Original Research
7 March 2023

Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System

Publication: Annals of Internal Medicine
Volume 176, Number 3
Visual Abstract. Mycobacterium abscessus Cluster in Cardiac Surgery Patients.
Mycobacterium abscessus is a rare but well-described pathogen that has been associated with nosocomial infections. This article reports on a nosocomial cluster of M abscessus infections in 4 cardiac surgery patients and the steps that were taken to investigate and abate the cluster.

Abstract

Background:

Nontuberculous mycobacteria are water-avid pathogens that are associated with nosocomial infections.

Objective:

To describe the analysis and mitigation of a cluster of Mycobacterium abscessus infections in cardiac surgery patients.

Design:

Descriptive study.

Setting:

Brigham and Women's Hospital, Boston, Massachusetts.

Participants:

Four cardiac surgery patients.

Intervention:

Commonalities among cases were sought, potential sources were cultured, patient and environmental specimens were sequenced, and possible sources were abated.

Measurements:

Description of the cluster, investigation, and mitigation.

Results:

Whole-genome sequencing confirmed homology among clinical isolates. Patients were admitted during different periods to different rooms but on the same floor. There were no common operating rooms, ventilators, heater-cooler devices, or dialysis machines. Environmental cultures were notable for heavy mycobacterial growth in ice and water machines on the cluster unit but little or no growth in ice and water machines in the hospital's other 2 inpatient towers or in shower and sink faucet water in any of the hospital's 3 inpatient towers. Whole-genome sequencing confirmed the presence of a genetically identical element in ice and water machine and patient specimens. Investigation of the plumbing system revealed a commercial water purifier with charcoal filters and an ultraviolet irradiation unit leading to the ice and water machines in the cluster tower but not the hospital's other inpatient towers. Chlorine was present at normal levels in municipal source water but was undetectable downstream from the purification unit. There were no further cases after high-risk patients were switched to sterile and distilled water, ice and water machine maintenance was intensified, and the commercial purification system was decommissioned.

Limitation:

Transmission pathways were not clearly characterized.

Conclusion:

Well-intentioned efforts to modify water management systems may inadvertently increase infection risk for vulnerable patients.

Primary Funding Source:

National Institutes of Health.

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Information & Authors

Information

Published In

cover image Annals of Internal Medicine
Annals of Internal Medicine
Volume 176Number 3March 2023
Pages: 333 - 339

History

Published online: 7 March 2023
Published in issue: March 2023

Keywords

Authors

Affiliations

Michael Klompas, MD, MPH https://orcid.org/0000-0001-8641-4498
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
Chidiebere Akusobi, MD, PhD https://orcid.org/0000-0002-1611-0015
Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.A., I.D.W.)
Jon Boyer, ScD, CIH
Department of Environmental Affairs, Brigham and Women's Hospital, Boston, Massachusetts (J.B.)
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (A.W., C.A.M.)
Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.A., I.D.W.)
Robert Tucker, MPH, CIC
Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (R.T., K.F.)
Chanu Rhee, MD, MPH
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
Karen Fiumara, PharmD
Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (R.T., K.F.)
Madelyn Pearson, DNP
Department of Nursing, Brigham and Women's Hospital, Boston, Massachusetts (M.P.)
Charles A. Morris, MD, MPH
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (A.W., C.A.M.)
Department of Medicine, Brigham and Women's Hospital, and Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (E.R.).
Meghan A. Baker, MD, ScD
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
Grant Support: By the National Institutes of Health (NIAID R21AI156772).
Reproducible Research Statement: Study protocol and statistical code: Not applicable. Data set: The data set describing the case patients and their exposures is not available for sharing because of the small number of patients and the consequent risk for identification.
Corresponding Author: Michael Klompas, MD, MPH, Department of Population Medicine, 401 Park Drive, Suite 401 East, Boston, MA 02215; e-mail, [email protected].
Author Contributions: Conception and design: M. Klompas, R. Tucker, E. Rubin, M.A. Baker.
Analysis and interpretation of the data: M. Klompas, I.D. Wolf, R. Tucker, C. Rhee, E. Rubin, M.A. Baker.
Drafting of the article: M. Klompas.
Critical revision for important intellectual content: M. Klompas, I.D. Wolf, R. Tucker, C. Rhee, E. Rubin, M.A. Baker.
Final approval of the article: M. Klompas, C. Akusobi, J. Boyer, A. Woolley, I.D. Wolf, R. Tucker, C. Rhee, K. Fiumara, M. Pearson, C.A. Morris, E. Rubin, M.A. Baker.
Provision of study materials or patients: I.D. Wolf.
Obtaining of funding: E. Rubin.
Administrative, technical, or logistic support: R. Tucker, M. Pearson.
Collection and assembly of data: M. Klompas, I.D. Wolf, R. Tucker, M.A. Baker.
This article was published at Annals.org on 7 March 2023.

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Michael Klompas, Chidiebere Akusobi, Jon Boyer, et al. Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System. Ann Intern Med.2023;176:333-339. [Epub 7 March 2023]. doi:10.7326/M22-3306

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