National Patient Safety Alert: Potential contamination of non-sterile alcohol-free skin cleansing wipes with Burkholderia spp: measures to reduce patient risk

National Patient Safety Alert: Potential contamination of non-sterile alcohol-free skin cleansing wipes with Burkholderia spp: measures to reduce patient risk

National Patient Safety Alert Reference Number:  NatPSA/2025/002/UKHSA

Date of issue: 26/06/2025

Explanation of identified safety issue

UKHSA is investigating an outbreak of Burkholderia stabilis involving individuals across the UK, linked to wipes. Following testing, Burkholderia spp (full identification pending) has been recovered from several non-sterile alcohol-free skin cleansing wipes, including those used for wound care and included in first aid kits.

Health professionals should be aware that skin cleansing wipes not marked as ‘sterile’ may present risk. Non-sterile alcohol-free wipes should not be used for cleaning of intravascular devices or for care of broken skin including wounds. UKHSA is making recommendations to reinforce good practice to protect patients including those most at risk of significant health consequences from B. stabilis.

Actions required

Actions to be completed by 29 August 2025

1. For intravascular access device care: ensure local guidance and practice reflects National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (EPIC3). Non-sterile alcohol-free wipes are not suitable for this purpose.
2. Ensure that patients in the community with intravascular devices are aware to only use wipes if instructed to by their clinical team. These patients should only use wipes provided or recommended by their clinical team in accordance with (1). Non-sterile alcohol-free wipes are not suitable. All patients with intravascular devices need this information even if they have not been instructed to access their line. Incorporate this into local guidance, patient education and information.
3. Community healthcare providers should advise patients to only use wipes marked as sterile on any broken skin including wounds. Ensure that local guidance, practice and patient information reflects NHS guidance.
4. NHS Trusts and independent sector laboratories are requested to submit any isolate from a new infection with Burkholderia cepacia complex, including any new isolations from cystic fibrosis patients to the UKHSA AMRHAI reference laboratory (details provided below).

Additional information

Further information and resources for healthcare professionals.

1. Healthcare professionals are asked to ensure local guidance and clinical practice is aligned with relevant guidelines for patients with intravascular devices, including:
   • • National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (EPIC3)
     • WHO’s (2024) ‘Guidelines for the prevention of bloodstream infections and other infections associated with the use of intravascular catheters – Part 1: peripheral catheters’.
2. Wipes used in first aid kits should be individually wrapped and sterile, in compliance with British Standard BS8599-1.
3. Advice for patients
   • • Patients with intravascular access devices who have concerns about their wellbeing or who have queries regarding their care in relation to this alert, should be instructed to contact their clinical team.
     • If patients are acutely unwell, they should seek medical attention via appropriate routes: NHS get medical help advice
     • Symptoms of intravascular line infections can include signs such as fever, chills, and redness, swelling, or pain around the insertion site.
     • Symptoms of infection can include redness, swelling, increased pain, warmth around a wound/break in skin, and pus or other drainage from the wound/break in skin.

Please see full guidance in the alert.