Penn State Hershey Medical Center issued a news release to report three infections in the last two years, including two patients who died.
It is unclear whether the infection caused both deaths. About 2,300 patients who had open heart surgery have been contacted about possible exposure. The hospital has already replaced all heater-coolers with new devices.
According to Dr. Carol Freer, chief medical officer for Hershey Medical Center:
“In the interest of patient safety, based on our own experience over the past several months as well as mounting clinical evidence, we recommend other hospitals carefully review their heater-cooler devices. We remain concerned that our recent experience may not be unique to our hospital.”
This is the second major outbreak of infections linked to heater-cooler devices. Last month, officials at WellSpan York Hospital in Pennsylvania reported eight infection and three deaths since 2011. About 1,300 were notified of exposure.
All of the patients were infected with nontuberculosis mycobacteria, which is commonly found in tap water but does not normally cause infections. When tap water is used in a heater-cooler device, the bacteria can “aerosolize” through the exhaust vent and land on a patient undergoing open heart surgery.