Commercial water purification system may have caused pathogen infection in 4 hospitalized patients

1. Commercial water purification system may have caused pathogen infection in 4 hospitalized patients

Abstract: https://www.acpjournals.org/doi/10.7326/M22-3306

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A study of 4 cardiac surgery patients in one hospital found that they developed Mycobacterium abscessus infections, a multidrug-resistant nontuberculous mycobacteria, potentially due to a commercial water purifier. The water purifier had been installed in the hospital to improve water palatability but was inadvertently removing chlorine from the supply lines feeding ice and water machines in the affected area of the hospital. The study is published in Annals of Internal Medicine.

Mycobacterium abscessus is a rare but well-described pathogen associated with hospital-acquired infections. Outbreaks have been attributed to contaminated water systems, including hospital plumbing, ice and water machines, humidifiers, medications, and disinfectants. M. abscessus can cause bloodstream infections, lung infections, and skin and soft tissue infections, mostly in patients with weak immune systems.

Researchers from Harvard Medical School and Brigham and Women's Hospital recounted a descriptive study of four cardiac surgery patients at Brigham and Women's Hospital who developed M abscessus infections. Three of the four infected patients died. An investigation of the hospital’s water sources revealed the presence of a genetically identical element in ice and water machines on the infected patients’ hospital floor.  The water leading to the ice and water machines in this area of the hospital was passing through a commercial water purifier with charcoal filters and ultraviolet irradiation which the investigators found was depleting chlorine levels.  This may have facilitated increased mycobacterial colonization of the ice and water machines. Mycobacteria were likely introduced into the hospital's water system via municipal water, which is often colonized with low levels of mycobacteria.

This study demonstrates the risk of unintended consequences associated with modifying water management systems in hospitals and the potential risk this can pose to patients.  It also bespeaks the importance of augmenting hospitals' water management programs to monitor and prevent mycobacteria in addition to Legionella as well as the potential value of initiatives to minimize vulnerable patients' exposure to tap ice and water during hospital care.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, Michael Klompas, MD, MPH, please email Jessica Pastore at jpastore@bwh.harvard.edu.

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2. YouTube’s credibility tags face “credibility conundrum” in fight against misinformation

Abstract: https://www.acpjournals.org/doi/10.7326/M23-0490   

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While YouTube’s newly introduced tagging policy attempts to steer consumers to credible information sources on the social media platform by prioritizing credible sources in the search algorithm, individuals may still tend to rely on sources they trust for health information, like friends or even celebrities. The authors of a new commentary published in Annals of Internal Medicine refer to this as the “credibility conundrum.” What one person considers “credible,” another may not.

Commentary authors, Christine Laine, MD, MPH, editor-in-chief of Annals of Internal Medicine, and Hussain Lalani, MD, MPH of Brigham and Women’s Hospital and Harvard Medical School, cited a recent patient encounter as an example of the credibility conundrum. When asked why she declined COVID-19 vaccination, a 70-year-old woman said that she lived with her daughter and wanted grandchildren. A “friend who reads a lot” told her that vaccinated people shed particles that affect the fertility of those around them. Even though advice she received from clinicians contradicted advice from her friend, the patient found her friend to be a more credible source of information.

It is uncertain how tagging individuals or organizations that medical experts deem “credible” and prioritizing them in search results will influence the public’s health literacy. YouTube and its panel of medical experts recognize this challenge and have invited feedback from users and content contributors. Health professionals who observe potentially problematic posts or have ideas about how to further elevate good health information should respond to YouTube’s invitation for feedback. But the editorialists say that health care professionals should also ask their patients who seem misinformed where they get their information and attempt to direct them to credible sources.  Studies show that sources considered to be trustworthy varied substantially by political affiliation, geography, and age. Being a trusted source for patients is one way physicians can help thwart the spread of misinformation while society works to solve this conundrum.   

Media contacts: For an embargoed PDF or to speak with corresponding author, Christine Laine, MD, MPH, please contact Angela Collom at acollom@acponline.org.

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3. Over-the-scope-clips may be more effective than standard treatment for some patients with nonvariceal upper gastrointestinal bleeding

Abstract: https://www.acpjournals.org/doi/10.7326/M22-1783

Editorial: https://www.acpjournals.org/doi/10.7326/M23-0449

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A randomized controlled trial of adults with active bleeding or a nonbleeding visible vessel from a nonvariceal cause on upper gastrointestinal endoscopy found that over-the-scope-clips (OTSCs) as an initial treatment may be better than standard treatment in reducing the risk for further bleeding from some nonvariceal upper gastrointestinal causes. The findings are published in Annals of Internal Medicine.

The current standard in endoscopic hemostasis includes the use of hemo-clips or contact thermal devices, but the failure rate with these methods may be up to 10 percent and further bleeding after endoscopic hemostasis increases mortality risk. OTSCs, which memory-shaped nitinol clips that are cap mounted onto the end of an endoscope, can be used in hemostasis. Currently, OTSCs are primarily used in severe or refractory bleeding from nonvariceal causes.

Researchers from several university hospitals in Hong Kong, China and Australia conducted a randomized controlled trial of 190 adult patients with active bleeding or a nonbleeding visible vessel from a nonvariceal cause on upper gastrointestinal endoscopy. Ninety-seven participants were assigned to receive standard treatment, and 93 received treatment using OTSCs. The authors found that the 30-day probability for bleeding in the standard treatment group was 14.6 percent and 3.2 percent for the OTSC group. However, while the findings suggest the use of OTSCs may be better than standard treatment in preventing further bleeding, the authors are not advocating routine primary use of OTSCs. Instead, they suggest that primary use of OTSCs may find a role in the treatment of ulcers predicted to fail standard endoscopic treatment.

An accompanying editorial from McGill University Health Centre supports the authors’ conclusion that their findings do not suggest that OTSCs should be used as an initial treatment for nonvariceal upper gastrointestinal bleeding. They say that while endoscopists should be trained in their use, OTSCs are also expensive compared to other therapies.  The editorialists say that OTSCs should be reserved for patients lesions at high risk for failure with standard treatments, such as those bleeding from ulcers exceeding 2 cm or located high in the gastric lesser curvature or posterior duodenal bulb.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with the corresponding author, James Y.W. Lau, MD, please email   laujyw@surgrey.cuhk.edu.hk.

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Ideas and Opinions

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