• Between 2020 and 2024, four hospitals in California and Colorado reported a total of 46 cases of Burkholderia multivorans infections. 

• The source of these infections was found to be contaminated ice and water from hospital ice machines.  

• Whole genome sequencing confirmed that the ice machines harbored the same bacterial strain (ST659). 

• The bacteria primarily affected immunocompromised and critically ill patients, causing respiratory, blood, and intra-abdominal infections. 

• Investigations by public health authorities revealed that these hospitals used identical ice machines and similar sanitizing products, which likely contributed to the contamination. 

• As a response, public health officials advised against using tap water and ice from these machines during patient care activities. 

• Although the ice machines were replaced, sporadic infections persisted. 

• This outbreak emphasizes the critical importance of implementing rigorous water management practices in hospitals to prevent similar incidents.

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