Contaminated aqueous benzalkonium chloride. An unnecessary hospital infection hazard.

During January and February 1975, nine patients on a single ward of a rural Tennessee hospital unexpectedly developed sepsis. The aseptic technique employed in the management of intravenous infusions was implicated. Pseudomonas cepacia was recovered from the following: bloodstream, inuse intravenous infusions and the antiseptic, aqueous benzalkonium chloride. The outbreak again calls attention to the infection risk associated with the use of this product. Selection of less hazardous antiseptics and disinfectants is strongly recommended.