An unusual source of Burkholderia cepacia outbreak in a neonatal intensive care unit

Summary During a two-month period, seven preterm infants in our neonatal intensive care unit (NICU) were found to have sepsis with Burkholderia cepacia demonstrated by blood culture. A complete environmental investigation was conducted to identify the source of infection. Caffeine citrate was found to be the source of this organism. The offending drug was immediately withdrawn from the NICU and the hospital pharmacy, and local authorities were informed. All seven babies were discharged with no infection-related morbidities.