Ice machines spread Legionella in hospital oncology unit, prompting testing overhaul

Editor's Note

Legionalla contaminated a hospital ice machine and likely infected an oncology patient through aspirated ice chips, according to an April 30 report in Healio.

Presented in a study at The Society for Healthcare Epidemiology of America (SHEA), the incident prompted immediate changes to water testing protocols at AdventHealth, Healio reports. 

As detailed in the article, the infected patient had severe mucositis and frequently requested ice chips to ease oral lesions. The patient experienced aspiration events and choking, which researchers concluded was the most likely route of infection. Hospital staff launched an environmental sampling initiative that tested six ice and water machines, two showers, and four sinks across two inpatient oncology units, with one low-traffic ice machine testing positive for Legionella pneumophila. Interviews with nurses confirmed that this machine had been the source of the patient’s ice chips.

According to the article, the discovery revealed a significant gap in the hospital’s monitoring protocols. At the time, only 1% (four of 270) of the facility’s ice machines were tested quarterly, and none were chosen at random. After the case, the hospital increased its testing to 22 randomly selected machines—roughly 8% of its inventory—and found that 10 of them (45.5%) were contaminated with Legionella.

Contaminated machines were taken offline and underwent full remediation, including 24-hour flushing, before being returned to service. The hospital also began replacing low-flow water systems to reduce bacterial risk in vulnerable units.