Pseudo-outbreak of Mycobacterium gordonae associated with water from refrigerated fountains

Between March 1997 and December 1997, acid-fast bacilli (AFB) were detected on sputum and/or gastric aspirates smears from five patients hospitalized in the chest medicine department. These specimens grew M. gordonae. Based o n AFB-positive smear and clinical presentation, four out of five patients r eceived antituberculous treatment until species identification was known. E pidemiological investigation revealed a heavy contamination of water collec ted from refrigerated fountains located on the same floor as the patient ca ses. Strains isolated from four patients and the refrigerated fountain exhi bited the same pulsed gel electrophoresis pattern (using DraI and XbaI enzy mes) suggesting that positive smears were related to drinking water from th e refrigerated fountain. This cluster of pseudo-infections underlines the n ecessity for a proper maintenance of water supply equipment in order to avo id inappropriate decisions deleterious for patients. (C) 2001 The Hospital Infection Society.