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Pseudo-outbreak of Mycobacterium gordonae Following the Opening of a Newly Constructed Hospital at a Chicago Medical Center

  • Kavitha Prabaker (a1), Chethra Muthiah (a2), Mary K. Hayden (a3), Robert A. Weinstein (a3) (a4), Jyothirmai Cheerala (a3), Mary L. Scorza (a3), John Segreti (a3), Mary A. Lavin (a5), Barbara A. Schmitt (a3), Sharon F. Welbel (a4), Kathleen G. Beavis (a6) and Gordon M. Trenholme (a3)...



To identify the source of a pseudo-outbreak of Mycobacterium gordonae


Outbreak investigation.


University Hospital in Chicago, Ilinois.


Hospital patients with M. gordonae-positive clinical cultures.


An increase in isolation of M. gordonae from clinical cultures was noted immediately following the opening of a newly constructed hospital in January 2012. We reviewed medical records of patients with M. gordonae-positive cultures collected between January and December 2012 and cultured potable water specimens in new and old hospitals quantitatively for mycobacteria.


Of 30 patients with M. gordonae-positive clinical cultures, 25 (83.3%) were housed in the new hospital; of 35 positive specimens (sputum, bronchoalveolar lavage, gastric aspirate), 32 (91.4%) had potential for water contamination. M. gordonae was more common in water collected from the new vs. the old hospital [147 of 157 (93.6%) vs. 91 of 113 (80.5%), P=.001]. Median concentration of M. gordonae was higher in the samples from the new vs. the old hospital (208 vs. 48 colony-forming units (CFU)/mL; P<.001). Prevalence and concentration of M. gordonae were lower in water samples from ice and water dispensers [13 of 28 (46.4%) and 0 CFU/mL] compared with water samples from patient rooms and common areas [225 of 242 (93%) and 146 CFU/mL, P<.001].


M. gordonae was common in potable water. The pseudo-outbreak of M. gordonae was likely due to increased concentrations of M. gordonae in the potable water supply of the new hospital. A silver ion-impregnated 0.5-μm filter may have been responsible for lower concentrations of M. gordonae identified in ice/water dispenser samples. Hospitals should anticipate that construction activities may amplify the presence of waterborne nontuberculous mycobacterial contaminants.

Infect Control Hosp Epidemiol 2014;00(0): 1–6


Corresponding author

Address correspondence to Kavitha Prabaker, MD, 1635 Aurora Ct, Box B163, Aurora, CO 80045 (


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These data were presented in part at ID Week 2013, San Francisco, CA, October 2–6, 2013.



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