A Centers for Disease Control and Prevention (CDC) report published on October 3, 2024, linked Burkholderia multivorans infections to ice machines in multiple healthcare facilities in the western United States. This post summarizes key findings, implications, and recommended practices for healthcare providers to ensure patient safety.
Background
Burkholderia multivorans, a member of the Burkholderia cepacia complex, is an opportunistic pathogen commonly found in soil and water. It poses a significant risk to immunocompromised patients, leading to severe infections. Previous outbreaks have linked this bacterium to contaminated medications and medical devices. However, a recent investigation linked the use of ice and water from ice machines in hospitals as a potential transmission route.
Between 2021 and 2022, 23 cases of Burkholderia multivorans were reported at two hospitals in Southern California. Further investigations revealed an additional 23 previously unreported cases between 2020 and 2024 across various hospitals in California and Colorado. All affected facilities used the same brand of ice machines, filters, and cleaning products, suggesting a common source of contamination.
Investigation findings
The investigation defined cases as infections from the outbreak strain (ST659) of Burkholderia multivorans in patients without cystic fibrosis. A total of 46 cases were identified across four hospitals:
- Northern California Hospital: 13 cases
- Two Southern California Hospitals: 23 cases (20 from Hospital B and 3 from Hospital C)
- Colorado Hospital: 8 cases
Environmental sampling indicated that B. multivorans was isolated from ice machines at some of these hospitals, confirming the link between contaminated ice and clinical cases.
Genomic testing revealed that the clinical and environmental isolates were genetically similar, with only minor variations. This reinforces the hypothesis that contaminated ice machines were a significant source of exposure for patients.
Recommendations for healthcare facilities
Given the serious nature of these findings, the report emphasizes the need for healthcare facilities to implement robust infection control measures. Key recommendations include:
- Avoiding tap water and ice for patient care: During outbreaks of water-related organisms, healthcare personnel should refrain from using tap water, including ice and water from ice machines, for any patient care activities.
- Regular monitoring and maintenance of ice machines: Facilities should work with a qualified firm to develop a comprehensive water management program to identify potential contamination sources and ensure the safety of water distribution systems.
- Prompt reporting: Healthcare personnel must notify public health officials of any suspected healthcare-associated outbreaks involving Burkholderia multivorans.
The association between Burkholderia multivorans infections and ice machines in healthcare settings underscores the critical need for vigilance in infection control practices. By taking proactive measures like implementing a comprehensive water management program and adopting building water treatment technologies, healthcare facilities can minimize the risk of contamination and protect vulnerable patients from serious infections.
