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Association of Bacillus cereus Infection with Contaminated Alcohol Prep Pads

Susan A. Dolan RN MS CIC, Cynthia Littlehorn MT SM(ASCP), Mary P. Glodé MD, Elaine Dowell MT SM(ASCP), Karen Xavier BS MT(ASCP), Ann-Christine Nyquist MD MSPH and James K. Todd MD
Infection Control and Hospital Epidemiology
Vol. 33, No. 7 (July 2012), pp. 666-671
DOI: 10.1086/666334
Stable URL:
Page Count: 6
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Association of Bacillus cereus Infection with Contaminated Alcohol Prep Pads
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Background. Bacillus species have caused healthcare-associated outbreaks of invasive disease as well as pseudo-outbreaks. We report an outbreak investigation of blood cultures positive for Bacillus cereus associated with alcohol prep pads (APPs) contaminated with B. cereus and Bacillus species resulting in a rapid internal product recall and subsequent international product recall.Design. Epidemiologic and microbiologic outbreak investigation.Setting. A 300-bed tertiary care children’s hospital in Aurora, Colorado.Patients. Patients with blood or cerebrospinal fluid cultures positive for B. cereus.Methods. Three patients with blood cultures positive for B. cereus were identified in late 2010. Breaches in procedural and surgical techniques, common interventions, and products were explored. The following 3 common products were cultured: sterile saline syringes, chlorhexidine/alcohol skin preparation solution, and APPs. Repetitive sequence-based polymerase chain reaction (Rep-PCR) was used to compare isolates obtained from patients and from APPs and was confirmed by independent pulsed-field gel electrophoresis.Results. There appeared to be a significant increase in blood cultures positive for B. cereus during 2009–2010. B. cereus and other Bacillus species were cultured from the internal contents of 63.3% of APPs not labeled as sterile, and 8 of the 10 positive lots were manufactured after 2007. None of the isolates obtained from the patients matched strains isolated from the APPs. However, some lots of APPs had strains that were indistinguishable from one another.Conclusions. APPs that were not labeled as sterile were contaminated with Bacillus species. The product was immediately recalled internally and replaced with APPs from another manufacturer that were labeled as sterile. On January 3, 2011, the manufacturer voluntarily recalled its APPs. Healthcare facilities, healthcare providers, and users of APPs should avoid the use of APPs not specifically labeled as sterile.

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