Nashville, TNLast October the CDC reported that M. chimaera contamination of heater/cooler devices, of which 60 to 70 percent stem from the Stockert 3T heater-cooler system had been found in Iowa and Pennsylvania. Just one month later, a global outbreak linking the devices was reported. M. chimaera is a rare bacteria, a species of nontuberculous mycobacterium (NTM).
The global outbreak was first reported by Infection Control & Hospital Epidemiology (Nov 14, 2016), the journal of the Society for Healthcare Epidemiology of America. The lead author of the study, Rami Sommerstein, MD, of Inselspital, Bern University Hospital in Switzerland, said “It is surprising that a global outbreak like this could go unnoticed for years. This dangerous infection has put many patients at risk all over the world.” The Swiss researcher said that Heater-Cooling Devices, or HCDs, are the source and it’s up to “different players”, from healthcare institutions to manufacturers, to act on containing the ongoing patient risk. “The most important action a hospital can take is to remove contaminated HCDs from the operating room and other critical areas. That is the only way to ensure that patients are protected from this infection moving forward."
In Tennessee at least one case of Nontuberculosis Mycobacterium (NTM) infection has recently surfaced and CDC expects more states to report infections. While hospitals nationwide have been sending warning letters to patients who had cardiac surgery between January 2012 to November 2016, (One Nashville hospital sent letters to 400 patients who underwent heart surgery) most institutions haven’t gone so far as to remove HCDs, the majority of which are Stockert 3T devices.
Health Canada reports that two cases have been found, both at the Montreal Heart Institute. But patients across Canada are being notified. In B.C. more than 20,000 heart patients are being told they may be at risk of NTM exposure. In that province 33 heater-cooler machines are in six hospitals. Health officials are scouring medical records to find any reports of infections, but they have an arduous task: it could take up to five years for the infection to be noticeable, but symptoms typically show within 18 months. Symptoms of NTM infection may include persistent or unexplained fever; night sweats; redness, heat, or pus around a surgical incision; muscle aches; unexplained weight loss; or fatigue.
As well, doctors in B.C. are sent letters informing them to consult medical microbiologists or infectious disease experts if they have any concerns about a patient. One thing B.C. hospitals do that other hospitals may not is use filtered water in the machines. Dr. Linda Hoang, a medical microbiologist at the B.C. Centre for Disease Control, said bacteria can build up in tubes and other areas of the devices if they are not maintained and disinfected correctly.
Meanwhile, the CDC last October ‘Updated the notification toolkit to include frequently asked questions for hospitals notifying patients of risk from contaminated heater-cooler devices used during cardiac surgery.” Judging from the number of Stockert 3T lawsuits filed, clearly that isn’t enough.
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