Long after resolution of the neonatal respiratory distress syndrome, deterioration of respiratory function in ventilated premature infants during severe nosocomial infections is commonly observed. Based on an increased oxygen demand and ventilatory support, impairment of the pulmonary surfactant system was hypothesized to occur. The clinical course of 10 premature neonates (764 +/- 57 g, 26.6 +/- 0.4 wk) with nosocomial infection mainly due to Staphylococcus epidermidis was divided into four periods in each individual patient: "before deterioration" (average 8 to 11 d of life), "deterioration" (11 to 17 d), "peak" (17 to 22 d), and "recovery" (22 to 24 d). A total of 810 airway specimens were obtained by small volume lavage (1 ml/kg bw), pooled to yield appropriate amounts for differential centrifugation into two distinct subfractions known as large surfactant aggregates (LA) and small surfactant aggregates (SA). "Before deterioration" the amount of phospholipids recovered was constant, and the two fractions were characterized by electron microscopic morphology and biochemical analysis. In the LA fraction lamellar body-like lipid structures were demonstrated, and the phospholipid composition was typical of pulmonary surfactant in premature neonates with a high content of phosphatidylcholine and phosphatidylinositol. With "deterioration" and "peak" the masses of total phospholipids and of phosphatidylcholine recovered were reduced (p < 0.05). At the same time the mass ratio of SA/LA for phosphatidylcholine decreased from 0.32 +/- 0.10 to 0.18 +/- 0.03, indicating a more pronounced decrease of the SA fraction (p < 0.05). The phospholipid composition in the LA fraction did not change during the course of nosocomial infection. In the SA fraction a decrease of phosphatidylcholine and a concomitant increase in lysophosphatidylcholine were observed at the "peak" of the infection. We concluded that, in ventilated premature neonates during nosocomial infection and respiratory deterioration, changes in phospholipid subfractions occur, possibly indicating impairment of pulmonary surfactant metabolism. These findings may be important when considering treatment of acute lung injury with nebulized exogenous surfactant.