title: Pseudo-outbreak of Legionella pneumophila serogroup 8 infection associated with a contaminated ice machine in a bronchoscopy suite.
abstract: OBJECTIVE
  To investigate the marked increase noted over an 8-month period in the number of Legionella pneumophila isolates recovered from bronchoalveolar lavage fluid specimens obtained during bronchoscopy in our healthcare system.
  
  
  METHODS
  Bronchoscopy suite that serves a 580-bed tertiary care center and a large, multisite, faculty practice plan with approximately 2 million outpatient visits per year.
  
  
  METHODS
  Cultures of environmental specimens from the bronchoscopy suite were performed, including samples from the air and water filters, bronchoscopes, and the ice machine, with the aim of identifying Legionella species. Specimens were filtered and acid-treated and then inoculated on buffered charcoal yeast extract agar. Serogrouping was performed on all isolates recovered from patient and environmental samples.
  
  
  RESULTS
  All L. pneumophila isolates recovered from patients were serogroup 8, a serogroup that is not usually recovered in our facility. An epidemiologic investigation of the bronchoscopy suite revealed the ice machine to be contaminated with L. pneumophila serogroup 8. Patients were exposed to the organism as a result of a recently adopted practice in the bronchoscopy suite that involved directly immersing uncapped syringes of sterile saline in contaminated ice baths during the procedures. At least 1 patient was ill as a result of the pseudo-outbreak. Molecular typing of isolates recovered from patient and environmental samples revealed that the isolates were indistinguishable.
  
  
  CONCLUSIONS
  Extensive cleaning of the ice machine and replacement of the machine's water filter ended the pseudo-outbreak. This episode emphasizes the importance of using aseptic technique when performing invasive procedures, such as bronchoscopies. It also demonstrates the importance of reviewing procedures in all patient areas to ensure compliance with facility policies for providing a safe patient environment.
authors.affiliation: Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. ans9112@med.cornell.edu
authors.forename: A N
authors.initials: AN
authors.lastname: Schuetz
authors.forename: R L
authors.initials: RL
authors.lastname: Hughes
authors.forename: R M
authors.initials: RM
authors.lastname: Howard
authors.forename: T C
authors.initials: TC
authors.lastname: Williams
authors.forename: F S
authors.initials: FS
authors.lastname: Nolte
authors.forename: D
authors.initials: D
authors.lastname: Jackson
authors.forename: B S
authors.initials: BS
authors.lastname: Ribner