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. 2025 Jul 21;5(1):e161.
doi: 10.1017/ash.2025.182. eCollection 2025.

The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia

Beevifatimah Ahamed Sha  1 , Paul Anantharajah Tambyah  2 , Shi Poh Li  1 , Sarathamani Rethenam  1 , Lilibeth Silagan Alenton  1 , Ling Chee Poh  1 , Yuan Sun Yong  1 , Peng Sii Yong  1 , Gabriel Yan Zherong  3 , Lasantha Ratnayake  4 , Michelle Ang  5 , Gerald Chua  6 , Surinder Kaur Pada  7
Affiliations

The risk of contaminated ultrasound gels in the intensive care unit: lessons from an outbreak of Burkholderia cenocepacia

Beevifatimah Ahamed Sha et al. Antimicrob Steward Healthc Epidemiol. .

Abstract

Background: Burkholderia cenocepacia is an environmental Gram-negative bacterium, resistant to many antibiotics and antiseptics, that can survive in aqueous hospital environments. We investigated an outbreak of B. cenocepacia in the intensive care unit (ICU) of Ng Teng Fong General Hospital, aiming to identify the source and prevent further transmission.

Methods: The outbreak was detected after two ICU patients developed B. cenocepacia bacteremia. Environmental samples, including ultrasound gels, and disinfectants, were collected. Whole genome sequencing (WGS) was used to determine clonality between clinical and environmental isolates. Immediate actions were taken, including a recall of ultrasound gel batches and the use of sterile gel sachets for high-risk procedures.

Results: Ultrasound gels from opened and unopened bottles from multiple hospital areas, including ICU and Radiology, were found to be contaminated with B. cenocepacia, with a specific batch (Brand A) linked to the outbreak. WGS analysis confirmed the genetic relatedness of clinical and environmental isolates. A hospital-wide recall of affected gel batches was implemented. Through our regional networks, notification of countries in our immediate region along with alerting our local health authorities for further investigation was also undertaken. Additionally, we continued surveillance of gels and identified further contaminated products.

Conclusions: This outbreak highlights the risks of contaminated medical products, specifically ultrasound gels. Effective environmental sampling, rapid identification, and clear communication with health authorities were key to controlling the outbreak. We have since revised our protocols to mandate the use of sterile gel for invasive procedures and continue monitoring for potential contamination in ultrasound gels.

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Conflict of interest statement

All authors have read and approved the final version of the manuscript and have no conflicts of interest to disclose.

Figures

Figure 1.
Figure 1.
Maximum likelihood phylogenetic analysis of 30 ST241 B. cenocepacia isolates.
Figure 2.
Figure 2.
Event timeline.
See this image and copyright information in PMC

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