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Mycobacterium chimaera infections among cardiothoracic surgery patients associated with heater-cooler devices—Kansas and California, 2019

Published online by Cambridge University Press:  06 October 2021

Kerui Xu*
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia
Lauren E. Finn
Affiliation:
Los Angeles County Department of Public Health, Los Angeles, California
Robert L. Geist
Affiliation:
Kansas Department of Health and Environment, Topeka, Kansas
Christopher Prestel
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Heather Moulton-Meissner
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Moon Kim
Affiliation:
Los Angeles County Department of Public Health, Los Angeles, California
Bryna Stacey
Affiliation:
Kansas Department of Health and Environment, Topeka, Kansas
Gillian A. McAllister
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Paige Gable
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Talar Kamali
Affiliation:
Los Angeles County Department of Public Health, Los Angeles, California
Annabelle de St Maurice
Affiliation:
Department of Pediatrics, Division of Pediatric Infectious Diseases, University of California at Los Angeles, Los Angeles, California
Shangxin Yang
Affiliation:
Department of Pathology and Laboratory Medicine, University of California at Los Angeles, Los Angeles, CA
Kiran M. Perkins
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Matthew B. Crist*
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
*
Author for correspondence: Kerui Xu, E-mail: kerui.xu@fda.hhs.gov. Or Matthew B. Crist, E-mail: cwu0@cdc.gov
Author for correspondence: Kerui Xu, E-mail: kerui.xu@fda.hhs.gov. Or Matthew B. Crist, E-mail: cwu0@cdc.gov

Abstract

Background:

In 2015, an international outbreak of Mycobacterium chimaera infections among patients undergoing cardiothoracic surgeries was associated with exposure to contaminated LivaNova 3T heater-cooler devices (HCDs). From June 2017 to October 2020, the Centers for Disease Control and Prevention was notified of 18 patients with M. chimaera infections who had undergone cardiothoracic surgeries at 2 hospitals in Kansas (14 patients) and California (4 patients); 17 had exposure to 3T HCDs. Whole-genome sequencing of the clinical and environmental isolates matched the global outbreak strain identified in 2015.

Methods:

Investigations were conducted at each hospital to determine the cause of ongoing infections. Investigative methods included query of microbiologic records to identify additional cases, medical chart review, observations of operating room setup, HCD use and maintenance practices, and collection of HCD and environmental samples.

Results:

Onsite observations identified deviations in the positioning and maintenance of the 3T HCDs from the US Food and Drug Administration (FDA) recommendations and the manufacturer’s updated cleaning and disinfection protocols. Additionally, most 3T HCDs had not undergone the recommended vacuum and sealing upgrades by the manufacturer to decrease the dispersal of M. chimaera–containing aerosols into the operating room, despite hospital requests to the manufacturer.

Conclusions:

These findings highlight the need for continued awareness of the risk of M. chimaera infections associated with 3T HCDs, even if the devices are newly manufactured. Hospitals should maintain vigilance in adhering to FDA recommendations and the manufacturer’s protocols and in identifying patients with potential M. chimaera infections with exposure to these devices.

Type
Original Article
Copyright
© The Author(s), 2021. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

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Footnotes

a

Authors of equal contribution.

References

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