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Originator: National Patient Safety Alert - UKHSA

Issue date: Originally issued on 07-Dec-2023 17:07:11. This version was issued on 07-Dec-2023 17:07:11

This alert has been issued to:
  • Care Trusts
  • Mental Health Trusts
  • Specialists Trusts
  • Learning Disabilities Trusts
  • Mental Health & Social Care Trusts
  • Ambulance Trusts
  • Mental Health & Learning Disabilities Trusts
  • Acute Trusts
  • Community Trusts

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • Social Care Providers (registered with CAS)
  • Special Health Authorities
  • Territorial CMOs in Northern Ireland, Scotland & Wales
  • Regional Directors of Public Health
  • Director of Public Health
  • GP - Locum
  • NHS 111 and Out of hours providers
  • GP Practices
  • Integrated Care Boards
  • Community Pharmacy
  • Primary Care Networks
  • GP Practices 1

Action category: Action

Title: Potential contamination of some carbomer-containing lubricating eye products with Burkholderia cenocepacia - measures to reduce patient risk

Broadcast content:

***02 April 2024 Update:

As of 21 March 2024, the UK Health Security Agency (UKHSA) and the multi-stakeholder Incident Management Team are satisfied that the risk associated with this outbreak has reduced. The Medicines and Healthcare products Regulatory Agency (MHRA) are satisfied that carbomer-containing lubricating eye products available on the UK market are safe to use. There is no longer an indication to avoid use of these products (aside from those that have been previously recalled). Therefore, the recommendation previously communicated to ‘avoid the use of all carbomer-containing eye products in individuals with cystic fibrosis, patients being cared for in critical care settings, the severely immunocompromised and patients awaiting lung transplantation’ is no longer required and has been stepped down.

The other recommendations within this National Patient Safety Alert remain. UKHSA has published further information on this outbreak in the Health Protection Report - Outbreak of Burkholderia cepacia complex associated with carbomer-containing lubricating eye products in the United Kingdom, 2023 to 2024 which can be accessed from the link below:


Update ends***

UKHSA is investigating an outbreak of Burkholderia cenocepacia involving individuals across the UK. This is an emerging issue and, following testing, B. cenocepacia was recovered from some lubricating carbomer eye products.

Additional information: NHS England Regions: please cascade this alert to community pharmacy contractors

Alert reference: NatPSA/2023/015/UKHSA

Action underway deadline: 11-Dec-2023

Action complete deadline: 17-Dec-2023


Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency