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A Cluster of Mycobacterium wolinskyi Surgical Site Infections at an Academic Medical Center

Published online by Cambridge University Press:  10 May 2016

Avish Nagpal*
Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
Jean E. Wentink
Infection Prevention and Control, Mayo Clinic, Rochester, Minnesota
Elie F. Berbari
Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota Infection Prevention and Control, Mayo Clinic, Rochester, Minnesota
Kimberly C. Aronhalt
Infection Prevention and Control, Mayo Clinic, Rochester, Minnesota
Alan J. Wright
Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota Infection Prevention and Control, Mayo Clinic, Rochester, Minnesota
Dale A. Krageschmidt
Industrial Hygiene, Mayo Clinic, Rochester, Minnesota
Nancy L. Wengenack
Division of Microbiology, Mayo Clinic, Rochester, Minnesota
Rodney L. Thompson
Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota Infection Prevention and Control, Mayo Clinic, Rochester, Minnesota
Pritish K. Tosh
Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
Division of Infectious Diseases, Mayo Clinic, Rochester, MN 55905 (



To study a cluster of Mycobacterium wolinskyi surgical site infections (SSIs).


Observational and case-control study.


Academic hospital.


Subjects who developed SSIs with M. wolinskyi following cardiothoracic surgery.


Electronic surveillance was performed for case finding as well as electronic medical record review of infected cases. Surgical procedures were observed. Medical chart review was conducted to identify risk factors. A case-control study was performed to identify risk factors for infection; Fisher exact or Kruskal-Wallis tests were used for comparisons of proportions and medians, respectively. Patient isolates were studied using pulsed-field gel electrophoresis (PFGE). Environmental microbiologic sampling was performed in operating rooms, including high-volume water sampling.


Six definite cases of M. wolinskyi SSI following cardiothoracic surgery were identified during the outbreak period (October 1, 2008–September 30, 2011). Having cardiac surgery in operating room A was significantly associated with infection (odds ratio, 40; P = .0027). Observational investigation revealed a cold-air blaster exclusive to operating room A as well a microbially contaminated, self-contained water source used in heart-lung machines. The isolates were indistinguishable or closely related by PFGE. No environmental samples were positive for M. wolinskyi.


No single point source was established, but 2 potential sources, including a cold-air blaster and a microbially contaminated, self-contained water system used in heart-lung machines for cardiothoracic operations, were identified. Both of these potential sources were removed, and subsequent active surveillance did not reveal any further cases of M. wolinskyi SSI.

Infect Control Hosp Epidemiol 2014;35(9):1169-1175

Original Article
© 2014 by The Society for Healthcare Epidemiology of America. All rights reserved.

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