Outbreak of nosocomial urinary tract infections due to Pseudomonas aeruginosa in a paediatric surgical unit associated with tap-water contamination

The First Swedish Outbreak with VIM-2-Producing Pseudomonas aeruginosa, Occurring between 2006 and 2007, Was Probably Due to Contaminated Hospital Sinks

Multidrug-resistant Pseudomonas aeruginosa is an increasing clinical problem worldwide. The aim of this study was to describe the first outbreak of a Verona integron-borne metallo-ß-lactamase (VIM)-2-producing P. aeruginosa strain in Sweden and its expansion in the region. A cluster of multidrug-resistant P. aeruginosa appeared at two neighbouring hospitals in 2006. The isolates were characterized by PCR, pulsed-field gel electrophoresis (PFGE), and whole-genome sequencing. Patient charts, laboratory records, and hygiene routines were reviewed, and patients, staff, and the environment were screened. The investigation revealed a clonal outbreak of a VIM-2-producing P. aeruginosa strain belonging to the high-risk clonal complex 111, susceptible only to gentamicin and colistin. No direct contact between patients could be established, but most of them had stayed in certain rooms/wards weeks to months apart. Cultures from two sinks yielded growth of the same strain. The outbreak ended when control measures against the sinks were taken, but new cases occurred in a tertiary care hospital in the region. In conclusion, when facing prolonged outbreaks with this bacterium, sinks and other water sources in the hospital environment should be considered. By implementing proactive control measures to limit the bacterial load in sinks, the waterborne transmission of P. aeruginosa may be reduced.

Antibiotic-resistant organisms establish reservoirs in new hospital built environments and are related to patient blood infection isolates

Background

Healthcare-associated infections due to antibiotic-resistant organisms pose an acute and rising threat to critically ill and immunocompromised patients. To evaluate reservoirs of antibiotic-resistant organisms as a source of transmission to patients, we interrogated isolates from environmental surfaces, patient feces, and patient blood infections from an established and a newly built intensive care unit.

Methods

We used selective culture to recover 829 antibiotic-resistant organisms from 1594 environmental and 72 patient fecal samples, in addition to 81 isolates from blood cultures. We conducted antibiotic susceptibility testing and short- and long-read whole genome sequencing on recovered isolates.

Results

Antibiotic-resistant organism burden is highest in sink drains compared to other surfaces. Pseudomonas aeruginosa is the most frequently cultured organism from surfaces in both intensive care units. From whole genome sequencing, different lineages of P. aeruginosa dominate in each unit; one P. aeruginosa lineage of ST1894 is found in multiple sink drains in the new intensive care unit and 3.7% of blood isolates analyzed, suggesting movement of this clone between the environment and patients.

Conclusions

These results highlight antibiotic-resistant organism reservoirs in hospital built environments as an important target for infection prevention in hospitalized patients.

Effectiveness of the systematic use of antimicrobial filters in the water taps of critical care units for the prevention of healthcare-associated infections with Pseudomonas aeruginosa

BACKGROUND

Pseudomonas aeruginosa (PA) is the third leading aetiological agent in healthcare-associated infections (HAIs) and the one most frequently found in patients with pneumonia associated with mechanical ventilation. In intensive care units (ICU), its appearance is associated with higher mortality, an increase in the days spent on ventilation, and hospital stay length and costs. Thus, evaluating strategies for preventing these infections is essential for their control. Therefore, our objective was to evaluate the effectiveness of the systematic use of antimicrobial filters in preventing PA infections in critical care units.

METHODS

This was an open experimental crossover study. A total of 2,156 patients admitted for more than 24 hours in critical care units were included, 1,129 of them in units with filters, and 1,027 in units without filters. The study groups were followed-up for 24 months and HAIs were checked for the presence of PA. Chi-squared test were used to compare the rate of HAIs between groups and we calculated 95% confidence intervals adjusted by Poisson regression for the rate ratio (RR) of the association magnitude.

RESULTS

Both groups were homogeneous in terms of intrinsic and extrinsic patient factors. The incidence of PA infections in the units with filters was 5.5 cases/1,000 hospitalized days and 5.4/1,000 hospitalized days for the units without water filters (RR = 1.09 [0.67-1.79]).

CONCLUSIONS

Routine placing antimicrobial filters in the water taps in critical care units was not an effective means of preventing the emergence of HAIs caused by PA.

Evaluation of Multidrug-Resistant P. aeruginosa in Healthcare Facility Water Systems

According to the WHO, P. aeruginosa is one of the antibiotic-resistant bacteria that represent the biggest threat to public health. The aim of the study was to establish the prevalence of antibiotic-resistant P. aeruginosa in the water systems of various healthcare facilities over the course of nine years. A total of 4500 tap water system samples were taken from seventeen healthcare facilities. The culture method was used to detect P. aeruginosa, and the isolates were then tested for antibiotic resistance using the standardised disc diffusion method. Eleven antibiotics from five different classes were tested. P. aeruginosa was found to have contaminated 2.07% (no. 93) of the water samples. The majority of positive samples came from the dental units (30.11%) and the ward kitchens (23.66%). Considering the total isolates, 56.99% (no. 3) were resistant to at least one of the antibiotics tested. A total of 71.43% of P. aeruginosa isolated from water emerging from dental unit handpieces was antibiotic-resistant, with 45% of it resistant to ≥3 classes of antibiotics. Out of the total isolates, 19.35% showed resistance to carbapenems. It would be advisable to systematically screen tap water for opportunistic micro-organisms such as P. aeruginosa, as many countries already do, including this in the Water Safety Plan.

Investigation and control of an outbreak due to a contaminated hospital water system, identified following a rare case of Cupriavidus pauculus bacteraemia

BACKGROUND

Cupriavidus pauculus is rare cause of clinical infection. We describe an outbreak of C. pauculus and other Gram-negative bacteraemias in a paediatric haemato-oncology unit secondary to a contaminated water supply and drainage system.

AIM

To describe the investigation and control measures implemented for a waterborne infection outbreak in a new build hospital.

METHODS

Extensive water testing from various points within the water system was undertaken. Taps, showerheads and components including flow straighteners underwent microbiological analysis. Drains were also swabbed. Surveillance for Gram-negative infections was established on the unit.

FINDINGS

Water testing revealed widespread contamination of the water and drainage system. Outlets were also heavily contaminated, including flow straighteners. Drains were found to have underlying structural abnormalities. Water testing enabled us to detect high-risk components within the water system such as the expansion vessels and outlets and the results assisted with hypotheses generation. Review of commissioning data and risk assessments revealed extensive risks present within the water system prior to and after hospital opening.

CONCLUSION

Careful design, adequate control measures and maintenance are essential for hospital water systems in order to prevent infections due to waterborne organisms. We discuss what can be learned from this incident with a view to future prevention.

Sink drains as reservoirs of VIM-2 metallo-β-lactamase-producing Pseudomonas aeruginosa in a Belgian intensive care unit: relation to patients investigated by whole-genome sequencing

BACKGROUND

Hospital-acquired infections caused by VIM-encoded metallo-β-lactamase-positive Pseudomonas aeruginosa are a major problem in intensive care units (ICUs) worldwide. A previous study conducted in the UZ Brussel hospital revealed that sink drains of the ICU were a possible source of various multidrug-resistant pathogenic bacteria.

AIM

To investigate the presence and persistence of VIM P. aeruginosa in the sink drains of the four adult ICUs and their role in nosocomial infections, emphasizing sink-to-patient transmission.

METHODS

Thirty-six sinks located in the ICUs of the UZ Brussel were sampled and screened for the presence of VIM P. aeruginosa in August and October 2019. Whole-genome sequencing (WGS) was performed on all positive sink drain isolates together with 61 isolates from patients who were retrospectively selected (ICU patients 2019-2020, N = 46; non-ICU patients 2019, N = 6).

FINDINGS

Twenty sinks were found positive for P. aeruginosa at both sampling time-points. WGS revealed that the predominating environmental cluster belonged to sequence type ST111. Ten additional STs were identified. VIM-2 was detected among all ST17 (N = 2) and ST111 (N = 14) sink drain isolates. Based on whole-genome multi-locus sequence typing analysis of all genomes, 15 clusters of highly related isolates were identified, of which seven included both sink drain and clinical isolates.

CONCLUSION

Our findings confirm that sink drains are a possible source of VIM-2 P. aeruginosa, probably after being contaminated with clinical waste from patients. Patients could be exposed to VIM-2 P. aeruginosa dispersed in their environment because of colonized sink drains.

Electrochemical Detection of Multianalyte Biomarkers in Wound Healing Efficacy

The targeted diagnosis and effective treatments of chronic skin wounds remain a healthcare burden, requiring the development of sensors for real-time monitoring of wound healing activity. Herein, we describe an adaptable method for the fabrication of carbon ultramicroelectrode arrays (CUAs) on flexible substrates with the goal to utilize this sensor as a wearable device to monitor chronic wounds. As a proof-of-concept study, we demonstrate the electrochemical detection of three electroactive analytes as biomarkers for wound healing state in simulated wound media on flexible CUAs. Notably, to follow pathogenic responses, we characterize analytical figures of merit for identification and monitoring of bacterial warfare toxin pyocyanin (PYO) secreted by the opportunistic human pathogen Pseudomonas aeruginosa. We also demonstrate the detection of uric acid (UA) and nitric oxide (NO^•), which are signaling molecules indicative of wound healing and immune responses, respectively. The electrochemically determined limit of detection (LOD) and linear dynamic range (LDR) for PYO, UA, and NO^• fall within the clinically relevant concentrations. Additionally, we demonstrate the successful use of flexible CUAs for quantitative, electrochemical detection of PYO from P. aeruginosa strains and cellular NO^• from immune cells in the wound matrix. Moreover, we present an electrochemical examination of the interaction between PYO and NO^•, providing insight into pathogen-host responses. Finally, the effects of the antimicrobial agent, silver (Ag⁺), on P. aeruginosa PYO production rates are investigated on flexible CUAs. Our electrochemical results show that the addition of Ag⁺ to P. aeruginosa in wound simulant decreases PYO secretion rates.

Antimicrobial s-PBC Coatings for Innovative Multifunctional Water Filters

Biological contamination is a typical issue in water treatment. Highly concentrated microbial suspensions in a water flow may cause filter occlusion and biofilm formation, affecting the lifespan and quality of water purification systems and increasing the risk of nosocomial infections. In order to contrast the biofilm formation, most of the conventional strategies rely on the water chemical modification and/or on the use of filters functional coatings. The former is unsafe for huge chemicals spilling required; therefore, we focus on the second approach and we propose the use of a sulfonated pentablock copolymer (s-PBC, commercially named Nexar™) as innovative multifunctional coating for improving the performance of commercial water filters. S-PBC-coated polypropylene (PP) samples were tested against the pathogen Pseudomonas aeruginosa. The covering of PP with s-PBC results in a more hydrophilic, acid, and negatively charged surface. These properties avoid the adhesion and proliferation attempts of planktonic bacteria, i.e., the biofilm formation. Inhibition tests were performed on the as-modified filters and an evident antibacterial activity was observed. The results point out the possibility of using Nexar^TM as coating layer for filters with antifouling properties and a simultaneous ability to remove bacteria and cationic dyes from water.

Nosocomial Infections: A History of Hospital-Acquired Infections

In the United States, healthcare acquired infections (HAIs) or nosocomial infections are the sixth leading cause of death. This article reviews the history, prevalence, economic costs, morbidity and mortality, and risk factors associated with HAIs. Types of infections described include bacterial, fungal, viral, and multidrug resistant infections that contribute to the most common causes of HAIs, which include catheter- associated urinary tract infections, hospital-acquired pneumonias, bloodstream infections, and surgical site infections. Most nosocomial infections are preventable and monitoring and prevention strategies are described.

Antibacterial Activity of Rationally Designed Antimicrobial Peptides

Many infectious diseases are still prevalent in the world's populations since no effective treatments are available to eradicate them. The reasons may either be the antibiotic resistance towards the available therapeutic molecules or the slow rate of producing adequate therapeutic regimens to tackle the rapid growth of new infectious diseases, as well as the toxicity of current treatment regimens. Due to these reasons, there is a need to seek and develop novel therapeutic regimens to reduce the rapid scale of bacterial infections. Antimicrobial Peptides (AMPs) are components of the first line of defense for prokaryotes and eukaryotes and have a wide range of activities against Gram-negative and Gram-positive bacteria, fungi, cancer cells, and protozoa, as well as viruses. In this study, peptides which were initially identified for their HIV inhibitory activity were further screened for antibacterial activity through determination of their kinetics as well as their cytotoxicity. From the results obtained, the MICs of two AMPs (Molecule 3 and Molecule 7) were 12.5 μg/ml for K. pneumoniae (ATCC 700603) and 6.25 μg/ml for P. aeruginosa (ATCC 22108). The two AMPs killed these bacteria rapidly in vitro, preventing bacterial growth within few hours of treatment. Furthermore, the cytotoxic activity of these two peptides was significantly low, even at an AMP concentration of 100 μg/ml. These results revealed that Molecule 3 and 7 have great potential as antibacterial drugs or could serve as lead compounds in the design of therapeutic regimens for the treatment of antibiotic-resistant bacteria.

Microorganism levels in spray from warm-water bidet toilet seats: factors affecting total viable and heterotrophic plate counts, and examination of the fluctuations and origins of Pseudomonas aeruginosa

The objectives of this study were to conduct an appropriate microbial evaluation of warm-water bidet toilet seats. Health-related advantages and disadvantages have been associated with using warm-water bidet toilet seats, which are classified according to the tank type, including tanks equipped with reservoir water heaters and on-demand tankless systems equipped with an instantaneous water heater. However, related bacterial research is sparse. Here, we performed a long-term survey of the behavior of microorganisms (i.e., the total viable count (TVC), heterotrophic plate counts (HPCs), and Pseudomonas aeruginosa count) in a university campus. We also examined the differences between the tank and on-demand types, and the origins of P. aeruginosa. A low TVC (≤1/mL) in the spray waters from both on-demand and tank-type warm-water bidet toilet seats showed low bacterial contamination, although there was an increase in HPC, i.e., growth of biofilms, inside in the warm-water bidet toilet seats. When P. aeruginosa was detected in spray water over an extended duration, the P. aeruginosa origin was considered as either from feces or tap water. Collectively our findings demonstrate that hygienic safety of warm-water bidet toilet seats is being maintained overall.

Transcriptional Responses of Pseudomonas aeruginosa to Potable Water and Freshwater

Many Pseudomonas aeruginosa infections are derived from residential, recreational, or surface water sources; thus, these environments represent an important preinfection niche. To better understand P. aeruginosa biology in these environments, we quantified transcriptional changes by microarray after exposure to diluted LB, diluted R2B, potable tap water, and freshwater from a eutrophic pond. Quantitative reverse transcription-PCR (qRT-PCR) confirmed the conservation of these responses in other water sources, and competition experiments were used to test the importance of three implicated metabolic pathways. The global transcriptional responses in potable water and freshwater showed strong induction of genes involved in metabolism of the head groups and acyl tails of phospholipids, as well as nucleotide metabolism, with commensurate decreased transcript expression of genes encoding their synthetic pathways. These data suggest that phospholipids and nucleotides are part of the nutritional milieu of these two environments. A unique response in municipal-delivered potable water was to the metals in the piping system, particularly copper. To identify potential nutrient sources used by P. aeruginosa in these environments, we used competition assays between the wild-type and deletion mutant strains in three pathways induced under these conditions. For phospholipid head-group metabolism, ethanolamine utilization (eutB) was important for competition in potable water, while choline oxidation (betBA) was important for competition in freshwater. Nucleotide utilization, particularly pyrimidine metabolism (dht), showed a trend toward importance in freshwater but was not statistically significant. These findings provide new insights into the P. aeruginosa response to potable water and freshwater and led to the identification of potentially important nutrient sources in these environments.IMPORTANCE Much of our knowledge about Pseudomonas aeruginosa comes from the infection niche, and much less is known about its lifestyle in the environment. P. aeruginosa is an adaptable bacterium capable of growing in many environments but is particularly common in potable water systems and freshwater. We used the transcriptional responses of P. aeruginosa to these environments to identify important nutrient sources specific to either of these two environments. Additionally, these environments could provide experimental situations to understand gene function for the large number of transcripts with unknown functions induced under these conditions.

Molecular epidemiology, resistance, and virulence properties of Pseudomonas aeruginosa cross-colonization clonal isolates in the non-outbreak setting

Pseudomonas aeruginosa is the predominant opportunistic pathogen leading to nosocomial infection and outbreak in hospitals. Hospitalized patients may be infected with this bacterium through close contact with contaminated environmental media. However, the molecular epidemiology, resistance, and virulence properties of Pseudomonas aeruginosa cross-colonization isolates has received limited attention in the non-outbreak setting. This study aims to investigate the epidemiological relationship of clinical and environmental P. aeruginosa isolates and to characterize the resistance and virulence properties of clonal clusters and sporadic strains in a non-outbreak setting. A total of 436 patients were screened for P. aeruginosa during hospitalization, and environmental samples were taken from their immediate ward media, including faucets, doorknobs, bedrails, pillows, quilts, and mattresses. As a result, 100 P. aeruginosa isolates were obtained, including 74 clinical strains and 26 environmental strains. By using Pulsed-Field Gel Electrophoresis, the fingerprint displayed 20 distinct clusters and 44 sporadic strains. According to identical genotypes, there were clear P. aeruginosa cross-colonization processes from the ward media to inpatients, indicating faucets, bedrails, and pillows as the main propagation media that had been contaminated by clonal isolates previously detected in other patients. In addition, there were P. aeruginosa transmission processes between inpatients that were unexplained for lack of epidemiological evidence. As compared to sporadic strains of P. aeruginosa, clonal clusters are more capable of producing high-level biofilm, developing multi-drug resistance and inducing high-degree cytotoxicity. Among P. aeruginosa clonal clusters, there was a strong positive correlation between antibiotic resistance and biofilm production. We conclude that constant cross-colonization of P. aeruginosa clonal isolates will pose a long-term serious threat in terms of nosocomial outbreaks. Thus, strict disinfection and sterilization procedures should be implemented for ward media, and P. aeruginosa in environments and patients should be closely monitored, especially those strains with strong resistance and virulence.

Hospital Drains as Reservoirs of Pseudomonas aeruginosa: Multiple-Locus Variable-Number of Tandem Repeats Analysis Genotypes Recovered from Faucets, Sink Surfaces and Patients

Identifying environmental sources of Pseudomonas aeruginosa (Pa) related to hospital-acquired infections represents a key challenge for public health. Biofilms in water systems offer protection and favorable growth conditions, and are prime reservoirs of microorganisms. A comparative genotyping survey assessing the relationship between Pa strains recovered in hospital sink biofilm and isolated in clinical specimens was conducted. Environmental strains from drain, faucet and sink-surface biofilm were recovered by a culture method after an incubation time ranging from 48 to 240 h. The genotyping of 38 environmental and 32 clinical isolates was performed using a multiple-locus variable-number of tandem repeats analysis (MLVA). More than one-third of Pa isolates were only cultivable following ≥48 h of incubation, and were predominantly from faucet and sink-surface biofilms. In total, 41/70 strains were grouped within eight genotypes (A to H). Genotype B grouped a clinical and an environmental strain isolated in the same ward, 5 months apart, suggesting this genotype could thrive in both contexts. Genotype E grouped environmental isolates that were highly prevalent throughout the hospital and that required a longer incubation time. The results from the multi-hospital follow-up study support the drain as an important reservoir of Pa dissemination to faucets, sink surfaces and patients. Optimizing the recovery of environmental strains will strengthen epidemiological investigations, facilitate pathway identification, and assist in identifying and controlling the reservoirs potentially associated to hospital-acquired infections.

Methodological approaches for monitoring opportunistic pathogens in premise plumbing: A review

Opportunistic premise (i.e., building) plumbing pathogens (OPPPs, e.g., Legionella pneumophila, Mycobacterium avium complex, Pseudomonas aeruginosa, Acanthamoeba, and Naegleria fowleri) are a significant and growing source of disease. Because OPPPs establish and grow as part of the native drinking water microbiota, they do not correspond to fecal indicators, presenting a major challenge to standard drinking water monitoring practices. Further, different OPPPs present distinct requirements for sampling, preservation, and analysis, creating an impediment to their parallel detection. The aim of this critical review is to evaluate the state of the science of monitoring OPPPs and identify a path forward for their parallel detection and quantification in a manner commensurate with the need for reliable data that is informative to risk assessment and mitigation. Water and biofilm sampling procedures, as well as factors influencing sample representativeness and detection sensitivity, are critically evaluated with respect to the five representative bacterial and amoebal OPPPs noted above. Available culturing and molecular approaches are discussed in terms of their advantages, limitations, and applicability. Knowledge gaps and research needs towards standardized approaches are identified.

Contamination of hospital tap water: the survival and persistence of Pseudomonas aeruginosa on conventional and 'antimicrobial' outlet fittings

BACKGROUND

Pseudomonas aeruginosa infections have been linked to contaminated hospital taps, highlighting the potential for tap outlet fittings (OF) to harbour biofilm. P. aeruginosa may be transferred to OFs via contaminated cleaning cloths. Suggested interventions include flushing regimens and alternative OF designs.

AIM

To investigate the transfer of P. aeruginosa from a contaminated cleaning cloth to conventional and 'antimicrobial/antibiofilm' OFs and to determine whether this contamination persists and/or leads to contamination of tap water.

METHODS

Microfibre cloths contaminated with P. aeruginosa (10⁸ cfu/mL) were used to wipe four different types of OF [one of conventional design (OF-A) and three marketed as 'antimicrobial' and/or 'antibiofilm' (OF- B, -C and -D)]. OFs were inserted into an experimental water distribution system for up to 24 h. Survival was assessed by culture. Single and multiple water samples were collected and cultured for P. aeruginosa.

FINDINGS

The median number of P. aeruginosa transferred from cloth to OF was 5.7 × 10⁵ cfu (OF-A), 1.9 × 10⁶ cfu (OF-B), 1.4 × 10⁵ cfu (OF-C) and 2.9 × 10⁶ cfu (OF-D). Numbers declined on all OFs during the 24 h period with log reductions ranging from 3.5 (OF-C) to 5.2 (OF-B; P > 0.05). All water samples delivered immediately after OF contamination contained P. aeruginosa at ≥10 cfu per 100 mL. Contamination of water delivered from OF-A persisted despite continued flushing. Water delivered from OF-B did not contain P. aeruginosa beyond the first flush.

CONCLUSION

Contaminated cleaning cloths may transfer P. aeruginosa to OFs, leading to contamination of tap water. Although not removing the potential for contamination, 'antimicrobial/antibiofilm' OFs may prevent P. aeruginosa from continually contaminating water delivered from the outlet.

Surveillance of surgical site infections by Pseudomonas aeruginosa and strain characterization in Tanzanian hospitals does not provide proof for a role of hospital water plumbing systems in transmission

Background

The role of hospital water systems in the development of Pseudomonas aeruginosa (P. aeruginosa) surgical site infections (SSIs) in low-income countries is barely studied. This study characterized P. aeruginosa isolates from patients and water in order to establish possible epidemiological links.

Methods

Between December 2014 and September 2015, rectal and wound swabs, and water samples were collected in the frame of active surveillance for SSIs in the two Tanzanian hospitals. Typing of P. aeruginosa was done by multi-locus sequence typing.

Results

Of 930 enrolled patients, 536 were followed up, of whom 78 (14.6%, 95% CI; 11.6–17.5) developed SSIs. P. aeruginosa was found in eight (14%) of 57 investigated wounds. Of the 43 water sampling points, 29 were positive for P. aeruginosa. However, epidemiological links to wound infections were not confirmed. The P. aeruginosa carriage rate on admission was 0.9% (8/930). Of the 363 patients re-screened upon discharge, four (1.1%) possibly acquired P. aeruginosa during hospitalization. Wound infections of the three of the eight P. aeruginosa SSIs were caused by a strain of the same sequence type (ST) as the one from intestinal carriage. Isolates from patients were more resistant to antibiotics than water isolates.

Conclusions

The P. aeruginosa SSI rate was low. There was no evidence for transmission from tap water. Not all P. aeruginosa SSI were proven to be endogenous, pointing to other routes of transmission.

The design of superhydrophobic stainless steel surfaces by controlling nanostructures: A key parameter to reduce the implantation of pathogenic bacteria

Reducing bacterial adhesion on substrates is fundamental for various industries. In this work, new superhydrophobic surfaces are created by electrodeposition of hydrophobic polymers (PEDOT-F₄ or PEDOT-H₈) on stainless steel with controlled topographical features, especially at a nano-scale. Results show that anti-bioadhesive and anti-biofilm properties require the control of the surface topographical features, and should be associated with a low adhesion of water onto the surface (Cassie-Baxter state) with limited crevice features at the scale of bacterial cells (nano-scale structures).

Pseudomonas aeruginosa in premise plumbing of large buildings

Pseudomonas aeruginosa is an opportunistic bacterial pathogen that is widely occurring in the environment and is recognized for its capacity to form or join biofilms. The present review consolidates current knowledge on P. aeruginosa ecology and its implication in healthcare facilities premise plumbing. The adaptability of P. aeruginosa and its capacity to integrate the biofilm from the faucet and the drain highlight the role premise plumbing devices can play in promoting growth and persistence. A meta‐analysis of P. aeruginosa prevalence in faucets (manual and electronic) and drains reveals the large variation in device positivity reported and suggest the high variability in the sampling approach and context as the main reason for this variation. The effects of the operating conditions that prevail within water distribution systems (disinfection, temperature, and hydraulic regime) on the persistence of P. aeruginosa are summarized. As a result from the review, recommendations for proactive control measures of water contamination by P. aeruginosa are presented. A better understanding of the ecology of P. aeruginosa and key influencing factors in premise plumbing are essential to identify culprit areas and implement effective control measures.

Bidet toilet seats with warm-water tanks: residual chlorine, microbial community, and structural analyses

Despite the reported health-related advantages of the use of warm water in bidets, there are health-related disadvantages associated with the use of these toilet seats, and the bacterial research is sparse. We conducted a survey on the hygienic conditions of 127 warm-water bidet toilet seats in restrooms on a university campus. The spray water from the toilet seats had less residual chlorine than their tap water sources. However, the total viable microbial count was below the water-quality standard for tap water. In addition, the heat of the toilet seats' warm-water tanks caused heterotrophic bacteria in the source tap water to proliferate inside the nozzle pipes and the warm-water tanks. Escherichia coli was detected on the spray nozzles of about 5% of the toilet seats, indicating that the self-cleaning mechanism of the spray nozzles was largely functioning properly. However, Pseudomonas aeruginosa was detected on about 2% of the toilet seats. P. aeruginosa was found to remain for long durations in biofilms that formed inside warm-water tanks. Infection-prevention measures aimed at P. aeruginosa should receive full consideration when managing warm-water bidet toilet seats in hospitals in order to prevent opportunistic infections in intensive care units, hematology wards, and other hospital locations.

Impact of electronic faucets and water quality on the occurrence of Pseudomonas aeruginosa in water: a multi-hospital study

OBJECTIVE

To compare Pseudomonas aeruginosa prevalence in electronic and manual faucets and assess the influence of connecting pipes and water quality.

SETTING

Faucets in 4 healthcare centers in Quebec, Canada.

METHODS

Water samples from 105 electronic, 90 manual, and 14 foot-operated faucets were analyzed for P. aeruginosa by culture and enzymatic detection, and swab samples from drains and aerators were analyzed by culture. Copper and residual chlorine concentrations, temperature, and flow rate were measured. P. aeruginosa concentrations were analyzed in 4 consecutive volumes of cold water and a laboratory study was conducted on copper pipes and flexible hoses.

RESULTS

P. aeruginosa contamination was found in drains more frequently (51%) than in aerators (1%) or water (culture: 4%, enzyme detection: 16%). Prevalence in water samples was comparable between manual (14%) and 2 types of electronic faucets (16%) while higher for foot-operated faucets (29%). However, type 2 electronic faucets were more often contaminated (31%) than type 1 (14%), suggesting that faucet architecture and mitigated volume (30 mL vs 10 mL) influence P. aeruginosa growth. Concentrations were 100 times higher in the first 250 mL than after flushing. Flexible hoses were more favorable to P. aeruginosa growth than copper and a temperature of 40°C led to higher counts.

CONCLUSIONS

The types of faucets and connecting pipes, flow rate, and water quality are important parameters influencing the prevalence and the concentrations of P. aeruginosa in faucets. High concentrations of P. aeruginosa in the first 250 mL suggest increased risk of exposure when using the first flush.

Post-Outbreak Investigation of Pseudomonas aeruginosa Faucet Contamination by Quantitative Polymerase Chain Reaction and Environmental Factors Affecting Positivity

OBJECTIVE

To perform a post-outbreak prospective study of the Pseudomonas aeruginosa contamination at the faucets (water, aerator and drain) by culture and quantitative polymerase chain reaction (qPCR) and to assess environmental factors influencing occurrence

SETTING

A 450-bed pediatric university hospital in Montreal, Canada

METHODS

Water, aerator swab, and drain swab samples were collected from faucets and analyzed by culture and qPCR for the post-outbreak investigation. Water microbial and physicochemical parameters were measured, and a detailed characterization of the sink environmental and design parameters was performed.

RESULTS

The outbreak genotyping investigation identified drains and aerators as the source of infection. The implementation of corrective measures was effective, but post-outbreak sampling using qPCR revealed 50% positivity for P. aeruginosa remaining in the water compared with 7% by culture. P. aeruginosa was recovered in the water, the aerator, and the drain in 21% of sinks. Drain alignment vs the faucet and water microbial quality were significant factors associated with water positivity, whereas P. aeruginosa load in the water was an average of 2 log higher for faucets with a positive aerator.

CONCLUSIONS

P. aeruginosa contamination in various components of sink environments was still detected several years after the resolution of an outbreak in a pediatric university hospital. Although contamination is often not detectable in water samples by culture, P. aeruginosa is present and can recover its culturability under favorable conditions. The importance of having clear maintenance protocols for water systems, including the drainage components, is highlighted.

Infect. Control Hosp. Epidemiol. 2015;36(11):1283–1291

[Nosocomial infections in urology]

Nosocomial infections (NI) may be a serious and mostly avoidable consequence of medical procedures and often cause a significant aggravation of the patients underlying disease. Following surgical site infections, urinary tract infections (UTI) represent the second most common fraction of NIs (22.4%) in Germany and contribute to approximately 155,000 nosocomial UTIs (nUTI) every year.Prevention of NI is of utmost individual as well as socioeconomic importance especially regarding the continuing worldwide increase in antibiotic resistance. National legislature has responded to this challenge by amending the German Law on the Prevention and Control of Infectious Diseases (IfSG) and other measures. Their practical importance for various clinical settings in urology is outlined in this overview.The correct use of urinary catheters has the greatest impact for prevention and control as nUTIs are associated with urinary catheters in most of the cases (80%). The recently updated guidelines of the Commission for Hospital Hygiene and Infection Prevention of the Robert Koch Institute (KRINKO) and the Association of the Scientific Medical Societies in Germany (AWMF) provide detailed recommendations in an evidence-based and practice-oriented manner as summarized in this article.

Evaluation of an MPN test for the rapid enumeration of Pseudomonas aeruginosa in hospital waters

In this study, the performance of a new most probable number (MPN) test (Pseudalert(®)/Quanti-Tray(®)) for the enumeration of Pseudomonas aeruginosa from hospital waters was compared with both international and national membrane filtration-based culture methods for P. aeruginosa: ISO 16266:2006 and UK The Microbiology of Drinking Water - Part 8 (MoDW Part 8), which both use Pseudomonas CN agar. The comparison based on the calculation of mean relative differences between the two methods was conducted according to ISO 17994:2014. Using both routine hospital water samples (80 from six laboratories) and artificially contaminated samples (192 from five laboratories), paired counts from each sample and the enumeration method were analysed. For routine samples, there were insufficient data for a conclusive assessment, but the data do indicate at least equivalent performance of Pseudalert(®)/Quanti-Tray(®). For the artificially contaminated samples, the data revealed higher counts of P. aeruginosa being recorded by Pseudalert(®)/Quanti-Tray(®). The Pseudalert(®)/Quanti-Tray(®) method does not require confirmation testing for atypical strains of P. aeruginosa, saving up to 6 days of additional analysis, and has the added advantage of providing confirmed counts within 24-28 hours incubation compared to 40-48 hours or longer for the ISO 16266 and MoDW Part 8 methods.

Outbreak of Multidrug-ResistantPseudomonas aeruginosaColonization and Infection Secondary to Imperfect Intensive Care Unit Room Design

Background.

Pseudomonas aeruginosahas been increasingly recognized for its ability to cause significant hospital-associated outbreaks, particularly since the emergence of multidrug-resistant strains. Biofilm formation allows the pathogen to persist in environmental reservoirs. Thus, multiple hospital room design elements, including sink placement and design, can impact nosocomial transmission ofP. aeruginosaand other pathogens.

Methods.

From December 2004 through March 2006, 36 patients exposed to the intensive care unit or transplant units of a tertiary care hospital were infected with a multidrug-resistant strain ofP. aeruginosa. All phenotypically similar isolates were examined for genetic relatedness by means of pulsed-field gel electrophoresis. Clinical characteristics of the affected patients were collected, and a detailed epidemiological and environmental investigation of potential sources was carried out.

Results.

Seventeen of the infected patients died within 3 months; for 12 (71%) of these patients, infection with the outbreak organism contributed to or directly caused death. The source of the outbreak was traced to hand hygiene sink drains, where biofilms containing viable organisms were found. Testing by use of a commercial fluorescent marker demonstrated that when the sink was used for handwashing, drain contents splashed at least 1 meter from the sink. Various attempts were made to disinfect the drains, but it was only when the sinks were renovated to prevent splashing onto surrounding areas that the outbreak was terminated.

Conclusion.

This report highlights the importance of biofilms and of sink and patient room design in the propagation of an outbreak and suggests some strategies to reduce the risks associated with hospital sinks.

Biofilm formation in an experimental water distribution system: the contamination of non-touch sensor taps and the implication for healthcare

Hospital tap water is a recognised source of Pseudomonas aeruginosa. U.K. guidance documents recommend measures to control/minimise the risk of P. aeruginosa in augmented care units but these are based on limited scientific evidence. An experimental water distribution system was designed to investigate colonisation of hospital tap components. P. aeruginosa was injected into 27 individual tap 'assemblies'. Taps were subsequently flushed twice daily and contamination levels monitored over two years. Tap assemblies were systematically dismantled and assessed microbiologically and the effect of removing potentially contaminated components was determined. P. aeruginosa was repeatedly recovered from the tap water at levels above the augmented care alert level. The organism was recovered from all dismantled solenoid valves with colonisation of the ethylene propylene diene monomer (EPDM) diaphragm confirmed by microscopy. Removing the solenoid valves reduced P. aeruginosa counts in the water to below detectable levels. This effect was immediate and sustained, implicating the solenoid diaphragm as the primary contamination source.

Aetiology, source and prevention of waterborne healthcare-associated infections: a review

The purpose of this review is to discuss the scientific literature on waterborne healthcare-associated infections (HCAIs) published from 1990 to 2012. The review focuses on aquatic bacteria and describes both outbreaks and single cases in relation to patient characteristics, the settings and contaminated sources. An overview of diagnostic methods and environmental investigations is summarized in order to provide guidance for future case investigations. Lastly, on the basis of the prevention and control measures adopted, information and recommendations are given. A total of 125 reports were included, 41 describing hospitalized children. All cases were sustained by opportunistic pathogens, mainly Legionellaceae, Pseudomonadaceae and Burkholderiaceae. Hot-water distribution systems were the primary source of legionnaires’ disease, bottled water was mainly colonized by Pseudomonaceae, and Burkholderiaceae were the leading cause of distilled and sterile water contamination. The intensive care unit was the most frequently involved setting, but patient characteristics were the main risk factor, independent of the ward. As it is difficult to avoid water contamination by microbes and disinfection treatments may be insufficient to control the risk of infection, a proactive preventive plan should be put in place. Nursing staff should pay special attention to children and immunosuppressed patients in terms of tap-water exposure and also their personal hygiene, and should regularly use sterile water for rinsing/cleaning devices.

Hospital water and opportunities for infection prevention

Nosocomial waterborne pathogens may reach patients through several modes of transmission. Colonization of healthcare facility waterworks can occur in the proximal infrastructure, in the distal water outlets, or both. Infections with waterborne organisms such as Legionella, mycobacteria, Pseudomonas, and others cause significant morbidity and mortality, particularly in immunocompromised patients. Hospitals should have prospective water safety plans that include preventive measures, as prevention is preferable to remediation of contaminated hospital water distribution systems. Whole-genome sequencing may provide more informative epidemiologic data to link patient infections with hospital water isolates.

Recovery of Pseudomonas aeruginosa culturability following copper- and chlorine-induced stress

This study investigated how quickly cells of the opportunistic pathogen Pseudomonas aeruginosa recover culturability after exposure to two of the most common environmental stressors present in drinking water, free chlorine and copper ions. Viable but nonculturable (VBNC) P. aeruginosa undetected by direct culturing following exposure to free chlorine or copper ions can survive in drinking water systems, with potential to recover, multiply, and regain infectivity. Cells were exposed to copper sulfate (0.25 mg Cu(2+)  L(-1) ) or free chlorine (initial dose of 2 mg Cl2  L(-1) ) for 24 h. Despite total loss of culturability and a reduction in viability from 1.2 × 10(7) to 4 × 10(3)  cells mL(-1) (3.5 log), cells exposed to chlorine recovered viability quickly after the depletion of free chlorine, while culturability was recovered within 24 h. Copper ions did not depress viability, but reduced culturability from 3 × 10(7) to 2.3 × 10(2)  cells mL(-1) (5.1 log); VBNC cells regained culturability immediately after copper ion chelation. A comparison between direct culturing and Pseudalert, a specific enzyme-based assay, was performed. Both detection methods were well correlated in the range of 10(2) -10(10)  cells L(-1) . However, correlations between the methods declined after exposure to copper ions.

Spatial and temporal analyses to investigate infectious disease transmission within healthcare settings

Background

Healthcare-associated infections (HCAIs) cause significant morbidity and mortality worldwide, and outbreaks are often only identified after they reach high levels. A wide range of data is collected within healthcare settings; however, the extent to which this information is used to understand HCAI dynamics has not been quantified.

Aim

To examine the use of spatiotemporal analyses to identify and prevent HCAI transmission in healthcare settings, and to provide recommendations for expanding the use of these techniques.

Methods

A systematic review of the literature was undertaken, focusing on spatiotemporal examination of infectious diseases in healthcare settings. Abstracts and full-text articles were reviewed independently by two authors to determine inclusion.

Findings

In total, 146 studies met the inclusion criteria. There was considerable variation in the use of data, with surprisingly few studies (N = 22) using spatiotemporal-specific analyses to extend knowledge of HCAI transmission dynamics. The remaining 124 studies were descriptive. A modest increase in the application of statistical analyses has occurred in recent years.

Conclusion

The incorporation of spatiotemporal analysis has been limited in healthcare settings, with only 15% of studies including any such analysis. Analytical studies provided greater data on transmission dynamics and effective control interventions than studies without spatiotemporal analyses. This indicates the need for greater integration of spatiotemporal techniques into HCAI investigations, as even simple analyses provide significant improvements in the understanding of prevention over simple descriptive summaries.

An integrated approach to control a prolonged outbreak of multidrug-resistant Pseudomonas aeruginosa in an intensive care unit

In this paper we aim to provide insight into the complexity of outbreak management in an intensive care unit (ICU) setting. In October 2010 four patients on the ICU of our tertiary care centre were colonized or infected with a multidrug-resistant strain of Pseudomonas aeruginosa (MDR-PA). An outbreak investigation was carried out and infection control measures were taken in an attempt to identify a potential source and stop transmission. The outbreak investigation included descriptive epidemiology, comprising retrospective case finding by reviewing the laboratory information system back to 2004 and prospective case finding by patient screening for MDR-PA. Furthermore, microbiological analysis, environmental screening and a case-control study were carried out. Infection control measures consisted of re-education of healthcare personnel on basic hygiene measures, auditing of hygiene procedures used in daily practice by infection control practitioners, and stepwise up-regulation of isolation measures. From February 2009 to January 2012, 44 patients on our ICU were found to be MDR-PA positive. MDR-PA isolates of the 44 patients showed two distinct AFLP patterns, with homology within each of the AFLP clusters of more than 93%. The VIM metallo-β-lactamase gene was detected in 20 of 21 tested isolates. A descriptive epidemiology investigation identified the rooms with the highest numbers of MDR-PA positive patients. The case-control study showed three factors to be independently associated with MDR-PA positivity: admission to ICU subunit 1 (OR, 6.1; 95% CI, 1.7, 22), surgery prior to or during admission (OR, 5.7; 95% CI, 1.6, 20) and being warmed-up with the warm-air blanket (OR, 3.6; 95% CI, 1.2, 11). After three environmental screening rounds, with sampling of sinks, furniture and devices in the ICU, without revealing a clear common source, a fourth environmental investigation included culturing of faucet aerators. Two faucets were found to be positive for MDR-PA and were replaced. The occurrence of new cases decreased with the strengthening of infection control measures and declined further with the removal of the common source. With this integrated approach a prolonged outbreak of P. aeruginosa was controlled. Contaminated faucet aerators on the ICU probably served as a persisting source, while interpatient transmission by medical staff was a likely way of spread. Seven months after the last case (January 2012) and 3 months after cessation of extended isolation measures (May 2012), single cases started to occur on the ICU, with a total of seven patients in the past year. No common source has yet been found.

Association between healthcare water systems and Pseudomonas aeruginosa infections: a rapid systematic review

BACKGROUND

Pseudomonas aeruginosa is an opportunistic pathogen with a particular propensity to cause disease in the immunocompromised. Water systems have been reported to contribute to P. aeruginosa transmission in healthcare settings.

AIM

To systematically assess the evidence that healthcare water systems are associated with P. aeruginosa infection; to review aspects of design that can increase their potential to act as a reservoir; and to compare the efficacy of strategies for eradicating contamination and preventing infection.

METHODS

A rapid review methodology with a three-step search strategy was used to identify published studies. Scientific advisors were used to identify unpublished studies.

FINDINGS

Twenty-five relevant studies were included. There was plausible evidence of transmission of P. aeruginosa from water systems to patients and vice versa, although no direct evidence to explain the exact mode of transfer. Two studies provided plausible evidence for effective interventions: point-of-use filters and increasing chlorine disinfection. Non-touch taps and aspects of water system design were identified as probable risk factors for P. aeruginosa biofilm formation and subsequent transmission to patients. Poor hand hygiene or compliance with contact precautions were identified as potential contributory factors; plausible evidence to confirm this was not available.

CONCLUSIONS

Water systems can act as a source of P. aeruginosa infection in healthcare settings, although the route of transmission is unclear. Contamination appears to be confined to the distal ends of a water system and can persist for prolonged periods. Further studies are required to establish effective methods of preventing transmission and eradicating P. aeruginosa from plumbing systems.

Influence of pre- and post-usage flushing frequencies on bacterial water quality of non-touch water fittings

Background

Non-touch fittings have been reported to be susceptible for Pseudomonas aeruginosa accumulation. A number of factors may contribute to this, including the frequency of usage, duration of water stagnation, or presence of plastic materials. Programmable non-touch fittings are appearing which allow regular automated post-flushing with cold water to prevent water stagnation. However, the ideal duration of post-flushing is unknown as well as the effect of pre-rinsing with cold water before use.

Methods

Eight non-touch fittings with brass valve blocks were mounted on a mobile test sink and connected to the same central water pipe source, differing only in presence or absence of water connection pipes, length of connection pipe, frequency of usage, and time intervals for pre- and post-usage water flush. The total bacteria colony-forming unit (cfu) counts were obtained by the spread plate technique.

Results

Low frequency of water use in combination with a long stagnating water column resulted in high bacterial cfu counts. Post-usage flushing for 2 seconds did not differ from no flushing. Flushing for 10 seconds with cold water after use or 30 seconds flush before use were both the most effective measures to prevent non-touch fittings from biofilm formation over a period of 20 weeks.

Conclusion

Further improvements in water fitting technology could possibly solve the problem of bacterial water contamination in health care settings.

Common Antimicrobial Resistance Patterns, Biotypes and Serotypes Found amongPseudomonas aeruginosaIsolatesfrom Patient's Stools and Drinking Water Sources in Jordan

Pseudomonas aeruginosa was isolated in low rates from stool specimens of outpatients and inpatients (7% versus 12%) but in higher rates from chlorinated and nonchlorinated water sources (15% versus 44%), respectively in Jordan. The same biotype was recognized among 90% of P. aeruginosa isolates from patient's stools and water sources using specific biochemical profiles. Three serogroups belonging to 01, 06 and 011 accounted for the majority of these isolates in water (66%) and stools (78%), respectively. All P. aeruginosa isolates from water were highly susceptible (87%-100%) to piperacillin-tazobactam, amikacin, gentamicin, imipenem, aztreonam, ceftazidime and ciprofloxacin, whereas the isolates from stool were slightly less susceptible (81%-98%) to these antimicrobials. P. aeruginosa isolates from water and stool sources were almost equally highly resistant to tetracycline (86%-89%) and carbenicillin (88%-89%), respectively. One common small plasmid (15.4 kb) was detected in 14/25 (56%) of multidrug-resistant P. aeruginosa isolates from both water and stool. This study demonstrates certain common epidemiological characteristics including antimicrobial resistance pattern, biotypes and serotypes among P. aeruginosa isolates from patient's stools and drinking water sources in Jordan.

Difficult-to-detect carbapenem-resistant IMP13-producing P. aeruginosa: experience feedback concerning a cluster of urinary tract infections at a surgical clinic in France

Background

We report a carbapenem-resistant P. aeruginosa clone responsible for a cluster of urinary tract infections in elderly surgery patients, diagnosed during a three-month period in a 59-bed surgical clinic.

Findings

The clonal nature of the cluster was established by molecular study of the P. aeruginosa isolates (PFGE and MLST). Despite an MIC of imipenem in the susceptibility range for two isolates, all were metallo-β-lactamase-producers (IMP13-type, clone ST621). We conducted a review of the medical and surgical procedures. We tested water delivered into the clinic and urological devices for the presence of the epidemic strain. The hygiene nurse observed hygiene practices. A week after the implementation of barrier precautions around the fourth infected patient, we studied the extent to which the patients hospitalised were colonised to assess whether the spread of the epidemic strain had been controlled.

Conclusions

1/ Our findings indicate the difficulties in the detection of the metallo-β-lactamase in this clone, that resulted in the alert being delayed. 2/ Unlike most investigations of UTI outbreaks described in urology wards, we did not detect any contaminated urological devices or water colonisation. 3/ Consistent with outbreaks involving the IMP-13 clone in critical care units, the observation of inadequate application of standard precautions argued for patient-to-patient transmission during urinary management of the urology patients. 4/ The implementation of barrier precautions around infected patients resulted in control of the spread of the epidemic clone. This report serves as an alert concerning a difficult-to-detect multidrug-resistant P. aeruginosa clone in elderly urology patients.

Plumbing of hospital premises is a reservoir for opportunistically pathogenic microorganisms: a review

Several bacterial species that are natural inhabitants of potable water distribution system biofilms are opportunistic pathogens important to sensitive patients in healthcare facilities. Waterborne healthcare-associated infections (HAI) may occur during the many uses of potable water in the healthcare environment. Prevention of infection is made more challenging by lack of data on infection rate and gaps in understanding of the ecology, virulence, and infectious dose of these opportunistic pathogens. Some healthcare facilities have been successful in reducing infections by following current water safety guidelines. This review describes several infections, and remediation steps that have been implemented to reduce waterborne HAIs.

Electronic-eye faucets: Legionella species contamination in healthcare settings

OBJECTIVE

To compare heterotrophic plate counts (HPCs) and Legionella species growth from electronic and manual faucet water samples.

DESIGN

Proportions of water samples with growth and colony-forming units were compared using Fisher's exact test and the Wilcoxon rank-sum test, respectively.

SETTING

Two psychiatric units and 1 medical unit in a 1,000-bed university hospital.

METHODS

Water samples were collected from 20 newly installed electronic faucets and 20 existing manual faucets in 3 hospital units. Manual faucets were located in rooms adjacent to the electronic faucets and received water from the same source. Water samples were collected between December 15, 2008, and January 29, 2009. Four electronic faucets were dismantled, and faucet components were cultured. Legionella species and HPC cultures were performed using standard methods.

RESULTS

Nearly all electronic faucets (19/20 [95%]) grew Legionella species from at least 1 water sample, compared with less than half (9/20 [45%]) of manual faucets ([Formula: see text]). Fifty-four (50%) of 108 electronic faucet water cultures grew Legionella species, compared with 11 (15%) of 75 manual faucet water cultures ([Formula: see text]). After chlorine dioxide remediation, 4 (14%) of 28 electronic faucet and 1 (3%) of 30 manual faucet water cultures grew Legionella species ([Formula: see text]), and 8 (29%) electronic faucet and 2 (7%) manual faucet cultures had significant HPC growth ([Formula: see text]). All 12 (100%) of the internal faucet components from 2 electronic faucets grew Legionella species.

CONCLUSIONS

Electronic faucets were more commonly contaminated with Legionella species and other bacteria and were less likely to be disinfected after chlorine dioxide remediation. Electronic faucet components may provide points of concentrated bacterial growth.

Rapid and sensitive detection of Pseudomonas aeruginosa in chlorinated water and aerosols targeting gyrB gene using real-time PCR

AIMS

For the rapid detection of Pseudomonas aeruginosa from chlorinated water and aerosols, gyrB gene-based real-time PCR assay was developed and investigated.

METHODS AND RESULTS

Two novel primer sets (pa722F/746MGB/899R and pa722F/746MGB/788R) were designed using the most updated 611 Pseudomonas and 748 other bacterial gyrB genes for achieving high specificity. Their specificity showed 100% accuracy when tested with various strains including clinical isolates from cystic fibrosis patients. The assay was tested with Ps. aeruginosa-containing chlorinated water and aerosols to simulate the waterborne and airborne transmission routes (detection limit 3·3 × 10² CFU per PCR-2·3 × 10³ CFU per PCR). No chlorine interference in real-time PCR was observed at drinking water level (c. 1 mg l⁻¹), but high level of chorine (12 mg l⁻¹) interfered the assay, and thus neutralization was needed. Pseudomonas aeruginosa in aerosol was successfully detected after capturing with gelatin filters with minimum 2 min of sampling time when the initial concentration of 10⁴ CFU ml⁻¹ bacteria existed in the nebulizer.

CONCLUSIONS

A highly specific and rapid assay (2-3 h) was developed by targeting gyrB gene for the detection of Ps. aeruginosa in chlorinated water and aerosols, combined with optimized sample collection methods and sample processing, so the direct DNA extraction from either water or aerosol was possible while achieving the desired sensitivity of the method.

SIGNIFICANCE AND IMPACT OF THE STUDY

  The new assay can provide timely and accurate risk assessment to prevent Ps. aeruginosa exposure from water and aerosol, resulting in reduced disease burden, especially among immune-compromised and susceptible individuals. This approach can be easily utilized as a platform technology for the detection of other types of micro-organisms, especially for those that are transmitted via water and aerosol routes, such as Legionella pneumophila.

Bacterial hand contamination and transfer after use of contaminated bulk-soap-refillable dispensers

Bulk-soap-refillable dispensers are prone to extrinsic bacterial contamination, and recent studies demonstrated that approximately one in four dispensers in public restrooms are contaminated. The purpose of this study was to quantify bacterial hand contamination and transfer after use of contaminated soap under controlled laboratory and in-use conditions in a community setting. Under laboratory conditions using liquid soap experimentally contaminated with 7.51 log(10) CFU/ml of Serratia marcescens, an average of 5.28 log(10) CFU remained on each hand after washing, and 2.23 log(10) CFU was transferred to an agar surface. In an elementary-school-based field study, Gram-negative bacteria on the hands of students and staff increased by 1.42 log(10) CFU per hand (26-fold) after washing with soap from contaminated bulk-soap-refillable dispensers. In contrast, washing with soap from dispensers with sealed refills significantly reduced bacteria on hands by 0.30 log(10) CFU per hand (2-fold). Additionally, the mean number of Gram-negative bacteria transferred to surfaces after washing with soap from dispensers with sealed-soap refills (0.06 log(10) CFU) was significantly lower than the mean number after washing with contaminated bulk-soap-refillable dispensers (0.74 log(10) CFU; P < 0.01). Finally, significantly higher levels of Gram-negative bacteria were recovered from students (2.82 log(10) CFU per hand) than were recovered from staff (2.22 log(10) CFU per hand) after washing with contaminated bulk soap (P < 0.01). These results demonstrate that washing with contaminated soap from bulk-soap-refillable dispensers can increase the number of opportunistic pathogens on the hands and may play a role in the transmission of bacteria in public settings.

Survival of Escherichia coli O157:H7 and Campylobacter jejuni in bottled purified drinking water under different storage conditions

Survival of Escherichia coli O157:H7 and Campylobacter jejuni that were separately inoculated into bottled purified drinking water was investigated during storage at 22, 4, and -18 °C for 5, 7, and 2 days, respectively. Two inoculation levels were used, 1 and 10 CFU/ml (10(2) and 10(3) CFU/100 ml). In samples inoculated with 10(2) CFU/100 ml, C. jejuni was not detectable (>2-log reduction) after storage under the conditions specified above. E. coli O157:H7 was detected on nonselective and selective media at log reductions of 1.08 to 1.25 after storage at 22 °C, 1.19 to 1.56 after storage at 4 °C, and 1.54 to 1.98 after storage at -18 °C. When the higher inoculation level of 10(3) CFU/100 ml was used, C. jejuni was able to survive at 22 and 4 °C, with 2.25- and 2.17-log reductions, respectively, observed on nonselective media. At these higher inoculation levels, E. coli O157:H7 was detectable at 22, 4, and -18 °C, with log reductions of 0.76, 0.97, and 1.21, respectively, achieved on nonselective media. Additionally, E. coli O157:H7 showed significant differences in culturability (P<0.05) on the nonselective and selective culture media under the different storage conditions, with storage at -18 °C for 2 days being the treatment most inhibiting. The percentage of sublethal injury of E. coli O157:H7 ranged from ∼33 to 75%, indicating that microbial examination of bottled water must be done carefully, otherwise false-negative results or underestimation of bacterial numbers could pose a health risk when low levels of pathogens are present.

A review of hand-washing techniques in primary care and community settings

AIM

This review seeks to identify the most effective hand-washing and hand-cleansing practice that could be used in primary care.

BACKGROUND

Healthcare associated infection is a major problem in the UK causing 5000 deaths every year. Current guidelines indicate expert opinion is the level of evidence for hand washing as an activity to reduce infection.

DESIGN

Systematic review.

METHOD

Publications on hand-washing, hand-cleansing studies, policy and practice-based documents were sought by searching several databases. Terms used included hand washing, hand cleansing, hand hygiene, hand decontamination, infection control and primary care.

RESULTS

Few articles described the hand-washing technique in detail and some publications simply referred to either the European and British Standards or the Centre for Disease Control statement on hand washing. Major discrepancies in hand position and water flow direction were found. Several methodological problems were also identified and few studies were undertaken in primary care.

CONCLUSION

This review has found a lack of evidence for hand-washing techniques being undertaken in practice today. Findings from hand-washing technique studies were inconclusive and methodological issues exist resulting in sparse reliable evidence. There is an urgent need to undertake methodologically sound studies of hand-washing techniques for use in the ever expanding scope of primary care practice.

RELEVANCE TO CLINICAL PRACTICE

Evidence for hand-washing and hand-cleansing techniques will inform healthcare professional practice, and contribute to the overall management of infection control in primary care.

Spatio-temporal analysis of infra-specific genetic variations among a Pseudomonas aeruginosa water network hospital population: invasion and selection of clonal complexes

AIMS

To investigate infra-specific spatio-temporal dynamics of a hospital water network Pseudomonas aeruginosa population. To infer the origin of water network isolates and assess their potential health hazard.

METHODS AND RESULTS

168 P. aeruginosa strains were isolated from tap waters and swabs of tap nozzle aerators of a hospital unit, over 2 years, and from rectal swabs and nosocomial infections. Genetic diversity among this collection was assessed by pulsed field gel electrophoresis of SpeI restricted genomic DNA. Virulence gene sets, biofilm properties, and hypochlorite resistance were analysed. Exactly 68% of the water samples and 74% of the tap nozzle aerators harboured P. aeruginosa. The strains were divided into 22 clonal lineages, with one dominant clone shown to have been involved in a nosocomial infection.

CONCLUSIONS

An important turnover among the P. aeruginosa hospital population was observed. Some clonal lineages were found to persist, spread in the unit, and diversify into clonal complexes. Rectal carriage appeared an important source of contamination of the water network.

SIGNIFICANCE AND IMPACT OF THE STUDY

High P. aeruginosa infra-specific population diversity suggested a broad ability in colonizing water networks but persistence analysis indicated a strong selection leading to the emergence of dominant clones.

[Stenotrophomonas maltophilia and Pseudomonas aeruginosa water-associated microbiologic risk assessment in Amiens' University Hospital Centre]

BACKGROUND

Pseudomonas aeruginosa (Psa) and Stenotrophomonas maltophilia (Smalto) are major opportunistic waterborne pathogens causing hospital-acquired infections. This study aimed to assess the biocontamination level of cold water used in Amiens' university hospital wards, from March to June 2008.

METHODS

We cultivated 122 pairs of cold water first jet and taps cotton-swabs on Cetrimide agar for Psa, on Stenotrophomonas maltophilia selective medium with coloured indicator (SM2i) for Smalto, on Mueller Hinton agar used as isolation medium reference for both, 48h at 30 degrees C. Data analysed with Epi-Info 6.04dFr were compared with chi(2) test, significant at p<.05.

RESULTS

Psa and Smalto were isolated in 26.2 and 14.8% of water samples and in 21.3 and 10.7% of swab samples respectively. They were associated in 11.5% of water samples and 5% of swab samples. Psa was alone in 13.1% of water samples and 7.4% of swab samples whereas Smalto was found in 6.6% of water and 2.5% of swabs. Psa and Smalto were isolated from 14.8% of water samples and 8.2% of swab samples of the same tap. Finally, respectively 35.2 and 17.2% of the cold water taps were biocontaminated by Psa and Smalto. In fact, microbiologic water taps contamination risk was two-fold higher for Psa than for Smalto, p<.001, without variation between wards.

CONCLUSION

Sm2i and Cetrimide are suited and efficient medium respectively for Smalto and Psa isolation. Cold-water samples are sufficient for waterborne pathogens biocontamination risk appraisal. Our results urged healthcare workers on efficient water fittings microbiologic risk control to prevent healthcare associated waterborne infections, notably due to Psa and Smalto.