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Outbreak of Pseudomonas aeruginosa
perichondritis associated with ear piercings and
a contaminated water system
Claire E. Brown
1
, Derren Ready
1,2
, Caroline Willis
3
, Ben Sims
3
, Nick Young
1
,
Elizabeth Sheridan
4
, Helen Osbourne
5
, Louise Jones
5
, Yvette Landy
5
, Naomi Long
1
,
Amy Walkden
1
, Jane F. Turton
6
, Karren Staniforth
6
, Ginny Moore
7
, Simon Parks
7
,
Patricia Barkoci
7
and Sarah Bird
1
1
Health Protection Operations, South West, UK Health Security Agency, Bristol, UK;
2
NIHR Health Protection Research
Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK;
3
Food Water and Environmental
Microbiology Laboratory Porton, UK Health Security Agency, Salisbury, UK;
4
Department of Microbiology, University
Hospitals Dorset, Dorset, UK;
5
Environmental Health Team, Bournemouth, Christchurch and Poole Council, Dorset, UK;
6
HCAI, Fungal, AMR, AMU and Sepsis Division, UK Health Security Agency, London, UK and
7
Diagnostics and Pathogen
Characterisation, UK Health Security Agency, Salisbury, UK
Abstract
In September 2023, the UK Health Security Agency’s (UKHSA) South West Health Protection
Team received notification of patients with Pseudomonas aeruginosa perichondritis. All five
cases had attended the same cosmetic piercing studio and a multi-disciplinary outbreak control
investigation was subsequently initiated. An additional five cases attending the same studio were
found. Seven of the ten cases had isolates available for Variable Number Tandem Repeat
(VNTR) typing at the UKHSA national reference laboratory. Clinical and environmental
P. aeruginosa isolates from the patients, handwash sink, tap water and throughout the wall-
mounted point-of-use water heater (including outlet water) were indistinguishable by VNTR
typing (11,6,2,2,1,3,6,3,11). No additional cases were identified after control measures were
implemented, which included replacing the sink and point-of-use heater.
The lack of specific recommendations to control for P. aeruginosa within Council-adopted ear-
piercing byelaws or national guidance means that a cosmetic piercing artist could inadvertently
overlook the risks from this bacterial pathogen despite every intention to comply with the law
and follow industry best practice advice. Clinicians, Environmental Health Officers and public
health professionals should remain alert for single cases of Pseudomonas perichondritis infec-
tions associated with piercings and have a low threshold for notification to local health
protection teams.
Introduction
P. aeruginosa is a Gram-negative, opportunistic, bacterial pathogen commonly found in wet
environments with the ability to form biofilms in water systems including contamination of taps,
flow straighteners, sinks and pipes [1]. This bacterium can colonise and infect the human body
and is known to cause a range of opportunistic infections in susceptible people, including
infections of skin and soft tissues, bloodstream, respiratory and urinary infections [2].
P. aeruginosa is a recognised cause of sporadic piercing-related infections, generally
occurring 2–4 weeks after the piercing has taken place. Transmission typically occurs through
direct contact of the piercing site with water or aftercare products contaminated with
P. aeruginosa [3,4]. Infections have previously been associated with swimming in fresh/pool
water and poor hygiene [3,4]. P. aeruginosa is the most common causative agent of perichon-
dritis [5,6] and piercing-related perichondritis is becoming more likely as high ear piercings
(defined as involving the superior third of the pinna cartilage) have grown in popularity
[7]. High ear piercing carries an increased risk of infection and complications because the area
has a low blood supply. If left untreated, perichondritis can result in invasive infections or
permanent deformity of the ear [3,5].
There are few reports of outbreaks of P. aeruginosa associated with piercings. These have
identified high ear piercing, contaminated aftercare solutions, newly trained staff and discount
events to encourage higher demand, as potential risk factors [1,4]. As Pseudomonas species is not
a notifiable causative agent under the Health Protection (Notification) Regulations 2010 [8]
burden of infections related to ear piercing is difficult to determine.
In September 2023, UK Health Security Agency (UKHSA) South West was notified by a local
hospital of a cluster of five cases of perichondritis that had been treated by the ENT department
Epidemiology and Infection
www.cambridge.org/hyg
Original Paper
Cite this article: Brown CE, Ready D, Willis C,
Sims B, Young N, Sheridan E, Osbourne H,
Jones L, Landy Y, Long N, Walkden A, Turton
JF, Staniforth K, Moore G, Parks S, Barkoci P
and Bird S (2025). Outbreak of Pseudomonas
aeruginosa perichondritis associated with ear
piercings and a contaminated water system.
Epidemiology and Infection,153, e8, 1–6
https://doi.org/10.1017/S0950268824001572
Received: 20 February 2024
Revised: 07 June 2024
Accepted: 01 July 2024
Keywords:
ear piercing; infection prevention and control;
P. aeruginosa; perichondritis; water system
Corresponding author:
D. Ready;
Email: derren.ready@ukhsa.gov.uk
© The Author(s), 2025. Published by Cambridge
University Press. This is an Open Access article,
distributed under the terms of the Creative
Commons Attribution licence (http://
creativecommons.org/licenses/by/4.0), which
permits unrestricted re-use, distribution and
reproduction, provided the original article is
properly cited.
following ear piercings undertaken at the same piercing venue. At the
time, P. aeruginosa had been cultured from specimens collected from
four of the cases. All cases required admission to the hospital for at
least 48 h with intravenous antibiotics administered and three cases
required surgical incision and drainage. A multi-agency outbreak
control team (OCT) was convened and led by the UKHSA South
West Health Protection Team (HPT) to identify the source and
extent of the outbreak and to support the implementation of control
measures to prevent further infections. Investigations focused on
identifying if the causative strain was common to all cases and
whether there were any common source exposures, which included
an investigation of the piercing venue environment. We describe the
investigation and control measures taken for this outbreak.
Methods
Case finding and case definitions
An alert was sent to local acute clinicians and primary care pro-
viders highlighting the possibility of P. aeruginosa infection in
patients presenting with a skin infection at the site of a recent
piercing. They were asked to seek advice on appropriate manage-
ment of such infections and to notify confirmed or suspected cases
to infection control teams (in acute settings) and the local health
protection team. Using client lists provided by the venue under
investigation, a “warn and inform”letter was sent to all individuals
who had any piercing performed at the venue since 01.08.2023
(100 people). The letter was sent to raise awareness of signs and
symptoms of piercing infection and to ask anyone who had experi-
enced an infection to contact the HPT, to assist in case finding and
epidemiological investigation.
For the purpose of the outbreak investigation, cases were defined
as a confirmed outbreak case if a person had a laboratory culture-
confirmed P. aeruginosa infection with the outbreak strain / Vari-
able Number Tandem Repeat (VNTR) type 11,6,2,2,1,3,6,3,11;
following a body-piercing (any part of the body) at the venue under
investigation from 1st August 2023 onwards; a probable case was as
confirmed, but with no strain VNTR typing being available.
Epidemiological methods
All individuals identified as having a piercing infection following
piercing at the venue under investigation were interviewed using a
bespoke online trawling questionnaire to gather information
including exposures and clinical presentation. This included infor-
mation about the piercing including body site, processes used in the
venue, aftercare advice given and practice, product provided/used,
symptoms and if medical care was sought.
Clinical microbiological methods
Samples collected from infected piercing sites were cultured to
recover P. aeruginosa and sent to the national Antimicrobial Resist-
ance and Healthcare Acquired Infections (AMRHAI) reference
unit for confirmation of identity and further typing. Typing was
carried out using Variable Number Tandem Repeat (VNTR) ana-
lysis at nine loci as previously described [9,10].
Environmental investigations
The ear-piercing service was being provided by a self-employed
cosmetic piercer who had previously registered with the local
Council in accordance with the provisions of the Local Government
(Miscellaneous Provisions) Act 1982. Upon first registration, the
business had been proactively visited by an Environmental Health
Officer and there had been no cause for concern with respect to
compliance with the locally adopted Byelaws for ear-piercing and
cosmetic piercing. With the exception of the circumstances of the
outbreak, the Council had not received any recent complaints about
hygiene or safety at the studio or the ear-piercing activity specific-
ally.
All cosmetic piercing was carried out in a separate small room to
the tattooing area and this was at the rear of the premises. Inside the
room was a portable trolley that was used to make the equipment
readily accessible during the piercing procedure. The room had a
single handwash basin with hot water provided via a wall-mounted
point-of-use water heater. A foot-operated bin was used for clinical
waste and a sharps bin was available for all sharps waste. Reusable
equipment was placed on one side for cleaning before the next use.
A small autoclave used to sterilise jewellery was situated in the
tattoo area, however, this remained accessible to the cosmetic
piercing artist.
The venue was visited the day after notification (day 1) by
Environmental Health to review procedures related to piercing,
and 16 environmental samples were taken from the taps and the
sink. Aftercare solutions, soap, disinfectants, alcohol wipes, envir-
onmental cleaning solutions and hot and cold water samples were
also collected. Follow-up environmental and water samples from
the ear-piercing room were taken 18 days later, after the sink and
wall-mounted point-of-use water heater had been replaced. As part
of the remedial work, the wall-mounted, point-of-use, water heater
from the ear-piercing room was removed and replaced with a new
heater. The original heater was removed from the premises and
transported to UKHSA where it was dismantled and tested.
Sampled products were transported to the UKHSA Food Water
and Environmental Microbiology (FW&E) Laboratory and tested
using a standard method. For soaps and solutions, an aliquot of 25 g
(or all of the available volume if less than 25 g) was homogenised
with sufficient Buffered Peptone Water (BPW) to prepare a 10
1
dilution. Swabs were immersed in 100 ml of BPW and agitated to
disperse any micro-organisms. A portion (0.5 ml) of this suspen-
sion was inoculated directly onto Pseudomonas CN Selective Agar
(PCN) plates and incubated at 37 °C for 48 h. The remaining
volume was incubated at 30 °C for 24 h after which time, a 10 μL
portion was sub-cultured to a PCN plate, which was then incubated
at 37 °C for 48 h. For water samples, a 100 ml aliquot was filtered
through a cellulose ester membrane (0.45 μm pore size) using
negative pressure. Filter membranes were placed onto PCN plates
and incubated as above. Presumptive Pseudomonas colonies (blue/
green or yellow/green and oxidase positive) were further identified
using a MALDI-ToF instrument (Bruker). Representative isolates
from each sample giving colony identifications as P. aeruginosa
were sent to the national UKHSA reference unit for confirmation of
identity and VNTR typing, as previously described [9,10].
Results
Seven confirmed and three probable cases were identified, with
dates of piercing at the venue between 37 days before notification
and the day of notification (Figure 1). All cases were female, with a
median age of 26 years (range: 14–49 years); seven cases required
admission to the hospital, and all reported attending secondary care
because of their infection. Questionnaires were completed with
8/10 cases (5 confirmed and 3 probable). For the 8 cases completing
the questionnaire, the median age was 26 years (range: 17–49 years).
2 Claire E. Brown et al.
All cases reported cartilage ear piercings (4/8; 50% Helix, 3/8; 38%
Tragus, 1/8; 13% antihelix). The median number of days from
piercing to first sign of infection was reported to be 3 days
(Range: 0–4 days). All cases reported that a needle was used to
perform the piercing. None of the cases reported the use of a spray
or solution during or immediately after the piercing process, five
cases mentioned the use of a wipe on the ear area. Three cases
reported purchasing an aftercare solution/spray from the venue to
use at home. A range of other aftercare options were reported by
cases including homemade saline solution/spray (6/8; 75%), solu-
tion/spray purchased elsewhere (2/8; 25%), and antibacterial pur-
chased elsewhere (1/8; 13%). In addition, two cases (25%) reported
using an antibacterial cream provided by their primary care Gen-
eral Practitioner (GP). Cases commonly reported accessing health-
care services for their infection, including GP services (8/8; 100%),
telephone advice via NHS 111 (7/8; 88%), ear, nose and throat (7/8,
88%), accident and emergency (6/8; 75%) and five cases reported
admission to the hospital (63%).
Microbiology
Bacterial isolates recovered from three of the cases were not avail-
able for VNTR typing as they had been discarded. Isolates from all
7 patients for which isolates were available and from environmental
samples (n = 7; Table 1) collected from sinks, cold water taps and
the wall-mounted, point-of-use, water heater, all shared a unique
VNTR profile of 11,6,2,2,1,3,6,3,11. A general profile of 11,6,2,2,1,3,
x,x,x (where x is variable) corresponds to the ‘clone C’lineage,
which is commonly found in the environment and associated with
human infections [9]. Follow-up samples of water from the ear-
piercing room 18 days later, after remedial action, were negative for
P. aeruginosa. As part of the remedial work, the wall-mounted
point-of-use water heater (Figure 2) from the ear-piercing room
was removed and dismantled and individual components were
tested for the presence of P. aeruginosa. Heavy colonisation with
P. aeruginosa was detected in multiple components (valves, O-rings
and tubing) before and after the heating element within the unit,
although no growth was observed from the heater itself.
Environmental investigations
Piercing was undertaken either by appointment or on a walk-in
basis. Every client was required to complete a consent form, and this
helped the investigators ascertain the number of people who had
received a piercing.
The procedures for preventing the risk of infection were deter-
mined by interviewing the piercer. Reusable body-piercing equipment,
such as clamps, were initially hand washed in the utensil wash sink and
then soaked in metal lidded trays for 30 min in a bactericidal multi-
enzyme detergent concentrate diluted with water from the washbasin
in accordance with the manufacturer’s instructions. The equipment
was then rinsed, air-dried, and placed in autoclave bags and then
autoclaved for 45 min. The sterilised equipment was subsequently
stored in its bag ready for use for a maximum of 3–4months.
All surfaces in the piercing room were cleaned with a cleaning
and disinfection solution (Chemgene) using disposable paper
towels that were disposed of in a foot-operated bin. Hands were
washed with a pre-prepared antimicrobial hand and skin cleanser
(Opti-Scrub) and dried with disposable paper towels. Gloves were
then worn. Equipment used for the piercing was set out in advance
Figure 1. Epidemic Curve: day of onset of confirmed and probable cases (n = 10).
Epidemiology and Infection 3
including clamps, needle, guide pin, gloves, jewellery, pre-injection
swab, spare paper towel for wiping excess petroleum jelly or bleed-
ing, ink (gentian violet), disposable ink pot and a toothpick.
The client’s skin was cleaned with a 70% alcohol pre-injection
swab. A toothpick is used to mark a dot for the piercing site on the
skin using ink from a disposable ink pot. The toothpick is then
discarded.
A single-use needle is used to pierce the skin and other equip-
ment is unpackaged from the sterilised autoclave bags as required.
A pre-made aftercare product is offered for post-piercing care.
Control measures
The existing Council-adopted byelaws for ear-piercing and cos-
metic piercing refer in general terms to the cleansing and steril-
isation of equipment and require, among other things, an
adequate supply of hot and cold water. There are no specific
references within the byelaws to control for P. aeruginosa in the
water supply. Similarly, the CIEH Tattooing and body-piercing
guidance toolkit [11] includes comprehensive guidance on many
aspects of health and safety and infection control, however, the
emphasis is on the control of blood-borne viral infections. The
lack of specific byelaws or guidance, consequently, means that a
cosmetic piercing artist could inadvertently overlook
P. aeruginosa as a risk despite having the best of intentions to
follow industry best practices.
Once the problem had been brought to the attention of the
business in question, the piercing artist voluntarily ceased higher
ear-piercing activities on day 2 and all piercing activities on day
4 while remedial action was undertaken.
A bespoke letter was drafted and sent by the IMT to the business
to help mitigate the risk, which included the use of alcohol hand gel
post-handwashing. This provided details of the investigation find-
ings to date, information about P. aeruginosa and detailed steps that
could be taken to reduce the risk to future clients.
Table 1. Pseudomonas aeruginosa results for swabs and water samples from
the ear-piercing and tattoo rooms in the premises used by patients
Date of
sampling Location Sampling point
Ps. aeruginosa
result
Outbreak
strain
Day 1 Ear-piercing
room
Swab of point-of-
use hot water
unit
Detected Yes
Swab of point of use
hot tap
Not detected –
Swab of the tap
handle
Not detected –
Cold water 2 cfu in 100 ml Yes
Water from the
autoclave
reservoir
Not detected in
100 ml
–
Day 2 Ear-piercing
room
Swab of plug-hole Detected Yes
Swab of cold tap Detected Yes
Swab of wash basin Detected Yes
Swab of
disinfectant
bottle
Not detected -
Point of use hot
water
>100 cfu in
100 ml
Yes
Cold water 1 cfu in 100 ml Yes
Aftercare solution Not detected –
Antimicrobial liquid
soap
Not detected –
Enzymatic
instrument
cleaner
Not detected –
Topical disinfectant
solution
Not detected –
Alcohol wipes Not detected –
Day 19 Ear-piercing
room
Cold water tap
-pre-flush Not detected in
100 ml
–
-post flush Not detected in
100 ml
–
Point of use hot
water tap
-pre-flush Not detected in
100 ml
–
-post flush Not detected in
100 ml
–
Swab of the wash
basin
Not detected –
Swab of plug hole Not detected –
Figure 2. Wall-mounted water-heater unit.
4 Claire E. Brown et al.
Discussion
This investigation found strong environmental, microbiological
and descriptive epidemiological evidence that an outbreak of
P. aeruginosa infections following ear piercings carried out in the
South West was associated with a single venue. All cases were in
females, which concurs with the findings of a systematic review
which reported that post-piercing perichondritis was most com-
monly seen in adolescent and young adult females [12]. According
to the review patients typically delay seeking medical care for
approximately one week following the initial onset of symptoms.
This might suggest that the verbal and written aftercare advice
clients’receive following their piercing could be improved to fur-
ther encourage healthcare-seeking behaviour when their piercing is
not healing as expected. In this outbreak, one additional case came
forward because of the warning and inform letter, which demon-
strated an added case ascertainment value to sending these letters.
The median number of days between the piercing date and onset
of first symptoms was 3 days which supported the hypothesis that
these infections occurred around the time of the piercing procedure
rather than resulting from exposure to a contaminated aftercare
solution. In previous studies, in which perichondritis outbreaks
were linked to P. aeruginosa-contaminated aftercare solutions or
sprays, longer time scales were seen before symptoms appeared,
typically being 14–15 days [4,13]. In this incident, the rapid
deployment of a bespoke trawling questionnaire allowed the Inci-
dent Management Team to quickly rule out any common aftercare
usage between the cases and focus controls at the venue.
Environmental swabs and water samples from the venue
recovered isolates of P. aeruginosa that were indistinguishable by
VNTR typing from the seven confirmed human cases. The use of
VNTR typing was key to this investigation in identifying that a
common type was shared between cases and environmental sam-
ples taken from the business. Whole genome sequencing (WGS)
provides a high level of strain characterisation and discrimination
[13], as VNTR is the accredited methodology for Pseudomonas
typing currently used by the UKHSA reference laboratory this
allowed comparison with an existing database of over 40,000 pre-
viously typed isolates. Although 19 VNTR loci are described for
Pseudomonas, for routine, rapid typing, a nine-locus scheme has
previously been shown to offer sufficient discrimination between
types [10]. Interestingly, environmental isolates from the water,
sink, and throughout the wall-mounted point-of-use water heater
suggested that contamination of the water system allowed a reser-
voir to persist in the environment. The persistence of P. aeruginosa
in water systems is well recognised as a risk in the healthcare
environment [14], and there is a requirement in the UK for water
in augmented care areas of hospitals to be monitored for this
organism (HTM 04-01) and for remedial actions to be put in place
where high levels are detected [15]. However, there are no similar
requirements for monitoring and control of hot and cold water
supplies outside of the hospital environment. It is evident that the
invasive nature of ear-piercing provides a portal of entry for this
pathogen and that it would be advantageous to update the existing
toolkit to facilitate risk reduction strategies. It has previously been
shown that the piercing method does not impact on risk of peri-
chonditis and prevention of post-piercing perichonditis should
focus on hygiene and aftercare [16].
Post-remedial action testing at day 19 did not recover
P. aeruginosa from the water systems and no additional cases were
identified after control measures were implemented and remedi-
ation of the venue was completed. In a similar outbreak in North
West England in 2016, indistinguishable P. aeruginosa types were
isolated from cases and environmental samples taken from taps and
sinks following an ear-piercing event [1], however, this outbreak
was also associated with an inexperienced practitioner. Piercings
can be carried out by untrained or inexperienced individuals, who
may have little to no knowledge of appropriate aseptic techniques
resulting in suboptimal hygiene and decontamination processes
[1,3]. Therefore, the availability of clear guidelines to reduce the risk
of post-piercing bacterial infections is key, especially, in conjunction
with proactive and close working of businesses with Environmental
Health teams [1].
Recommendations
Recommendations to piercers should focus on education, hygiene
and aftercare;
•Good record-keeping to support case ascertainment and warn
and inform communication.
•Use of single-use sterile products where possible.
•Ensure verbal and written advice is given to customers to
highlight the risk of high ear piercings and encourage clients’
healthcare-seeking behaviour. Aftercare leaflets are available
within the CIEH toolkit.
•Ensure training of piercing practitioners in appropriate aseptic
techniques
•Ensure regular maintenance of water systems and heaters
Recommendations to clinicians and public health professionals;
•Improve case ascertainment using letters to health profes-
sionals and customers.
•Trawling questionnaires can be used to rapidly identify com-
mon exposures among cases.
•In outbreak settings water samples should be collected from
sinks traps, water heaters and water outlets.
•Environmental Health Practitioners to foster close working
relationships with local venues.
•Guidance to tattooists and piercers could be updated to cover
the risk of both Pseudomonas infections and contaminated
water systems.
Conclusion
Compared to piercing of the ear lobe, high ear (cartilage) piercings
are associated with a greater risk of complications which can be
more difficult to treat [3]. Accurate and prompt diagnosis of
Pseudomonas perichondritis is key as it requires treatment with
appropriate antimicrobial therapy [7]. As P. aeruginosa perichon-
dritis infection can lead to abscess formation, loss of cartilage and
complications requiring surgical intervention, antibiotic therapy,
drainage, and debridement, resulting in potentially lifelong disfig-
urement, clinicians should remain alert for cases of Pseudomonas
perichondritis infections associated with piercings. Whilst all pier-
cing procedures carry a risk of infection it is unusual to see a cluster
of inpatient admissions of this severity in a short period. Rapid
public health action was likely to have prevented further cases as no
additional cases were seen after controls and remediation were put
in place.
Data availability statement. This manuscript describes a limited series of
cases, and as such there is no broader dataset for release. Any queries regarding
the data can be directed to the authors.
Epidemiology and Infection 5
Acknowledgements. The authors would like to thank members of the Out-
break Control Team. DR acknowledges support from the NIHR Health Protec-
tion Research Unit in Behavioural Science and Evaluation at the University of
Bristol.
Author contribution. Investigation: A.C.W., H.O., K.S., E.S., N.L., P.B., S.P.,
B.S., C.W., C.E.B., J.T., L.J., N.Y., S.B., Y.L., D.R.; Methodology: A.C.W., H.O.,
K.S., E.S., N.L., P.B., S.P., B.S., C.W., C.E.B., G.M., L.J., N.Y., S.B., Y.L., D.R.;
Project administration: A.C.W., H.O., N.L., B.S., L.J., Y.L.; Writing –review &
editing: A.C.W., H.O., K.S., E.S., N.L., P.B., S.P., B.S., C.W., C.E.B., G.M., J.T.,
L.J., N.Y., S.B., Y.L., D.R.; Resources: E.S., D.R.; Conceptualization: C.W., C.E.B.,
N.Y., S.B., D.R.; Formal analysis: C.W., C.E.B., J.T., N.Y., S.B., D.R.; Writing –
original draft: C.W., C.E.B., G.M., J.T., N.Y., S.B., D.R.; Visualization: C.E.B.;
Supervision: S.B.
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