We report an ICU outbreak of Burkholderia cepacia bacteremia, root cause analysis and risk factor assessment. A cluster of 8 cases of Burkholderia bacteremia with similar antimicrobial susceptibility pattern were observed within 45 days in PCTICU, suggesting an outbreak. Environmental samples (n=21) from all potential reservoirs were taken & processed according to standard microbiological procedures. B.cepacia with similar susceptibility pattern was isolated from deionized water (outside supply), used in humidifier reservoirs for delivery of low–flow oxygen therapy. With immediate effect, in–house reverse osmosis water was put to use. Risk factors were previous hospitalizations; co–morbidities; antimicrobial administration and duration of mechanical ventilation. Implementing best practices in respiratory therapy, administration of I.V. fluids and parenteral nutrition, play an indispensible role in preventing outbreaks due to environmental contaminants. Surveillance cultures of fluids administered to patients is a critical element of Hospital Infection Control practices.