Nontuberculous Mycobacteria
|
M. abscessus
|
Pseudo-infections/infections, distilled water contaminated |
Switched to commercial, sterile water and reagents in lab and in endoscope reprocessing |
Lai et al. (1998)
|
M. abscessus
|
Injection site infections due to contaminated benzalkonium chloride |
Recommended that the clinic stop use of benzalkonium chloride or other quaternary ammonium compounds as an injection site disinfectant |
Tiwari et al. (2003)
|
M. abscessus
|
Surgical, unknown exposure |
Antibiotics, surgical excision, no remediation of water system |
Garrison et al. (2009)
|
M. abscessus (massiliense) |
Localized, post-surgical infections after laparoscopy and other procedures |
Improved cleaning and sterilization protocols |
Duarte et al. (2009); Leão et al. (2010)
|
M. avium complex |
Hydrotherapy pools, aerosols |
None |
Angenent et al. (2005)
|
M. chelonae
|
Injection site infections |
Automatic injectors for mesotherapy rinsed with tap water between uses, infection control response not specified |
Carbonne et al. (2009)
|
M. chelonae
|
Pseudo-outbreak, automated bronchoscope washer |
Began changing filters on schedule |
Chroneou et al. (2008)
|
M. chelonae (and Methylobacterium mesophilicum)
|
Pseudo-outbreak, automated endoscope washer |
Replaced endoscopes and switched from glutaraldehyde to peracetic acid disinfection |
Kressel and Kidd (2001)
|
M. chelonae
|
Laparoscopy port-site infections |
Stopped rinsing laparoscopic equipment with tap water, switched from glutaraldehyde to ethylene oxide sterilization |
Vijayaraghavan et al. (2006)
|
M. chelonae
|
Respiratory colonizations/infections, unknown exposure route from drinking water |
POU membrane filters installed and maintained on sink faucets |
Williams et al. (2011)
|
M. fortuitum
|
Pseudo-infections; sputum samples; contaminated with ice |
Disinfected ice machine and installed filter; replace ice machines |
Gebo et al. (2002); LaBombardi et al. (2002)
|
M. gordonae
|
Pseudo-infections; sputum samples; contaminated with drinking water |
Advise patients not to rinse mouths with tap water before sampling; replaced rubber tubing in drinking fountain |
Arnow et al. (2000); Lalande et al. (2001)
|
M. mucogenicum
|
Bacteremia, CVC exit site infection |
Removed catheters; protected CVC exit sites from water during bathing; replaced contaminated faucets, and achieved optimal water chlorination |
Kline et al. (2004); Cooksey et al. (2008); Livni et al. (2004)
|
M. paraffinicum
|
Pseudo-infections and colonizations from ice |
Installed inline membrane filters in ice machines |
S-H Wang et al. (2009)
|
M. simiae
|
Pseudo-infections, unknown exposure route from drinking water |
Hyperchlorination |
El Sahly et al. (2002)
|
M. xenopi
|
Spinal infections |
Stopped rinsing surgical devices with tap water after disinfection |
Astagneau et al. (2001)
|
M. xenopi
|
Pseudo-infections, bronchoscope-associated |
Stopped rinsing bronchoscopes with tap water |
Bennett et al. (1994)
|
M. xenopi
|
Surgical, unknown exposure |
Antibiotics, no remediation of water system |
Bishburg et al. (2004)
|
Legionella pneumophila
|
|
Ice machine |
Disinfection of ice machine: 2h flush with 2.6% sodium hypochlorite, replace tubing connecting machine to water system; cold water supply: 83 ppm sodium hypochlorite for 48 h; follow-up surveillance: microbiological environmental sampling |
Graman et al. (1997)
|
|
Ice machine |
Ice from machine was not intended for consumption, hospital had Legionella control policy for drinking water |
Bencini et al. (2005)
|
|
Ice and contaminated syringes |
Cleaned ice machine, replaced filter, improved aseptic practices |
Schuetz et al. (2009)
|
|
Water taps, shower heads |
Superheated water, cleaned shower heads with a sonicating washer, and raised the hot water storage tank temperature from 43 to 52 °C |
Mermel et al. (1995)
|
|
Showers/central hot water |
Replaced showers heated by central hot water with electric showers |
Oliveira et al. (2007)
|
|
Nebulizers in a clinical spa |
Restructured (updated) water system and heat shock treatment, superheated steam for nebulization machines |
Leoni et al. (2006)
|
|
Wash basin |
Replaced faucet mixing valves, installed filters, chlorinated hot water system |
Brûlet et al. (2008)
|
|
Pseudo-infections, Bronchoscopes |
Introduction of regular water filter maintenance program and microbiological surveillance |
Mitchell et al. (1997)
|
|
Drinking water, unknown exposure of bone marrow transplant patients |
Supplemental heat and chlorine treatment of hot water system |
Oren et al. (2002)
|
|
Central hot water system |
Peracetic acid, repeated short term treatments only effective temporarily |
Ditommaso et al. (2005)
|
Pseudomonas aeruginosa
|
|
Sinks |
Repaired plumbing, replaced sinks, and disinfected sink traps with bleach on a maintenance schedule |
Bert et al. (1998)
|
Pasteurize taps weekly, use sterile water for food and medicine in patients’ gastric tubes |
Bukholm et al. (2002)
|
Cleaning and disinfection unsuccessful due to biofilm formation, necessitated a structural review of the hospital’s water system, repeated dismantling and disinfection of drains |
Gillespie et al. (2000)
|
Treated sink with chlorine |
Berthelot et al. (2001)
|
Used contact precautions (healthcare workers wore gowns and gloves, patient isolation) for all colonized or infected cases; staff education; enhanced environmental cleaning; disinfection of hand hygiene sink drains; and renovation of hand hygiene sinks to prevent splashing of drain contents Outbreak controlled only after sink renovation |
Hota et al. (2009)
|
Replaced faucet taps |
Ferroni et al. (1998)
|
Sterilized faucet aerators, installed single-use filters on ICU water outlets |
Trautmann et al. (2001); Reuter et al. (2002); Trautmann et al. (2005)
|
|
Sensor mixer sink faucets |
Silver nitrate, replaced sensor taps with non-sensor mixer taps |
Durojaiye et al. (2011)
|
|
Bacteremia, sink or shower probable source |
Installed disposable sterile filters on all taps and showers, replaced weekly |
Vianelli et al. (2006)
|
|
Bacteremia, CVC exit site infection |
Chlorination of water lines and use of disposable seven-day filters on all taps and showers, use of microbiologically controlled water for high risk patients |
Aumeran et al. (2007)
|
|
Water bath to thaw frozen plasma |
Replaced waterbath with a dry heat incubator |
Muyldermans et al. (1998)
|
|
Disinfectant hand soap, sink faucets |
Installation of water filters and water network hyperchlorination, follow-up surveillance of environmental samples |
Fanci et al. (2009)
|
|
General patient room environment |
Changed room surface cleaning solution to a disinfectant, added filters to patient room faucets and showerheads, disinfected drains with peroxides |
Engelhart et al. (2002)
|
Other Gram-negative bacteria
|
Serratia marcescens
|
Drinking water |
Provided sterile drinking water for critical care patients |
Horcajada et al. (2006)
|
Acinetobacter baumannii
|
Sinks |
Changed surface cleaning solution to a disinfectant effective against A. baumannii
|
Debast et al. (1996)
|
Stenotrophomonas maltophilia
|
Sinks in a NICU |
Reinforced hand disinfection, switched to sterile water for bathing newborns |
Verweij et al. (1998)
|
S. maltophilia
|
Faucet aerators, water taps, shower heads, decorative fountain |
Disinfection of aerators with bleach |
Weber et al. (1999)
|
Acinetobacter junii
|
Faucet aerators, sink faucets |
Removed aerators |
Kappstein et al. (2000)
|
N on-fermentative Gram-negative bacilli (NFGNB) |
Faucet aerators |
Use of sterile water in ICU, infection control education of hospital staff |
J-L Wang et al. (2009)
|
Sphingomonas paucimobilis
|
Catheters (showering) |
Instituted routine removal and hypochlorite disinfection of faucet aerators and showerheads |
Perola et al. (2002)
|
Burkholderia cepacia
|
Antiseptics, clinical solutions, soaps, mouthwash |
Patient skin and heparin vial caps were disinfected with alcohol diluted with tap water. Hospital switched to single-use alcohol swabs |
Nasser et al. (2004)
|