Hospital Tap Water: A Reservoir of Risk for Health Care-Associated Infection

First isolation of Mycobacterium saskatchewanense from medical devices

Mycobacterium saskatchewanense is a species of pigmented slow-growing Non-Tuberculous Mycobacteria (NTM), positive for Mycobacterium avium complex (MAC) by AccuProbe system. MAC organisms have frequently been isolated from different medical devices. This is the first study reporting isolation of M. saskatchewanense from medical devices and highlights the importance of correctly identifying the NTMs that often colonize sanitary water. GenoType Mycobacterium CM CE-IVD kit (CM) was used as the first step of NTM strain identification, and all positive cultures were found to be components of MAC. Then, GenoType NTM-DR CE-IVD kit (NTM-DR) was used to differentiate the different species. Sub-culture on solid media were used for: (i) phenotypical confirmation by colony morphology and Matrix-Assisted Laser Desorption/Ionization-Time of Flight (MALDI-TOF) mass spectrometry; (ii) molecular confirmation by Next Generation Sequencing. All positive cultures were identified as M. intracellulare by CM and NTM-DR assays, whereas colony morphology showed bright yellow scotochromogenic growth. MALDI-TOF analyses identified the strains as M. saskatchewanense with a high score, and identification was confirmed by NGS analysis based on the hsp-65 region. This paper suggests that it is important to actively monitor NTM contamination in medical devices that use sanitary water, to prevent the possibility of patients becoming infected.

An extraoral approach to intraoral cooling-a feasibility study in non-cancer patients

BACKGROUND

Cryotherapy, using ice chips (IC) is an effective strategy to prevent chemotherapy-induced oral mucositis (OM) in selected cancer patient cohorts. However, although effective, use of IC may cause adverse reactions, e.g., nausea, numbness, and shooting pain in the teeth, which could have an adverse impact on the medical treatment. Furthermore, IC requires water of good quality to minimize risk of serious systemic infections. To eliminate these disadvantages, novel cooling devices have emerged as alternative cooling modalities. Thus, the aim was to evaluate the efficacy and tolerability profile of extraoral cooling for intraoral temperature reduction.

SUBJECTS AND METHODS

This experimental pilot study was conducted at the Institute of Odontology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden. In total, six healthy volunteers were enrolled in this study. At baseline and following 30-, and 60 min of cooling with the extraoral cooling device, intraoral mucosal temperatures were measured using a thermographic camera, and a questionnaire related to tolerability was completed.

RESULTS

Following 30-, and 60 min of cooling, the intraoral temperature decreased with 2.0 °C and 2.3 °C, respectively. Extraoral cooling was well tolerated, and all subjects endured the entire cooling session of 60 min.

CONCLUSION

Extraoral cooling reduces intraoral mucosal temperatures and is a well-tolerated cooling modality.

The Presence of Opportunistic Premise Plumbing Pathogens in Residential Buildings: A Literature Review

Opportunistic premise plumbing pathogens (OPPP) are microorganisms that are native to the plumbing environment and that present an emerging infectious disease problem. They share characteristics, such as disinfectant resistance, thermal tolerance, and biofilm formation. The colonisation of domestic water systems presents an elevated health risk for immune-compromised individuals who receive healthcare at home. The literature that has identified the previously described OPPPs (Aeromonas spp., Acinetobacter spp., Helicobacter spp., Legionella spp., Methylobacterium spp., Mycobacteria spp., Pseudomonas spp., and Stenotrophomonas spp.) in residential drinking water systems were systematically reviewed. By applying the Preferred reporting items for systematic reviews and meta-analyses guidelines, 214 studies were identified from the Scopus and Web of Science databases, which included 30 clinical case investigations. Tap components and showerheads were the most frequently identified sources of OPPPs. Sixty-four of these studies detected additional clinically relevant pathogens that are not classified as OPPPs in these reservoirs. There was considerable variation in the detection methods, which included traditional culturing and molecular approaches. These identified studies demonstrate that the current drinking water treatment methods are ineffective against many waterborne pathogens. It is critical that, as at-home healthcare services continue to be promoted, we understand the emergent risks that are posed by OPPPs in residential drinking water. Future research is needed in order to provide consistent data on the prevalence of OPPPs in residential water, and on the incidence of waterborne homecare-associated infections. This will enable the identification of the contributing risk factors, and the development of effective controls.

Non-thermal plasma-based inactivation of bacteria in water using a microfluidic reactor

Failure of conventional water treatment systems may lead to the contamination of water sources, which can cause outbreaks of waterborne healthcare associated infections. Advanced oxidation processing by non-thermal plasma has the potential to treat water without the addition of chemicals. Antibiotic resistant Pseudomonas aeruginosa and Escherichia coli were chosen to investigate the use of non-thermal plasma generated in a microfluidic reactor to disinfect bacteria contaminated water. The microfluidic reactor used in this study utilized a dielectric barrier discharge, in a gas-liquid phase annular flow regime. Microbiological analysis of water inoculated with P. aeruginosa and E. coli was carried out before and after plasma treatment. Using air as the carrier gas, effective disinfection of water was achieved. At the lowest flow rate (35 µL/min), P. aeruginosa and E. coli viability were drastically reduced, with an approximate 8 log maximum decrease in viability following an estimated residence time of 5 s of plasma treatment. Scanning electron microscopy indicated changes in cell morphology due to the plasma treatment. Live/Dead assays revealed that the membranes of the cells had been damaged after plasma treatment. This work demonstrated that non-thermal plasma has the potential to disinfect against microbial contamination in water.

Water as a Source of Antimicrobial Resistance and Healthcare-Associated Infections

Healthcare-associated infections (HAIs) are one of the most common patient complications, affecting 7% of patients in developed countries each year. The rise of antimicrobial resistant (AMR) bacteria has been identified as one of the biggest global health challenges, resulting in an estimated 23,000 deaths in the US annually. Environmental reservoirs for AMR bacteria such as bed rails, light switches and doorknobs have been identified in the past and addressed with infection prevention guidelines. However, water and water-related devices are often overlooked as potential sources of HAI outbreaks. This systematic review examines the role of water and water-related devices in the transmission of AMR bacteria responsible for HAIs, discussing common waterborne devices, pathogens, and surveillance strategies. AMR strains of previously described waterborne pathogens including Pseudomonas aeruginosa, Mycobacterium spp., and Legionella spp. were commonly isolated. However, methicillin-resistant Staphylococcus aureus and carbapenem-resistant Enterobacteriaceae that are not typically associated with water were also isolated. Biofilms were identified as a hot spot for the dissemination of genes responsible for survival functions. A limitation identified was a lack of consistency between environmental screening scope, isolation methodology, and antimicrobial resistance characterization. Broad universal environmental surveillance guidelines must be developed and adopted to monitor AMR pathogens, allowing prediction of future threats before waterborne infection outbreaks occur.

Innovative intraoral cooling device better tolerated and equally effective as ice cooling

PURPOSE

Most of the patients who receive myeloablative therapy prior to stem cell transplantation develop oral mucositis (OM). This adverse reaction manifests as oral mucosal erythema and ulcerations and may require high doses of morphine for pain alleviation. OM may also interfere with food intake and result in weight loss, a need for parenteral nutrition, and impaired quality of life. To date, there have been very few studies of evidence-based interventions for the prevention of OM. Cryotherapy, using ice chips, has been shown to reduce in an efficient manner the severity and extent of OM, although clinical applications are still limited due to several shortcomings, such as adverse tooth sensations, problems with infectious organisms in the water, nausea, and uneven cooling of the oral mucosa. The present proof-of-concept study was conducted to compare the tolerability, temperature reduction, and cooling distribution profiles of an intra-oral cooling device and ice chips in healthy volunteers who did not receive myeloablative treatment, and therefore, did not experience the symptoms of OM.

METHODS

Twenty healthy volunteers used the cooling device and ice chips for a maximum of 60 min each, using a cross-over design. The baseline and final temperatures were measured at eight intra-oral locations using an infra-red thermographic camera. The thermographic images were analysed using two digital software packages. A questionnaire was used to assess the tolerability levels of the two interventions.

RESULTS

The intra-oral cooling device was significantly better tolerated than the ice-chips (p = 0.0118). The two interventions were equally effective regarding temperature reduction and cooling distribution.

CONCLUSIONS

The intra-oral cooling device shows superior tolerability in healthy volunteers. Furthermore, this study shows that temperature reduction and cooling distribution are achieved equally well using either method.

A systematic review of waterborne infections from nontuberculous mycobacteria in health care facility water systems

Healthcare-acquired infections are an increasing problem for health care providers and policy makers. Water is an overlooked source of infectious microorganisms in health care facilities. Waterborne nontuberculous mycobacteria (NTM) are ubiquitous, and particularly problematic in health care facility water systems, and cause a variety of diseases. The purpose of this review is to assess health care associated NTM infections from health care facility water systems. We documented susceptible populations, modes of transmission, and the median attack rate (e.g. patients infected per patients exposed). We aimed to identify transmission risk factors and inform evidence-based policies for infection control and prevention. We searched Embase, PubMed, Web of Science and clinicaltrials.gov without date restrictions. English language articles with original data on NTM waterborne infections in health care settings were included. Randomized controlled trials, descriptive studies (case reports, case series), case-control studies, cohort studies, cross-sectional surveys, and quasi-experimental studies on nosocomial waterborne infections were included. Three investigators independently screened titles and abstracts for relevant articles, and one screened full-text articles. Data were extracted by one investigator, and a second confirmed accuracy for 10% of results. We included 22 observational studies. Immunocompromised, post-surgical, and hemodialysis patients were commonly affected populations. A range of exposure routes such as uncovered central venous catheters (CVCs), wound exposure, and contamination during surgical procedures was reported. The median attack rate was 12.1% (interquartile range, 11-27.2). Waterborne NTM infection affects susceptible patients through common, preventable exposure routes. Effective prevention strategies will require both medical and environmental health expertise, and inter-professional cooperation will optimize these efforts.

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.

Use of an ultraviolet light at point-of-dispense faucet to eliminate Pseudomonas aeruginosa

Tap water is believed to be a significant source of Pseudomonas aeruginosa in health care environments. This study evaluated an ultraviolet (UV) light point-of-dispense water treatment system for control of P aeruginosa. No P aeruginosa was detected in 30 different water dispensers in which the UV light device had been operating for 1-34 months. In comparison, P aeruginosa was found in other taps that did not feature this UV light system.

Genotypic diversity and antibiotic resistance in Sphingomonadaceae isolated from hospital tap water

The aim of this study was to infer about the modes and extent of dispersion of Sphingomonadaceae via tap water. Sphingomonadaceae isolated from tap water samples in different places of a hospital were compared, based on intra-species genetic variability and antibiotic resistance phenotypes. These isolates were also compared with others isolated before from houses and dental chairs, served by the same municipal water supply system. Sphingomonadaceae from hospital tap water comprised members of the genera Sphingomonas, Sphingobium, Novosphingobium and Blastomonas. In general, distinct genotypes of Sphingomonadaceae were detected in different hospital areas and in tap water outside the hospital, suggesting these bacteria are not persistent or widespread in the urban water distribution system. Possible intrinsic antibiotic resistance, observed in most or all members of the family or of a genus, was observed for colistin in Sphingomonadaceae, aminoglycosides in the genus Blastomonas and beta-lactams in the genus Sphingobium. Possible acquired resistance phenotypes, not common to all members of a given species, comprised fluoroquinolones, cephalosporins and sulphonamides. Although the potential of Sphingomonadaceae as opportunistic pathogens may be low, the capacity of these bacteria to thrive in water supply systems, combined with the intrinsic or acquired antibiotic resistance, may raise the risk associated with their occurrence in hospital tap water.

Preventive efficacy and cost-effectiveness of point-of-use water filtration in a subacute care unit

Infections with Pseudomonas aeruginosa and other waterborne pathogens (WBPs) are major contributors to serious morbidity and mortality in hospitals. We sought to determine whether point-of-use (POU) water filtration might result in decreased risk of infection in the subacute care unit (SACU) of a 208-bed medical center. Our findings indicate that POU water filtration can significantly and cost-effectively reduce colonization of and infection with WBPs, including ventilator-associated pneumonia, in an SACU.