A recent report from the Centers for Disease Control and Prevention (CDC) highlights an outbreak of Burkholderia multivorans infections linked to contaminated ice machines in hospitals. According to the CDC’s October 3 Morbidity and Mortality Weekly Report, 46 patients across four hospitals were affected.
B. multivorans is part of the Burkholderia cepacia complex, a group of Gram-negative opportunistic bacteria found in soil and water. Outbreaks associated with these organisms have been linked to contaminated medications, aqueous medical products, and medical devices. They pose significant clinical risks, particularly as they can be antibiotic-resistant and lead to severe infections in immunocompromised and critically ill patients.
The hospitals involved in the outbreaks—three in California and one in Colorado—used the same brand of ice machines and associated products. Initially, 23 cases were identified at two hospitals, with an additional 23 cases later discovered at the other two.
The contaminated ice and water were used in various clinical care activities, including bed baths, swallow evaluations, and applying ice packs for pain relief. Infections were reported between 2020 and 2024. Once the source was identified, the affected ice machines were promptly taken out of service.
To prevent similar outbreaks, the CDC advises healthcare facilities to develop and implement a comprehensive water management program and to avoid using tap water for patient care.
For more details, you can access the CDC’s full report here.
Compliance Perspective
Issue
Ice machines have several mechanical components that can promote microbial amplification and biofilm formation. The use of ice and tap water for clinical care activities has been recognized as a potential route for the transmission of water-related opportunistic pathogens, including B. multivorans, leading to healthcare-associated infections. The Centers for Medicare & Medicaid Services (CMS) requires facilities to establish and maintain an infection prevention and control program. This includes the development of water management plans and documentation to ensure that each facility:
- Conducts a facility risk assessment to identify areas where opportunistic waterborne pathogens (e.g., Legionella, Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread, particularly in water sources like ice machines
- Develops and implements a water management program that adheres to ASHRAE industry standards
- Specifies testing protocols and acceptable ranges for control measures, documenting the results of testing and corrective actions taken when control limits are not maintained
- Maintains compliance with other applicable federal, state, and local requirements
Discussion Points
- Review the facility’s Infection Control Plan and the policies and procedures for water management to mitigate the risk of growth and spread of opportunistic pathogens in all water systems, including ice machines. Revise as necessary.
- Train all staff on the facility’s Infection Control Plan and water management policies and procedures. Document these trainings and file signed documentation in each employee’s education file.
- Conduct periodic audits to ensure water samples are tested for the presence of B. multivorans and other opportunistic pathogens in the facility’s water supply. Confirm that appropriate staff are trained to collect and submit samples for testing, and that they understand the procedures to follow if samples test positive for B. multivorans or other pathogens. Ensure that a designated registered nurse competently serves as the facility’s Infection Preventionist.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
