August 13, 2009
Legionnaires caused by unsterilized ice
Four patients at an Arizona hospital were incorrectly diagnosed with Legionnaires' disease last year because of un-sterilized ice, health officials said.
The Centers for Disease Control and Prevention's Mortality and Morbidity Weekly Report said unsterilized ice for bronchoscopies -- inspection inside the lungs using a flexible tube and video camera -- can transmit Legionella bacteria, which may lead to incorrect diagnosis.
Investigators said ice from two machines that were connected to the hospital's water system, which was contaminated with the bacteria Legionella, was used in bronchoscopies. As as result, the patients were incorrectly diagnosed with Legionnaires' disease, when in reality, they had been contaminated by the ice used in the bronchoscopies.
This investigation shows the importance of routine Legionella testing and the need to protect patient safety by following guidelines on proper use and sterilization of medical equipment, the report said.
Legionnaires' disease is a serious form of pneumonia that patients can develop if they are exposed to water that is contaminated with Legionella bacteria.