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Whapham CA, Walker JT. Too much ado about data: Continuous remote monitoring of water temperatures, circulation and throughput can assist in the reduction of hospital-associated waterborne infections. J Hosp Infect 2024:S0195-6701(24)00223-8. [PMID: 38960042 DOI: 10.1016/j.jhin.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND National and international guidance provides advice on maintenance and management of water systems in healthcare buildings, however, healthcare-associated waterborne infections (HAWI) are increasing. This narrative review identifies parameters critical to water quality in healthcare buildings and assesses if remote sensor monitoring can deliver safe water systems thus reducing HAWI. METHOD A narrative review was performed using the following search terms 1) consistent water temperature AND waterborne pathogen control OR nosocomial infection 2) water throughput AND waterborne pathogen control OR nosocomial infection 3) remote monitoring of in-premise water systems AND continuous surveillance for temperature OR throughput OR flow OR use. Databases employed were PubMed, CDSR (Clinical Study Data Request) and DARE (Database of Abstracts of Reviews of Effects) from Jan 2013 - Mar 2024. FINDINGS Single ensuite-patient rooms, expansion of wash-hand basins, widespread glove use, alcohol gel and wipes have increased water system stagnancy resulting in amplification of waterborne pathogens and transmission risk of Legionella, Pseudomonas and Non-Tuberculous Mycobacteria. Manual monitoring does not represent temperatures across large complex water systems. This review deems that multiple point continuous remote sensor monitoring is effective at identifying redundant and low use outlets, hydraulic imbalance and inconsistent temperature delivery across in-premise water systems. CONCLUSION As remote monitoring becomes more common there will be greater recognition of failures in temperature control, hydraulics and balancing in water systems and there remains much to learn as we adopt this developing technology within our hospitals.
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Affiliation(s)
- C A Whapham
- Independent Water Hygiene Consultant, Ludlow UK.
| | - J T Walker
- Independent Microbiology Consultant, Walker on Water, Salisbury UK
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Baker AW, Nick SE, Jia F, Graves AM, Warren BG, Zavala S, Stout JE, Lee MJ, Alexander BD, Davidson RM, Anderson DJ. Mycobacterium immunogenum acquisition from hospital tap water: a genomic and epidemiologic analysis. J Clin Microbiol 2024; 62:e0014924. [PMID: 38690881 PMCID: PMC11237794 DOI: 10.1128/jcm.00149-24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 04/06/2024] [Indexed: 05/03/2024] Open
Abstract
We identified 23 cases of Mycobacterium immunogenum respiratory acquisition linked to a colonized plumbing system at a new hospital addition. We conducted a genomic and epidemiologic investigation to assess for clonal acquisition of M. immunogenum from hospital water sources and improve understanding of genetic distances between M. immunogenum isolates. We performed whole-genome sequencing on 28 M. immunogenum isolates obtained from August 2013 to July 2021 from patients and water sources on four intensive care and intermediate units at an academic hospital. Study hospital isolates were recovered from 23 patients who experienced de novo respiratory isolation of M. immunogenum and from biofilms obtained from five tap water outlets. We also analyzed 10 M. immunogenum genomes from previously sequenced clinical (n = 7) and environmental (n = 3) external control isolates. The 38-isolate cohort clustered into three clades with pairwise single-nucleotide polymorphism (SNP) distances ranging from 0 to 106,697 SNPs. We identified two clusters of study hospital isolates in Clade 1 and one cluster in Clade 2 for which clinical and environmental isolates differed by fewer than 10 SNPs and had less than 0.5% accessory genome variation. A less restrictive combined threshold of 40 SNPs and 5% accessory genes reliably captured additional isolates that met clinical criteria for hospital acquisition, but 12 (4%) of 310 epidemiologically unrelated isolate pairs also met this threshold. Core and accessory genome analyses confirmed respiratory acquisition of multiple clones of M. immunogenum from hospital water sources to patients. When combined with epidemiologic investigation, genomic thresholds accurately distinguished hospital acquisition.
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Affiliation(s)
- Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Sophie E Nick
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Fan Jia
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado, USA
| | - Amanda M Graves
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Bobby G Warren
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Sofia Zavala
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jason E Stout
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mark J Lee
- Department of Pathology and Clinical Microbiology Laboratory, Duke University School of Medicine, Durham, North Carolina, USA
| | - Barbara D Alexander
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pathology and Clinical Microbiology Laboratory, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca M Davidson
- Center for Genes, Environment and Health, National Jewish Health, Denver, Colorado, USA
| | - Deverick J Anderson
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Nick SE, Yarrington ME, Reynolds JM, Anderson DJ, Baker AW. Risk Factors for and Outcomes Following Early Acquisition of Mycobacterium abscessus Complex After Lung Transplantation. Open Forum Infect Dis 2024; 11:ofae209. [PMID: 38746951 PMCID: PMC11093398 DOI: 10.1093/ofid/ofae209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 04/10/2024] [Indexed: 06/02/2024] Open
Abstract
Background Lung transplant recipients are at increased risk of Mycobacterium abscessus complex (MABC) acquisition and invasive infection. We analyzed risk factors and outcomes of early post-lung transplant MABC acquisition. Methods We conducted a retrospective matched case-control study of patients who underwent lung transplant from 1/1/2012 to 12/31/2021 at a single large tertiary care facility. Cases had de novo MABC isolation within 90 days post-transplant. Controls had no positive MABC cultures and were matched 3:1 with cases based on age and transplant date. Recipient demographics and pre-/peri-operative characteristics were analyzed, and a regression model was used to determine independent risk factors for MABC acquisition. We also assessed 1-year post-transplant outcomes, including mortality. Results Among 1145 lung transplants, we identified 79 cases and 237 matched controls. Post-transplant mechanical ventilation for >48 hours was independently associated with MABC acquisition (adjusted odds ratio, 2.46; 95% CI, 1.29-4.72; P = .007). Compared with controls, cases required more days of hospitalization after the MABC index date (28 vs 12 days; P = .01) and had decreased 1-year post-transplant survival (78% vs 89%; log-rank P = .02). One-year mortality appeared highest for cases who acquired M. abscessus subsp. abscessus (31% mortality) or had extrapulmonary infections (43% mortality). Conclusions In this large case-control study, prolonged post-transplant ventilator duration was associated with early post-lung transplant MABC acquisition, which in turn was associated with increased hospital-days and mortality. Further studies are needed to determine the best strategies for MABC prevention, surveillance, and management.
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Affiliation(s)
- Sophie E Nick
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Michael E Yarrington
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - John M Reynolds
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Deverick J Anderson
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
| | - Arthur W Baker
- Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Durham, North Carolina, USA
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Cao X, Xiong H, Fan Y, Xiong L. Comparing the Effects of Two Culture Methods to Determine the Total Heterotrophic Bacterial Colony Count in Hospital Purified Water. J Epidemiol Glob Health 2024; 14:184-192. [PMID: 38358615 PMCID: PMC11043230 DOI: 10.1007/s44197-023-00186-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/26/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Accurately detecting the quantity of microorganisms in hospital purified water is of significant importance for early identification of microbial contamination and reducing the occurrence of water-borne hospital infections. The choice of detection method is a prerequisite for ensuring accurate results. Traditional Plate Count Agar (PCA) belongs to a high-nutrient medium, and there may be limitations in terms of accuracy or sensitivity in detecting microorganisms in hospital purified water. On the other hand, Reasoner's 2A agar (R2A) has characteristics, such as low-nutrient levels, low cultivation temperature, and extended incubation time, providing advantages in promoting the growth of aquatic microorganisms. This study, through comparing the differences in total colony counts between two detection methods, aims to select the method more suitable for the growth of aquatic microorganisms, offering new practical insights for accurately detecting the total count of heterotrophic bacteria in hospital purified water. METHODS The most commonly used plate count agar (PCA) method, and the R2A agar culture were adopted to detect microorganisms and determine the total number of bacterial colonies in the water for oral diagnosis and treatment water and terminal rinse water for endoscopes in medical institutions. The two water samples were inoculated by pour plate and membrane filtration methods, respectively. Using statistical methods including Spearman and Pearson correlation, Wilcoxon signed-rank sum test, paired-Chi-square test, and linear regression, we analyze the differences and associations in the bacterial counts cultivated through two different methods. RESULTS In 142 specimens of the water, the median and interquartile range of the heterotrophic bacterial colony number under the R2A culture method and under the PCA culture method were 200 (Q1-Q3: 25-18,000) and 6 (Q1-Q3: 0-3700). The total number of heterotrophic bacteria colonies cultured in R2A medium for 7 days was more than that cultured in PCA medium for 2 days (P < 0.05). The linear regression results showed a relatively strong linear correlation between the number of colonies cultured by the R2A method and that cultured by the PCA method (R2 = 0.7264). The number of bacterial species detected on R2A agar medium is greater than that on PCA agar medium. CONCLUSION The R2A culture method can better reflect the actual number of heterotrophic bacterial colonies in hospital purified water. After logarithmic transformation, the number of colonies cultured by the two methods showed a linear correlation.
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Affiliation(s)
- Xiongjing Cao
- Department of Hospital Infection Management, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan, 430022, China
| | - Huangguo Xiong
- Department of Hospital Infection Management, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan, 430022, China
| | - Yunzhou Fan
- Department of Hospital Infection Management, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan, 430022, China
| | - Lijuan Xiong
- Department of Hospital Infection Management, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Ave, Wuhan, 430022, China.
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Klompas M, Akusobi C, Boyer J, Woolley A, Wolf ID, Tucker R, Rhee C, Fiumara K, Pearson M, Morris CA, Rubin E, Baker MA. Mycobacterium abscessus Cluster in Cardiac Surgery Patients Potentially Attributable to a Commercial Water Purification System. Ann Intern Med 2023; 176:333-339. [PMID: 36877966 DOI: 10.7326/m22-3306] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Nontuberculous mycobacteria are water-avid pathogens that are associated with nosocomial infections. OBJECTIVE To describe the analysis and mitigation of a cluster of Mycobacterium abscessus infections in cardiac surgery patients. DESIGN Descriptive study. SETTING Brigham and Women's Hospital, Boston, Massachusetts. PARTICIPANTS Four cardiac surgery patients. INTERVENTION Commonalities among cases were sought, potential sources were cultured, patient and environmental specimens were sequenced, and possible sources were abated. MEASUREMENTS Description of the cluster, investigation, and mitigation. RESULTS Whole-genome sequencing confirmed homology among clinical isolates. Patients were admitted during different periods to different rooms but on the same floor. There were no common operating rooms, ventilators, heater-cooler devices, or dialysis machines. Environmental cultures were notable for heavy mycobacterial growth in ice and water machines on the cluster unit but little or no growth in ice and water machines in the hospital's other 2 inpatient towers or in shower and sink faucet water in any of the hospital's 3 inpatient towers. Whole-genome sequencing confirmed the presence of a genetically identical element in ice and water machine and patient specimens. Investigation of the plumbing system revealed a commercial water purifier with charcoal filters and an ultraviolet irradiation unit leading to the ice and water machines in the cluster tower but not the hospital's other inpatient towers. Chlorine was present at normal levels in municipal source water but was undetectable downstream from the purification unit. There were no further cases after high-risk patients were switched to sterile and distilled water, ice and water machine maintenance was intensified, and the commercial purification system was decommissioned. LIMITATION Transmission pathways were not clearly characterized. CONCLUSION Well-intentioned efforts to modify water management systems may inadvertently increase infection risk for vulnerable patients. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
| | - Chidiebere Akusobi
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.A., I.D.W.)
| | - Jon Boyer
- Department of Environmental Affairs, Brigham and Women's Hospital, Boston, Massachusetts (J.B.)
| | - Ann Woolley
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (A.W., C.A.M.)
| | - Ian D Wolf
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (C.A., I.D.W.)
| | - Robert Tucker
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (R.T., K.F.)
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
| | - Karen Fiumara
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (R.T., K.F.)
| | - Madelyn Pearson
- Department of Nursing, Brigham and Women's Hospital, Boston, Massachusetts (M.P.)
| | - Charles A Morris
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (A.W., C.A.M.)
| | - Eric Rubin
- Department of Medicine, Brigham and Women's Hospital, and Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (E.R.)
| | - Meghan A Baker
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, and Department of Medicine and Department of Quality and Safety, Brigham and Women's Hospital, Boston, Massachusetts (M.K., C.R., M.A.B.)
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