title: Pseudo-outbreak of Mycobacterium fortuitum due to contaminated ice machines.
abstract: BACKGROUND
  An almost 4-fold increase from normal baseline levels in the isolation of Mycobacterium fortuitum from respiratory tract specimens was observed. The majority of these isolates were obtained from patients residing on 1 of 2 wards, prompting an epidemiologic investigation.
  
  
  METHODS
  In addition to patient specimens, environmental cultures were collected from various water sources on the 2 affected wards. Samples were also collected from uninvolved areas of the hospital. All specimens were cultured with use of a continuously monitored broth system for the isolation of mycobacteria.
  
  
  RESULTS
  The respiratory tracts of 19 patients were colonized by M fortuitum. Surveillance cultures obtained from uninvolved areas of the hospital were either negative for mycobacteria or were colonized by M avium complex or M gordonae. Two ice machines, servicing the affected areas each, were colonized by M fortuitum in multiple cultures.
  
  
  CONCLUSIONS
  The M fortuitum pseudo-outbreak was due to contaminated ice machines located on each of the affected units. After removal and replacement of the ice machines, the pseudo-outbreak resolved.
authors: Department of Pathology, St. Vincent's Hospital, New York, New York 10011, USA.
authors: Vincent J
authors: VJ
authors: Labombardi
authors: Anne Marie
authors: AM
authors: O'brien
authors: Jay W
authors: JW
authors: Kislak
mesh_terms: D003428:Cross Infection / Q000453:epidemiology / Q000209:etiology / Q000382:microbiology; D004196:Disease Outbreaks; D004866:Equipment Contamination; D004865:Equipment and Supplies, Hospital / Q000382:microbiology*; D005516:Food Microbiology; D006757:Hospital Units; D006801:Humans; D007053:Ice / Q000032:analysis*; D017053:Infection Control; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology* / Q000209:etiology / Q000382:microbiology*; D019907:Mycobacterium fortuitum / Q000302:isolation & purification*; D009519:New York City
chemical_list: D007053:Ice