In December 2020, Public Health England identified a cluster of Burkholderia contaminans cases from different hospitals. As there was a wide distribution of cases, it was thought to be due to a common product source and national outbreak was declared. During the investigation a further outbreak strain was identified, B. cepacia genomovar-1 which was also included in the investigation.

The multidisciplinary investigation team included IPC subject matter experts who had a good insight into the care of patients and challenges of the healthcare environment. They were therefore well placed to contact and engage with busy IPC teams during unprecedent pandemic challenges to gather valuable information about the cases. This information help identify common themes, inform product selection, support the development of the trawling questionnaire and analytical epidemiological study.

A single brand of ultrasound gel was found to be the source of the B.cepacia – genomovar-1 outbreak. The role of IPC was pivotal in liaising with IPC teams and users of ultrasound gel which highlighted a lack of national and local ultrasound gel guidance and areas of questionable practice and risk.

IPC specialists helped to inform and deliver control measures that were put in place to mitigate the risk, including the development of interim ultrasound gel guidance and a webinar to support the delivery of key messages.

A Field Safety Notice was issued in June 21 recalling certain batch numbers of environmental disinfectant wipes that were found to be contaminated with B.contaminams. Whole Genome Sequencing confirmed that that wipes matched the outbreak strain.