Subject
    Nursing
    Nursing not elsewhere classified
    Health services and systems
    Public health
    Publication URI
    http://hdl.handle.net/10072/349013
    Collection
    • Journal articles

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