title: A systematic review of waterborne infections from nontuberculous mycobacteria in health care facility water systems.
abstract: Healthcare-acquired infections are an increasing problem for health care providers and policy makers. Water is an overlooked source of infectious microorganisms in health care facilities. Waterborne nontuberculous mycobacteria (NTM) are ubiquitous, and particularly problematic in health care facility water systems, and cause a variety of diseases. The purpose of this review is to assess health care associated NTM infections from health care facility water systems. We documented susceptible populations, modes of transmission, and the median attack rate (e.g. patients infected per patients exposed). We aimed to identify transmission risk factors and inform evidence-based policies for infection control and prevention. We searched Embase, PubMed, Web of Science and clinicaltrials.gov without date restrictions. English language articles with original data on NTM waterborne infections in health care settings were included. Randomized controlled trials, descriptive studies (case reports, case series), case-control studies, cohort studies, cross-sectional surveys, and quasi-experimental studies on nosocomial waterborne infections were included. Three investigators independently screened titles and abstracts for relevant articles, and one screened full-text articles. Data were extracted by one investigator, and a second confirmed accuracy for 10% of results. We included 22 observational studies. Immunocompromised, post-surgical, and hemodialysis patients were commonly affected populations. A range of exposure routes such as uncovered central venous catheters (CVCs), wound exposure, and contamination during surgical procedures was reported. The median attack rate was 12.1% (interquartile range, 11-27.2). Waterborne NTM infection affects susceptible patients through common, preventable exposure routes. Effective prevention strategies will require both medical and environmental health expertise, and inter-professional cooperation will optimize these efforts.
authors.affiliation: Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Trudy
authors.initials: T
authors.lastname: Li
authors.affiliation: The Water Institute, Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7431, Chapel Hill, NC, 27599, USA. Electronic address: labebe@live.unc.edu.
authors.forename: Lydia S
authors.initials: LS
authors.lastname: Abebe
authors.affiliation: The Water Institute, Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7431, Chapel Hill, NC, 27599, USA.
authors.forename: Ryan
authors.initials: R
authors.lastname: Cronk
authors.affiliation: The Water Institute, Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, 135 Dauer Drive, CB#7431, Chapel Hill, NC, 27599, USA. Electronic address: jbartram@email.unc.edu.
authors.forename: Jamie
authors.initials: J
authors.lastname: Bartram
mesh_terms: D003428:Cross Infection / Q000453:epidemiology*; D004784:Environmental Monitoring; D006268:Health Facilities; D006801:Humans; D009164:Mycobacterium Infections / Q000453:epidemiology*; D009170:Nontuberculous Mycobacteria; D014871:Water Microbiology; D014881:Water Supply; D000069578:Waterborne Diseases / Q000453:epidemiology*
keywords: HCAI; Health care acquired infection; Hospital acquired infection; Water outbreaks; Water safety