A hospital-acquired outbreak of catheter-related nontuberculous mycobacterial infection in children on peritoneal dialysis

Catheter-related nontuberculous mycobacterial infection in children with chronic renal failure on peritoneal dialysis (PD) is rare. However, there have been five such infections in infants among PD patients at our center. Although the patients were treated with antibiotics to which the organisms showed in vitro sensitivity, they were clinically drug resistant. Hence, all PD catheters needed to be removed. Thereafter, following hemodialysis treatment for approximately 1 month, the PD catheters were replaced, with no recurrence of infection. On investigation of the infection route, it was found that these bacteria had colonized around a shower head in one of the bathrooms. These findings suggest that, in cases where hot water systems at hospitals are considered at a high risk, frequent sterilization is needed, especially around the shower heads. It is also necessary to reconsider current standard practices in the management of catheter exit sites, especially if the national incidence of infection increases.