Outbreak of healthcare-associated Burkholderia cenocepacia bacteraemia attributed to contaminated sterile ultrasound gel used for central venous cannulation: Issues with global notification and response

We report an outbreak Burkholderia cenocepacia bacteremia in 12 patients in ICUs caused by contaminated sterile ultrasound gel associated with use during central line insertion within four hospitals in Australia. The outbreak investigation identified the point source as contaminated sterile gel packaged in sachets for use within the sterile ultrasound probe cover. All 12 patient isolates and the isolate grown from the gel were the same MLST sequence type with SNP based typing demonstrating that all linked isolates clustered together. Identifying, arresting and preventing single point source outbreaks in multiple jurisdictions is critically reliant on an integrated and coordinated response that draws on both formal and informal professional networks.