Outbreak of healthcare-associated Burkholderia cenocepacia bacteraemia and infection attributed to contaminated ‘sterile’ gel used for central line insertion under ultrasound guidance and other procedures

Prof. Ramon Shaban1,2,10, Dr Samuel Maloney2,3, Dr John Gerrard2,3, Professor Peter Collignon4,5,6, Dr Deborough Macbeth2,10, Professor Marilyn Cruickshank10, Dr Anna Hume2,3, Dr Amy Jennison9, Dr Rikki Graham9, Mr Haakon Bergh8, Dr Heather Wilson6, Dr Petra Derrington7

1Menzies Health Institute Queensland, Griffith University, Kessels Rd, NATHAN, Australia,

2Infection Control Department, Division of Infectious Diseases and Immunology Gold Coast Hospital and Health Service, Southport, Australia,

3Gold Coast Hospital and Health Service Pathology Queensland | Health Support Queensland, Southport, Australia,

4The Canberra Hospital, Australia, Canberra, Australia,

5School of Medicine, Australian National University, Canberra, Australia,

6Department of Infectious Diseases and Microbiology Canberra Hospital and Health Services, Canberra, Australia,

7Pathology Queensland | Health Support Queensland Department of Health | Queensland Government, Brisbane, AUSTRALIA,

8Central Microbiology – Molecular Bacteriology /Quality Pathology Queensland | Health Support Queensland, Brisbane, Australia,

9Molecular Epidemiology, Public Health Microbiology Forensic and Scientific Services | Health Support Queensland Department of Health | Queensland Government, Brisbane, Australia,

10School of Nursing and Midwifery, Griffith University, Australia, Nathan, Australia


We report an outbreak of Burkholderia cenocepacia bacteraemia and infection in 11 patients predominately in ICUs caused by contaminated sterile ultrasound gel used in central line insertion and sterile procedures within four hospitals in Australia.


Burkholderia cenocepacia was first identified in the blood cultures of a patient from the intensive care unit (ICU) at the Gold Coast University Hospital on the 26th of March 2017, with subsequent cases during April. The Outbreak Response Team (ORT) commenced investigative measures including liaison with medical and scientific peers across Australia via professional electronic forums, discovering other isolates in neighbouring health services.


The outbreak investigation identified the point source as contaminated sterile gel packaged in sachets for use within the sterile ultrasound probe cover. In total, 11 patient isolates of Burkholderia cenocepacia with the same MLST sequence type were identified. This typing was the same as identified in the contaminated gel isolate with SNP based typing, demonstrating that all linked isolates clustered together. We estimate the time period from confirmation of point source to TGA notification, issuance of recall notice and national organisation notification was 36 hrs.


Identifying, arresting and preventing this and other single point-source outbreaks in multiple jurisdictions is critically reliant on a rapid, integrated and coordinated response that draws on both formal and informal professional networks.


Professor Ramon Shaban is Clinical Chair of Infection Prevention and Control at Gold Coast Health and Director of the Griffith University Graduate Infection Prevention and Control Programs Credentialled Infection Control Professional Expert (CICP-E), he is a member of the Australian Strategic and Technical Advisory Group on Antimicrobial Resistance and the Australian Commission on Safety and Quality in Health Care Healthcare-associated Infection Advisory Committee. He is President of the Australasian College for Infection Prevention and Control, a Senior Editor of Infection, Disease and Health, and in 2016 was a Temporary Advisor (Antimicrobial Resistance) to the World Health Organization Western Pacific Region.

Recent Comments