Outbreak of Burkholderia stabilis Infections Associated with Contaminated Nonsterile, Multiuse Ultrasound Gel - 10 States, May-September 2021
MMWR Morb Mortal Wkly Rep. 2022 Dec 2;71(48):1517-1521. doi: 10.15585/mmwr.mm7148a3.ABSTRACTIn July 2021, the Virginia Department of Health notified CDC of a cluster of eight invasive infections with Burkholderia stabilis, a bacterium in the Burkholderia cepacia complex (BCC), among hospitalized patients at hospital A. Most patients had undergone ultrasound-guided procedures during their admission. Culture of MediChoice M500812 nonsterile ultrasound gel used in hospital A revealed contamination of unopened product with B. stabilis that matched the whole genome sequencing (WGS) of B. stabilis strains found among patients. CDC and hospital A, in collaboration with partner health care facilities, state and local health departments, and the Food and Drug Administration (FDA), identified 119 B. stabilis infections in 10 U.S. states, leading to the national recall of all ultrasound gel products produced by Eco-Med Pharmaceutical (Eco-Med), the manufacturer of MediChoice M500812. Additional investigation of health care facility practices revealed frequent use of nonsterile ultrasound gel to assist with visualization in preparation for or during invasive, percutaneous procedures (e.g., intravenous catheter insertion). This practice could have allowed introduction of contaminated ultrasound gel into sterile body sites when gel and associated viable bacteria were not completely removed from skin, leading to invasive infections. This outbreak highlights the importance of appropriate use...
Source: MMWR Morb Mortal Wkl... - Category: Epidemiology Authors: Matthew J Hudson Stacy C Park Amy Mathers Hardik Parikh Janet Glowicz David Dar Marjan Nabili John J LiPuma Amy Bumford Matthew A Pettengill Mark R Sterner Julie Paoline Stacy Tressler Tiina Peritz Jane Gould Stuart R Hutter Heather Moulton-Meissner Kiran Source Type: research
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