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News From the Centers for Disease Control and Prevention
January 27, 1999

Nosocomial Burkholderia cepacia Infection and Colonization Associated With Intrinsically Contaminated Mouthwash—Arizona, 1998

JAMA. 1999;281(4):318. doi:10.1001/jama.281.4.318-JWR0127-4-1

MMWR. 1998;47:926-928

During August 1996-June 1998, 74 patients at two hospitals in Arizona had cultures positive for Burkholderia cepacia. Most isolates were from the respiratory tracts of patients in intensive-care units (ICUs). Because of the large number of B. cepacia isolates, personnel at both hospitals requested the Arizona Department of Health Services assist in an investigation. This report summarizes the results of the investigation.

A case of infection or colonization was defined as a positive culture for B. cepacia from the respiratory tract of any ICU patient at these hospitals during August 31, 1996-June 12, 1998 (epidemic period). Hospital microbiology records were reviewed to identify all isolates of B. cepacia during the pre-epidemic (January 1, 1994-August 30, 1996) and epidemic periods. Case-patient medical records, respiratory therapy procedures, and ICU nursing procedures were reviewed.