Recent outbreaks of nontuberculous mycobacteria (NTM) infections in ambulatory surgery centers (ASCs) have highlighted critical gaps in infection prevention and control (IPC) across outpatient settings. From January 2023 through November 2024, an outbreak of Mycobacterium fortuitum prosthetic joint infections affected 17 patients who underwent hip or knee procedures at two ASCs in Tennessee, prompting a comprehensive public health investigation. The investigation identified multiple systemic gaps, including the absence of a formal water management program, limited infection prevention staffing and training, and inadequate surveillance and reporting systems.
In this CORHA Spotlight, Dr. Godwin shares key insights from the outbreak investigation, offering practical lessons for public health professionals, facility leaders, and infection preventionists to strengthen IPC programs and prevent similar events in outpatient settings.
Lessons Learned from the Outbreak
One lesson we learned is simply what we didn’t—and still don’t—know about the outpatient setting, like the volume, types of procedures, and barriers they face. The other big takeaway was that when healthcare workers are implicated in outbreaks, it is critical to focus on the gaps in the system at an organizational level that allow IPC lapses to occur rather than scrutinizing an individual worker. This approach to shared accountability and a commitment to creating safer systems is often referred to as “just culture.” Just culture is usually referenced in the context of medical errors but can be applied during an outbreak investigation and response process as well, especially if individual behaviors may contribute to transmission. A just culture approach aims to not just contain one outbreak but also prevent future outbreaks through fostering an organization-wide culture of safety, reporting, fairness.
The outbreak also underscored challenges in detection and reporting. Although NTM is reportable in Tennessee, instead of the state's health department being notified of the first case, the cluster was not reported until multiple cases occurred. Because interpretation of what constitutes a “cluster” can be up to facilities in some cases, facilities may struggle with defining the cluster, leading to underreporting. This led Tennessee to create more detailed reporting guidance for providers to ensure that all clusters are reported, and all settings are aware of the guidance applies to them. Additionally, concerns about litigation and licensing consequences can discourage early reporting, despite evidence that transparent communication builds patient trust.
Another gap is the lack of setting-specific reporting for ASCs. Unlike acute care hospitals, ASCs often lack required reporting of surgical site infections (SSIs), limiting real-time outbreak detection. While systems like NHSN provide standardized definitions and trend monitoring, data lag and limited outpatient participation reduce their utility for rapid response.
How CORHA Guidance Can Help
CORHA’s NTM Recommended Practices for Healthcare Outbreak Response guidance provides a critical framework for outbreak investigations, including reminders to request acid-fast cultures for non-resolving infections and to review facility practices, policies, and infrastructure. However, many ASC infection preventionists need awareness of other CORHA foundational tools to know how to track infections, conduct laboratory lookbacks, and create line lists before organism-specific guidance can be fully leveraged. Connecting outpatient IPC staff with CORHA, APIC, and public health resources is essential to ensure they are not “out to sea” without support.
Regarding the guidance to investigate even a single case of NTM, an initial assessment of the likelihood of healthcare association is important, as is reaching out to public health early to help monitor for additional cases from that facility and others in the area. There are limits to what you can interpret from just one case, however. It can be difficult to differentiate what could be a product of individual risk factors and a healthcare-associated infection.
Key Infection-Control Lapses and Systemic Challenges
One of the most significant challenges in outpatient settings is the lack of dedicated IPC staff. Unlike hospitals or long-term care facilities, where teams of infection preventionists support surveillance and prevention, outpatient centers often rely on nurse managers who juggle multiple responsibilities without specialized IPC training. This creates vulnerabilities in oversight and implementation of infection-control practices.
Water management programs also emerged as a critical but commonly neglected area. These programs require coordination across facilities management and administration, along with specialized expertise resources that many outpatient facilities may lack. Without robust oversight, water systems can become reservoirs for pathogens like NTM.
Outpatient settings often involve complex ownership structures, with corporations, physician groups, and building owners sharing responsibilities. This can obscure accountability for critical functions like water management, HVAC maintenance, and environmental services. Facilities should define roles and duties in written infection control programs and ensure IPC professionals are included in major operational decisions.
Regular auditing of IPC practices using standardized tools is another key step. Audits should be conducted consistently by trained personnel to identify gaps before they lead to patient harm. Facilities should prioritize interrupting transmission pathways, even when the source cannot be fully remediated.
Key Messages for Leaders and Practitioners
Strong IPC programs, including water management, surveillance, and auditing are fundamental to preventing healthcare-associated infections, regardless of the organism. Transparency is equally important. Provider notification during outbreaks can accelerate detection, guide testing and treatment, and surface barriers to patient safety.
Raising Awareness of Uncommon Outbreak Threats
To improve awareness of NTM and other uncommon pathogens, we need to continue to publish public health findings and share protocols and tools. Storytelling and human impact narratives can also elevate awareness and drive action. Professional organizations and public health networks are well positioned to engage the public and media, providing context while respecting patient privacy.
By strengthening IPC infrastructure, fostering transparency, and leveraging CORHA’s resources, outpatient facilities can close critical gaps and better protect patients from emerging and uncommon infectious threats.