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  • A cluster of three extrapulmonary Mycobacterium abscessus infections linked to well-maintained water-based heater-cooler devices

  • Jessica L. Seidelman, Arthur W. Baker, Sarah S. Lewis, Bobby G. Warren, Aaron Barrett, Amanda Graves, Carly King, Bonnie Taylor, Jill Engel, Desiree Bonnadonna, Carmelo Milano, Richard J. Wallace, Matthew Stiegel, Deverick J. Anderson, Becky A. Smith
  • Journal:
    Infection Control & Hospital Epidemiology / Volume 45 / Issue 5 / May 2024
    Published online by Cambridge University Press:
    21 December 2023, pp. 644-650
    Print publication:
    May 2024
    • Article
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  • Background:

    Various water-based heater-cooler devices (HCDs) have been implicated in nontuberculous mycobacteria outbreaks. Ongoing rigorous surveillance for healthcare-associated M. abscessus (HA-Mab) put in place following a prior institutional outbreak of M. abscessus alerted investigators to a cluster of 3 extrapulmonary M. abscessus infections among patients who had undergone cardiothoracic surgery.

    Methods:

    Investigators convened a multidisciplinary team and launched a comprehensive investigation to identify potential sources of M. abscessus in the healthcare setting. Adherence to tap water avoidance protocols during patient care and HCD cleaning, disinfection, and maintenance practices were reviewed. Relevant environmental samples were obtained. Patient and environmental M. abscessus isolates were compared using multilocus-sequence typing and pulsed-field gel electrophoresis. Smoke testing was performed to evaluate the potential for aerosol generation and dispersion during HCD use. The entire HCD fleet was replaced to mitigate continued transmission.

    Results:

    Clinical presentations of case patients and epidemiologic data supported intraoperative acquisition. M. abscessus was isolated from HCDs used on patients and molecular comparison with patient isolates demonstrated clonality. Smoke testing simulated aerosolization of M. abscessus from HCDs during device operation. Because the HCD fleet was replaced, no additional extrapulmonary HA-Mab infections due to the unique clone identified in this cluster have been detected.

    Conclusions:

    Despite adhering to HCD cleaning and disinfection strategies beyond manufacturer instructions for use, HCDs became colonized with and ultimately transmitted M. abscessus to 3 patients. Design modifications to better contain aerosols or filter exhaust during device operation are needed to prevent NTM transmission events from water-based HCDs.

  • 7 - Becoming Party to a Treaty: Consent to Be Bound and Entry into Force

  • Jill Barrett, Queen Mary University of London, Robert Beckman, National University of Singapore
  • Book:
    Handbook on Good Treaty Practice
    Published online:
    27 January 2020
    Print publication:
    12 March 2020, pp 244-288

  • Summary

    There is a crucial difference between creating a treaty, expressing consent to be bound by it and bringing it into force. The focus of this chapter is on completing the process of consenting to be bound and bringing the treaty into force, once the decision to become a party has been taken and treaty officials are asked to prepare the documentation and take care of procedures. The process is examined at both the international and domestic levels. It concludes by considering the action needed immediately after entry into force, in particular publication of the treaty text and registration at the UN under Article 102 of the UN Charter.

  • 6 - Preparing to Become Party to a Treaty

  • Jill Barrett, Queen Mary University of London, Robert Beckman, National University of Singapore
  • Book:
    Handbook on Good Treaty Practice
    Published online:
    27 January 2020
    Print publication:
    12 March 2020, pp 203-243

  • Summary

    The chapter concerns steps to consider in preparing to become party to a treaty. It examines the eligibility of States and IOs to participate in multilateral treaties, including scenarios in which eligibility to join a treaty is not clear and what procedures may be used to resolve such issues. The chapter explains the importance of understanding ‘modes of expressing consent to be bound’, and choosing the appropriate mode. It looks at how a treaty may be made by exchange of instruments. Lastly, the chapter considers internal preparations to give consent to be bound for States and IOs, including consultations with stakeholders.

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