Consecutive outbreaks of Burkholderia cepacia complex caused by intrinsically contaminated chlorhexidine mouthwashes.

Background: We report 2 consecutive outbreaks of the Burkholderia cepacia complex (Bcc) in an intensive care unit (ICU) and describe its characteristics and consequences.

Methods: Over a 72-day period, a multidisciplinary ICU team detected 2 distinct periods of high and unusual incidence of Bcc isolates that were recovered from cultures of endotracheal aspirate. Cultures of tap water, ultrasound gel and mouthwash (opened and unopened bottles) were performed.