| 2015 |
Outpatient dental clinic |
24 children with odontogenic infections with Mycobacterium abscessus after undergoing pulpotomy procedures All children required hospitalization and surgical intervention. Water samples from dental station waterlines were positive for M. abscessus with laboratory typing showing matching strains to patient isolates. Likely mode of transmission was the use of water from dental waterlines during pulpotomy procedures without water quality monitoring or disinfection of the waterlines.10–11 |
| 2016 |
Neonatal intensive care unit (NICU) |
8 infants colonized or infected with Pseudomonas aeruginosa Tap water and surface samples from sinks and expressed breast milk in the NICU were positive for P. aeruginosa. Concern for multiple water transmission routes, including preparation of breast milk and infant formula near sinks, suboptimal cleaning of breast pump equipment, and use of tap water for filling humidifier reservoirs of infant incubators |
| 2016–2017 |
Skilled nursing facilities |
163 bloodstream infections of Burkholderia cepacia complex among patients from 59 nursing facilities across 5 states Isolates from manufactured prefilled saline flush syringes were positive for B. cepacia complex with laboratory typing showing closely-related strains to patient isolates. Nationwide recall of the contaminated saline flush syringes issued Inspection of manufacturing facility identified deficiencies that could have contributed to contamination16 |
| 2017 |
Burn unit |
5 infections of multidrug-resistant P. aeruginosa among patients in burn unit Water samples from hydrotherapy room notable for heterotrophic plate count of >1 million colony-forming units/mL Samples from family handwashing sinks and counters, hydrotherapy room equipment, and various sink drains were positive for P. aeruginosa of multiple different strains on molecular typing. Likely modes of transmission included insufficient cleaning of hydrotherapy equipment and poor environmental cleaning practices. |
