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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

Published online by Cambridge University Press:  23 May 2017

Amanda Guspiel ,
Jeremiah Menk ,
Andrew Streifel ,
Keith Messinger ,
John Wagner ,
Patricia Ferrieri  and
Susan Kline
Amanda Guspiel
Affiliation:
University of Minnesota Health and University of Minnesota Health Masonic Children’s Hospital, Minneapolis, Minnesota
Jeremiah Menk
Affiliation:
Biostatistical Design and Analysis Center (BDAC), Clinical and Translational Science Institute (CTSI), University of Minnesota, Minneapolis, Minnesota
Andrew Streifel
Affiliation:
Environmental Health Department, University of Minnesota, Minneapolis, Minnesota
Keith Messinger
Affiliation:
University of Minnesota Health and Masonic Children’s Hospital, Minneapolis, Minnesota
John Wagner
Affiliation:
Department of Pediatrics, Hematology-Oncology, University of Minnesota, Minneapolis, Minnesota
Patricia Ferrieri
Affiliation:
Department of Laboratory Medicine and Pathology, University of Minnesota and Infectious Disease Diagnostic Lab, University of Minnesota Medical Center and University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota
Susan Kline*
Affiliation:
Department. of Medicine, Infectious Disease Division, University of Minnesota and University of Minnesota Health and University of Minnesota Health and University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota.
*
Address correspondence to Susan Kline, MD, MPH, 420 Delaware St SE, MMC 250, Minneapolis, MN 55455 (Kline003@umn.edu).
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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

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 38 , Issue 7 , July 2017 , pp. 792 - 800
Copyright
© 2017 by The Society for Healthcare Epidemiology of America. All rights reserved 

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Footnotes

a

Infection Prevention Department, Allina Health East Region, St. Paul, Minnesota [A.G.]

b

Facilities Department, Lakeview Hospital, Stillwater, Minnesota [K.M.].

PREVIOUS PRESENTATION: These data were presented in part on 2 occasions: First, Guspiel, Messinger, Stebbins, and Streifel presented an abstract and poster at the Association for Professionals in Infection Control and Epidemiology (APIC) 2013 Annual Meeting, Fort Lauderdale, Florida on June 8–10, 2013, titled “What Is the Risk for Patients Ingesting Ice and Water from Your Facilities Ice Machines? A Process Improvement Project.” The abstract was published in June 2013 in the American Journal of Infection Control 2013;41(6 Suppl):S69–S70. Second, Kline S, Guspiel A, Streifel A, et al. presented an abstract and poster at the Infectious Disease Conference: IDWeek 2013, in San Francisco, California, on October 5, 2013, titled “Outbreak Investigation into an Increased Incidence of Non-tuberculous Mycobacterium in Sputum Cultures in Pediatric Blood and Marrow Transplant Patients.”

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