The infection was caused by Mycobacterium abscessus, which is typically found in soil and water throughout the nation and does not cause infections in healthy people. It is a rare cause of surgical infection.
“We now believe that surgery processes involving the use of tap water may have inadvertently brought the organism into the perioperative environment,” Robert Mobley Jr., MD, the system’s medical director of quality, said in a news release. “At this time, we have not been able to find any single cause or process as the trigger for the outbreak, but we’ve taken extraordinary measures to protect our patients — and believe we’ve succeeded.”
The measures Dr. Mobley referred to include:
• Installing bacteriologic point-of-use water filters in operating rooms
• Eliminating slow-flow areas of internal water pipes
• Flushing scrub sinks for 10 minutes in the morning before use
• Strengthening a machine’s manufacturer-recommended disinfectant schedule
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