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Illnesses in Colorado Children’s Hospital Prompts Discovery of Contaminated Alcohol Pads

A small cluster of unusual illnesses at a Colorado children’s hospital prompted an investigation that swiftly identified alcohol prep pads contaminated with Bacillus cereus bacteria, according to a report in the July issue of Infection Control and Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America. The investigation ultimately led to an international recall of the contaminated products.

The illnesses prompted an immediate investigation by the hospital’s infection prevention and control team and microbiology laboratory. The investigators focused on time, place, persons, procedures, equipment, and products that may have been common to each case. They 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.

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