Association of Bacillus cereus Infection with Contaminated Alcohol Prep Pads

Background. Bacillus species have caused healthcare-associated outbreaks of invasive disease as well as pseudo-outbreaks. We report an outbreak investigation of blood cultures positive for Bacillus cereus associated with alcohol prep pads (APPs) contaminated with B. cereus and Bacillus species resulting in a rapid internal product recall and subsequent international product recall.Design. Epidemiologic and microbiologic outbreak investigation.Setting. A 300-bed tertiary care children’s hospital in Aurora, Colorado.Patients. Patients with blood or cerebrospinal fluid cultures positive for B. cereus.Methods. Three patients with blood cultures positive for B. cereus were identified in late 2010. Breaches in procedural and surgical techniques, common interventions, and products were explored. The following 3 common products were cultured: sterile saline syringes, chlorhexidine/alcohol skin preparation solution, and APPs. Repetitive sequence-based polymerase chain reaction (Rep-PCR) was used to compare isolate...