Management of Risks From Water and Ice From Ice Machines for the Very Immunocompromised Host: A Process Improvement Project Prompted by an Outbreak of Rapidly Growing Mycobacteria on a Pediatric Hematopoietic Stem Cell Transplant (Hsct) Unit

Abstract

BACKGROUND In 2011, pediatric hematopoietic stem cell transplant (HSCT) patients were moved from an older hospital to a new children's hospital. To minimize bacterial growth in the new hospital's water during construction, the plumbing system was flushed and disinfected before occupancy. However, 6 months after occupancy, an increased incidence of rapidly growing mycobacteria (RGM) was detected in clinical cultures. Over 10 months, 15 pediatric HSCT patients were infected, while no pediatric HSCT patients had been infected in the preceding 12 months. OBJECTIVE To determine the cause of the outbreak and to interrupt patient acquisition of RGM. METHODS Water samples were collected from water entering the hospital and from drinking water and ice machines (DWIMs) from the old and new hospitals. Total heterotrophic plate counts (HPCs, CFU/mL) of water were undertaken, and select isolates were identified as RGM. RESULTS The cause of the outbreak was increased bacterial levels in the water (including RGM) in the DWIMs in the new (2011) hospital. Tests revealed higher HPCs in drinking water and ice from the DWIMs in the new hospital than in the DWIMs in the old hospital. Ultimately, HPCs were reduced by several different interventions. CONCLUSION In response to an RGM outbreak, HSCT patients were banned from ingesting DWIM ice and water and bottled water was provided. Since this interverntion 4 years ago, no additional RGM isolates have been identified in HSCT patient cultures. Our measures to reduce HPCs to goal levels in drinking water from DWIMs were successful, but the HPCs for ice have not consistently reached the goal of <500 CFU/mL. Infect Control Hosp Epidemiol 2017;38:792-800.

Water Management for Construction: Evidence for Risk Characterization in Community and Healthcare Settings: A Systematic Review

“…The female patient case was related to a positive cold-water sample from a tap in the patient room. Third, infection preventionists and healthcare leadership teams were baffled to be investigating a waterborne pathogen issue in a newly constructed area or building [17,22,24,39]. Baker et al [17] reported this type of incident in a two-phase outbreak involving Mycobacterium abscessus.…”

“…Other opportunistic waterborne pathogens such as NTM and Sphingomonas, spp. accounted for 197 (22%) disease cases and 29 (26%) deaths [17,24,33]. Investigators conducting studies about non-Legionella waterborne pathogens find minimal emphasis is placed on water management across all microbials (i.e., all genera/species) [24,27,55].…”

“…accounted for 197 (22%) disease cases and 29 (26%) deaths [17,24,33]. Investigators conducting studies about non-Legionella waterborne pathogens find minimal emphasis is placed on water management across all microbials (i.e., all genera/species) [24,27,55]. Guspiel et al [24] complemented ANSI/ASHRAE Standard 188 committee for establishing minimum standard of care document and raising awareness within the administrative C-Suite.…”

“…However, an acute emphasis on Legionella marginalizes other infectious waterborne disease issues. Guspiel et al [24] dealt with an outbreak condition of rapidly growing mycobacteria when pediatric stem cell transplant patients were moved into a new children's hospital. Oversized ice machines selected for water efficiency had to be replaced with smaller units and remediation of all drinking fountains and ice machines was necessary.…”

Mycobacterium abscessus Complex Infections in Children: A Review

“…The cause of this outbreak was determined to be high heterotrophic plate counts (bacterial colony forming units/ml water), including rapidly growing mycobacteria, in the water and ice from the drinking water and ice machines on the pediatric BMT unit. Ultimately, the high heterotrophic plate counts in drinking water and ice were reduced by several different interventions, including 0.005-μm filters for the water entering the drinking water and ice machines, silver-impregnated components in the machines and copper tubing for pipes leading to the drinking water and ice machines, and the addition of UV disinfection devices to the machines [25••, 35]. …”