Hospital Water Supply Contaminated With Mycobacteria Abscessus Kills Two Patients
A UK coroner has ruled that the deaths of two women, Anne Martinez and Karen Starling, followed exposure to Mycobacteria abscessus. An inquest has found that they were likely to have contracted the infection from a contaminated water supply at the new site for the Royal Papworth Hospital in Cambridge, United Kingdom.
The hospital site opened in May 2019 and three months later, testing confirmed that two patients were positive for the presence of M. abscessus. The hospital had previously undergone inspection that confirmed the site was safe and ready to open, and that the water supply was safe to use. Testing further confirmed the presence of other positive cases around this time.
Anne Martinez and Karen Starling were both recipients of a double lung transplant at the new site, not long after the hospital opened. The assistant coroner, Keith Morton, stated that neither patient would have died if they had not been infected by M. abscessus.
A version of this article reporting the on deaths of two transplant patients from a hospital water supply contaminated with Mycobacteria abscessus appeared in Legionella Control International’s newsletter. To get it in your inbox, sign up for free here.
What is Mycobacteria abscessus?
Mycobacteria abscessus is one of several types of mycobacteria that exist in the environment around us that can also infiltrate man-made water systems and contaminate hospital equipment and devices.
Mycobacteria abscessus is highly resistant to treatment and therefore presents a significant risk in healthcare settings. While many infections caused by the bacteria are skin related, some can affect the lungs. This is particularly notable among those who are immunocompromised, as the two patients were in this case, having just received lung transplants.
According to the Royal Papworth Hospital website, regular testing for this bacterium has been in place for years. A statement from the chief executive at the hospital, Eilish Midlane, made it clear that the hospital followed all the correct procedures regarding water safety at the time. They further confirmed that specialist water filters were added to outlets following the discovery of the outbreak, along with a hydrogen peroxide dosing system to boost water treatment.
Latest guidance on water safety does not cover M. abscessus
According to Mr Morton, the current guidance on offer from the Department of Health and Social Care concerning water safety does not include information about M. abscessus. As such, those with responsibility for managing the water systems in a healthcare setting such as the Royal Papworth Hospital, would likely not know about it. They could follow all the guidance provided and conduct water safety risk assessments, test water samples, and provide maintenance, and still not be aware of Mycobacteria abscessus potentially getting into the systems.
A response is now required from the Department of Health and Social Care, which must be received within 56 days, making the deadline 2nd January.
How dangerous is Mycobacteria abscessus?
Most healthy people could encounter the bacteria and not experience any issues. However, the danger occurs among those whose immune systems are not able to fend off infection as they usually would. Since M. abscessus can enter the lungs and cause an infection there, those with lung conditions are at particular risk. As Ms Martinez and Ms Starling had both successfully undergone lung transplants, they were at greater risk of an opportunistic infection.
Mr Morton noted that 34 patients had tested positive for M. abscessus, with fresh cases still coming to the fore, although these were now less frequent than before.
Should there be changes to water safety guidance to cover Mycobacteria abscessus?
Those in charge of maintaining water safety systems at hospitals and other similar premises will know about legionella, Pseudomonas aeruginosa, and other waterborne bacteria. However, it would not be a surprise if many of those in this important role were unaware of the concerns surrounding Mycobacteria abscessus. This is despite its ability to cause opportunistic infections among those who are specifically at greater risk of developing such an infection.
It seems clear that such changes should be made to improve patient safety in all hospitals and healthcare settings. Another point of concern is that infections caused by M. abscessus are difficult to treat. While antibiotics are used to tackle infections, treatment can be prolonged and there is some resistance to drugs. Clearly, doing everything possible to avoid infection in the first place is the better path to take, and this includes improving water safety practices.
For now, we await the response from the Department of Health and Social Care, to determine whether they will make changes to the current water safety guidelines. If no changes are to be made, they must outline why they are making this decision. The Report to Prevent Future Deaths, written by the coroner and covering three detailed pages, indicates that any hospital patient may potentially be at risk of death if they contract this infection.
While Royal Papworth Hospital did indeed take steps to mitigate the infections once they were discovered, infections are still happening, albeit far fewer of them. We shall be looking to see what the response is from the Health Secretary in this case and how it might affect the steps taken in future.
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We are experienced in the healthcare role of Authorising Engineer (Water) and can assist organisations in the development of water safety management teams, policies, and procedures to safeguard people across large scale and multi-site property portfolios, complex facilities and those considered to be higher risk.
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