In October 2010, a child at The Children's Hospital (TCH) in Aurora, Colorado, with newly diagnosed leukemia developed clinical sepsis 24 hours after insertion of an implanted vascular access device. The child also developed extensive cellulitis at the insertion site, requiring surgical debridement, intensive care, antibiotics, prolonged wound management, and outpatient treatment. Cultures of the child's blood and tissue specimens grew Bacillus cereus. An investigation found neither breach of infection control procedures nor any violations of sterile surgical technique.