1246 infection control & hospital epidemiology october 2017, vol. 38, no. 10


3T units were contaminated within the manufacturing site.6 Contamination of the ECMOs could have occurred at the site of manufacturing, like the LivaNova 3T units, or fromwater supplies at our hospital.1,6 Further work on M. chimaera isolates related to ECMOdevices is required.Here, we showthat, similarly to HCUs, decontamination procedures are essential to reduce the microbial load in the ECMO devices and that weekly microbiological sam- pling is required tomonitor the bioburden in the ECMO devices. On initial examination, the ECMO devices had a high microbial load,withTVC >300CFUper 100 mL.TheTVCresults following disinfection using the pre-2017 protocol showed that thismethod was inadequate. The disinfection regimen implemented in 2017 has been effective in reducing the bioburden. However, the ongoing maintenance to eliminate biofilm requires additional resources. Clearly, the increased disinfection and sampling proce- dures recommended by the manufacturer have added a con- siderable burden of duties and costs for perfusionists, cardiology, and surgical staff. The decontamination guidance recommended by themanufacturers is time-consuming, taking up to 24 hours for a high-level disinfection. Garvey et al4,5 (2016, 2017) have shown that enhanced decontamination ofHCUs has led to degradation of the internal cooper fixings, and a similar affect could be seen with the ECMO devices. Previous studies have shown that HCUs aerosolize microorganisms present in the HCUs themselves such as M. chimaera.2,3 It has been postulated that ECMOdevices might be associated with the similar problem.8 In this study, we did not attempt to demonstrate that the organisms detected in theHU35s had aerosolized. Trudizinski et al8 (2016) undertook environ- mental sampling and did not detect any aerosolization. At present, no conclusive link of transmission from the ECMO units to patients has been confirmed. Further investigation of ECMO devices is needed to better understand whether transmission occurs via these devices. To ourknowledge,thisisthe first report to focus on the decontamination of ECMO devices. The risk of infections from M. chimaera is still low in the


context of other risks; transmission from an ECMO device to a patient has not yet been described.6 However, a heavily biofouled ECMO may have the potential to aerosolize like the HCUs.1–3 The decontamination of these devices is likely to have an essential role in mitigating risk, and this report highlights the fact that technique is important. Clinicians need to consider the mitigation of infection risk versus the need to maintain a patient’s respiratory and cardiac function using ECMO devices.6


acknowledgments


We thank the Infection Prevention and Control and Clinical Perfusion Teams at the University Hospitals Birmingham NHS Foundation Trust. Financial support: No financial support was provided relevant to this article. Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.


Affiliation: University Hospitals Birmingham NHS Foundation Trust,


Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, United Kingdom. Address correspondence to Mark I. Garvey, PhD, MSc, BSc, DipHIC, Uni-


versity Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, B15 2WB (mark.garvey@uhb.nhs.uk).


Received April 16, 2017; accepted July 5, 2017; electronically published


August 14, 2017 © 2017 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2017/3810-0016. DOI: 10.1017/ice.2017.163


references


1. Sax H, Bloemberg G, Hasse B, et al. Prolonged outbreak of Mycobacterium chimaera infection after open-chest heart surgery. Clin Infect Dis 2015;61:67–75.


2. Sommerstein R, Ruegg C, Kohler P, Bloemberg G, Kuster SP, Sax H. Transmission of Mycobacterium chimaera from heater- cooler units during cardiac surgery despite an ultraclean air ventilation system. Emerg Infect Dis 2016;22:1008–1013.


3. Sommerstein R, Schreiber PW, Diekema DJ, et al. Mycobacterium chimaera outbreak associated with heater cooler devices: piecing the puzzle together. Infect Control Hosp Epidemiol 2017; 38:103–108.


4. Garvey M, Ashford R, Bradley T, Martin T, Walker J, Jumaa P. Decontamination of Sorin heater-cooler units associated with contamination with atypical mycobacteria. J Hosp Infect 2016;93:229–234.


5. Garvey MI, Bradley CW, Walker J. A year in the life of a con- taminated heater cooler unit with Mycobacterium chimaera? Infect Control Hosp Epidemiol 2017;38:705–711.


6. Chand M, Lamagni T, Kranzer K, et al. Insidious risk of severe Mycobacterium chimaera infection in cardiac surgery patients. Clin Infect Dis 2016;64:335–342.


7. Mycobacterium chimaera infections associated with cardio- pulmonary bypass clinical guidance for secondary care. Public Health England website. https://www.gov.uk/government/ uploads/system/uploads/attachment_data/file/605650/Secondary_ care_advice_on_Mycobacterium_chimaera_infections_associated_ with_cardiopulmonary_bypass.pdf. Published February 2017. Accessed July 10, 2017.


8. Trudzinski FC, Schlotthauer U, Kamp A, et al. Clinical implica- tions of Mycobacterium chimaera detection in thermoregulatory devices used for extracorporeal membrane oxygenation (ECMO), Germany, 2015 to 2016. Euro Surveill 2016;21: pii:30398. doi: 10.2807/1560-7917.ES.2016.21.46.30398.


9. Mycobacterial infections associated with heater cooler units used in cardiothoracic surgery. Advice for providers of cardiothoracic surgery. Public Health England website. https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/434189/ M_chimaera_advice_for_providers.pdf. Published July 2015. Accessed July 10, 2017.


10. Maquet Getinge Group. Revised cleaning and descaling of Heater Unit 35. URPL website. http://www.urpl.gov.pl/sites/default/files/ Zmieniona%20Instrukcja%20Obs%C5%82ugi_3.pdf. Published 2017. Accessed July 10, 2017.


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99  |  Page 100  |  Page 101  |  Page 102  |  Page 103  |  Page 104  |  Page 105  |  Page 106  |  Page 107  |  Page 108  |  Page 109  |  Page 110  |  Page 111  |  Page 112  |  Page 113  |  Page 114  |  Page 115  |  Page 116  |  Page 117  |  Page 118  |  Page 119  |  Page 120  |  Page 121  |  Page 122  |  Page 123  |  Page 124  |  Page 125  |  Page 126  |  Page 127  |  Page 128  |  Page 129  |  Page 130  |  Page 131  |  Page 132  |  Page 133  |  Page 134  |  Page 135  |  Page 136  |  Page 137  |  Page 138  |  Page 139  |  Page 140  |  Page 141  |  Page 142  |  Page 143  |  Page 144