Exposure to NTM can happen in many places including residential buildings and healthcare settings. NTM exposures are often traced back to potable water as a source; healthcare facilities pose a particular challenge because they are large buildings with complex water systems. This can result in water stagnation and variation in water quality that can lead to growth of microorganisms like NTM. NTM can form difficult-to-eliminate biofilms, which are collections of microorganisms that stick to each other and adhere to surfaces in moist environments such as the insides of pipes.
From a plumbing system, contaminated water can be spread by:
- Shower heads and sink faucets
- Hydrotherapy equipment, such as jetted therapy baths
- Medical equipment such as respiratory machines, bronchoscopes, and heater-cooler devices
- Ice machines
- Intravenous infusions or intramuscular or intradermal injections
- Decorative fountains and water features
In order to prevent healthcare-associated infections caused by NTM, healthcare facilities should develop an effective water management program. Water management programs can reduce the risk of infections from water-related organisms such as NTM, Pseudomonas, and Legionella. A water management program is developed by a multidisciplinary team that can identify potential issues in a water system, regularly evaluate water quality, and implement control procedures when quality metrics are not met.
Healthcare facilities should also implement strong general infection control practices that prevent exposures to NTM and other water-related organisms. This includes:
- Preparation of injections and intravenous fluids away from sinks or other water sources
- Storage of materials and equipment used in invasive procedures (including injections) away from water sources
- Following the manufacturer’s instructions for maintenance and use of medical devices that use water (e.g., hydrotherapy equipment, heater cooler devices)
- Avoiding the use of tap water or non-sterile ice in invasive procedures
Healthcare-associated NTM infections and outbreaks can occur when environmental and infection control factors permit susceptible hosts to be exposed to NTM from a healthcare facility’s water system. Susceptibility to these infections increases for patients who are older, immunocompromised, or have other medical conditions such as open wounds. These infections can occur in a number of different healthcare settings, can be related to various exposure pathways, and can affect a range of patient populations.
Surveillance for extrapulmonary infections can lead to identification of healthcare-associated NTM infections and earlier detection of outbreaks. Laboratory identification of the species of NTM is important as it enables recognition of infections potentially related to a common source. Facilities should know and comply with the reporting requirements of their health department as some health departments have made extrapulmonary NTM reportable in their jurisdiction in order to facilitate outbreak detection.
NTM outbreaks have been related to a variety of medical procedures and practices including:
- Breast surgery
- Heart surgery, including the use of heater-cooler devices
- Eye surgery with exposure to consumer-grade humidifiers
- Dental procedures
- Medical tourism
- Cosmetic surgery
- Medicine compounding and mixing
- Medication preparation
- Injection preparation and administration
- Central line placement and maintenance
- Manufacturing of medical products
Healthcare Facilities Should:
- Establish a healthcare water management program
- Follow the Centers for Medicare & Medicaid Services healthcare facility requirement to prevent Legionella infections as outlined in CMS Memo S&C 17-30-Hospitals/CAHs/NHs [PDF – 4 pages]
- Consider conducting surveillance for NTM infections
- Recognize that identifying NTM species can help determine public health actions
- Determine their lab capacity for testing for NTM and, if testing capabilities are limited, identify reference laboratories that can assist with NTM species identification
- Notify public health of NTM infections as per their state reporting requirements
- Consider reporting all extrapulmonary NTM infections to public health as this may help promptly identify an outbreak (Council of State and Territorial Epidemiologists Standardized Case Definition for Extrapulmonary Nontuberculous Mycobacteria Infections [PDF – 12 pages])
- Notify health departments of NTM outbreaks
Examples of select healthcare-associated NTM outbreaks
- Baker AW, Lewis SS, Alexander BD, Chen LF, Wallace RJ Jr, et al. Two-Phase Hospital-Associated Outbreak of Mycobacterium abscessus: Investigation and Mitigation. Clin Infect Dis. 2017; 64(7):902-911.
- Lyman MM, Grigg C, Kinsey CB, Keckler MS, Moulton-Meissner H, Cooper E, Soe MM, Noble-Wang J, Longenberger A, Walker SR, Miller JR, Perz JF, Perkins KM. Invasive Nontuberculous Mycobacterial Infections among Cardiothoracic Surgical Patients Exposed to Heater-Cooler Devices. Emerg Infect Dis. 2017 May;23(5):796-805.
- Peralta G, Tobin-D’Angelo M, Parham A, et al. Notes from the Field. Mycobacterium abscessus Infections Among Patients of a Pediatric Dentistry Practice — Georgia, 2015. MMWR Morb Mortal Wkly Rep 2016;65:355–356.
- Brown-Elliott BA, Wallace RJ Jr, Tichindelean C, Sarria JC, McNulty S, Vasireddy R, Bridge L, Mayhall CG, Turenne C, Loeffelholz M. Five-year outbreak of community- and hospital-acquired Mycobacterium porcinum infections related to public water supplies. J Clin Microbiol. 2011;49(12):4231-8.
- Conger NG, O’Connell RJ, Laurel VL, Olivier KN, Graviss EA, Williams-Bouyer N, Zhang Y, Brown-Elliott BA, Wallace RJ Jr. Mycobacterium simae outbreak associated with a hospital water supply [PDF – 6 pages]. Infect Control Hosp Epidemiol. 2004;25(12):1050-5.
- Edens C, Liebich L, Halpin AL, Moulton-Meissner H, Eitniear S, Zgodzinski E, Vasko L, Grossman D, Perz JF, Mohr MC. Mycobacterium chelonae Eye Infections Associated with Humidifier Use in an Outpatient LASIK Clinic–Ohio, 2015. MMWR Morb Mortal Wkly Rep. 2015 Oct 23;64(41):1177.