Introduction:

The Burkholderia cepacia has been described as an outbreaks-causing agent, in which case frequently corresponds to environmental sources.

Materials and Methods:

Having the clinical suspicion of an outbreak or a pseudo-outbreak of B. cepacia in an Intensive Care Unit (ICU), samples in sterile solutions were sent to the laboratory for microbiologic study and molecular analysis.

Results:

Eigth patients with positive blood cultures for B. cepacia were identifed in the adults and pediatric ICU, ages between 3 months to 88 years. Blood cultures were taken through a central venous catheter. None of the patients presented clinical manifestations of infection. There was a positive culture of B. cepacia in a chlorhexidine sachet soap batch and in samples from the washbasin that was correlated with molecular analysis with patient samples. The withdrawal of the chlorhexidine sachet soap batch plus the optimization of cleaning and disinfection processes and patient isolation, were effective to control the pseudo-outbreak, without presenting infection.

Conclusions:

One pseudo-outbreak was documented by B. cepacia, affecting the adult and pediatric ICU caused by the contamination of a chlorhexidine sachet soap batch and the washbasins.

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