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During a hospital outbreak of Pseudomonas cepacia a traditional epidemiological investigation was proved to be misleading. Suppression of the suspected antiseptic did not stop the epidemics. A further investigation proved that it was due to the intravenous injection of contamineted anesthetic vials. Fever, chills, lack of hemodynamic disorders and of metastatic absceses characterize the clinical state of the infected patients. The removal of the catheters for perfusion was sometimes necessary to stop the bacteraemia. A lack of medical information is responsible of the outbreak.
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