Fig. 1

Epidemiological curve of the B. cepacia UTI outbreak. Even after implementing infection control measures, cases of infection continued to occur until the contaminated anesthetic gel was recalled and the outbreak terminated. a A report on August 21, 2018 showed that most B. cepacia infections originated prior to hospital admission, indicating that the cases did not constitute an outbreak. b On September 13, 2018, case findings were expanded to include the entire hospital and the epidemiological investigation was repeated, confirming the outbreak. B. cepacia was only detected from a cystoscope used by one patient. c Terminal disinfection was performed on October 26, 2018. d The cystoscope sampling method was replaced on November 11, 2018. B. cepacia was detected from one batch of anesthesia gel, then all anesthesia gels were recalled and the outbreak was terminated