Nontuberculous Mycobacterium (NTM) Infections Associated with Heater-Cooler Devices Joseph Perz, DrPH Team Leader, Quality Standards & Safety Prevention and Response Branch Division of Healthcare Quality Promotion Centers for Disease Control and Prevention HICPAC November 5, 2015 Office of Surveillance, Epidemiology, and Laboratory Services Scientific Education and Professional Development Program Office
14
Embed
Nontuberculous Mycobacterium (NTM) Infections …...2015/10/23 · Nontuberculous Mycobacterium (NTM) Infections Associated with Heater -Cooler Devices Joseph Perz, DrPH Team Leader
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Nontuberculous Mycobacterium (NTM) Infect ions Associated with Heater-Cooler Devices
Joseph Perz, DrPHTeam Leader, Quality Standards & Safety
Prevention and Response BranchDivision of Healthcare Quality Promotion
Centers for Disease Control and Prevention
HICPACNovember 5, 2015
Office of Surveillance, Epidemiology, and Laboratory ServicesScientific Education and Professional Development Program Office
Nontuberculous Mycobacterium (NTM)
NTM = mycobacteria that do not cause tuberculosis
Slow-growing
Found in surface water, tap water, and soil
Opportunist ic
Healthcare Immunocompromised patients
Breaches in normal host defenses
Novel exposure pathways
• Direct and indirect exposures to water
MMWR / October 23, 2015 / Vol. 64 / No. 41
• Four patients with M. chelonae infection after LASIK surgery at an ASC
• A consumer grade misting humidifier was contaminated with M. chelonae
M. chimaera detected in heater-cooler water circuits and air samples collected w/ units operat ing
Clinical Infect ious Diseases 2015;61(1):67–75
On June 15 2015, Sorin Group USA, issued a Field Safety Notice, followed on July 15 2015 by a Class II Recall:
• Stating that “although water from the heater cooler device is not intended to contact the patient directly, fluid leakage from the device or aerosolization generated by a contaminated water circuit during device operation may create conditions in which the organisms could potentially contact the patient and subsequently contaminate the surgical site.”
• Indicating an Error in Labeling, requiring revisions to instructions for cleaning and disinfection.
Recent US Outbreak Invest igat ion
July 20, 2015 – PA DoH notified of a cluster of NTM infect ions among cardiac surgery pat ients
Heater-cooler units were removed and replaced
CDC provided on-site assistance with invest igat ion
8 cases of invasive NTM (MAC/M. chimaera) infect ion
Preliminary epidemiologic and laboratory findings substant iate that heater-cooler units = source
Hospital has not ified affected pat ients/families as well as over 1300 potent ially exposed pat ients
• Scope: All heater-cooler devices• Recommendations include:
• Adhere to current manufacturer instructions • Sterile or filtered water• Direct exhaust away• Remove units w/ signs of contamination• MedWatch reporting
The findings and conclusions in this report are those of the authors and do not necessarily represent the officia l position of the Centers for Disease Control and Prevention.
Office of Surveillance, Epidemiology, and Laboratory ServicesScientific Education and Professional Development Program Office