We thank Dr. Scharer for his comments and share his concerns about the use of multiple-dose medications for inhalation therapy. Multiple-dose medication vials are commonly used because they offer reduced drug costs and convenience compared with single-dose vials. In fiscal year 1995, the Houston Veterans Affairs Medical Center purchased 10 000 multiple-dose bottles (40 doses/bottle) of albuterol for nebulization at a cost of $33 000. This Figure translates to a cost of $0.08 per treatment if all 400 000 potential treatments are given. Unit dose vials cost our hospital $0.40 per vial; at this price, the same 400 000 treatments would cost $160 000. Therefore, purchase of multiple-dose bottles of albuterol results in a potential annual savings of $127 000 for this medication alone. These are idealized calculations, and actual savings would probably not be as high; however, in this era of cost containment, it is difficult not to embrace this type of direct savings.

However, as shown by the outbreak we described and that reported previously by Dr. Scharer and his colleagues, hidden hazards are associated with such attempts at cost containment. We have become aware of three additional outbreaks of Burkholderia (Pseudomonas) cepacia respiratory tract colonization or infections associated with nebulized albuterol therapy. Moreover, examples of infectious complications of multiple-dose medications used for reasons other than respiratory therapy continue to surface [1]. With the increased emphasis on cost containment, we and others [2] are concerned that understaffing will result in more nosocomial infections because of inadequate adherence to infection-control guidelines by overburdened health care personnel. Potential savings obtained through decreased personnel and medication expenses may not be realized when the substantial costs associated with nosocomial infections are considered.

The pharmaceutical industry must also address the questionable value of benzalkonium chloride as a medication preservative in multiple-dose medications. Resistance to benzalkonium chloride has been well described in Pseudomonas and Burkholderia. Furthermore, this agent adsorbs to materials (for example, rubber and plastic) that are commonly used to store or dispense medications in which it is used as a preservative. As shown by the outbreak we described, reliance on benzalkonium chloride as a medication preservative can be problematic, particularly when infection-control practices are not strictly followed.