Contaminated Water and a Mycobacterium Outbreak at a Pennsylvania Pediatric Facility

Mycobacterium abscessus is a nontuberculous mycobacterium that lives in water and soil. It is an opportunistic germ that has caused waterborne outbreaks in health care settings.

On September 29, 2022, the Pennsylvania Department of Health learned that ventilator-dependent residents of a 34-bed pediatric facility had respiratory samples positive for M. abscessus. The facility was licensed for residential services, not as a health care facility. Counting each resident's first positive culture from March to August 2022, there were three cases: two colonizations and one clinical infection. The department investigated to find the risk factors and recommend infection prevention and control (IPC) measures.

What the inspectors saw

At a site visit on October 12:

• In three observed episodes of respiratory care, therapists did not use aseptic technique.
• Hand hygiene was done at 30 of 37 observed opportunities (81%).
• Tracheostomy tubes were cleaned for reuse by a home-made method — nonmedical cleaning tools and an ultraviolet baby-bottle sterilizer with no documented effectiveness — instead of either of the manufacturer's methods. The manufacturer gives separate instructions for home and for health care settings, the latter stricter.

The department told the facility to follow the stricter health care instructions and to use aseptic practice in respiratory care. At a second visit on October 31, practices had improved, but tubes were still not reprocessed to the health care instructions.

The water

Parts of the building had been unused for 2 years, raising concern about stagnant, contaminated water, and the facility had no water management plan and did not monitor water quality, as is recommended to prevent water-related infections.

On October 31 the department took 21 environmental samples — faucets, aerators, showerheads and drains, filtered water and ice machines, and water where the affected residents lived.

• M. abscessus itself was found in a shower drain.
• Other mycobacteria turned up across the building — in sinks, the filtered-water machine and the ice machine.
• Bacterial counts in water from one resident's room sink and from the sink where tracheostomy tubes were reprocessed were far above the EPA's safe-drinking-water limit of 500 colony-forming units per mL, both in the first water out of the tap and after running it for 5 minutes.

Bacterial counts (heterotrophic plate counts) were done only on paired water samples.

The department advised hiring a water management consultant, building a water management program, and fitting point-of-use filters in clinical areas until the water consistently met EPA standards. The facility did so with a consultant, and the department kept monitoring alongside it for 8 months.

What it shows

The evidence points to poor water quality and inadequate infection control. Long-unused space probably left stagnant water in the pipes, and with no water management program, nobody was checking it. The facility's licensing rules did not stress the infection control needed for residents with high medical needs, such as those on ventilators. Any congregate home that cares for people on ventilators should meet health care standards for infection control.

Sources

Based on Sinkevitch JN, Paoline J, Smee A, et al., "Notes from the Field: Mycobacterium abscessus Outbreak Related to Contaminated Water Among Ventilator-Dependent Residents of a Pediatric Facility — Pennsylvania, 2022," MMWR Morbidity and Mortality Weekly Report, volume 72, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report's text gives a count of samples with mycobacteria that its own table does not bear out, so no count is given here.