Burkholderia cepacia – outbreak in obstetric patients due to intrinsic contamination of non-sterile ultrasound gel

When the cluster was realised a microbiological investigation of the environment was initiated (e.g. surfaces, equipment, ultrasound gels of different manufacturers). Isolates of three different patients and four isolates of ultrasound gel bottles (two opened and two sealed) were investigated by Puls-Field-Gel-Electrophoresis (PFGE) to clarify clonality and source. Environmental specimens revealed no growth of B. cepacia. The four bottles from the incriminated manufacturer (two opened, two sealed bottles, all belonging to the same batch) were highly contaminated with B. cepacia (up to 40.000 CFU/ml). These isolates and the three patients' isolates showed the same genotype pattern by PFGE. We, therefore, concluded that the whole batch of these non-sterile gels was affected by monoclonal intrinsic contamination with B. cepacia due to insufficiently controlled manufacturing procedures. There is a need for discussion about microbiological contamination levels tolerated in such non-sterile ultrasound gels, especially when used on susceptible sites such as mucous membranes.