April 30, 2025
2 min learn
Key takeaways:
- A affected person in an oncology unit was contaminated with Legionella after aspirating and choking whereas consuming ice chips.
- The hospital decided that a number of of its ice machines had been contaminated with the micro organism.
ORLANDO — Legionella can survive and unfold by ice machines, doubtlessly infecting sick sufferers relying on their situation, in response to a examine offered at SHEA Spring.
“We had by no means had this occur earlier than,” Carrigan Hayes, MPH, CIC, an infection prevention specialist at AdventHealth, advised Healio. “We’ve got had different ice machines take a look at optimistic earlier than, however not essentially scientific instances that might doubtlessly be linked. This was the primary occasion that we noticed this.”
A case of Legionella an infection at a hospital revealed that ice machines weren’t being examined typically sufficient, resulting in extra rigorous protocols. Picture: Adobe Inventory
Legionnaires’ illness is a extreme kind of pneumonia attributable to the Legionella micro organism. In keeping with the CDC, individuals might be contaminated with the micro organism by respiration mists that comprise it, though it not often additionally causes infections in different elements of the physique, resembling the center and wound infections.
Legionella infections have been linked to hospital scorching water techniques, cooling towers, dishwashers and even road cleansing vans that use high-pressure hoses to clear roadways.
After confirming {that a} affected person had been contaminated with Legionella pneumophilia in June 2024, Hayes and colleagues launched an environmental sampling initiative, contacting the water administration workforce to check six ice and water machines, two showers and 4 sinks in two inpatient oncology models.
The outcomes recognized an ice machine in a low visitors space of one of many oncology models that examined optimistic for Legionella, Hayes mentioned.
Based mostly on interviews with the unit’s nursing workforce, the affected person had incessantly requested for ice chips to ease oral lesions and the implicated ice machine was the place the particular person’s ice chips got here from, Hayes mentioned.
Though Legionella usually solely causes infections when aspirated, this affected person had been consuming the ice chips and, due to extreme mucositis, having aspiration occasions and choking, which Hayes mentioned the researchers decided to have been the probably methodology of an infection.
In keeping with the examine, simply 4 of 270 ice machines on the hospital had been examined every quarter, with no randomization of testing.
In response to the findings, Legionella water testing protocols on the facility had been expanded from 4 (1%) ice machines to 22 (8%) randomized ice machines. The researchers discovered that 10 of the 22 (45.5%) ice machines examined optimistic for the micro organism, in response to the examine.
Ice machines that had been contaminated had been taken offline and totally remediated, then flushed for twenty-four hours earlier than being reinstalled within the unit, Hayes mentioned.
Along with growing the variety of ice machines by 120% for the quarterly testing program, the hospital additionally applied a testing program to switch low-flow water techniques in hospital models, in response to the examine.
“Check the ice machines extra recurrently,” Hayes mentioned. “Simply by testing extra, we noticed extra take a look at optimistic all through the hospital. We had 270 ice machines — we weren’t routinely testing greater than 1%, so I feel that’s the largest takeaway.
“Any water supply simply must be routinely examined to maintain, particularly, the immunocompromised affected person inhabitants protected,” she added.
References:
- CDC. Legionella (Legionnaires’ illness and Pontiac fever): About Legionnaires’ illness. https://www.cdc.gov/legionella/about/index.html. Up to date Jan. 24, 2024. Accessed April 30, 2025.
- Hayes C, et al. Summary 151. Introduced at SHEA Spring; April 27-30, 2025; Orlando.
For extra info:
Carrigan Hayes, MPH, CIC, might be reached at carrigan.hayes@adventhealth.com.
Sources/Disclosures
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Hayes C, et al. Summary 151. Introduced at: SHEA Spring 2025; April 27-30, 2025; Orlando.
Disclosures:
Hayes experiences no related monetary disclosures.
