TWO extensive healthcare-associated outbreaks of Burkholderia cepacia complex have been reported across the United Kingdom and Ireland, highlighting the persistent risk posed by contaminated medical and hygiene products in hospital environments. The outbreaks, spanning more than a decade, involved Burkholderia cepacia and Burkholderia contaminans and underscore the diagnostic and infection control challenges these organisms present.
Investigators identified 153 cases linked to B. cepacia and 66 cases involving B. contaminans. A large majority of isolates were recovered from invasive sites, reflecting the potential for severe infection among hospitalized patients. The outbreak strain of B. cepacia was traced to non-sterile ultrasound gel, while B. contaminans was initially suspected to be linked to the same product. Further analysis confirmed disinfectant wipes as the source, with genomic evidence showing a close relationship between clinical and product isolates.
Outbreak control required coordinated action across multiple agencies. The implicated wipes were removed from circulation, while procurement of the ultrasound gel was suspended. National guidance was issued rapidly, including a Patient Safety Alert to mitigate further risk. The investigation highlighted the difficulties of identifying the true source of infection in complex healthcare environments where multiple non-sterile products are in routine use.
The findings reinforce the need for healthcare systems to adopt a low threshold for investigating clusters of B. cepacia complex infections. Multidisciplinary approaches, rapid product withdrawal, and prompt dissemination of guidance were shown to be critical for protecting patients. The authors emphasize that contaminated water-based products remain an underrecognized threat to hospital safety and call for heightened vigilance among infection control teams and procurement bodies.
For U.S. clinicians, these findings offer an important reminder that the risk of product-linked outbreaks is not confined to specific regions. Similar vigilance and preparedness are required to prevent widespread infection when contaminated products enter healthcare supply chains.
Reference: Doran J et al. Two concurrent nationwide healthcare-associated outbreaks of Burkholderia cepacia complex linked to product contamination, UK and Ireland, 2010-2023. Infect Control Hosp Epidemiol. 2025:1-7.
