title: A nosocomial pseudo-outbreak of Mycobacterium xenopi due to a contaminated potable water supply: lessons in prevention.
abstract: OBJECTIVE
  To determine risk factors for Mycobacterium xenopi isolation in patients following a pseudo-outbreak of infection with the organism.
  
  
  METHODS
  Retrospective cohort analysis of mycobacteriology laboratory specimen records and frequency-matched case-control study of hospital patients.
  
  
  METHODS
  General community hospital.
  
  
  METHODS
  For the case-control study, 13 case patients and 39 randomly selected controls with mycobacterial cultures negative for M xenopi, frequency matched by specimen source, whose specimens were submitted from June 1990 through June 1991.
  
  
  RESULTS
  Between June 1990 and June 1991, M xenopi was isolated from 13 clinical specimens processed at a midwestern hospital, including sputum (n = 6), bronchial washings (2), urine (4), and stool (1). None of the patients with M xenopi-positive specimens had apparent mycobacterial disease, although five received antituberculosis drug therapy for a range of one to six months. Specimens collected in a nonsterile manner were more likely to grow the organism than those collected aseptically (3.1% versus 0, relative risk = infinity, P = 0.003). M xenopi isolation was attributed to exposure of clinical specimens to tap water, including rinsing of bronchoscopes with tap water after disinfection, irrigation with tap water during colonoscopy, gargling with tap water before sputum collection, and collecting urine in recently rinsed bedpans. M xenopi was isolated from tap water in 20 of 24 patient rooms tested, the endoscopy suite, and the central hot water mixing tank, but not from water in the microbiology laboratory. The pseudo-outbreak occurred following a decrease in the hot water temperature from 130 degrees F to 120 degrees F in 1989.
  
  
  CONCLUSIONS
  Maintenance of a higher water temperature and improved specimen collection protocols and instrument disinfection procedures probably would have prevented this pseudo-outbreak.
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, GA.
authors.forename: D H
authors.initials: DH
authors.lastname: Sniadack
authors.forename: S M
authors.initials: SM
authors.lastname: Ostroff
authors.forename: M A
authors.initials: MA
authors.lastname: Karlix
authors.forename: R W
authors.initials: RW
authors.lastname: Smithwick
authors.forename: B
authors.initials: B
authors.lastname: Schwartz
authors.forename: M A
authors.initials: MA
authors.lastname: Sprauer
authors.forename: V A
authors.initials: VA
authors.lastname: Silcox
authors.forename: R C
authors.initials: RC
authors.lastname: Good
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control*; D004196:Disease Outbreaks / Q000517:prevention & control; D005260:Female; D006761:Hospitals; D006801:Humans; D017053:Infection Control / Q000379:methods; D008297:Male; D008875:Middle Aged; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control*; D009170:Nontuberculous Mycobacteria; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States; D014871:Water Microbiology