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Baker AW, Nick SE, Jia F, Graves AM, Warren BG, Zavala S, Stout JE, Lee MJ, Alexander BD, Davidson RM, Anderson DJ. Mycobacterium immunogenum acquisition from hospital tap water: a genomic and epidemiologic analysis. J Clin Microbiol 2024; 62:e0014924. [PMID: 38690881 PMCID: PMC11237794 DOI: 10.1128/jcm.00149-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/06/2024] [Indexed: 05/03/2024] Open
Abstract
We identified 23 cases of Mycobacterium immunogenum respiratory acquisition linked to a colonized plumbing system at a new hospital addition. We conducted a genomic and epidemiologic investigation to assess for clonal acquisition of M. immunogenum from hospital water sources and improve understanding of genetic distances between M. immunogenum isolates. We performed whole-genome sequencing on 28 M. immunogenum isolates obtained from August 2013 to July 2021 from patients and water sources on four intensive care and intermediate units at an academic hospital. Study hospital isolates were recovered from 23 patients who experienced de novo respiratory isolation of M. immunogenum and from biofilms obtained from five tap water outlets. We also analyzed 10 M. immunogenum genomes from previously sequenced clinical (n = 7) and environmental (n = 3) external control isolates. The 38-isolate cohort clustered into three clades with pairwise single-nucleotide polymorphism (SNP) distances ranging from 0 to 106,697 SNPs. We identified two clusters of study hospital isolates in Clade 1 and one cluster in Clade 2 for which clinical and environmental isolates differed by fewer than 10 SNPs and had less than 0.5% accessory genome variation. A less restrictive combined threshold of 40 SNPs and 5% accessory genes reliably captured additional isolates that met clinical criteria for hospital acquisition, but 12 (4%) of 310 epidemiologically unrelated isolate pairs also met this threshold. Core and accessory genome analyses confirmed respiratory acquisition of multiple clones of M. immunogenum from hospital water sources to patients. When combined with epidemiologic investigation, genomic thresholds accurately distinguished hospital acquisition.
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Affiliation(s)
- Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Sophie E Nick
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Fan Jia
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado, USA
| | - Amanda M Graves
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Bobby G Warren
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Sofia Zavala
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jason E Stout
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mark J Lee
- Department of Pathology and Clinical Microbiology Laboratory, Duke University School of Medicine, Durham, North Carolina, USA
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pathology and Clinical Microbiology Laboratory, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca M Davidson
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado, USA
| | - Deverick J Anderson
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Mitigation of nontuberculous mycobacteria in hospital water: challenges for infection prevention. Curr Opin Infect Dis 2022; 35:330-338. [PMID: 35849523 DOI: 10.1097/qco.0000000000000844] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize recent literature on nontuberculous mycobacteria in water of healthcare systems. Despite improvement in identification techniques and emergence of infection prevention and control programs, nontuberculous mycobacteria remain present in hospital water systems, causing outbreaks and pseudo-outbreaks in healthcare settings. RECENT FINDINGS Waterborne outbreaks and pseudo-outbreaks of nontuberculous mycobacteria continue to affect hospitals. Improvements in methods of identification and investigation, including MALDI-TOF and whole genome sequencing with evaluation of single nucleotide polymorphisms, have been used successfully in outbreak and pseudo-outbreak investigations. Recent studies have shown control of outbreaks in immunocompromised patients through the use of sterile water for consumption, as well as control of pseudo-outbreaks by using sterile water for procedures. Construction activities have been implicated in outbreaks and pseudo-outbreaks of nontuberculous mycobacteria. Water management programs are now required by the Joint Commission, which will likely improve water risk mitigation. SUMMARY Improvement in detection and identification of nontuberculous mycobacteria has led to increasing recognition of waterborne outbreaks and pseudo-outbreaks. Water management programs are of vital importance in infection prevention.
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Baker AW, Stout JE, Anderson DJ, Sexton DJ, Smith B, Moehring RW, Huslage K, Hostler CJ, Lewis SS. Tap Water Avoidance Decreases Rates of Hospital-onset Pulmonary Nontuberculous Mycobacteria. Clin Infect Dis 2021; 73:524-527. [PMID: 32829397 DOI: 10.1093/cid/ciaa1237] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Indexed: 11/15/2022] Open
Abstract
We analyzed the impact of a hospital tap water avoidance protocol on respiratory isolation of nontuberculous mycobacteria (NTM). After protocol implementation, hospital-onset episodes of respiratory NTM isolation on high-risk units decreased from 41.0 to 9.9 episodes per 10 000 patient-days (incidence rate ratio, 0.24; 95% confidence interval, .17-.34; P < .0001).
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Affiliation(s)
- Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Jason E Stout
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Deverick J Anderson
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Daniel J Sexton
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Becky Smith
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebekah W Moehring
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Kirk Huslage
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Christopher J Hostler
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
- Durham VA Health Care System, Durham, North Carolina, USA
| | - Sarah S Lewis
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Takajo I, Iwao C, Aratake M, Nakayama Y, Yamada A, Takeda N, Saeki Y, Umeki K, Toyama T, Hirabara Y, Fukuda M, Okayama A. Pseudo-outbreak of Mycobacterium paragordonae in a hospital: possible role of the aerator/rectifier connected to the faucet of the water supply system. J Hosp Infect 2020; 104:545-551. [DOI: 10.1016/j.jhin.2019.11.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/20/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
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Scanlon MM, Gordon JL, McCoy WF, Cain MF. Water Management for Construction: Evidence for Risk Characterization in Community and Healthcare Settings: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2168. [PMID: 32214051 PMCID: PMC7143259 DOI: 10.3390/ijerph17062168] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/17/2020] [Accepted: 03/21/2020] [Indexed: 12/26/2022]
Abstract
Construction activities are a known risk contributing to the growth and spread of waterborne pathogens in building water systems. The purpose of the study is to integrate evidence for categorizing construction activity risk factors contributing to waterborne disease in community and healthcare settings, establish severity of such risk factors and identify knowledge gaps. Using a systematic review, the inclusion criteria were: 1) studies with disease cases suspected to be associated with construction activities and waterborne pathogens, and 2) active construction work described in a community or healthcare setting. Each construction activity risk factor was correlated across all studies with the number of disease cases and deaths to establish risk severity. The eligibility review and quantitative synthesis yielded 31 studies for inclusion (community, n = 7 and healthcare, n = 24). From 1965 to 2016, a total of 894 disease cases inclusive of 112 deaths were associated with nine construction activity risk factors and waterborne pathogens. The present study findings support the need for building owners, water management teams and public health professionals to address construction activity risk factors and the analysis of current knowledge deficiencies within the scope of an ongoing water management program. The impact of construction activities on waterborne disease is preventable and should no longer be considered incidental nor accidental.
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Affiliation(s)
- Molly M. Scanlon
- Phigenics, LLC, 3S701 West Avenue, Suite 100, Warrenville, IL 60555, USA; (W.F.M.); (M.F.C.)
- Department of Community, Environment, and Policy, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, AZ 85724, USA
| | | | - William F. McCoy
- Phigenics, LLC, 3S701 West Avenue, Suite 100, Warrenville, IL 60555, USA; (W.F.M.); (M.F.C.)
| | - Melissa F. Cain
- Phigenics, LLC, 3S701 West Avenue, Suite 100, Warrenville, IL 60555, USA; (W.F.M.); (M.F.C.)
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Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the emerging literature on nontuberculous mycobacteria outbreaks in healthcare settings. As our ability to identify mycobacterial species develops, we are better able to recognize epidemiologic connections and better understand the prevalence and importance of these outbreaks and pseudo-outbreaks in healthcare settings. RECENT FINDINGS The number of outbreaks related to nontuberculous outbreaks is increasing because of heightened awareness and better diagnostic tests for species level identification of mycobacteria. Outbreaks in healthcare settings have been related to cardiac surgery, plastic surgery, including medical tourism, colonized humidifiers and heater-cooler devices, imperfect disinfection, and hospital water sources. Mycobacteria have a predilection to form biofilms, are resistant to disinfection and are prevalent in hospital water systems. Patients with structural lung disease like cystic fibrosis patients are at particularly high risk for mycobacterial infection. It has been thought that acquisition in this patient population is from common environmental exposure; however, there is increasing evidence that transmission in this patient population can occur through either direct or indirect patient-to-patient spread. SUMMARY Mycobacteria outbreaks in healthcare settings have been underrecognized. As we identify additional clusters of infection with better diagnostic tools and heightened awareness, we will likely need better infection control practices to prevent infections in healthcare settings.
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Baker AW, Lewis SS, Alexander BD, Chen LF, Wallace RJ, Brown-Elliott BA, Isaacs PJ, Pickett LC, Patel CB, Smith PK, Reynolds JM, Engel J, Wolfe CR, Milano CA, Schroder JN, Davis RD, Hartwig MG, Stout JE, Strittholt N, Maziarz EK, Saullo JH, Hazen KC, Walczak RJ, Vasireddy R, Vasireddy S, McKnight CM, Anderson DJ, Sexton DJ. Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation. Clin Infect Dis 2017; 64:902-911. [PMID: 28077517 DOI: 10.1093/cid/ciw877] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/03/2017] [Indexed: 12/17/2022] Open
Abstract
Background Nontuberculous mycobacteria (NTM) commonly colonize municipal water supplies and cause healthcare-associated outbreaks. We investigated a biphasic outbreak of Mycobacterium abscessus at a tertiary care hospital. Methods Case patients had recent hospital exposure and laboratory-confirmed colonization or infection with M. abscessus from January 2013 through December 2015. We conducted a multidisciplinary epidemiologic, field, and laboratory investigation. Results The incidence rate of M. abscessus increased from 0.7 cases per 10000 patient-days during the baseline period (January 2013-July 2013) to 3.0 cases per 10000 patient-days during phase 1 of the outbreak (August 2013-May 2014) (incidence rate ratio, 4.6 [95% confidence interval, 2.3-8.8]; P < .001). Thirty-six of 71 (51%) phase 1 cases were lung transplant patients with positive respiratory cultures. We eliminated tap water exposure to the aerodigestive tract among high-risk patients, and the incidence rate decreased to baseline. Twelve of 24 (50%) phase 2 (December 2014-June 2015) cases occurred in cardiac surgery patients with invasive infections. Phase 2 resolved after we implemented an intensified disinfection protocol and used sterile water for heater-cooler units of cardiopulmonary bypass machines. Molecular fingerprinting of clinical isolates identified 2 clonal strains of M. abscessus; 1 clone was isolated from water sources at a new hospital addition. We made several water engineering interventions to improve water flow and increase disinfectant levels. Conclusions We investigated and mitigated a 2-phase clonal outbreak of M. abscessus linked to hospital tap water. Healthcare facilities with endemic NTM should consider similar tap water avoidance and engineering strategies to decrease risk of NTM infection.
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Affiliation(s)
- Arthur W Baker
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina.,Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Sarah S Lewis
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina.,Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina.,Duke University Clinical Microbiology Laboratory, Durham, North Carolina
| | - Luke F Chen
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina.,Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Richard J Wallace
- Duke University Clinical Microbiology Laboratory, Durham, North Carolina
| | | | - Pamela J Isaacs
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina
| | - Lisa C Pickett
- Division of Trauma and Critical Care, Duke University Hospital, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Duke University Hospital, Durham, North Carolina
| | - Peter K Smith
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, North Carolina
| | - John M Reynolds
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Hospital, Durham, North Carolina
| | - Jill Engel
- Duke University Hospital, Durham, North Carolina
| | - Cameron R Wolfe
- Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, North Carolina
| | - Robert D Davis
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, North Carolina
| | - Matthew G Hartwig
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, North Carolina
| | - Jason E Stout
- Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Nancy Strittholt
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina
| | - Eileen K Maziarz
- Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Jennifer Horan Saullo
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina
| | - Kevin C Hazen
- Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Richard J Walczak
- Perfusion Services, Duke University Hospital, Durham, North Carolina
| | - Ravikiran Vasireddy
- Mycobacteria/Nocardia Research Laboratory, Department of Microbiology, University of Texas Health Science Center, Tyler
| | - Sruthi Vasireddy
- Mycobacteria/Nocardia Research Laboratory, Department of Microbiology, University of Texas Health Science Center, Tyler
| | - Celeste M McKnight
- Duke University Clinical Microbiology Laboratory, Durham, North Carolina
| | - Deverick J Anderson
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina.,Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
| | - Daniel J Sexton
- Duke Program for Infection Prevention and Healthcare Epidemiology, Duke University Hospital, Durham, North Carolina.,Division of Infectious Diseases, Duke University Hospital, Durham, North Carolina
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Abstract
The list of clinically important slow-growing nontuberculous mycobacteria (NTM) continues to expand as new species are identified and older ones are found to be pathogenic. Based on pigment production, the strains may be classified as photochromogenic, scotochromogenic, or unpigmented. Some of these organisms are not newly discovered but have heretofore been considered virtually nonpathogenic. Previously, many were regarded as contaminants when isolated from clinical specimens. Ubiquitous in nature, many NTM have been isolated from groundwater or tap water, soil, house dust, domestic and wild animals, and birds. Most infections result from inhalation or direct inoculation from environmental sources. They are not spread from person to person. The infections may be localized or disseminated. In most cases, the optimal regimen or duration of therapy has not been firmly established. The results of in vitro susceptibility testing may be used to select a therapeutic regimen. Many experts recommend clarithromycin with companion drugs such as rifampin and ethambutol for most, but not all, slowly growing species. Aminoglycosides, clofazimine, fluoroquinolones, linezolid, pyrazinamide, or trimethoprim-sulfamethoxazole also may be effective against some strains. Immunocompetent patients with clinically significant infections with NTM usually should receive 18 to 24 months of therapy. Infected immunocompromised patients, particularly those with disseminated infection, probably should receive therapy as long as their immune systems remain impaired. Some of the species discussed include Mycobacterium alsiense, M. celatum, M. gordonae, M. haemophilum, M. kyorinense, M. malmoense, M. simiae complex, M. szulgai, M. terrae complex, M. ulcerans, and M. xenopi.
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Abstract
Mycobacterium gordonae is a slow growing, pigmented, nontuberculous mycobacterium. It is commonly associated with environmental contamination of clinical specimens, but it is also a recognized pathogen in immunocompromised hosts. We describe an immunocompetent child with a spontaneously occurring skin ulcer on the face caused by M. gordonae infection.
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