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A Nosocomial Pseudo-Outbreak of Mycobacterium xenopi Due to a Contaminated Potable Water Supply: Lessons in Prevention

Published online by Cambridge University Press:  21 June 2016

David H. Sniadack ,
Stephen M. Ostroff ,
Michael A. Karlix ,
Ronald W. Smithwick ,
Benjamin Schwartz ,
Mary Ann Sprauer ,
Vella A. Silcox  and
Robert C. Good
David H. Sniadack
Affiliation:
Centers for Disease Control and Prevention, Atlanta, Georgia
Stephen M. Ostroff
Affiliation:
Centers for Disease Control and Prevention, Atlanta, Georgia
Michael A. Karlix
Affiliation:
Indiana State Department of Health, Indianapolis, Indiana
Benjamin Schwartz
Affiliation:
Centers for Disease Control and Prevention, Atlanta, Georgia
Mary Ann Sprauer
Affiliation:
Indiana State Department of Health, Indianapolis, Indiana
Vella A. Silcox
Affiliation:
Centers for Disease Control and Prevention, Atlanta, Georgia
Robert C. Good
Affiliation:
Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract

Objectives:

To determine risk factors for Mycobacterium xenopi isolation in patients following a pseudo-outbreak of infection with the organism.

Design:

Retrospective cohort analysis of mycobacteriology laboratory specimen records and frequency-matched case-control study of hospital patients.

Setting:

General community hospital.

See also page 642

Patients:

For the case-control study, 13 case patients and 39 randomly selected controls with mycobacterial cultures negative for M xen-opi, frequency matched by specimen source, whose specimens were submitted from June 1990 through June 1991.

Results:

Between June 1990 and June 1991, M xenopi was isolated from 13 clinical specimens processed at a midwestern hospital, including sputum (n = 6), bronchial washings (2), urine (4), and stool (1). None of the patients with M xenopi- positive specimens had apparent mycobacterial disease, although five received antituberculosis drug therapy for a range of one to six months. Specimens collected in a nonsterile manner were more likely to grow the organism than those collected aseptically (3.1% versus 0, relative risk= infinity, P= 0.003). M xenopi isolation was attributed to exposure of clinical specimens to tap water, including rinsing of bronchoscopes with tap water after disinfection, irrigation with tap water during colonoscopy, gargling with tap water before sputum collection, and collecting urine in recently rinsed bedpans. M xenopi was isolated from tap water in 20 of 24 patient rooms tested, the endoscopy suite, and the central hot water mixing tank, but not from water in the microbiology laboratory. The pseudo-outbreak occurred following a decrease in the hot water temperature from 130°F to 120°F in 1989.

Conclusions:

Maintenance of a higher water temperature and improved specimen collection protocols and instrument disinfection procedures probably would have prevented this pseudo-outbreak (Infect Control Hosp Epidemiol 1993;14:636-641).

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 14 , Issue 11 , November 1993 , pp. 636 - 641
Copyright
Copyright © The Society for Healthcare Epidemiology of America 1993

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