Published online by Cambridge University Press: 02 January 2015
Three consecutive patients undergoing automated peritoneal dialysis developed peritonitis with a nonfermenting gram-negative rod. The same organism was recovered from the dialysate produced by the machine and from its tap water supply. This is the first such outbreak in which the causative organism was also recovered from the tap water supply to the machine. The organism persisted in the machine following standard 3% formaldehyde disinfection, but was eradicated by 10% formaldehyde disinfection.