An outbreak of Burkholderia cenocepacia associated with contaminated chlorhexidine solutions prepared in the hospital

From October to December 2007, an outbreak of Burkholderia cenocepacia occurred in a secondary care hospital. The 19 B cenocepacia isolated from the patients, the chlorhexidine solutions of each different ward, and the purified water that diluted these solutions exhibited an identical pulsed-field gel electrophoresis pattern. Inadequate preparation of chlorhexidine solutions diluted with contaminated purified water may have resulted in an outbreak of B cenocepacia. Adequate preparation of chlorhexidine solutions should be emphasized.