Pseudomonas cepacia in an intensive care nursery

A small epidemic of Pseudomonas cepacia infection in an intensive care nursery was associated with contaminated, distilled water. This appeared to have occurred because of a leak in the distiller, contaminating its effluent. The distilled water was not subsequently sterilized, nor were the bottles used to distribute it. The epidemic was promptly terminated by substitution of sterile, distilled water distributed in sterile containers. Both professional and nonprofessional hospital personnel failed to oversee the appropriateness of handling of patient care materials.