An epidemic in a coronary care unit caused by Pseudomonas species.

Five patients in a coronary care unit were involved in an epidemic caused by a nonfermenting Gram-negative bacillus, presumptively identified by our laboratory as Pseudomonas cepacia. All medications administered intravenously to these patients were cultured. Because morphine was the only such medication common to the treatment of all the patients involved, a vial used in the unit at that time was cultured, as were two previously-entered vials of saline solution and several sterile vials of distilled water used in the preparation of injectable medication. The Pseudomonas cepacia organism was recovered from one of the vials of saline solution. The epidemic ended as soon as the practice of re-entering the vials of sterile saline solution was discontinued.