Potential Contamination of Non-Sterile Alcohol-Free Skin Cleansing Wipes with Burkholderia spp: Measures to Reduce Patient Risk

The UK Health Security Agency (UKHSA) has issued a National Patient Safety Alert (NatPSA) regarding the potential contamination of non-sterile alcohol-free skin cleansing wipes with Burkholderia spp., particularly Burkholderia stabilis. This follows an outbreak involving multiple individuals across the UK, with confirmed cases linked to the use of these wipes.

This NatPSA, reference NatPSA/2025/002/UKHSA, reinforces safe practice guidance and the use of appropriate products for intravascular access device care and care of broken skin including wounds.

Following an NHS Supply Chain review of our existing frameworks, and in consultation with relevant framework Category teams, items that are currently under investigation by UKHSA are not listed on any of our frameworks, including those covering first aid and wound care kits.

In alignment with this NatPSA, NHS Supply Chain is actively undertaking activities to ensure resilience of its sterile product offer to support application of the recommendations outlined in the NatPSA. 

• Burkholderia stabilis was recovered from several non-sterile alcohol-free wipes, including those used for wound care and in first aid kits.
• 48 confirmed cases have been reported in the UK, with 77% of isolates retrieved from normally sterile body sites (e.g. blood).
• Many cases involved those with indwelling intravascular devices or recent line insertions/removals, immunocompromised individuals or those with serious co-morbidities.

Clinical Practice and Guidance Updates

• Do not use non-sterile alcohol-free wipes for:
  • Cleaning intravascular devices.
  • Care of broken skin or wounds.
• Ensure local clinical guidance aligns with EPIC3 guidelines for preventing healthcare-associated infections.

Patient Education

• Patients with intravascular devices should be informed to only use wipes recommended by their clinical team.
• Reinforce that only sterile wipes should be used on broken skin or wounds.

Community and Home Care

• Community healthcare providers must ensure patients understand the risks and proper use of wipes.
• Incorporate this information into patient education materials and discharge instructions.

Surveillance and Reporting

• NHS Trusts and labs are asked to submit any new Burkholderia cepacia complex isolates to the UKHSA AMRHAI reference lab for further investigation.

This alert has been issued as a National Patient Safety Alert. 

The NHS England National Patient Safety Team was the first national body to have been accredited to issue National Patient Safety Alerts by the National Patient Safety Alerting Committee (NaPSAC). All National Patient Safety Alerts are required to meet NaPSAC’s thresholds and standards. 

These thresholds and standards include working with patients, frontline staff and experts to ensure alerts provide clear, effective actions for safety-critical issues. 

NaPSAC requires providers to introduce new systems for planning and coordinating the actions required by any National Patient Safety Alert across their organisation, with executive oversight. 

Failure to take the actions required under any National Patient Safety Alert may lead to CQC taking regulatory action. 

Patient safety alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS). 

See our Useful Links section to read more about our Medical and Surgical Consumables category and associated frameworks, together with further information about National Patient Safety Alerts and the Central Alert System.