Late-onset ventilator-associated pneumonia due to Mycobacterium chelonae and an unusual transmission pathway

A ventilated patient developed fatal late-onset pneumonia due to a Mycobacterium chelonae strain identified from the tap water of his room. The transmission pathway hypothesis was tap water microaspiration after gastric lavage and/or gastroscopy for bezoar management. In high-risk patients, tap water must be avoided for gastric care.