Through literature review livanova became aware of 13 patients mycobacterium abscessus infections at (b)(6) hospital.Within the article it is stated that the hospital used heater-cooler 3t systems.Reportedly all patient had extensive preoperative comorbidities and complicated postoperative courses in addition to mycobacterium abscessus infection.Data presented in the article were collected between august 2013 and may 2014 and between december 2014 and june 2015.Moreover, within the article it is stated that despite changes of the instruction for use in 2010 recommending filtered tap water, it was found that water changes were performed with unfiltered tap water for the devices in use at the hospital and that the disinfection procedure was not applied according to the ifu.Cultures from biofilms of heater-cooler devices were negative fro m.Abscessus while the culture from biofilm of the faucet used to fill the units was positive to m.Abscessus.Reportedly, on early may 2015, the hospital changed the approach and followed the ifu.
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