Ice machines were source of Legionnaires'

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After one patient died and two were sickened by Legionnaires' disease in November and December at UPMC Presbyterian, where they contracted the disease, UPMC has a message for hospitals nationwide.

"Hospitals in the U.S.: If you have not been looking in ice machines for Legionella, please look," Tami Minnier, UPMC's chief quality control officer, said Friday. "That's the message."

The three hospital-acquired Legionnaires' cases were the first to occur in more than two years at UPMC Presbyterian, she said, and led to a thorough cleaning and disinfection of all of the hospital system's 500 ice machines in 20 hospitals -- including 80 machines in Presbyterian.

Although the cases occurred about five months ago, Ms. Minnier said that UPMC began talking publicly about it this week because it had a difficult time finding existing hospital protocols on Legionnaires' disease and ice machines and little discussion about the issue around the country.

The second goal of going public, she conceded, was to make sure the public did not put UPMC in the same boat as the Veterans Affairs Pittsburgh Healthcare System. The VA was lambasted with criticism over the past 1½ years for how it dealt with an Legionnaires' outbreak here that infected at least 22 veterans, six of whom died over a 16-month period in 2011 and 2012.

She said the UPMC outbreak began in mid-November when an older woman who was immuno-compromised was in the hospital and contracted what was thought to be pneumonia.

Several days before the woman died in mid-November, doctors confirmed that she had contracted Legionnaires' disease, Ms. Minnier said.

The staff remembered that the woman had aspirated while sucking on ice chips in the hospital.

Tests confirmed that the ice machine the ice chips had come from was contaminated with Legionella bacterium.

But a question remained: How did Legionella bacterium, which typically grows best in warm water, grow in the cold water used in the ice machine?

After tearing apart the machine, Ms. Minnier said, staff discovered that ice machines contain a water reservoir located next to a compressor, which can heat up enough to warm the water in the reservoir and allow the growth of Legionella.

Presbyterian then began testing for Legionella in all of its ice machines, starting with those in areas where immune-compromised patients were treated.

Before it could test all of the machines in the hospital, during the first two weeks of December, two more patients in other parts of the building tested positive for Legionnaires' disease.

Further testing of ice machines near those patients' rooms found Legionella as well, and testing of all of the machines found about 20 percent of Presbyterian's 80-plus ice machines were infected.

Sean D. Hamill: shamill@post-gazette.com.


First Published May 2, 2014 11:50 AM

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