Notes from the Field: Mycobacterium abscessus Outbreak Related to Contaminated Water Among Ventilator-Dependent Residents of a Pediatric Facility ― Pennsylvania, 2022

On October 31, PADOH collected 21 environmental samples from faucets, aerators, showerheads and drains, filtered water and ice machines, and water samples from clinical care areas where residents with M. abscessus colonization or infection resided. PADOH recommended that the facility hire a water management consultant, develop a water management program, and install point-of-use filters in clinical areas until water quality consistently met EPA standards. Organism growth and heterotrophic plate count* results for environmental specimens collected from water sources in a pediatric facility — Pennsylvania, 2022Return to your place in the text Sampling site Sample type NTM identified Heterotrophic plate counts (CFU/mL)† Resident 1 room sink First-catch water Mycobacterium franklinii; M. chelonae 25,000 Post-flush water M. franklinii; M. chelonae 7,800 Faucet swab M. gordonae NP Tracheostomy tube reprocessing room sink First-catch water M. chelonae; M. llatzerense; M. franklinii 9,600 Post-flush water M. llatzerense 5,500 Faucet swab No NTM growth§ NP Resident 2 room sink Faucet swab M. gordonae NP Aerator swab No suspected growth NP Filtered water machine First-catch water M. chelonae; M. llatzerense NP Spout swab M. gordonae NP Stand-alone shower in shower room First-catch water M. llatzerense NP Faucet swab No NTM growth NP Drain swab M. chelonae; M. abscessus NP Multipurpose room sink First-catch water M. franklinii; M. llatzerense NP Faucet swab M. gordonae NP Hallway handwashing sink First-catch water M. llatzerense NP Faucet swab M. gordonae NP Ice machine Ice M. peregrinum; M. llatzerense NP Ice guard swab No NTM growth NP Chute swab No NTM growth NP Drain swab No NTM growth NP Abbreviations: CFU = colony-forming unit; HPC = heterotrophic plate count; NP = not performed; NTM = nontuberculosis mycobacterium. * HPCs measure carbon-consuming microorganisms in water and can be used to assess conditions affecting microbial growth in a water source or distribution system.