Patients were infected with antibiotic-resistant bacteria living in the plumbing of the National Institutes of Health’s hospital in Bethesda, Md., contributing to at least three deaths in 2016.

A study published Wednesday in the New England Journal of Medicine found that, from 2006 to 2016, at least 12 patients at the NIH Clinical Center, which provides experimental therapies and hosts research trials, were infected with Sphingomonas koreensis, an uncommon bacteria. The paper, written by NIH researchers, suggests that the infections came from contaminated water pipes, where the bacteria may have been living since as early as 2004, soon after construction of a new clinical center building.

This report is the latest instance of pathogenic contamination at the NIH, an issue that has roiled the highest ranks of the agency in recent years. The Clinical Center was the site of a superbug outbreak in 2011, and fungi were found in drug vials in 2015. After a scathing April 2016 internal report concluded that NIH researchers sometimes put patient safety at risk, Director Francis Collins replaced the top leadership at the Clinical Center.


However, infections like this are not uncommon in medical centers — the Centers for Disease Control and Prevention estimates that about 4 percent of hospital patients pick up diseases from the hospital environment.

“It is not exceptional for a hospital to have a [hospital-originating] infection,” Dr. Tara Palmore, hospital epidemiologist at the Clinical Center and one of the study’s authors, said in an interview. “They occur in every hospital.”

Wednesday’s paper is the NIH’s first broad disclosure of the Sphingomonas koreensis infections. Palmore said information about the infections was presented at a 2017 scientific meeting and at an NIH lecture that was broadcast online.

“Scientific publication is one way of many to discuss information – and always has a lag time,” she said through the spokesperson.

According to the paper, the hospital became aware of the problem in 2016, when six patients at the Clinical Center came down with similar infections over the course of six months. They were all infected with a type of Sphingomonas bacteria, which live in water. Four were infected with the drug-resistant Sphingomonas koreensis, and three of them died.

It’s unclear whether Sphingomonas koreensis is what killed those patients, who had undergone stem cell transplants, which leave patients vulnerable to infections.

“The three patients who died also had multiple other life-threatening conditions, which were complications of their underlying disease,” Palmore said.

“[Sphingomonas koreensis] are fairly weak bacteria,” she said. “But in a patient who is highly immunosuppressed, it doesn’t take a highly virulent bacteria to cause additional illness.”

The cluster of Sphingomonas infections prompted researchers to search the hospital’s water infrastructure to see where the bacteria might have been hiding out. They found Sphingomonas koreensis living in water that came out of the faucets in patient rooms, as well as inside the sink faucets themselves.

The paper details some changes that were made to the Clinical Center’s water system after the cluster was discovered, including increasing the temperature of the water and adding more chlorine. Palmore said the low chlorine level was identified and fixed in a matter of days.

She added that the staff at the Clinical Center are still experimenting with different configurations of water pipes — “literally taking out plumbing and putting it in a different shape” — in an effort to minimize the amount of bacteria that can grow in the water system.

“It’s a long-term project in our hospital that proceeds at a slow pace because we can’t turn the entire hospital into our laboratory,” Palmore said.

No new Sphingomonas koreensis infections have been reported at the Clinical Center since 2016, when the changes were made.

This story was updated with comments from Dr. Tara Palmore.

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  • As in the Food Inspection program, everything must be tested for microbial contamination, or at least it should be. Both air and water.

  • This should be kind of concerning, after all it was the NIH. Local hospitals are even worse. In many cases the filth is visible, blood, mucus, and fecal matter, left behind by hurried cleaners, is the norm. Even more concerning is the refusal of local media outlets to cover this serious safety matter.

  • Nurses change beds, the cleaners do not. The cleaners do an amazing job in all hospitals I worked at. They are paid a pittance and there’s often just the one person per ward,cleaning and going round with the meals cart. I’d agree they suffer from understaffing and no support network and more need to be hired.
    There’s many policies in place to prevent hospital acquired infections and test patients for them,cleaners are but a small part of. I do encourage you to read up on cleanliness champion if you want to know more. Cleaners are not at fault here and even if they contributed to the issue, it’s a complex matter to do with water structures, staffing levels, infection control and etc.

  • Bleach is the one thing that kills many kinds of germs. ALL hospitals and medical facilities should be putting bleach into their drains of all kinds. They should also take a large cup of bleach and soak every faucet in a cup of bleach. But most of all medical facilities have got to get better at cleaning their facilities with germ killing bleach. I have been in numerous health facilities over the years and I’ve seen dried up blood spots on many health facilities walls, beds and most anything else in their facilities which told me that the people charged with cleaning those facilities aren’t doing a good job when in fact they should be doing a thorough job in cleaning everything. When was the last time you ever saw a cleaning person cleaning walls and EVERYTHING else in medical facilities. Germs love medical facilities because there is so many places to be without being destroyed in some way because no one ever gets around to cleaning the environment where germs live. We have got to stop this by requiring that ALL medical facilities hire EXCELLENT cleaning services that will clean every inch of the medical facilities. It’s obvious that the cleaning personnel that we currently have cleaning our medical facilities aren’t doing their jobs right. It’s obvious that we have to have better cleaning of our medical facilities! It’s obvious that the medical community has no interest in doing their cleaning job right so let’s start making laws that require them to do so for our own good!

    • Research demonstrates biofilm and the bacterial pathogens residing there are highly resistant to traditional disinfectants. Bacteria in Biofilm may be as much as 500 times to 1,000 times more resistant to sanitizing chemicals than free-flowing (planktonic) cells of the same species. Chemicals are creating antibiotic resistant organisms…..

  • In addition to sanitizing their pipes, they should pay attention to dead legs in the plumbing. These are sections that are not used frequently, like a faucet that is seldom used. Bacteria can live in those things and get into the main water stream. This is a problem for homeowners too — like if you have a sprinkler system that only gets used in the summer but is dead all winter. Legionnaire’s Disease is the major risk. In the home, you might have legs that were used for a dishwasher or washing machine that isn’t there anymore. Also, the icemaker on a refrigerator. All legs need to be flushed regularly.

    • Niher here. Good advice about dead legs. I have always had concerns about that drinking fountain in the middle of the hall, use the fountain near the restrooms!

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