Hospital Water and Ice Machines Linked to Bacterial Infection Outbreaks in Multiple States: CDC

A total of 46 infections from the same bacterial strain have now been reported at hospitals in Northern California, Southern California and Colorado, all of which can be traced to the same brand of hospital water and ice machines, according to federal health officials.

Two Southern California hospitals had an outbreak of the bacteria Burkholderia multivorans in 2021 and 2022, causing 23 patient infections. However, that number has now doubled, with two more at one of the Southern California locations, as well as 13 at a hospital in Northern California and eight at a hospital in Colorado, all occurring from 2020 through 2024, and each involving bacteria with similar genetic sequences.

According to a report from the U.S. Centers for Disease Control and Prevention (CDC) issued on October 3, health officials have found that the four hospitals reporting the B. multivorans infections all used the same brand of ice machine, filter, descaling and sanitizing products for their water.

B. multivorans is a rare but emerging bacteria that is often linked to cystic fibrosis patients. It is commonly found in soil and water, and is not usually dangerous to healthy people. However, it is resistant to antibiotics, and can cause bacterial meningitis among those with weakened immune systems. This serious infection of the brain and spinal cord membranes can be deadly in a few hours without immediate medical intervention.

Ice and water contaminated with B. multivorans bacteria were found in machines at the first two Southern California hospitals linked to the initial outbreak, and the additional infections have now been linked to the same brand of hospital ice and water machine products.

Outbreaks of bacteria have previously been linked to contaminated medications, medical products and devices. The use of ice and water at hospitals has been recognized as a potential transmission route for water-related pathogens like B. multivorans, since ice machines contain mechanical components that support the bacteria’s growth.

To help reduce patient infection risks, the CDC recommends hospitals create a water management plan to control the growth and spread of bacteria in ice machines and other water systems.

If there is a water-related bacteria outbreak at a hospital, the CDC says the facility should consider avoiding the use of any tap water, including ice and water that comes from ice machines. Health care personnel should also notify public health officials of any bacterial outbreaks at their facilities.

Hospital Bacterial Infections Often Spread Through Contaminated Water

This is not the first time bacterial infections have been linked to hospital ice and water machines, as a 2023 report published in the Annals of Internal Medicine showed that an outbreak of Mycobacterium abscessus at a Boston-area hospital could be linked to the specific hospital tower’s commercial water purifier.

In this instance, four patients fell ill after undergoing heart surgery at Brigham and Women’s Hospital in 2017 and 2018.  All four patients were housed in the same hospital tower and used the same water purifying system. Patients in the hospital’s other two towers, which were on a different water purifying system, did not fall ill.

Researchers eventually found high levels of the mycobacteria and low levels of sanitizing agents in the water and ice machines in the tower where the infections occurred, but not in the machines in the other two towers.