02/03/23 Health Advisory: Multistate Cluster of Antibiotic Resistant Bacteria Associated with Artificial Tears

Warning yellow triangle with black exclamation point on left. "Health Advisory" on right.

Actions requested

  • Providers, facilities and consumers should stop using EzriCare Artificial Tears until epidemiological investigations and lab analyses are complete.
  • Labs that identify carbapenem-resistant Pseudomonas aeruginosa (CRPA) or Verona Integron-mediated Metallo-β-lactamase (VIM) in any specimen should submit the isolate to Washington State Public Health Labs.


Washington State Department of Health (DOH) and Centers for Disease Control and Prevention (CDC) are investigating a cluster of antibiotic-resistant infections that may be linked to artificial tears. The most frequently reported brand was EzriCare Artificial Tears, a preservative-free product dispensed in muti-dose bottles. These over-the-counter eye drops are sold widely in stores and online. CDC’s tests of EzriCare Artificial Tears found VIM-CRPA in opened EzriCare bottles. They are further characterizing the VIM-CRPA to determine if they match the outbreak strain. CDC continues to test unopened bottles of EzriCare Artificial Tears.

From May 17, 2022, to Jan. 19, 2023, CDC, with state and local health departments, identified 56 isolates from 50 patients in 11 states: California, Colorado, Connecticut, Florida, New Jersey, New Mexico, New York, Nevada, Texas, Utah and Washington. Specimen collection occurred in outpatient and inpatient settings May to December 2022. Isolates were found in clinical cultures of cornea (10), sputum or bronchial wash (11), urine (6), other nonsterile sources (4), blood (2), and from rectal swabs (23). Patient outcomes include permanent vision loss resulting from ocular infection, hospitalization, and death from bloodstream infection.

In addition to carbapenem resistance, isolates in this cluster are resistant to ceftazidime and cefepime; the subset of isolates that underwent antimicrobial susceptibility testing for ceftazidime‐avibactam and ceftolozane‐tazobactam were also resistant to these agents. Isolates are sequence type (ST) 1203, harbor blaVIM‐80 and blaGES‐9 (a combination not previously observed in the United States) and are closely related based on analysis of whole genome sequencing (WGS) data.