Recognising Hazards & Seeing Risks

Sinkevitch and co-workers from the US Centers for Disease Control & Prevention (CDC) have recently reported on the investigation into three cases of Mycobacterium abscessus colonisation and/or infection in ventilator dependent paediatrics at a residential facility.  Mycobacterium abscessus is one of the Non-Tuberculous Mycobacterium (NTM) species responsible for severe respiratory, skin and mucosal infections, and in addition is one of the most antibiotic resistant, leaving few viable therapeutic options.    The CDC and colleagues from the local health authority (Pennsylvania Department of Health – PADOH) found significant problems at the residential facility including:

  • Failure to follow aseptic technique
  • The facility had created their own procedure for tracheotomy tube reprocessing for which there was no validation or verification data confirming effectiveness
  • Recommendations for facility staff to follow the manufacturer’s more stringent instructions for tracheostomy tube reprocessing were not undertaken
  • Many areas within the facility had not been used for an extended period of time (2 years) 
  • No Water Safety Plan or water quality monitoring programme was being undertaken 

With these findings raising significant concerns regarding stagnant water with conditions conducive for microbial amplification, PADOH collected 21 environmental and water samples from multiple locations including taps, aerators, showerheads, drains, filtered water, ice machines and locations where individuals with colonisation and/or infection had been resident. 16/21 (76%) samples, including the ice and filtered water samples, were positive for Mycobacterium species (M. chelonae, M. franklinii, M. gordonae, M. Ilatzerense), including ice and filtered water samples.  Mycobacterium abscessus was recovered from a shower drain swab.  Additionally, 4 samples collected from the tracheostomy tube reprocessing room were found to have Heterotrophic Plate Counts of between 5500 – 25000 CFU/mL which is above acceptable levels for US drinking water (Environmental Protection Agency, HPC ≤ 500 CFU/mL.

PADOH recommended installation of point-of-use water filters in order to protect users and keep operations going, whilst in parallel engaging a water consultant to support development, implementation and operation of a Water Safety Plan. PADOH continued their support for an 8 month period through collaborative monitoring.

Simply put, the building owners, management and staff did not see the hazards nor the risks from their water quality, lack of water system management, their own infection prevention and control practices and the consequential impact on ventilator-dependent residents. 

It is hard to believe that this facility and all of its staff “fell through the gap” regarding water hygiene.  However, it is clear that without competence, without relevant skills, knowledge and experience, the hazards of in-premise water systems and multiple risks to users can be missed.  Protocols adopted without supporting validation and verification documentation is more common than you think.  If you want to discuss any aspect of water hygiene, protocol development and documentation or training needs for your team, please contact us at:


Sinkevitch JN, Paoline J, Smee A et al.  Notes from the Field:  Mycobacterium abscessus Outbreak Relatedto Contaminated Water Among Ventilator-Dependent Residents of a Pediatric Facility – Pennsylvaniz, 2022.  MMWR Morb Mortal Wkly Rep 2023; 72:1151-2.  DOI:

Johansen MD, Herrmann JL, Kremer L. Non-tuberculous mycobacteria and the rise of Mycobacterium abscessus. Nat Rev Microbiol. 2020 Jul;18(7):392-407. doi: 10.1038/s41579-020-0331-1. Epub 2020 Feb 21. PMID: 32086501.

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