The antiseptic used? clorhexidine? was alcoholic or water solution?

And the blood transfusion? Were they transfused?

Vonberg RP, Gastmeier P. Hospital-acquired infections related to contaminated substances. J Hosp Infect. 2007 Jan;65(1):15-23. Epub 2006 Dec 4. Review.

PMID:17145102

Ebner W, Meyer E, Schulz-Huotari C, Scholz R, Zilow G, Daschner FD. Pseudocontamination of blood components with Burkholderia cepacia during quality controls. Transfus Med. 2005 Jun;15(3):241-2.

PMID:15943710

García-Erce JA, Grasa JM, Solano VM, Gimeno JJ, López A, Hernández MJ, Marco ML, Arribas JL, Giralt M. Bacterial contamination of blood components due to Burkholderia cepacia contamination from clorhexidine bottles. Vox Sang. 2002 Jul;83(1):70-1. 

PMID: 12100392

Burkholderia

Dear Colleague

In early 2000, we had an outbreak of bacteremia in Sao Paulo related to Burkholderia. In the investigation we found that there was contamination with zinc ampoule were added to parenteral nutrition in ICU patients or not.

The problem was resolved after the withdrawal of the product.

I believe that research should focus injectables solutions and investigate the contamination through the microbiological control.

Good luck

Ralstonia pickettii and Burkholderia cepacia complex bloodstream infections related to infusion of contaminated water for injection

B.M. Moreira , M.B.G.P. Leobons, F.L.P.C. Pellegrino, M. Santos, L.M. Teixeira, E. de Andrade Marques, J.L.M. Sampaio, C.L. Pessoa-Silva

DOI: http://dx.doi.org/10.1016/j.jhin.2004.09.036

Evaluating the quality of outbreak reports on health care-associated infections in São Paulo, Brazil, during 2000-2010 using the ORION statement findings and recommendations

Amanda Luiz Pires Maciel, RN, Denise Brandão de Assis, MD, MSc, Geraldine Madalosso, MD, MSc, Maria Clara Padoveze, RN, MSc, PhD

DOI: http://dx.doi.org/10.1016/j.ajic.2013.12.017