Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System
Authors' conclusion
Well-intentioned efforts to modify water management systems may inadvertently increase infection risk for vulnerable patients.
Study context
- Population
- Cardiac surgery patients with a Mycobacterium abscessus infection cluster, Brigham and Women's Hospital, Boston
- Participants
- 4 patients
- Outcome
- Description of the cluster, investigation and mitigation
Methodological detailssingle-centre
- Single-centre
Main finding
As reported in the abstract
- WGS confirmed homology among clinical isolates
- Patients admitted at different periods to different rooms, same floor; no common operating rooms, ventilators, heater-cooler devices or dialysis machines
- Heavy mycobacterial growth in ice and water machines on cluster unit; little or no growth in ice and water machines of other 2 towers or in shower and sink faucet water in all 3 towers
- WGS confirmed a genetically identical element in ice and water machine and patient specimens
- Commercial water purifier (charcoal filters, UV irradiation) feeding ice and water machines in cluster tower only; chlorine normal in municipal source water but undetectable downstream of purifier
- No further cases after sterile and distilled water for high-risk patients, intensified machine maintenance and decommissioning of the purification system
- Limitation: transmission pathways not clearly characterized
Original publication
Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System. Ann Intern Med. Published 7 March 2023. doi:10.
Composed by AI from the published abstract and checked against it. How Briefs are made →