Illnesses in Colorado Children’s Hospital due to Contaminated Alcohol Pads
A small cluster of unusual illnesses at a Colorado children’s hospital led to an investigation that quickly found alcohol preparation pads contaminated with Bacillus cereus bacteria, according to a report in the July issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America. The investigation led to an international recall of the contaminated products.
“At Children’s Hospital Colorado, three patients in the fall of 2010 were seriously ill and had positive cultures of an unusual nature, in this case, cultures associated with Bacillus cereus” (Susan Dolan, RN, MS, CIC, certified infection control nurse and one of the investigators)
Bacillus cereus is a spore-forming, gram-positive bacterium and is known to cause food poisoning and other more serious infections, especially in individuals with weakened immune systems. The bacteria are capable of surviving in alcohol solutions.
The occurrence of these illnesses prompted an immediate investigation by the hospitals microbiology laboratory and the infection prevention and control team. The investigation focused on time, places, procedures, persons, equipment and products that may have been common to each case. The investigators found three products with which each patient had contact;
- a saline solution used to flush intravenous (IV) catheters
- alcohol preparation pads that have a variety of uses in healthcare such as disinfecting the cap on an IV catheter
- a solution and device used to disinfect the skin before invasive procedures
After a matter of days, laboratory tests revealed Bacillus cereus and other Bacillus species growing from the preparation pads. This prompted an immediate recall of the product throughout the paediatric healthcare system. The Colorado Department of Public Health and Environment and the Food and Drug Administration were notified of these findings and both agencies confirmed the preparation pads as being contaminated with Bacillus on the inside and outside of the package. Following this, there was issued an international recall of the contaminated wipes and the eventual discontinuation of the brand identified.
“Alcohol prep pads are among one of the most widely used products in healthcare, but are not always sterile products. Many healthcare facilities were using these pads but were not aware there were non-sterile because there were not labelled as such.” (Dolan)
As a result of the investigation, Children’s Hospital Colorado now uses only preparations pads explicitly labelled as sterile. The researchers suggest regulations requiring clear labelling on such products.