title: Insidious Risk of Severe Mycobacterium chimaera Infection in Cardiac Surgery Patients.
abstract: BACKGROUND
  An urgent UK investigation was launched to assess risk of invasive Mycobacterium chimaera infection in cardiothoracic surgery and a possible association with cardiopulmonary bypass heater-cooler units following alerts in Switzerland and The Netherlands.
  
  
  METHODS
  Parallel investigations were pursued: (1) identification of cardiopulmonary bypass-associated M. chimaera infection through national laboratory and hospital admissions data linkage; (2) cohort study to assess patient risk; (3) microbiological and aerobiological investigations of heater-coolers in situ and under controlled laboratory conditions; and (4) whole-genome sequencing of clinical and environmental isolates.
  
  
  RESULTS
  Eighteen probable cases of cardiopulmonary bypass-associated M. chimaera infection were identified; all except one occurred in adults. Patients had undergone valve replacement in 11 hospitals between 2007 and 2015, a median of 19 months prior to onset (range, 3 months to 5 years). Risk to patients increased after 2010 from <0.2 to 1.65 per 10000 person-years in 2013, a 9-fold rise for infections within 2 years of surgery (rate ratio, 9.08 [95% CI, 1.81-87.76]). Endocarditis was the most common presentation (n = 11). To date, 9 patients have died. Investigations identified aerosol release through breaches in heater-cooler tanks. Mycobacterium chimaera and other pathogens were recovered from water and air samples. Phylogenetic analysis found close clustering of strains from probable cases.
  
  
  CONCLUSIONS
  We identified low but escalating risk of severe M. chimaera infection associated with heater-coolers with cases in a quarter of cardiothoracic centers. Our investigations strengthen etiological evidence for the role of heater-coolers in transmission and raise the possibility of an ongoing, international point-source outbreak. Active management of heater-coolers and heightened clinical awareness are imperative given the consequences of infection.
authors.affiliation: National Infection Service, Public Health England.|Guy's and St Thomas' NHS Foundation Trust, and.|National Institute for Health Research Health Protection Research Unit in Respiratory Infections, Imperial College London.
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authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Lamagni
authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Kranzer
authors.affiliation: Nuffield Department of Medicine, University of Oxford.
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authors.lastname: Hedge
authors.affiliation: National Infection Service, Public Health England.
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authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Parks
authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Collins
authors.affiliation: Nuffield Department of Medicine, University of Oxford.
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authors.lastname: Del Ojo Elias
authors.affiliation: National Infection Service, Public Health England.
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authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Brown
authors.affiliation: National Infection Service, Public Health England.|National Institute for Health Research Health Protection Research Unit in Respiratory Infections, Imperial College London.
authors.forename: E Grace
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authors.lastname: Smith
authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Hoffman
authors.affiliation: National Infection Service, Public Health England.
authors.forename: Peter
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authors.lastname: Kirwan
authors.affiliation: Public Health Wales NHS Trust, Cardiff.
authors.forename: Brendan
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authors.affiliation: Vaccine Preventable Diseases, Health Protection Scotland, Glasgow, and.
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authors.affiliation: Health Protection Service, Public Health Agency Northern Ireland, Belfast, United Kingdom.
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authors.affiliation: National Infection Service, Public Health England.
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authors.affiliation: National Infection Service, Public Health England.
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authors.affiliation: National Infection Service, Public Health England.
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authors.affiliation: National Infection Service, Public Health England.
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authors.affiliation: National Infection Service, Public Health England.|European Programme for Intervention Epidemiology Training, European Centre for Disease Prevention and Control, Stockholm, Sweden.
authors.forename: Antonio
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authors.lastname: Isidro Carrion Martin
authors.affiliation: National Infection Service, Public Health England.|Field Epidemiology Service, Public Health England, Newcastle.
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authors.lastname: Dolan
authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Bhatt
authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Skingsley
authors.affiliation: National Infection Service, Public Health England.
authors.forename: André
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authors.lastname: Charlett
authors.affiliation: National Infection Service, Public Health England.
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authors.lastname: Pearce
authors.affiliation: National Infection Service, Public Health England.
authors.forename: Katherine
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authors.lastname: Russell
authors.affiliation: South Tees Hospitals Foundation NHS Trust, Middlesbrough.|Society for Cardiothoracic Surgery in Great Britain and Ireland, London.
authors.forename: Simon
authors.initials: S
authors.lastname: Kendall
authors.affiliation: Papworth Hospital NHS Foundation Trust, Cambridge.|Association of Cardiothoracic Anaesthetists, London.
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Klein
authors.affiliation: Royal Wolverhampton NHS Trust, Wolverhampton.
authors.forename: Stephen
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authors.lastname: Robins
authors.affiliation: Royal Brompton and Harefield NHS Foundation Trust, London.
authors.forename: Silke
authors.initials: S
authors.lastname: Schelenz
authors.affiliation: Guy's and St Thomas' NHS Foundation Trust, and.
authors.forename: William
authors.initials: W
authors.lastname: Newsholme
authors.affiliation: University Hospital South Manchester NHS Foundation Trust, Manchester.
authors.forename: Stephanie
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authors.lastname: Thomas
authors.affiliation: Leeds Teaching Hospitals NHS Trust, Leeds, and.
authors.forename: Tim
authors.initials: T
authors.lastname: Collyns
authors.affiliation: Public Health Wales NHS Trust, Cardiff.|Cardiff and Vale University Health Board, Cardiff, United Kingdom.
authors.forename: Eleri
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authors.lastname: Davies
authors.affiliation: Vaccine Preventable Diseases, Health Protection Scotland, Glasgow, and.
authors.forename: Jim
authors.initials: J
authors.lastname: McMenamin
authors.affiliation: Health Protection Service, Public Health Agency Northern Ireland, Belfast, United Kingdom.
authors.forename: Lorraine
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authors.lastname: Doherty
authors.affiliation: Nuffield Department of Medicine, University of Oxford.
authors.forename: Tim E A
authors.initials: TE
authors.lastname: Peto
authors.affiliation: National Infection Service, Public Health England.|Nuffield Department of Medicine, University of Oxford.
authors.forename: Derrick
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authors.lastname: Crook
authors.affiliation: National Infection Service, Public Health England.|National Institute for Health Research Health Protection Research Unit in Respiratory Infections, Imperial College London.
authors.forename: Maria
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authors.affiliation: National Infection Service, Public Health England.
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mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000391:Air Microbiology; D002315:Cardiopulmonary Bypass / Q000009:adverse effects*; D002648:Child; D015331:Cohort Studies; D004866:Equipment Contamination; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009165:Mycobacterium Infections, Nontuberculous / Q000453:epidemiology* / Q000382:microbiology / Q000401:mortality / Q000635:transmission; D009170:Nontuberculous Mycobacteria / Q000145:classification / Q000235:genetics / Q000302:isolation & purification*; D012189:Retrospective Studies; D012307:Risk Factors; D013523:Surgical Equipment / Q000382:microbiology*; D013530:Surgical Wound Infection / Q000453:epidemiology* / Q000382:microbiology* / Q000401:mortality; D006113:United Kingdom / Q000453:epidemiology; D014871:Water Microbiology
keywords: aerosol release; cardiac surgical procedures.; disease outbreaks; equipment contamination; nontuberculous mycobacteria