Hospital microbial environment: need for continual surveillance.

In an epidemic of nosocomial infection, Pseudomonas cepacia emerged as a significant pathogen capable of causing severe infection. The epidemic was controlled by tracing and controlling the source of the infection, which proved to be "sterile" water and "in-use" dilution antiseptic. Problems of sterile water were controlled by regular maintenance of equipment and surveillance. Antiseptic problems were overcome by changing the type of antiseptic, and paying attention to correct concentration of "in-use" dilution. A four-year follow-up of the water supply shows no further problems. Further infectious episodes caused by P. cepacia have not been encountered.