Bacteria in hospital ice machines blamed for patient death

Legionella bacteria found in hospital ice machines at UPMC Presbyterian contributed to one patient's death and sickened two others


Legionella bacteria in ice machines at UPMC Presbyterian contributed to one patient's death and sickened two others, according to an article on the TribLive website.

The article said the situation was discovered when a patient aspirated ice chips.

The deadly bacteria in ice machines prompted the sterilization of about 500 machines in UPMC's 20 hospitals, the article said. Machines that tested positive for Legionella were removed. Those remaining are being sterilized and fitted with filters.

UPMC officials declined to identify the person who died or the other victims, saying only that the cases occurred in late 2013.

UPMC officials notified state and Allegheny County health departments and the federal Centers for Disease Control and Prevention. The CDC did not comment on the matter, though a spokesman confirmed the agency knew that Legionella can contaminate hospital ice machines.

“I believe a revision of CDC guidelines is long overdue for this,” said Dr. Joseph S. Cervia, a Legionnaires' expert and clinical professor of medicine at Hofstra North Shore-LIJ School of Medicine in Hempstead, N.Y.

The task of sterilizing ice machines is complicated, because different manufacturers made them, said John Innocenti, president and CEO of UPMC Presbyterian. He declined to release the company names but said they had been notified about the problem.

“The way we disinfect one machine might not work in another,” Innocenti said in the article.

He said UPMC engineers were stumped by Legionella in ice machines because the machines function with a cold water line. The bacteria grow best in warm water, according to the CDC.

But Innocenti said UPMC's inspection found a reservoir within the ice machines that holds water.

“That alone would be fine, but in the ice machine, you have compressors that get warm, and in essence, they heat the water that's in the ice machines, allowing Legionella colonies to form,” he said in the article.

Read the article.

 

 



May 7, 2014


Topic Area: Maintenance and Operations


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