UPMC mold infections stemmed from improper use of negative-pressure rooms, CDC says — 5 things to know

The CDC released findings Thursday from its investigation into a cluster of mold infections at two UPMC hospitals in Pittsburgh that contributed to the deaths of four organ transplant patients.

The following are five things to know about the agency's findings.

1. Three of the infections were classified as probable cases, and the fourth case was classified as suspected. All four patients had solid organ transplants — in the three probable cases, patients received heart (two) and lung (one) transplants, while the fourth patient received a second liver transplant.

2. The three patients with probable cases received care in the same room of a 20-bed cardiothoracic intensive care unit. That room was the only negative-pressure isolation room in the unit, and none of the three patients needed negative-pressure isolation.

3. The room had a door leading to a carpeted hallway and family room. "Frequent use of this door by personnel and visitors might have disturbed airflow, allowing dust and mold spores, if present, to enter the room," reads the CDC report.

4. "Caring for immunosuppressed patients in negative-pressure environments has been previously identified as a risk factor for invasive mold infections, possibly related to the potential to concentrate dust and mold spores in these rooms," the CDC report concludes. "This investigation highlights how unnecessary placement of immunocompromised patients in negative-pressure rooms could result in net harm and therefore should be avoided."

5. In a statement to Trib Live, Tami Minnier, MSN, RN, UPMC's chief quality officer, said, "Our hope is that other medical centers will learn from our experience and implement the rigorous controls we voluntarily put in place to ensure patient safety. We appreciate the ongoing support from the CDC, as well as that of our local and state health authorities."

More articles on patient safety:
Hospital rooms should stop making people sick
Fourth UPMC patient with mold infection dies after outbreak
CDC: Source of UPMC mold that killed 3 could not be found

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