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Department of Health Urges Hospitals to Increase Vigilance after Nontuberculosis Mycobaterium Infections Identified in Patients at Penn State Hershey Medical Center


Health care facilities that perform open heart surgeries on bypass should follow updated guidance after second hospital identifies cluster of rare NTM infections


Harrisburg, PA – The Pennsylvania Department of Health is urging health care facilities to follow recently updated guidance on cleaning heater-cooler devices used in open heart cardiopulmonary bypass procedures after a cluster of patients at Penn State Hershey Medical Center tested positive for Nontuberculous Mycobacterium (NTM) infections.


On November 5, the department learned that the infections were caused by the same species of bacteria and immediately required the hospital to replace their heater-cooler devices due to the suspected link between the units and NTM infections. Additional laboratory work on the specimens is underway.


This is the second instance of patients testing positive for the rare bacterial infection in a Pennsylvania hospital. The first confirmed cluster of infections occurred at WellSpan York Hospital, with investigation results demonstrating a convincing link between NTM infections and the heater-cooler devices used during open heart surgeries to warm and cool a patient’s blood during cardiopulmonary bypass.


“Protecting the health and wellbeing of patients remains the highest priority for my department,” said Secretary of Health Dr. Karen Murphy. “We are reaching out directly to all health care facilities in Pennsylvania that perform heart surgeries with bypass to ensure that they know not only the recommended methods for cleaning these heater-cooler units but also how to assess the devices for signs of contamination.”


The department is also urging health care providers to heighten their awareness of possible NTM infections among patients who have symptoms and a history of cardiac surgery.


NTM bacteria grow slowly in the lab and in patients. NTM is unusual in that it can take several years before people who are infected with it are diagnosed. Because of this, the latest patients under review as being at risk of infection include those that had heart surgeries requiring cardiopulmonary bypass at Penn State Hershey Medical Center dating back approximately four years, from November 5, 2011, through November 5, 2015.


NTM bacteria are commonly found in soil and water, including tap water. NTM are usually not harmful, but can cause infections in patients who have had invasive health care procedures and those with weakened immune systems. It does not normally make healthy people sick. NTM is not contagious and cannot be spread from person to person.


Symptoms of infections caused by NTM can include:

  • Fever;

  • Pain, redness, heat, or pus around a surgical incision;

  • Weight loss;

  • Night sweats;

  • Joint pain;

  • Muscle pain; and

  • Loss of energy.


Patients should talk to their health care provider if they have any of the above symptoms so they can be further evaluated. The hospital will begin this week to notify patients that had open heart surgery on bypass from November 5, 2011, through November 5, 2015. More information is available from Penn State Hershey Medical Center by calling their toll-free hotline at 1-877-467-7484 (1-877-GO-PSHVI) or by visiting


Visit the Department of Health’s website at to learn more.


MEDIA CONTACTS: Amy Worden or Penny Ickes, Pa. Department of Health, 717-787-1783


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