We report on a pseudooutbreak of Burkholderia cepacia because of the use of a contaminated disinfectant during quality controls in a university blood bank. No septic reactions associated with transfusions had been reported in patients over the last 6 months. Analysis of the individual quality control procedures showed that a disinfectant based on a quaternary ammonium compound (QAC) had been used in order to disinfect the rubber stopper of the blood culture bottle. B. cepacia was found in a sample taken from this disinfectant, which was prepared with concentrate and tap water according to the manufacturer's instructions. The four isolates (one in disinfectant and three in blood components) were found to be identical in their biochemical reactions and resistance patterns. QAC-based disinfectants are not efficacious against a part of the spectrum of gram-negatives and are therefore inadequate. After introduction of an alcohol-based preparation, no more cases of B. cepacia contamination have been identified.
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