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Two concurrent nationwide healthcare-associated outbreaks of Burkholderia cepacia complex linked to product contamination, UK and Ireland, 2010–2023
Published online by Cambridge University Press: 04 September 2025
Abstract
Background:
Species of the Burkholderia (B.) cepacia complex (Bcc) have been implicated in multiple nosocomial outbreaks linked to contaminated water-based products, including liquid soaps, mouthwash, and other non-alcoholic aqueous solutions.
Objective:
We describe two substantial healthcare-associated outbreaks of Bcc (B. cepacia and B. contaminans) in the United Kingdom and Ireland associated with contaminated products. We highlight the challenges during investigation and mitigation, and provide recommendations.
Methods:
A multidisciplinary, multi-stakeholder investigation across both outbreaks was adopted, involving interviews, trawling questionnaires, and targeted product sampling.
Results:
There were 153 and 66 confirmed cases in the B. cepacia and B. contaminans outbreaks, respectively. Cases predominantly comprised hospitalized individuals, and 70% of isolates were recovered from an invasive site. The outbreak strain of B. cepacia was isolated from non-sterile ultrasound gel. An analytical study suggested the B. contaminans cluster was also linked to ultrasound gel; however, a disinfectant wipe product was subsequently identified as the source (0–3 single nucleotide polymorphism differences between case and wipe isolates).
Outbreak control measures:
The affected disinfectant wipes were withdrawn. The ultrasound gel was not recalled but health system procurement was suspended, rapid clinical guidance was produced and a National Patient Safety Alert was issued. Inter-organizational partnership was required to mitigate risks.
Conclusion:
Identifying the source of outbreaks associated with contaminated products can be challenging, requiring complex multi-stakeholder interventions. We recommend a low threshold for investigation of Bcc clusters, adopting a multidisciplinary approach to investigation and mitigation, implementing interventions focusing on practice, and prompt product removal to protect patients.
Information
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- © Crown Copyright - UK Health Security Agency, 2025. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America
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An addendum has been issued for this article:
Jason Doran
[Opens in a new window]Jason Doran
, Clare Foster
[Opens in a new window]Clare Foster
, Mike Saunders
[Opens in a new window]Mike Saunders
, Nastassya L Chandra
[Opens in a new window]Nastassya L Chandra
, Jane F Turton
[Opens in a new window]Jane F Turton
, Dervla TD Kenna
[Opens in a new window]Dervla TD Kenna
, Caroline Willis
, Alex Orlek
[Opens in a new window]Alex Orlek
, Lesley L. Smith
, Peter Hoffman
, Hannah Choi
[Opens in a new window]Hannah Choi
, Geraldine Leong
, Mariyam Mirfenderesky
[Opens in a new window]Mariyam Mirfenderesky
, Mark H. Wilcox
[Opens in a new window]Mark H. Wilcox
, Neville Q Verlander
[Opens in a new window]Neville Q Verlander
, Susanna Frost
[Opens in a new window]Susanna Frost
, David Elliott
[Opens in a new window]David Elliott
, Amy Weaver
[Opens in a new window]Amy Weaver
, Yu Wan
[Opens in a new window]Yu Wan
, Susan Hopkins
[Opens in a new window]Susan Hopkins
, Isabel Oliver
[Opens in a new window]Isabel Oliver
, Colin S Brown
[Opens in a new window]Colin S Brown
and J.W.T. Elston
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