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Management of Risks From Water and Ice From Ice Machines for the Very Immunocompromised Host: A Process Improvement Project Prompted by an Outbreak of Rapidly Growing Mycobacteria on a Pediatric Hematopoietic Stem Cell Transplant (Hsct) Unit

  • Amanda Guspiel (a1), Jeremiah Menk (a2), Andrew Streifel (a3), Keith Messinger (a4), John Wagner (a5), Patricia Ferrieri (a6) and Susan Kline (a7)...

In 2011, pediatric hematopoietic stem cell transplant (HSCT) patients were moved from an older hospital to a new children’s hospital. To minimize bacterial growth in the new hospital’s water during construction, the plumbing system was flushed and disinfected before occupancy. However, 6 months after occupancy, an increased incidence of rapidly growing mycobacteria (RGM) was detected in clinical cultures. Over 10 months, 15 pediatric HSCT patients were infected, while no pediatric HSCT patients had been infected in the preceding 12 months.


To determine the cause of the outbreak and to interrupt patient acquisition of RGM.


Water samples were collected from water entering the hospital and from drinking water and ice machines (DWIMs) from the old and new hospitals. Total heterotrophic plate counts (HPCs, CFU/mL) of water were undertaken, and select isolates were identified as RGM.


The cause of the outbreak was increased bacterial levels in the water (including RGM) in the DWIMs in the new (2011) hospital. Tests revealed higher HPCs in drinking water and ice from the DWIMs in the new hospital than in the DWIMs in the old hospital. Ultimately, HPCs were reduced by several different interventions.


In response to an RGM outbreak, HSCT patients were banned from ingesting DWIM ice and water and bottled water was provided. Since this interverntion 4 years ago, no additional RGM isolates have been identified in HSCT patient cultures. Our measures to reduce HPCs to goal levels in drinking water from DWIMs were successful, but the HPCs for ice have not consistently reached the goal of <500 CFU/mL.

Infect Control Hosp Epidemiol 2017;38:792–800

Corresponding author
Address correspondence to Susan Kline, MD, MPH, 420 Delaware St SE, MMC 250, Minneapolis, MN 55455 (
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Infection Prevention Department, Allina Health East Region, St. Paul, Minnesota [A.G.]


Facilities Department, Lakeview Hospital, Stillwater, Minnesota [K.M.].

PREVIOUS PRESENTATION: These data were presented in part on 2 occasions: First, Guspiel, Messinger, Stebbins, and Streifel presented an abstract and poster at the Association for Professionals in Infection Control and Epidemiology (APIC) 2013 Annual Meeting, Fort Lauderdale, Florida on June 8–10, 2013, titled “What Is the Risk for Patients Ingesting Ice and Water from Your Facilities Ice Machines? A Process Improvement Project.” The abstract was published in June 2013 in the American Journal of Infection Control 2013;41(6 Suppl):S69–S70. Second, Kline S, Guspiel A, Streifel A, et al. presented an abstract and poster at the Infectious Disease Conference: IDWeek 2013, in San Francisco, California, on October 5, 2013, titled “Outbreak Investigation into an Increased Incidence of Non-tuberculous Mycobacterium in Sputum Cultures in Pediatric Blood and Marrow Transplant Patients.”

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Infection Control & Hospital Epidemiology
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  • EISSN: 1559-6834
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