Stephen I. Feller , 2025-04-30 21:27:00
April 30, 2025
2 min read
Key takeaways:
- A patient in an oncology unit was infected with Legionella after aspirating and choking while consuming ice chips.
- The hospital determined that several of its ice machines were contaminated with the bacteria.
ORLANDO — Legionella can survive and spread through ice machines, potentially infecting ill patients depending on their condition, according to a study presented at SHEA Spring.
“We had never had this happen before,” Carrigan Hayes, MPH, CIC, infection prevention specialist at AdventHealth, told Healio. “We have had other ice machines test positive before, but not necessarily clinical cases that could potentially be linked. This was the first instance that we saw this.”
A case of Legionella infection at a hospital revealed that ice machines were not being tested often enough, leading to more rigorous protocols. Image: Adobe Stock
Legionnaires’ disease is a severe type of pneumonia caused by the Legionella bacteria. According to the CDC, people can be infected with the bacteria by breathing mists that contain it, although it rarely also causes infections in other parts of the body, such as the heart and wound infections.
Legionella infections have been linked to hospital hot water systems, cooling towers, dishwashers and even street cleaning trucks that use high-pressure hoses to clear roadways.
After confirming that a patient had been infected with Legionella pneumophilia in June 2024, Hayes and colleagues launched an environmental sampling initiative, contacting the water management team to test six ice and water machines, two showers and four sinks in two inpatient oncology units.
The results identified an ice machine in a low traffic area of one of the oncology units that tested positive for Legionella, Hayes said.
Based on interviews with the unit’s nursing team, the patient had frequently asked for ice chips to ease oral lesions and the implicated ice machine was where the person’s ice chips came from, Hayes said.
Although Legionella generally only causes infections when aspirated, this patient had been consuming the ice chips and, because of severe mucositis, having aspiration events and choking, which Hayes said the researchers determined to have been the most likely method of infection.
According to the study, just four of 270 ice machines at the hospital were tested each quarter, with no randomization of testing.
In response to the findings, Legionella water testing protocols at the facility were expanded from four (1%) ice machines to 22 (8%) randomized ice machines. The researchers found that 10 of the 22 (45.5%) ice machines tested positive for the bacteria, according to the study.
Ice machines that were contaminated were taken offline and fully remediated, then flushed for 24 hours before being reinstalled in the unit, Hayes said.
In addition to increasing the number of ice machines by 120% for the quarterly testing program, the hospital also implemented a testing program to replace low-flow water systems in hospital units, according to the study.
“Test the ice machines more regularly,” Hayes said. “Just by testing more, we saw more test positive throughout the hospital. We had 270 ice machines — we weren’t routinely testing more than 1%, so I think that’s the biggest takeaway.
“Any water source just needs to be routinely tested to keep, especially, the immunocompromised patient population safe,” she added.
References:
- CDC. Legionella (Legionnaires’ disease and Pontiac fever): About Legionnaires’ disease. https://www.cdc.gov/legionella/about/index.html. Updated Jan. 24, 2024. Accessed April 30, 2025.
- Hayes C, et al. Abstract 151. Presented at SHEA Spring; April 27-30, 2025; Orlando.
For more information:
Carrigan Hayes, MPH, CIC, can be reached at carrigan.hayes@adventhealth.com.
Sources/Disclosures
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Hayes C, et al. Abstract 151. Presented at: SHEA Spring 2025; April 27-30, 2025; Orlando.
Disclosures:
Hayes reports no relevant financial disclosures.
