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CDC updates about infected prep pads

For readers following the FDA recall of alcohol prep pads [1], the CDC has added information with “Notes from the Field: Contamination of Alcohol Prep Pads with Bacillus cereus Group and Bacillus Species [2] — Colorado, 2010” in  Morbidity and Mortality Weekly Report (MMWR) for March 25.

The story involves two separate incidents at The Children’s Hospital (THC) in Aurora, CO, which led investigators to Bacillus cereus-infected alcohol prep pads.

In October 2010, a child at THC developed B cereus and an investigation revealed there had been no improper infection control practices or unsterilized surgical equipment. In November 2010, an infant at the hospital became clinically septic after a jugular line was placed, but again, no improper infection control practices were found.

According to the report, TCH then focused its investigation on three single-use disposable items that were used on both children:

The alcohol prep pads were not labeled as either sterile or nonsterile on the outside of each pad’s packaging  or on the box they came in. Hospital investigators found that B cereus was present in 40 of the 60 alcohol pads around the hospital.

THC stopped using all  nonsterile alcohol prep pads after the investigation and replaced with only  sterile ones.