LAUSR

BACKGROUND In June 2018, two patients were identified with positive blood cultures for Burkholderia cepacia (B. cepacia), with a third identified in July of 2018. All occurred in the Emergency Department of a 310-bed hospital with a history of one positive blood culture for B. cepacia in the previous eight years. B. cepecia has been associated with outbreaks related to contaminated medications and devices. METHODS An investigation was conducted to look for commonalities among the patients. Areas of investigation included members of the care team and their role, patient care equipment, room location, patient demographics, medical histories, prior to admission medications, travel history, and occupation. RESULTS One commonality among all three patients was identified: all cultures were collected by either Nurse A or Nurse B, members of the vascular access team, during ultrasound guided peripheral intravenous catheter insertion. Vascular access team members were using refilled ultrasound gel bottles during procedures because of the recent change to a product with a less desirable applicator tip. Five ultrasound gel bottles were collected and submitted for environmental culturing. B. cepacia was cultured from 2 of 5 bottles (bottle 1 belonging to Nurse A and bottle 3 belonging to Nurse B). Pulsed-field gel electrophoresis confirmed that: the B. cepacia isolates from patient 1, patient 2, and bottle 1 were identical; the isolates from patient 3 and bottle 3 were closely related; and the B. cepacia strains from all patients and environmental samples possibly originated from a common source. CONCLUSIONS Often, staff do not understand the importance of why bottles should not be refilled. It is important to educate your staff, assess your facility's practices related to ultrasound gel, and include end user input on product selection; with end user input, this pseudo-outbreak could have been avoided