July 30, 2014 — This is the second in a series of three articles that discuss an outbreak of an unusual type of atypical mycobacterium following surgical procedures performed in an operating room within the Greenville Healthcare System (Greenville, SC).

The first article in this series by Lawrence F Muscarella, PhD is: “4th Patient Dies, 15 Infected at Greenville Memorial Hospital Linked to Contaminated Tap Water” (published in June, 2014).  And, the third article in this series is: “Greenville Health System Settles a Lawsuit Claiming Negligence Caused a Patient’s Infection, Death” (published in July, 2015).

This outbreak resulted in 15 infected patients, four of whom died. According to officials, this outbreak at Greenville Memorial Hospital, reported to be due to contaminated tap water, was a likely contributing factor in these four patient deaths.


Two TV interviews, Comment: Two WPSA News 7 television aired two interviews of this article’s author (Dr. Lawrence F Muscarella) discussing Greenville Memorial Hospital’s deadly outbreak. Read his comments in WPSA’s July, 2014, article “GHS Infection Investigation Zeros In On Tap Water.”


Mycobacterium abscessus

Mycobacterium abscessus is the name of the atypical mycobacterium that infected Greenville Memorial Hospital’s 15 patients.

M. abscessus rarely infects patients in the healthcare setting, and it is not transmitted from patient to patient, meaning it is not contagious.

Further, M. abscessus, whose incubation time can be as long as two months, generally causes symptoms of infection only in patients who are already ill or immuno-suppressed. Healthy patients are usually not affected by this organism, and for these reasons, this mycobacterial species is called an “opportunistic” organism.

A national concern?

Greenville Memorial Hospital’s mycobacterial outbreak likely has significant national implications.

Indeed, there remains the possibility that other hospitals across the U.S., too, may be susceptible to this same type of deadly mycobacterial infection.

Water filters installed

According to a news report, Greenville Health System recently installed a new water filtration system on all of its campuses to prevent another outbreak of atypical mycobacteria.

Indeed, installing this new filtration system, which should prevent bacteria greater than 2 microns from passing, is “an extraordinary measure,” as stated by hospital officials, who added that: “This is a very unusual thing for organizations to do. It’s not standard by any means, (but) we’ve taken that on so as to protect our patients.”

The installation of this filtration system was performed as a comprehensive corrective action, even though only the tap water leading into one operating room of one of Greenville Health System’s hospitals (i.e., Greenville Memorial Hospital) was reported to be contaminated with the outbreak’s mycobacteria.

Recommendations to prevent infection

Some recommendations for the prevention of transmission of atypical mycobacteria in the healthcare setting include:

1. Maintain and replace any installed water filters, to ensure that these filters themselves, over time, do not become colonized with bacteria, contaminate the tap water, and sources of bacterial outbreaks.

2. Do not routinely flash sterilize surgical instruments. Only “flash” instruments in emergency situations. (Refer to Dr. Muscarella’s related article “Flash or Immediate use Steam Sterilization: A Position Statement.”)

[Note: This list is incomplete. More recommendations will be added in the near future. Continue to review this article for periodic updates.]

3. Do not terminally rinse surgical instruments with water originating from a tap.

  • The use of wet instruments poses an increased risk of infection, patient morbidity and mortality.
  • As Greenville Memorial Hospital can now attest, tap water can be a reservoir for opportunistic bacteria. resulting in patient infections with associated morbidity and mortality.
  • Assure all surgical instruments are dry prior to their use to avoid such types of outbreaks as Greenville Memorial Hospital’s 15 infections of atypical mycobacteria. (Instrument drying can be assisted, as required, using 70% alcohol, followed by forced air.)

4. If bacterial contamination of a healthcare facility’s water supply is suspected, consider temporarily elevating its temperature (e.g., above 70°C), being consistent with guidelines and with measures taken to prevent patient and employee scalding.(3)

  • Decontamination of plumbing fixtures is recommended to prevent them from becoming a nidus of bacterial colonization and infection.
  • Performing scheduled preventive maintenance procedures of hospital water systems is important to the prevention of disease transmission.

5. Only use sterile water  for virtually every application in the operating room setting.

  • Fill the heater-cooler device’s reservoirs with sterile water (or, less ideally, with 0.2 micron filter water).
  • Splash guards may be required if nearby sinks could, during water splashing, contaminate surrounding surfaces and/or instruments with waterborne bacteria.(10)

6. Assure all critical surgical instruments (and semi-critical instruments, when feasible) used in the operating room are cleaned and sterilized using a steam autoclave.

  • Do not routinely flash sterilize surgical instruments (see No. 2, above);
  • High-level disinfect semi-critical instruments, such as flexible endoscopes, that cannot be steam sterilized, assuring that they are rinsed with bacteria-free or sterile water following chemical immersion;
  • Do not terminally rinse critical instruments with non-sterile water;
  • In general, do not high-level disinfect critical instruments used in the operating room setting, especially those instruments that are not rinsed with water labeled as bona fide sterile;
  • Proper storage of surgical instruments, like of flexible endoscopes, is crucial to the prevention of bacterial outbreaks;
  • Assure all steam autoclaves in use are being properly maintained and serviced;
  • Wrap critical instruments prior to their sterilization; and
  • Routinely monitor sterilizers using FDA-cleared biological indicators.

8.  Thoroughly clean of all surgical instruments (in the designated area — i.e., the central supply department, not the operating room). (Refer to a related article by Dr. Muscarella — click here — that discusses the importance of thorough cleaning of arthroscopic hand-pieces.)

9. Do not reuse single-use, disposable surgical instruments (unless performed in accordance with FDA regulations).

10. Once a bacterial outbreak investigation is completed, perform a root cause analysis to ensure that one or more effective corrective actions are employed for each of the adverse event’s identified deviations. (Refer to Dr. Muscarella’s quality services — click here — for assistance whenever performing such an analysis.)

11. Notify all affected patients of an adverse event responsible for, or that poses an increased risk of, infection in the healthcare setting.

Article by: Lawrence F Muscarella, PhD; posted 7-30-2014; updated 10/16/2016, Rev A.

Note: Dr. Muscarella is the president of LFM Healthcare Solutions, LLC, an independent quality improvement company. Click here for a discussion of his quality services.

References:

1. Muscarella LF. Déjà vu … all over again? The importance of instrument drying. Infect Control Hosp Epidemiol 2000 Oct;21(10):628-9.

2. Muscarella LF. Inconsistencies in endoscope-reprocessing and infection-control guidelines: The importance of endoscope drying. Am J Gastroenterol 2006;101:2147-2154.

3. Phillips MS, von Reyn CF. Nosocomial infections due to non-tuberculous mycobacteria. Clin Infect Dis 2001; 33:1363–74. (Click here)

4. Dorozynski A. Poor sterilisation of instruments leads to infection outbreak in Paris. BMJ 1997 Sep 20;315:699. (Click here)

5. Chaudhuri S, Sarkar D, Mukerji R. Diagnosis and management of atypical mycobacterial infection after laparoscopic surgery. Indian J Surg Dec 2010; 72(6): 438–442. (Click here)

6. Muscarella LF. The importance of bronchoscope reprocessing guidelines: Raising the standard of care. Chest 2004 Sep;126(3):1001-2. (Click here)

7. Dudzinski DM, Hebert PC, Foglia MB, et al. The disclosure dilemma — large-scale adverse events. N Eng J Med 2010 Sep;363;10(978-986).

8. Ramsey AH, Oemig TV, Davis JP,  et al. An outbreak of bronchoscopy-related Mycobacterium tuberculosis infections due to lack of bronchoscope leak testing. Chest 2002;121;976-981.

9. Vijayaraghavan R1, Chandrashekhar R, Sujatha Y, et al. Hospital outbreak of atypical mycobacterial infection of port sites after laparoscopic surgery. J Hosp Infect 2006 Dec;64(4):344-7.

10. Hota S, Hirji Z, Stockton K, et al. Outbreak of Multidrug-Resistant Pseudomonas aeruginosa Colonization and Infection Secondary to Imperfect Intensive Care Unit Room Design. Infect Control Hosp Epidemiol 2009 Jan;30(1):25-33.

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