Cluster of tuberculosis cases in North Carolina: Possible association with atomizer reuse

Background: Three patients with identical strains of M tuberculosis (TB) underwent bronchoscopy on the same day at hospital A. Methods: We reviewed each patient's clinical history, hospital A's infection control practices for bronchoscopies, and specimen and isolate handling at each of 3 laboratories involved. We searched for possible community links between patients. Restriction fragment length polymorphism was performed on TB isolates. Results: The first patient who underwent bronchoscopy had biopsy-confirmed granulomatous pulmonary TB. A sputum sample collected from the third patient 6 weeks after the bronchoscopy produced an isolate with an identical restriction fragment length polymorphism pattern to isolates collected during the bronchoscopies. No evidence existed for community transmission or laboratory contamination; the only common link was the bronchoscopy. Different bronchoscopes were used for each patient. Hospital ventilation and wall-suctioning were functioning well. Respiratory technicians reported sometimes reusing the nozzles of atomizers on more than one patient. A possible mechanism for transmission was contamination from the first patient of the atomizer ii it was used to apply lidocaine to the pharynx and nasal passages of other patients. Conclusions: A contaminated atomizer may have caused TB transmission during bronchoscopy. Hospital A changed to single-use atomizers after this investigation.