Contaminated eye gel contributed to one death and dozens of infections - UKHSA report

April 03, 2024

One person in the UK has died and many others were infected after using a contaminated gel to treat dry eyes, a government report has suggested.

The UK Health Security Agency (UKHSA) investigated an outbreak of the bacteria Burkholderia cepacia complex (Bcc) associated with specific brands of lubricating eye gel.

A Health Protection Report said there were 52 confirmed and six probable cases across the UK linked with the outbreak between January 2023 and February 2024.

Twenty five of these people were considered to have "clinically significant infections attributable to Bcc" - 11 of which had eye infections, 9 had respiratory infections and four had bacteremia (bacteria entering the bloodstream).

Two people with cystic fibrosis were infected, and while one was treated, the other died with the report finding Bcc infection was "considered to have contributed to the death of one case".

Of all those affected, the youngest person was a baby while the oldest was 91 years old.

Seven out of 10 cases (71%) were among patients in hospital with 38 cases needing critical care.

Bcc is widely found within the environment, such as soil and water, and are naturally resistant to many antibiotics, the report said.

Safety notice

It added Bcc "very rarely causes infection" among healthy people but can cause severe infections in people with weakened immune systems and those living with cystic fibrosis.

In November last year, the medicines watchdog, the Medicines and Healthcare products Regulatory Agency (MHRA), issued a safety notice on certain batches of carbomer-containing gel "due to possible microbiological contamination".

At the time, certain batches of three eye gels were recalled - AaCarb, Aacomer and Puroptics.

Following this, the charity Cystic Fibrosis Trust urged people not to use the withdrawn products.

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The MHRA said that it has now received "sufficient assurance from manufacturers and suppliers to conclude that products available on the UK market are safe to use and free of contamination".

Cystic Fibrosis Trust has now said: "All patients can now use carbomer-containing lubricating eye products, with the exception of the recalled products."

"UKHSA will continue to follow up new cases and keep vigilance for emergent clusters of Burkholderia cepacia complex," the Health Protection Report said.

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