title: Pacemaker pocket infection due to environmental mycobacteria: Successful management of an outbreak and steps for prevention in future.
abstract: BACKGROUND
  An outbreak of surgical site infection (SSI) due to environmental mycobacteria (EMB) occurred in a hospital in Eastern India.
  
  
  METHODS
  A quality improvement project (QIP) was undertaken to analyze the causes and prevent further outbreak. Step (1) Proof of the need: Four patients who had undergone pacemaker implantation consecutively during a 10-day period developed SSI. Step (2) Diagnostic journey: Since all patients developed SSI within 2 months of implantation, a common source of infection was likely. Atypical mycobacteria (AMB) were grown from surgical sites as well as from the surface of operation table, image intensifier, and lead aprons. It was a rapid growing variety that lacked pigment, a characteristic of EMB with pathogenic potential. The EMB was finally traced to its source, the overhead water tank. Step (3) Remedial journey: By thorough cleaning of the water tank and enriching its chlorine content, the EMB was eliminated from its source. Step (4) Holding the gains: Protocol for cleaning the water tank once in 3 months was made. A checklist was prepared to ensure compliance to asepsis protocol in the operation theater. In the ensuing 5 years, the infection did not recur.
  
  
  RESULTS
  The bacteria that caused SSI were identified as EMB that grew in the water tank and contaminated the operation room. It could be eliminated by appropriate measures.
  
  
  CONCLUSIONS
  Water is a potential reservoir for EMB. Use of the term 'environmental mycobacteria' instead of 'atypical mycobacteria' will generate awareness about contamination as the cause of SSI.
authors.affiliation: Head of the Department of Cardiology and in-charge ICU, Tata Main Hospital, Jamshedpur, India. Electronic address: bharatjsr@gmail.com.
authors.forename: Vijaya
authors.initials: V
authors.lastname: Bharat
authors.affiliation: Microbiologist, Panacea Hospital, Bangalore, India.
authors.forename: Vivek
authors.initials: V
authors.lastname: Hittinahalli
authors.affiliation: Pathologist, Tata Main Hospital, Jamshedpur, India.
authors.forename: Meenakshi
authors.initials: M
authors.lastname: Mishra
authors.affiliation: Senior Surgeon, Tata Main Hospital, Jamshedpur, India.
authors.forename: Sridhar
authors.initials: S
authors.lastname: Pradhan
mesh_terms: D000368:Aged; D001145:Arrhythmias, Cardiac / Q000628:therapy; D019468:Disease Management; D004196:Disease Outbreaks / Q000517:prevention & control* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007194:India / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D009161:Mycobacterium / Q000302:isolation & purification*; D009164:Mycobacterium Infections / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D010138:Pacemaker, Artificial / Q000009:adverse effects* / Q000382:microbiology; D016459:Prosthesis-Related Infections / Q000453:epidemiology / Q000382:microbiology / Q000517:prevention & control*; D012189:Retrospective Studies
keywords: Environmental mycobacteria; Outbreak of SSI; Pacemaker pocket infection; Quality improvement project