BACKGROUND: Cases of Ralstonia colonization/infection occasionally reported by hospitals has generated increased interest in an organism previously little known to most clinicians. Our goal was to determine the incidence of respiratory colonizations and infections involving Ralstonia and the association of mechanical ventilation (limited to reports on respiratory-related occurrences in the U.S.A.) and propose a decision chart to assist response. METHODS: We performed a secondary analysis of published clinical reports of Ralstonia to determine the potential risks for respiratory colonization and infection in the USA and if being on mechanical ventilation (MV) had an influence on colonization and conversion to infection (symptomatic). RESULTS: The odds of developing colonization with Ralstonia were eight times higher and the likelihood of developing infection with Ralstonia was twelve times higher in those mechanically ventilated compared to those not mechanically ventilated. CONCLUSIONS: Our results suggest that individuals who are currently on mechanical ventilation and are Ralstonia culture-positive have an increased risk for colonization and may have increased propensity to the development of infection (two decision trees for approaching diagnosis and therapy included).