An outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection associated with nebulized albuterol therapy

Ann Intern Med. 1995 May 15;122(10):762-6. doi: 10.7326/0003-4819-122-10-199505150-00005.


Objective: To investigate an outbreak of Burkholderia (formerly Pseudomonas) cepacia respiratory tract colonization and infection in mechanically ventilated patients.

Design: A retrospective case-control and bacteriologic study.

Setting: Veterans Affairs medical center.

Patients: 42 mechanically ventilated patients who developed respiratory tract colonization or infection with B. cepacia and 135 ventilator-dependent controls who were not colonized and did not develop infections.

Measurements: Clinical and demographic data; benzalkonium chloride concentrations and pH levels in albuterol sulfate solutions; repetitive-element polymerase chain reaction (PCR)-mediated molecular fingerprinting on eight patient isolates and three environmental B. cepacia isolates that were available for study.

Results: 42 patients had B. cepacia respiratory tract colonization or infection. Observation of intensive care unit and respiratory care personnel showed faulty infection control procedures (for example, the same multiple-dose bottle of albuterol was used for many mechanically ventilated patients). More case patients (39 [92.9%]) than controls (95 [70.4%]; P = 0.006) received nebulized albuterol, and case patients (67.5 treatments) received more treatments than controls (18 treatments; P < 0.001). In-use albuterol solutions had pH values that were unstable, and benzalkonium chloride concentrations declined over time to levels capable of supporting bacterial growth. Medication nebulizers and in-use bottles of albuterol harbored B. cepacia. Molecular fingerprints of patient isolates and environmental B. cepacia isolates were identical using repetitive-element PCR. No further isolates of B. cepacia were identified after institution of appropriate infection control procedures.

Conclusions: Multiple-dose medications and reliance on benzalkonium chloride as a medication preservative provide a mechanism for nosocomial spread of microorganisms, particularly if infection control procedures are not carefully followed. Repetitive-element PCR is a useful fingerprinting technique for molecular epidemiologic studies of B. cepacia.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.

MeSH terms

  • Aged
  • Albuterol / administration & dosage
  • Burkholderia cepacia* / isolation & purification
  • Case-Control Studies
  • Cross Infection / epidemiology*
  • Disease Outbreaks
  • Drug Contamination
  • Equipment Contamination
  • Humans
  • Middle Aged
  • Nebulizers and Vaporizers*
  • Pseudomonas Infections / epidemiology*
  • Respiration, Artificial / adverse effects*
  • Respiratory Tract Infections / epidemiology*
  • Respiratory Tract Infections / microbiology
  • Retrospective Studies


  • Albuterol