Ahamed Sha Beevifatimah, Tambyah Paul Anantharajah, Poh Li Shi, Rethenam Sarathamani, Alenton Lilibeth Silagan, Chee Poh Ling, Sun Yong Yuan, Sii Yong Peng, Yan Zherong Gabriel, Ratnayake Lasantha, Ang Michelle, Chua Gerald, Pada Surinder Kaur
Infection Control Nurse, Ng Teng Fong General Hospital, Singapore, Singapore.
Department of Infectious Disease, National University Hospital, Singapore, Singapore.
Antimicrob Steward Healthc Epidemiol. 2025 Jul 21;5(1):e161. doi: 10.1017/ash.2025.182. eCollection 2025.
is an environmental Gram-negative bacterium, resistant to many antibiotics and antiseptics, that can survive in aqueous hospital environments. We investigated an outbreak of in the intensive care unit (ICU) of Ng Teng Fong General Hospital, aiming to identify the source and prevent further transmission.
The outbreak was detected after two ICU patients developed bacteremia. Environmental samples, including ultrasound gels, and disinfectants, were collected. Whole genome sequencing (WGS) was used to determine clonality between clinical and environmental isolates. Immediate actions were taken, including a recall of ultrasound gel batches and the use of sterile gel sachets for high-risk procedures.
Ultrasound gels from opened and unopened bottles from multiple hospital areas, including ICU and Radiology, were found to be contaminated with , with a specific batch (Brand A) linked to the outbreak. WGS analysis confirmed the genetic relatedness of clinical and environmental isolates. A hospital-wide recall of affected gel batches was implemented. Through our regional networks, notification of countries in our immediate region along with alerting our local health authorities for further investigation was also undertaken. Additionally, we continued surveillance of gels and identified further contaminated products.
This outbreak highlights the risks of contaminated medical products, specifically ultrasound gels. Effective environmental sampling, rapid identification, and clear communication with health authorities were key to controlling the outbreak. We have since revised our protocols to mandate the use of sterile gel for invasive procedures and continue monitoring for potential contamination in ultrasound gels.
是一种环境革兰氏阴性菌，对多种抗生素和防腐剂具有抗性，可在医院的水性环境中存活。我们对新加坡黄廷方综合医院重症监护病房（ICU）爆发的疫情进行了调查，旨在确定源头并防止进一步传播。
在两名ICU患者发生菌血症后检测到此次疫情。收集了包括超声凝胶和消毒剂在内的环境样本。采用全基因组测序（WGS）来确定临床分离株和环境分离株之间的克隆性。立即采取了行动，包括召回超声凝胶批次，并在高风险操作中使用无菌凝胶小包装。
在包括ICU和放射科在内的多个医院区域，从打开和未打开的瓶子中取出的超声凝胶被检测出受到污染，其中一个特定批次（品牌A）与此次疫情有关。WGS分析证实了临床分离株和环境分离株的基因相关性。医院对受影响的凝胶批次进行了全院范围的召回。通过我们的区域网络，我们还通知了周边地区的国家，并提醒当地卫生当局进行进一步调查。此外，我们继续对凝胶进行监测，并发现了更多受污染的产品。
此次疫情凸显了受污染医疗产品的风险，特别是超声凝胶。有效的环境采样、快速识别以及与卫生当局的清晰沟通是控制疫情的关键。此后，我们修订了规程，规定在侵入性操作中必须使用无菌凝胶，并继续监测超声凝胶中潜在的污染情况。
