Cluster of mycobacteria infections after total joints traced to OR nurse

Editor's Note

This investigation by the Kentucky Department for Public Health and Centers for Disease Control and Prevention of eight cases of rapidly growing mycobacteria (RGM) infections in a Kentucky hospital after total joint replacement procedures found that the presence of a particular OR nurse was significantly associated with the infections.

Environmental sampling at the nurse’s home identified an outdoor hot tub as the likely source. The hot tub reservoir was eliminated, and hospital policies were revised to correct lapses in infection control procedures.

At 8 years of follow-up, no new cases of RGM infections have been identified.

The multifactorial nature of the cause of the infections highlights the importance of overlapping or redundant layers of infection protection to prevent patient harm, the researchers conclude.