From December 29, 1988, to January 21, 1989, Pseudomonas cepacia was isolated from peritoneal fluid of four patients and blood of two patients at a children's hospital in Texas. In three of four patients who were receiving inpatient peritoneal dialysis for renal failure, clinical findings were consistent with peritonitis. Two intensive-care unit (ICU) patients, who were not on dialysis, whose blood cultures grew the organism had no clinical findings attributable to P. cepacia bacteremia.
Hospital personnel recovered P. cepacia in pure culture from three previously opened 1-gallon containers of Clinidine, a povidone-iodine solution (Clinipad Corporation, Guilford, Connecticut, Lot #823529, expiration date: September 1991). Solution from this lot was being used by the peritoneal dialysis staff to disinfect tops of multidose vials of dialysis fluid additives, peritoneal fluid administration set connectors, and ports of peritoneal dialysis systems. Clinidine was also being used by ICU staff for antisepsis of skin before venipuncture
Contaminated Povidone-Iodine Solution—Texas. Arch Dermatol. 1989;125(5):607. doi:10.1001/archderm.1989.01670170021002