A Suspected Hospital Outbreak of Pseudobacteremia Due to Pseudomonas stutzeri

Pseudomonas stutzeri was recovered from blood cultures of 24 patients from 1977 through 1979 at one Mayo Clinic-affiliated hospital. During the investigation it was determined that aqueous green soap--used throughout the hospital to prepare the skin for iv insertions--had probably become contaminated with P. stutzeri. The use of aqueous green soap was discontinued, but eight additional cases of pseudobacteremia occurred in 1980-1981 and one case occurred in 1982. With one exception, all of the patients appeared to have pseudobacteremia rather than true bacteremia; the outbreak ceased only after aqueous green soap was deleted as a standard stock item from the hospital formulary.