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  • Title: Pseudo-outbreak of Mycobacterium fortuitum due to contaminated ice machines.
    Author: Labombardi VJ, O'brien AM, Kislak JW.
    Journal: Am J Infect Control; 2002 May; 30(3):184-6. PubMed ID: 11988715.
    Abstract:
    BACKGROUND: An almost 4-fold increase from normal baseline levels in the isolation of Mycobacterium fortuitum from respiratory tract specimens was observed. The majority of these isolates were obtained from patients residing on 1 of 2 wards, prompting an epidemiologic investigation. METHODS: In addition to patient specimens, environmental cultures were collected from various water sources on the 2 affected wards. Samples were also collected from uninvolved areas of the hospital. All specimens were cultured with use of a continuously monitored broth system for the isolation of mycobacteria. RESULTS: The respiratory tracts of 19 patients were colonized by M fortuitum. Surveillance cultures obtained from uninvolved areas of the hospital were either negative for mycobacteria or were colonized by M avium complex or M gordonae. Two ice machines, servicing the affected areas each, were colonized by M fortuitum in multiple cultures. CONCLUSIONS: The M fortuitum pseudo-outbreak was due to contaminated ice machines located on each of the affected units. After removal and replacement of the ice machines, the pseudo-outbreak resolved.
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