A small cluster of unusual illnesses at a Colorado children’s hospital prompted an investigation that quickly identified alcohol prep pads contaminated with Bacillus cereus bacteria, according to a report in the July issue of Infection Control and Hospital Epidemiology . The investigation also led to an international recall of the specific brand of alcohol prep pads involved.
“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,” said Susan Dolan, RN, MS, CIC, a certified infection control nurse and one of the investigators.
A spore-forming, gram-positive bacteria, Bacillus cereus are historically known to cause food poisoning, but can also cause more serious infections, especially in people with weakened immune systems. The bacteria are capable of surviving in alcohol solutions.
The investigators found three products with which each patient had contact: a solution and device used to disinfect the skin before invasive procedures, a saline solution used to flush intravenous (IV) catheters, and alcohol prep pads that have a variety of uses in healthcare such as disinfecting the cap on an IV catheter.
Lab tests showed B. cereus and other Bacillus species growing from the prep pads, prompting an immediate recall of the product throughout the pediatric healthcare system. The investigation ultimately led to an international recall of the contaminated wipes and the eventual discontinuation of the brand identified in the case.
“Alcohol prep pads are among one of the most widely used products in healthcare, but are not always sterile products,” Dolan said. “Many healthcare facilities were using these pads but were not aware they were non-sterile because they were not labeled as such.”
As a result of the investigation, Children’s Hospital Colorado now uses only prep pads explicitly labeled as sterile. The researchers suggest regulations requiring clear labeling on such products.