Notes from the Field: Mycobacterium abscessus Outbreak Related to Contaminated Water Among Ventilator-Dependent Residents of a Pediatric Facility ― Pennsylvania, 2022

Investigation and Outcomes

On October 12, PADOH conducted a site visit to observe IPC practices. Three instances of respiratory care were observed, during which respiratory therapists failed to follow aseptic technique. Of 37 observed opportunities for hand hygiene, 30 (81%) were compliant. With regard to tracheostomy tube reprocessing (i.e., cleaning and disinfection for reuse), the manufacturer provided different instructions for home care and health care settings; the latter included stricter processes to reduce the risk for pathogen transmission. Staff members did not follow either of the manufacturer’s processes, and instead, created their own procedure using nonmedical cleaning tools and an ultraviolet baby bottle sterilizer for which there is no documentation of effectiveness. PADOH recommended that the facility follow the more stringent manufacturer instructions for tracheostomy tube reprocessing for health care settings* and use aseptic practices during respiratory care. A second site visit on October 31 showed improvement in IPC practices; however, staff members were still not reprocessing tracheostomy tubes following manufacturer recommendations for health care. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.^†

Multiple areas of the building had not been in use for 2 years, raising concern about stagnant water and contamination. The facility did not have a water management plan or monitor water quality, as is recommended to prevent water-related infections (2). On October 31, PADOH collected 21 environmental samples from faucets, aerators, showerheads and drains, filtered water and ice machines, and water samples from clinical care areas where residents with M. abscessus colonization or infection resided. Mycobacterium species were identified in 16 (76%) of 21 environmental samples; M. abscessus was identified from a shower drain swab (Table). Heterotrophic plate counts of paired first-catch and post-flush^§ water samples in a room sink of a resident and the reprocessing room sink where tracheostomy tubes were reprocessed exceeded Environmental Protection Agency (EPA) standards for safe drinking water^¶ (3). PADOH recommended that the facility hire a water management consultant, develop a water management program, and install point-of-use filters in clinical areas until water quality consistently met EPA standards. The facility implemented recommendations in collaboration with a water management consultant; PADOH continued collaborative monitoring for an 8-month period.

Preliminary Conclusions and Actions

Epidemiologic and laboratory evidence suggest that this outbreak of M. abscessus was related to substandard water quality and inadequate IPC practices. Extended disuse of space in the building potentially resulted in stagnant water in plumbing, and the lack of a water management program meant that water quality was unmonitored. The facility licensing requirements did not emphasize IPC standards necessary for residents with high medical needs, including those who are dependent on ventilators. In ventilator-capable congregate settings IPC-recommended procedures should meet health care standards to prevent transmission of infectious organisms.