Three California hospitals and one in Colorado owned the same brand of ice machine and brands of filters, descaling and sanitizing products. Twenty-three B. multivorans cases were originally reported at two hospitals, and the CDC discovered 23 more at two others.
The ice and water used from these machines were used for several clinical care activities, including bed baths, swallow evaluations and topical application of ice packs for analgesia.
The 46 cases occurred between 2020 and 2024, and after realizing the cause of the outbreaks, the machines were removed from service.
To reduce the risk of an outbreak like these, the CDC recommends healthcare facilities devise and implement a water management program and avoid the use of tap water for patient care.
Access the CDC’s report here.
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