3 deaths at Brigham and Women's may be linked to bacteria in water purifier: Report

Bacteria from a water purification system may be linked to three deaths at Brigham and Women's Hospital in Boston, according to research published in Annals of Internal Medicine.

Mycobacterium abscessus, a bacteria found in water that can sometimes lead to hospital-acquired infections, was detected in four patients who were admitted to the hospital in 2018 on the same floor. Though efforts were made to control the infections, three of the four patients died.  

Brigham and Women's infection control team was alerted and began to investigate. The floor they stayed on was the only commonality between them, according to the report. 

"Every healthcare facility in the world will have a potential [encounter] with hospital-acquired infections," Michael Klompas, MD, the lead on the investigation and infectious disease physician at Brigham and Women's, told The Boston Globe. "It’s not a unique problem to us. If we pretend it doesn't exist, we will never be as successful as we can be if we confront these head on."

Usually, these bacteria are rarely found in hospital environments and pose minimal threat to healthy individuals, but for immunocompromised patients, it can become more serious, the report said.

"Investigation of the plumbing system revealed a commercial water purifier with charcoal filters and an ultraviolet irradiation unit leading to the ice and water machines in the cluster tower but not the hospital's other inpatient towers," researchers wrote. "… There were no further cases after high-risk patients were switched to sterile and distilled water, ice and water machine maintenance was intensified, and the commercial purification system was decommissioned."

Ultimately, after their investigation, clinicians concluded in the report that this instance was isolated and rare and "well-intentioned efforts to modify water management systems may inadvertently increase infection risk for vulnerable patients."

Becker's reached out to Brigham and Women’s Hospital for comment and received the following statement: "We are thankful to the researchers for their incredible detective work to identify the probable source of these infections. This work is important because this bacteria is commonly found in municipal water and can colonize any hospital's water systems. The work our team performed to identify the probable source of these infections and the controls we’ve implemented to prevent them can act as a model for other hospitals to address this issue and better protect their patients."


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