Silent bronchoscopy-associated outbreak of Stenotrophomonas maltophilia and pseudo-outbreak of Mycobacterium gordonae linked to contaminated rinse water and a damaged bronchoscope.

Authors

Regev Cohen, Yelena Losev, Mor Rubinstein, Maya Brodsky, Milena Pitashny, Orna Ben-Natan, Aliza Vaknin, Mohammed Ganayem, Michael Kuchuk

Published in

American journal of infection control. Oct 16, 2026. Epub Oct 16, 2026.

Abstract

Bronchoscopy-associated outbreaks may remain unrecognized when contamination is difficult to distinguish from infection.
Following increased Mycobacterium gordonae isolation from bronchoalveolar lavage (BAL), we performed environmental sampling, bronchoscope assessment, a reprocessing audit, and whole-genome sequencing. Recovery of Stenotrophomonas maltophilia from automated endoscope reprocessor (AER) water prompted retrospective review of S. maltophilia-positive BAL cultures.
Six BAL-associated M. gordonae isolates were identified during 2024-2025. Three available isolates were genomically indistinguishable (0 single-nucleotide polymorphisms), consistent with a common source or contamination process. Other nontuberculous mycobacteria and water-associated organisms were recovered from the AER water supply, although M. gordonae was not. A concurrent outbreak of S. maltophilia-positive BAL cultures was identified; positivity increased from 0.6% during 2017-2023 to 12.9% during January-June 2025. Use of damaged bronchoscope RC41 was associated with S. maltophilia cases (94% vs 46%; OR 17.73, 95% CI 2.01-156.46; p=0.002). Following RC41 removal, water-system remediation, and reprocessing changes, no further BAL-associated M. gordonae or S. maltophilia isolates were detected.
Investigation of an apparent M. gordonae pseudo-outbreak revealed a concurrent S. maltophilia outbreak in the setting of contaminated AER water and a damaged bronchoscope. These findings highlight point-of-use water quality, device integrity, traceability, and surveillance.

PMID:
42887699
Bibliographic data and abstract were imported from PubMed on 17 Oct 2026.

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