For readers following the FDA recall of alcohol prep pads , the CDC has added information with “Notes from the Field: Contamination of Alcohol Prep Pads with Bacillus cereus Group and Bacillus Species  — 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:
- Sterile syringes prefilled with sterile saline solution,
- Sterile applicators packaged with a 2% chlorhexidine gluconate/70% alcohol solution for skin preparation
- Pledgets packaged with 70% isopropyl alcohol (alcohol prep pads)
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.