PHILADELPHIA — Three patients who underwent heart surgery at Penn Presbyterian Medical Center contracted unusual infections linked to a medical device called a heater-cooler, bringing the total of such cases in Pennsylvania to at least 20, according to the Philadelphia Enquirer.

A fourth patient at Penn Presbyterian tested positive for the type of bacteria in question but did not show signs of infection, said Patrick J. Brennan, chief medical officer of the University of Pennsylvania health system.

Three of the four patients remain under the care of Penn physicians and are “doing well,” while the fourth was treated at another hospital, Brennan said. Elsewhere, similar infections have been linked to patient deaths.

Heater-coolers have been in widespread use for decades to heat or cool the blood of patients on a heart-lung bypass machine, needed for procedures such as open-heart surgery. The temperature is modulated by means of circulating water that does not come into contact with the patient’s blood, so the device was not thought to pose a risk of infection.

Infectious-disease experts now say otherwise, because small amounts of water can become aerosolized and escape through a vent in the device.

The microbes causing the infections, called mycobacteria, often are present in tap water and soil. They pose no risk to healthy people, but for a gravely ill patient whose chest cavity is opened for surgery, the bacteria can spell trouble.

Further complicating the picture, these microbes grow very slowly. They do not lead to symptoms for many months, so the field of medicine was initially slow to link infections to the heater-cooler devices.

The mycobacteria infections in Pennsylvania were first reported in October 2015 at WellSpan York Hospital and in November 2015 at Penn State Hershey Medical Center. Additional cases have since come to light, for a total of 12 at York and five at Penn State Hershey, the hospitals said.

Hospitals have rushed to respond in different ways to the emerging threat, as the machines are essential to performing a variety of lifesaving surgeries. Some hospitals have used only sterilized or filtered water in the devices, at the recommendation of the Food and Drug Administration.

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