1219. Outbreak Investigation of Burkholderia cepacia Linked to Contaminated Ultrasound Gel

Abstract

Abstract Background This presentation will highlight how a multiuse hospital product was determined to be contaminated with Burkholderia cepacia (BCC) in the summer of 2021. The investigation began when there was a cluster of inpatients at one campus with blood cultures growing BCC. A multidisciplinary team was quickly assembled to investigate these cases. Swift action by the system team identified the source of the contamination, removed the product from use, and implemented evidence-based guidelines for safe ultrasound gel use. Methods The investigation began with thorough chart reviews. An epi curve was created to visually display the outbreak. A literature review was conducted to review previous outbreaks of BCC. It was determined that all the patients had undergone ultrasound procedures. The team immediately focused on multiuse bottles of ultrasound gel. Results Initial case investigation revealed a cluster of 9 patients growing BCC. The specimen source was primarily blood, but 2 patients had cultures from other sources. Ultrasound was the only commonality found. 37 opened and unopened product samples of 9 different water-based products were sent to the lab for testing. BCC was identified in 8 samples of non-sterile ultrasound gel. Immediate action was taken to rapidly recall the product system wide. Supply Chain quickly purchased and distributed a replacement product at all campuses. The manufacturer was contacted, the Department of Health was notified, and Infection Prevention alerted neighboring health care systems. Conclusion Risk assessments were done to assess the use of ultrasound gel and the cleaning of transducers within the health care system. System wide education commenced for the proper use of ultrasound gel and equipment to prevent patient infections. A total of 11 patients were identified with BCC during the outbreak. Whole genome sequencing linked 10 of the patient isolates to a national outbreak associated with contaminated ultrasound gel. This investigation emphasizes both the need for rapid mobilization in the event of an outbreak to prevent additional morbidity and mortality and the importance of assessing appropriate use of non-sterile ultrasound gel and equipment within healthcare facilities. Disclosures Brett Gilbert, D.O., F.A.C.O.I., Pfizer: speaker bureau.