The role of water in healthcare-associated infections

A bronchoscopy-associated pseudo-outbreak of Mycobacterium chelonae and Mycobacterium mucogenicum associated with contaminated ice machine water and ice

A pseudo-outbreak of bronchoscopy-associated Mycobacterium chelonae and M. mucogenicum was traced to contaminated ice machine water and ice. A nonsterile ice bath was used to cool uncapped, sterile, saline syringes used to slow procedural bleeding. Joining the growing evidence of bronchoscopy pseudo-outbreaks, our investigation describes several lessons for future prevention.

Breaking away from an endemic state of multidrug-resistant Pseudomonas aeruginosa by daily sink disinfection

The detection rate of multidrug-resistant Pseudomonas aeruginosa in patients admitted to 2 wards and the intensive care unit decreased from 20.3% (129 of 636 isolates) to 4.2% (37 of 889 isolates) after the start of disinfection of hand washing sinks using alkyl diaminoethylglycine hydrochloride.

Microbial Waterborne Diseases in India: Status, Interventions, and Future Perspectives

Water plays a vital role as a natural resource since life is unsustainable without it. If water is polluted or contaminated, it results in several health issues among people. Millions of people are infected with waterborne diseases globally, and India is no exception. In the present review, we have analyzed the outbreaks of waterborne diseases that occurred in several Indian states between 2014 and 2020, identified the key infections, and provided insights into the performance of sanitation improvement programs. We noted that acute diarrheal disease (ADD), typhoid, cholera, hepatitis, and shigellosis are common waterborne diseases in India. These diseases have caused about 11,728 deaths between 2014 and 2018 out of which 10,738 deaths occurred only after 2017. The outbreaks of these diseases have been rising because of a lack of adequate sanitation, poor hygiene, and the absence of proper disposal systems. Despite various efforts by the government such as awareness campaigns, guidance on diet for infected individuals, and sanitation improvement programs, the situation is still grim. Disease hotspots and risk factors must be identified, water, sanitation, and hygiene (WASH) services must be improved, and ongoing policies must be effectively implemented to improve the situation. The efforts must be customized to the local environment. In addition, the possible effects of climate change must be projected, and strategies must be accordingly optimized.

A meta-analysis of Legionella pneumophila contamination in hospital water systems

BACKGROUND

Legionella pneumophila is a common cause of community-acquired pneumonia. We aimed to determine the pooled rates of L pneumophila contamination in the water environment of the hospital.

METHODS

We searched PubMed, Embase, Web of Science, Chinese National Knowledge Infrastructure, WangFang and Science Direct, The Cochrane Library, and Science Finder, for relevant studies published until December 2022. Stata 16.0 software was used to determine pooled contamination rates, publication bias, and subgroup analysis.

RESULTS

Forty-eight eligible articles with a total of 23,640 samples of water were evaluated, and the prevalence of L pneumophila was 41.6%. The results of the subgroup analysis showed that the pollution rate of L pneumophila in hot water (47.6%) was higher than that in other water bodies. The rates of L pneumophila contamination were higher in developed countries (45.2%), culture methods (42.3%), published between 1985 and 2015 (42.9%), and studies with a sample size of less than 100 (53.0%).

CONCLUSIONS

L pneumophila contamination in medical institutions is still very serious and should be paid attention to, especially in developed countries and hot water tanks.

Review on infection control strategies to minimize outbreaks of the emerging pathogen Elizabethkingia anophelis

BACKGROUND

Elizabethkingia anophelis is a multi-drug resistant emerging opportunistic pathogen with a high mortality rate, causing healthcare-associated outbreaks worldwide.

METHODS

We report a case of E. anophelis pleuritis, resulting from transmission through lung transplantation, followed by a literature review of outbreak reports and strategies to minimize E. anophelis transmission in healthcare settings.

RESULTS

From 1990 to August 2022, 14 confirmed E. anophelis outbreak cohorts and 21 cohorts with suspected E. anophelis outbreaks were reported in literature. A total of 80 scientific reports with recommendations on diagnostics and infection control measures were included and summarized in our study.

CONCLUSION

Strategies to prevent and reduce spread of E. anophelis include water-free patient rooms, adequate hygiene and disinfection practices, and optimized diagnostic techniques for screening, identification and molecular typing.

Water Safety Plan, Monochloramine Disinfection and Extensive Environmental Sampling Effectively Control Legionella and Other Waterborne Pathogens in Nosocomial Settings: The Ten-Year Experience of an Italian Hospital

Legionella contamination control is crucial in healthcare settings where patients suffer an increased risk of disease and fatal outcome. To ensure an effective management of this health hazard, the accurate application of a hospital-specific Water Safety Plan (WSP), the choice of a suitable water disinfection system and an extensive monitoring program are required. Here, the ten-year experience of an Italian hospital is reported: since its commissioning, Legionellosis risk management has been entrusted to a multi-disciplinary Working Group, applying the principles of the World Health Organization's WSP. The disinfection strategy to prevent Legionella and other waterborne pathogens relies on the treatment of domestic hot water with a system ensuring the in situ production and dosage of monochloramine. An average of 250 samples/year were collected and analyzed to allow an accurate assessment of the microbiological status of water network. With the aim of increasing the monitoring sensitivity, in addition to the standard culture method, an optimized MALDI-ToF MS-based strategy was applied, allowing the identification of Legionella species and other relevant opportunistic pathogens. Data collected so far confirmed the effectiveness of this multidisciplinary approach: the fraction of positive samples never overcame 1% on a yearly basis and Legionnaires' Disease cases never occurred.

Estimating Waterborne Infectious Disease Burden by Exposure Route, United States, 2014

More than 7.15 million cases of domestically acquired infectious waterborne illnesses occurred in the United States in 2014, causing 120,000 hospitalizations and 6,600 deaths. We estimated disease incidence for 17 pathogens according to recreational, drinking, and nonrecreational nondrinking (NRND) water exposure routes by using previously published estimates. In 2014, a total of 5.61 million (95% credible interval [CrI] 2.97-9.00 million) illnesses were linked to recreational water, 1.13 million (95% CrI 255,000-3.54 million) to drinking water, and 407,000 (95% CrI 72,800-1.29 million) to NRND water. Recreational water exposure was responsible for 36%, drinking water for 40%, and NRND water for 24% of hospitalizations from waterborne illnesses. Most direct costs were associated with pathogens found in biofilms. Estimating disease burden by water exposure route helps direct prevention activities. For each exposure route, water management programs are needed to control biofilm-associated pathogen growth; public health programs are needed to prevent biofilm-associated diseases.

Sanitary installations and wastewater plumbing as reservoir for the long-term circulation and transmission of carbapenemase producing Citrobacter freundii clones in a hospital setting

BACKGROUND

Accumulating evidence shows a role of the hospital wastewater system in the spread of multidrug-resistant organisms, such as carbapenemase producing Enterobacterales (CPE). Several sequential outbreaks of CPE on the geriatric ward of the Ghent University hospital have led to an outbreak investigation. Focusing on OXA-48 producing Citrobacter freundii, the most prevalent species, we aimed to track clonal relatedness using whole genome sequencing (WGS). By exploring transmission routes we wanted to improve understanding and (re)introduce targeted preventive measures.

METHODS

Environmental screening (toilet water, sink and shower drains) was performed between 2017 and 2021. A retrospective selection was made of 53 Citrobacter freundii screening isolates (30 patients and 23 environmental samples). DNA from frozen bacterial isolates was extracted and prepped for shotgun WGS. Core genome multilocus sequence typing was performed with an in-house developed scheme using 3,004 loci.

RESULTS

The CPE positivity rate of environmental screening samples was 19.0% (73/385). Highest percentages were found in the shower drain samples (38.2%) and the toilet water samples (25.0%). Sink drain samples showed least CPE positivity (3.3%). The WGS data revealed long-term co-existence of three patient sample derived C. freundii clusters. The biggest cluster (ST22) connects 12 patients and 8 environmental isolates taken between 2018 and 2021 spread across the ward. In an overlapping period, another cluster (ST170) links eight patients and four toilet water isolates connected to the same room. The third C. freundii cluster (ST421) connects two patients hospitalised in the same room but over a period of one and a half year. Additional sampling in 2022 revealed clonal isolates linked to the two largest clusters (ST22, ST170) in the wastewater collection pipes connecting the rooms.

CONCLUSIONS

Our findings suggest long-term circulation and transmission of carbapenemase producing C. freundii clones in hospital sanitary installations despite surveillance, daily cleaning and intermittent disinfection protocols. We propose a role for the wastewater drainage system in the spread within and between rooms and for the sanitary installations in the indirect transmission via bioaerosol plumes. To tackle this problem, a multidisciplinary approach is necessary including careful design and maintenance of the plumbing system.

Environmental Monitoring of Legionella in Hospitals in the Campania Region: A 5-Year Study

Legionella is a pathogen that colonizes soils, freshwater, and building water systems. People who are most affected are those with immunodeficiencies, so it is necessary to monitor its presence in hospitals. The purpose of this study was to evaluate the presence of Legionella in water samples collected from hospitals in the Campania region, Southern Italy. A total of 3365 water samples were collected from January 2018 to December 2022 twice a year in hospital wards from taps and showers, tank bottoms, and air-treatment units. Microbiological analysis was conducted in accordance with the UNI EN ISO 11731:2017, and the correlations between the presence of Legionella and water temperature and residual chlorine were investigated. In total, 708 samples (21.0%) tested positive. The most represented species was L. pneumophila 2-14 (70.9%). The serogroups isolated were 1 (27.7%), 6 (24.5%), 8 (23.3%), 3 (18.9%), 5 (3.1%), and 10 (1.1%). Non-pneumophila Legionella spp. represented 1.4% of the total. Regarding temperature, the majority of Legionella positive samples were found in the temperature range of 26.0-40.9 °C. An influence of residual chlorine on the presence of the bacterium was observed, confirming that chlorine disinfection is effective for controlling contamination. The positivity for serogroups other than serogroup 1 suggested the need to continue environmental monitoring of Legionella and to focus on the clinical diagnosis of other serogroups.

Source Control of Gram-Negative Bacteria Using Self-Disinfecting Sinks in a Swedish Burn Centre

Several retrospective studies have identified hospital sinks as reservoirs of Gram-negative bacteria. The aim of this study was to prospectively investigate the bacterial transmission from sinks to patients and if self-disinfecting sinks could reduce this risk. Samples were collected weekly from sinks (self-disinfecting, treated with boiling water, not treated) and patients in the Burn Centre at Linköping University Hospital, Sweden. The antibiotic susceptibility of Gram-negative isolates was tested, and eight randomly chosen patient isolates and their connected sink isolates were subjected to whole genome sequencing (WGS). Of 489 sink samples, 232 (47%) showed growth. The most frequent findings were Stenotrophomonas maltophilia (n = 130), Pseudomonas aeruginosa (n = 128), and Acinetobacter spp. (n = 55). Bacterial growth was observed in 20% of the samplings from the self-disinfecting sinks and in 57% from the sinks treated with boiling water (p = 0.0029). WGS recognized one transmission of Escherichia coli sampled from an untreated sink to a patient admitted to the same room. In conclusion, the results showed that sinks can serve as reservoirs of Gram-negative bacteria and that self-disinfecting sinks can reduce the transmission risk. Installing self-disinfecting sinks in intensive care units is an important measure in preventing nosocomial infection among critically ill patients.

Environmental contamination with highly resistant microorganisms after relocating to a new hospital building with 100% single-occupancy rooms: A prospective observational before-and-after study with a three-year follow-up

INTRODUCTION

Inanimate surfaces within hospitals can be a source of transmission for highly resistant microorganisms (HRMO). While many hospitals are transitioning to single-occupancy rooms, the effect of single-occupancy rooms on environmental contamination is still unknown. We aimed to determine differences in environmental contamination with HRMO between an old hospital building with mainly multiple-occupancy rooms and a new hospital building with 100% single-occupancy rooms, and the environmental contamination in the new hospital building during three years after relocating.

METHODS

Environmental samples were taken twice in the old hospital, and fifteen times over a three-year period in the new hospital. Replicate Organism Direct Agar Contact-plates (RODACs) were used to determine colony forming units (CFU). Cotton swabs premoistened with PBS were used to determine presence of methicillin-resistant Staphylococcus aureus, carbapenemase-producing Pseudomonas aeruginosa, highly resistant Enterobacterales, carbapenem-resistant Acinetobacter baumannii, and vancomycin-resistant Enterococcus faecium. All identified isolates were subjected to whole genome sequencing (WGS) using Illumina technology.

RESULTS

In total, 4993 hospital sites were sampled, 724 in the old and 4269 in the new hospital. CFU counts fluctuated during the follow-up period in the new hospital building, with lower CFU counts observed two- and three years after relocating, which was during the COVID-19 pandemic. The CFU counts in the new building were equal to or surpassed the CFU counts in the old hospital building. In the old hospital building, 24 (3.3%) sample sites were positive for 49 HRMO isolates, compared to five (0.1%) sample sites for seven HRMO isolates in the new building (P < 0.001). In the old hospital, 89.8% of HRMO were identified from the sink plug. In the new hospital, 71.4% of HRMO were identified from the shower drain, and no HRMO were found in sinks.

DISCUSSION

Our results indicate that relocating to a new hospital building with 100% single-occupancy rooms significantly decreases HRMO in the environment. Given that environmental contamination is an important source for healthcare associated infections, this finding should be taken into account when considering hospital designs for renovations or the construction of hospitals.

Ecological Study of Sick Building Syndrome among Healthcare Workers at Johor Primary Care Facilities

INTRODUCTION

Persistent exposure to indoor hazards in a healthcare setting poses a risk of SBS. This study determines the prevalence of and risk factors for SBS among healthcare workers in health clinics.

METHODS

A cross-sectional study was conducted across four health clinics from February 2022 to May 2022. As part of the study, self-administered questionnaires were completed to determine symptoms related to SBS. An indoor air quality (IAQ) assessment was conducted four times daily for fifteen minutes at five areas in each clinic (laboratory, lobby, emergency room, pharmacy, and examination room).

RESULT

Most of the areas illustrated poor air movement (<0.15 m/s), except for the laboratory. The total bacterial count (TBC) was above the standard limit in both the lobby and emergency room (>500 CFU/m³). The prevalence of SBS was 24.84% (77) among the healthcare workers at the health clinics. A significant association with SBS was noted for those working in the examination room (COR = 2.86; 95% CI = 1.31; 6.27) and those experiencing high temperature sometimes (COR = 0.25; 95% CI = 0.11; 0.55), varying temperature sometimes (COR = 0.31; 95% CI = 0.003), stuffy air sometimes (COR = 0.17; 95% CI = 0.005; 0.64), dry air sometimes (COR = 0.20; 95% CI = 0.007; 0.64), and dust sometimes (COR = 0.25; 95% CI = 0.11; 0.60) and everyday (COR = 0.34; 95% CI = 0.14; 0.81). Only healthcare workers in the examination room (AOR = 3.17; 95% CI = 1.35; 7.41) were found to have a significant risk of SBS when controlling for other variables.

CONCLUSION

SBS is prevalent among healthcare workers at health clinics.

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.

Patients in hospitals often have a suppressed immune system, putting them at increased risk of infection by bacteria that are resistant to antibiotics, some of which may come from sources in the hospital environment. We sampled multiple different surfaces in an established and a newly built intensive care unit and collected patient infection samples. We tested bacteria in these samples for their resistance to antibiotics and sequenced the genetic code of the bacteria to identify relationships between environmental and patient infections. We found the most antibiotic resistant organisms in hospital sink drains. Our sequencing data revealed strains of a certain kind of bacteria could form reservoirs and survive in sink drains and also cause patient infections. These results highlight the importance of removing these antibiotic resistant organism reservoirs to prevent infections.

Sukhum, Newcomer et al. evaluate reservoirs of antibiotic-resistant organisms within the built environment and patient samples from an established and a newly-built intensive care unit. The authors demonstrate colonization of sink drains and other sites and show relatedness between environmental reservoirs and patient infections.

Reducing the Risk of Healthcare Associated Infections from Legionella and Other Waterborne Pathogens Using a Water Management for Construction (WMC) Infection Control Risk Assessment (ICRA) Tool

Construction activities in healthcare settings potentially expose building occupants to waterborne pathogens including Legionella and have been associated with morbidity and mortality. A Water Management for Construction—Infection Control Risk Assessment (WMC-ICRA) tool was developed addressing gaps in building water management programs. This enables healthcare organizations to meet the requirements of ANSI/ASHRAE Standard 188 referenced in numerous guidelines and regulations. A WMC-ICRA was modeled after the ICRA required for prevention and control of airborne pathogens to reduce the risk of healthcare associated infections. The tool allows users to evaluate risk from waterborne pathogen exposure by analyzing construction activities by project category and building occupant risk group. The users then select an appropriate level of risk mitigation measures. Technical aspects (e.g., water age/stagnation, flushing, filtration, disinfection, validation testing), are presented to assist with implementation. An exemplar WMC-ICRA tool is presented as ready for implementation by infection prevention and allied professionals, addressing current gaps in water management, morbidity/mortality risk, and regulatory compliance. To reduce exposure to waterborne pathogens in healthcare settings and improve regulatory compliance, organizations should examine the WMC-ICRA tool, customize it for organization-specific needs, while formulating an organizational policy to implement during all construction activities.

Direct-PCR from rectal swabs and environmental reservoirs: A fast and efficient alternative to detect blaOXA-48 carbapenemase genes in an Enterobacter cloacae outbreak setting

Carbapenemase-producing bacteria are a risk factor in clinical settings worldwide. The aim of the study was to accelerate the time to results during an outbreak situation with bla_OXA-48-positive Enterobacter cloacae by using a real-time multiplex quantitative PCR (qPCR) directly on rectal swab specimens and on wastewater samples to detect carbapenemase-producing bacteria. Thus, we analyzed 681 rectal swabs and 947 environmental samples during a five-month period by qPCR and compared the results to culture screening. The qPCR showed a sensitivity of 100% by testing directly from rectal swabs and was in ten cases more sensitive than the culture-based methods. Environmental screening for bla_OXA-48-carbapenemase genes by qPCR revealed reservoirs of different carbapenemase genes that are potential sources of transmission and might lead to new outbreaks. The rapid identification of patients colonized with those isolates and screening of the hospital environment is essential for earlier patient treatment and eliminating potential sources of nosocomial infections.

Self-Disinfecting Paints with the Natural Antimicrobial Substances: Colophony and Curcumin

The risk of infection arising from indirect sources-namely, contaminated surfaces-has been proved, particularly in healthcare facilities. In the attempt to minimize this problem, innumerable research projects involving the development of surfaces with self-disinfecting properties are being conducted. In this work, wall-paints with self-disinfecting properties were developed with the scope of being applied in environments prone to contamination, such as those at healthcare settings. Our approach was to develop new paint formulations containing two natural plant-based products with known antimicrobial activity-colophony (CLF) and curcumin (CUR). The natural substances were separately incorporated on a commercial paint and their antibacterial activity was evaluated with several bacterial species following ISO 22196. To assess the paints' safety, cytotoxicity tests were performed on HaCaT and A549 cell lines, using tests on extracts and direct contact tests, as suggested by the standardized protocol ISO 10993. In general, both paints containing CLF and CUR were able to reduce the bacterial growth after 24 h, compared with the control, the commercial unmodified paint. Colophony was even able to reduce the number of culturable bacteria by over 2 log for Staphylococcus aureus, Escherichia coli, and Bacillus cereus. Regarding the cytotoxicity tests performed (WST-1, NRU, and LDH), both formulations revealed promising results regardless of the methodology used.

A cluster of Achromobacter xylosoxidans led to identification of Pseudomonas aeruginosa and Serratia marcescens contamination at a long-term-care facility

A cluster of Achromobacter xylosoxidans, an emerging multidrug-resistant aquaphilic bacterium, was identified in 3 long-term-care facility residents. As Pseudomonas aeruginosa and Serratia marcescens were also present in clinical specimens, we conducted an investigation of all 3 water-associated species and identified P. aerguniosa and S. marcescens contamination at the facility. Sequencing analysis linked P. aeruginosa to a clinical isolate. Findings highlight the need for precautionary measures to prevent transmission of water-associated multidrug-resistant bacteria in long-term-care facilities.

Outbreak of Pseudomonas aeruginosa producing VIM carbapenemase in an intensive care unit and its termination by implementation of waterless patient care

BACKGROUND

Long-term outbreaks of multidrug-resistant Gram-negative bacilli related to hospital-building water systems have been described. However, successful mitigation strategies have rarely been reported. In particular, environmental disinfection or replacement of contaminated equipment usually failed to eradicate environmental sources of Pseudomonas aeruginosa.

METHODS

We report the investigation and termination of an outbreak of P. aeruginosa producing VIM carbapenemase (PA-VIM) in the adult intensive care unit (ICU) of a Swiss tertiary care hospital with active case finding, environmental sampling and whole genome sequencing (WGS) of patient and environmental strains. We also describe the implemented control strategies and their effectiveness on eradication of the environmental reservoir.

RESULTS

Between April 2018 and September 2020, 21 patients became either infected or colonized with a PA-VIM strain. For 16 of them, an acquisition in the ICU was suspected. Among 131 environmental samples collected in the ICU, 13 grew PA-VIM in sink traps and drains. WGS confirmed the epidemiological link between clinical and environmental strains and the monoclonal pattern of the outbreak. After removing sinks from patient rooms and implementation of waterless patient care, no new acquisition was detected in the ICU within 8 months after the intervention.

DISCUSSION

Implementation of waterless patient care with removal of the sinks in patient rooms was successful for termination of a PA-VIM ICU outbreak linked to multiple environmental water sources. WGS provides highly discriminatory accuracy to investigate environment-related outbreaks.

Healthcare-Associated Legionnaires' Disease, Europe, 2008-2017

Healthcare-associated Legionnaires’ disease (HCA LD) can cause nosocomial outbreaks with high death rates. We compared community-acquired LD cases with HCA LD cases in Europe during 2008−2017 using data from The European Surveillance System. A total of 29 countries reported 40,411 community-acquired and 4,315 HCA LD cases. Of the HCA LD cases, 2,937 (68.1%) were hospital-acquired and 1,378 (31.9%) were linked to other healthcare facilities. The odds of having HCA LD were higher for women, children and persons <20 years of age, and persons >60 years of age. Out of the cases caused by Legionella pneumophila with a known serotype, community-acquired LD was more likely to be caused by L. pneumophila serogroup 1 (92.3%) than was HCA LD (85.1%). HCA LD patients were more likely to die. HCA LD is associated with specific patient demographics, causative strains, and outcomes. Healthcare facilities should consider these characteristics when designing HCA LD prevention strategies.

Microbial Air Quality in Healthcare Facilities

There is increasing evidence that indoor air quality and contaminated surfaces provide an important potential source for transmission of pathogens in hospitals. Airborne hospital microorganisms are apparently harmless to healthy people. Nevertheless, healthcare settings are characterized by different environmental critical conditions and high infective risk, mainly due to the compromised immunologic conditions of the patients that make them more vulnerable to infections. Thus, spread, survival and persistence of microbial communities are important factors in hospital environments affecting health of inpatients as well as of medical and nursing staff. In this paper, airborne and aerosolized microorganisms and their presence in hospital environments are taken into consideration, and the factors that collectively contribute to defining the infection risk in these facilities are illustrated.

Long-Term Exposure to Octenidine in a Simulated Sink Trap Environment Results in Selection of Pseudomonas aeruginosa, Citrobacter, and Enterobacter Isolates with Mutations in Efflux Pump Regulators

Octenidine-based disinfection products are becoming increasingly popular for infection control of multidrug-resistant (MDR) Gram-negative isolates. When a waste trap was removed from a hospital and allowed to acclimatize in a standard tap rig in our laboratory, it was shown that Klebsiella pneumoniae, Pseudomonas aeruginosa, and Citrobacter and Enterobacter spp. were readily isolated. This study aimed to understand the potential impact of prolonged exposure to low doses of a commercial product containing octenidine on these bacteria. Phenotypic and genotypic analyses showed that P. aeruginosa strains had increased tolerance to octenidine, which was characterized by mutations in the Tet repressor SmvR. Enterobacter species demonstrated increased tolerance to many other cationic biocides, although not octenidine, as well as the antibiotics ciprofloxacin, chloramphenicol, and ceftazidime, through mutations in another Tet repressor, RamR. Citrobacter species with mutations in RamR and MarR were identified following octenidine exposure, and this is linked to development of resistance to ampicillin, piperacillin, and chloramphenicol, as well as an increased MIC for ciprofloxacin. Isolates were able to retain fitness, as characterized by growth, biofilm formation, and virulence in Galleria mellonella, after prolonged contact with octenidine, although there were strain-to-strain differences. These results demonstrate that continued low-level octenidine exposure in a simulated sink trap environment selects for mutations that affect smvR It may also promote microbial adaptation to other cationic biocides and cross-resistance to antibiotics, while not incurring a fitness cost. This suggests that hospital sink traps may act as a reservoir for more biocide-tolerant organisms.IMPORTANCE Multidrug-resistant (MDR) strains of bacteria are a major clinical problem, and several reports have linked outbreaks of MDR bacteria with bacterial populations in hospital sinks. Biocides such as octenidine are used clinically in body washes and other products, such as wound dressings for infection control. Therefore, increased tolerance to these biocides would be detrimental to infection control processes. Here, we exposed bacterial populations originally from hospital sink traps to repeated dosing with an octenidine-containing product over several weeks and observed how particular species adapted. We found mutations in genes related to biocide and antibiotic susceptibility, which resulted in increased tolerance, although this was species dependent. Bacteria that became more tolerant to octenidine also showed no loss of fitness. This shows that prolonged octenidine exposure has the potential to promote microbial adaptation in the environment and that hospital sink traps may act as a reservoir for increased biocide- and antibiotic-tolerant organisms.

A prospective multicentre surveillance study to investigate the risk associated with contaminated sinks in the intensive care unit

OBJECTIVES

The aim was to assess the incidence of sink contamination by multidrug-resistant (MDR) Pseudomonas aeruginosa and Enterobacteriaceae, risk factors for sink contamination and splashing, and their association with clinical infections in the intensive care setting.

METHODS

A prospective French multicentre study (1 January to 30 May 2020) including in each intensive care unit (ICU) a point-prevalence study of sink contamination, a questionnaire of risk factors for sink contamination (sink use, disinfection procedure) and splashing (visible plashes, distance and barrier between sink and bed), and a 3-month prospective infection survey.

RESULTS

Seventy-three ICUs participated in the study. In total, 50.9% (606/1191) of the sinks were contaminated by MDR bacteria: 41.0% (110/268) of the sinks used only for handwashing, 55.3% (510/923) of those used for waste disposal, 23.0% (62/269) of sinks daily bleached, 59.1% (126/213) of those daily exposed to quaternary ammonium compounds (QACs) and 62.0% (285/460) of those untreated; 459 sinks (38.5%) showed visible splashes and 30.5% (363/1191) were close to the bed (<2 m) with no barrier around the sink. MDR-associated bloodstream infection incidence rates ≥0.70/1000 patient days were associated with ICUs meeting three or four of these conditions, i.e. a sink contamination rate ≥51%, prevalence of sinks with visible splashes ≥14%, prevalence of sinks close to the patient's bed ≥21% and no daily bleach disinfection (6/30 (20.0%) of the ICUs with none, one or two factors vs. 14/28 (50.0%) of the ICUs with three or four factors; p 0.016).

DISCUSSION

Our data showed frequent and multifactorial infectious risks associated with contaminated sinks in ICUs.

Structure of Bacterial Community with Resistance to Antibiotics in Aquatic Environments. A Systematic Review

Aquatic environments have been affected by the increase in bacterial resistant to antibiotics. The aim of this review is to describe the studies carried out in relation to the bacterial population structure and antibiotic resistance genes in natural and artificial water systems. We performed a systematic review based on the PRISMA guideline (preferred reporting items for systematic reviews and meta-analyzes). Articles were collected from scientific databases between January 2010 and December 2020. Sixty-eight papers meeting the inclusion criteria, i.e., "reporting the water bacterial community composition", "resistance to antibiotics", and "antibiotic resistance genes (ARG)", were evaluated according to pre-defined validity criteria. The results indicate that the predominant phyla were Firmicutes and Bacteroidetes in natural and artificial water systems. Gram-negative bacteria of the family Enterobacteraceae with resistance to antibiotics are commonly reported in drinking water and in natural water systems. The ARGs mainly reported were those that confer resistance to β-lactam antibiotics, aminoglycosides, fluoroquinolones, macrolides and tetracycline. The high influence of anthropogenic activity in the environment is evidenced. The antibiotic resistance genes that are mainly reported in the urban areas of the world are those that confer resistance to the antibiotics that are most used in clinical practice, which constitutes a problem for human and animal health.

Efficacy and Effectiveness of Showerheads Attached with Point-of-use (POU) Filter Capsules in Preventing Waterborne Diseases in a Japanese Hospital

Tap water contamination is a growing concern in healthcare facilities, and despite chlorination, tap water in these facilities contains several pathogenic microorganisms causing healthcare-associated waterborne infections or nosocomial outbreaks. Shower units are particularly prone to contamination as they are conducive for bacterial growth and can even produce bioaerosols containing pathogenic bacteria. Shower units coupled with point-of-use (POU) water filters are a simple and safe option; however, their efficacy has been under-reported. Therefore, we determined the efficacy of showerheads attached with a POU filter capsule in preventing infections in our hospital. We investigated the presence of pathogenic bacteria in water sampled from three shower units. After replacing the original shower units with new ones incorporated with a sterile-grade water filter capsule (0.2 µm; QPoint™), the water samples were analyzed for up to 2 months. The POU filters removed several pathogenic bacteria (Mycobacterium, Pseudomonas, Stenotrophomonas, Aeromonas, and Klebsiella spp.). Filter effectiveness depends on regional water quality and we believe that effective tap water treatment combined with the use of POU filters (introduced at a reasonable cost in healthcare facilities) can considerably minimize waterborne diseases in hospitals and improve patient care.

Are Sink Drainage Systems a Reservoir for Hospital-Acquired Gammaproteobacteria Colonization and Infection? A Systematic Review

Increasing rates of antimicrobial-resistant organisms have focused attention on sink drainage systems as reservoirs for hospital-acquired Gammaproteobacteria colonization and infection. We aimed to assess the quality of evidence for transmission from this reservoir. We searched 8 databases and identified 52 studies implicating sink drainage systems in acute care hospitals as a reservoir for Gammaproteobacterial colonization/infection. We used a causality tool to summarize the quality of evidence. Included studies provided evidence of co-occurrence of contaminated sink drainage systems and colonization/infection, temporal sequencing compatible with sink drainage reservoirs, some steps in potential causal pathways, and relatedness between bacteria from sink drainage systems and patients. Some studies provided convincing evidence of reduced risk of organism acquisition following interventions. No single study provided convincing evidence across all causality domains, and the attributable fraction of infections related to sink drainage systems remains unknown. These results may help to guide conduct and reporting in future studies.

A dominant strain of Elizabethkingia anophelis emerged from a hospital water system to cause a three-year outbreak in a respiratory care center

BACKGROUND

Elizabethkingia species are ubiquitous bacteria but uncommonly cause human infection. An outbreak of Elizabethkingia anophelis bacteraemia was observed in a respiratory care center of a tertiary hospital in Taiwan from 2015 to 2018.

METHODS

Clinical and environmental isolates were collected for the outbreak investigation. Pulsed-field gel electrophoresis (PFGE) and complete-genome sequencing were conducted to elucidate the mechanism of transmission.

FINDINGS

The three-year outbreak involved 26 patients with E. anophelis bacteraemia and the incidence significantly increased during the outbreak period compared with that observed from 2010 to 2014 (P<0.05). All 26 clinical isolates during the outbreak period belonged to a cluster by PFGE analysis. In contrast, the PFGE pattern was heterogeneous among comparative historical strains. Hospital tap water was highly contaminated by Elizabethkingia species (18/34, 52.9%); among that, five E. anophelis belonged to the outbreak cluster (5/18, 27.8%). As for the inanimate surface survey, 3.4% sites (4/117) revealed positive growth of E. anophelis including two from feeding tubes/bags and two from sputum suction regulators. All four isolates belonged to the outbreak clone. The outbreak strain had no apparent relationship to currently known E. anophelis strains worldwide through complete-genome sequencing analysis. Specific infection control strategies aimed at water source control and environmental disinfection were implemented subsequently and the outbreak ended in mid-2018.

CONCLUSIONS

A specific E. anophelis strain was identified from a three-year outbreak. The elucidation of the mechanism of dominance and intra-hospital transmission is crucial for development of corresponsive infection control policies and outbreak control.

Implementation of Legionella Prevention Policy in Health Care Facilities: The United States Veterans Health Administration Experience

CONTEXT

The Veterans Health Administration requires implementation of Legionella prevention policy in potable water systems at Department of Veterans Affairs (VA) medical facilities across the United States and territories.

PROGRAM

The Veterans Health Administration Central Office program offices with expertise in engineering and clinical aspects of Legionella prevention policy have provided joint, structured on-site assistance to VA medical facilities for consultation on policy implementation. Site visits included review of facility documentation and data, discussions with staff, touring of buildings, and development of recommendations.

IMPLEMENTATION

Information obtained from on-site consultative assistance provided to VA medical facilities from December 2012 through January 2018 was reviewed to identify engineering and clinical challenges and lessons from implementation of Legionella prevention policy in VA health care buildings. Fifteen consultative site visits were conducted during this period regarding implementation of Legionella prevention and validation of effectiveness.

EVALUATION

It was found that implementation of Legionella prevention policy in potable water systems was complex and practices varied for each building. Common implementation challenges included capability of applying engineering controls, water stagnation, and assessment of health care association of Legionella cases. Process challenges included routine verification of actions, methods for assessing environmental validation data, and documentation of requirements. It was found that consistent and data-driven implementation of policy is crucial for an effective program.

DISCUSSION

Guidance and standards documents in the community for Legionella prevention in building water systems are often general in nature, but implementation requires specific decisions and routine assessments and modifications to optimize outcomes. This real-world review of challenges and lessons from a large health care system with a detailed primary Legionella prevention policy informs future development of guidance and policy, both within and external to VA, and can provide insight to other health care facilities planning to implement practices for water safety.

Novel use of culturomics to identify the microbiota in hospital sink drains with and without persistent VIM-positive Pseudomonas aeruginosa

In hospitals, Verona Integron-encoded Metallo-beta-lactamase (VIM)-positive Pseudomonas aeruginosa may colonize sink drains, and from there, be transmitted to patients. These hidden reservoirs are difficult to eradicate since P. aeruginosa forms biofilms that resist disinfection. However, little is known on the composition of these biofilms. Therefore, culturomics was used for the first time to investigate the viable microbiota in four hospital sink drain samples with longstanding VIM-positive P. aeruginosa drain reservoirs (inhabited by high-risk clone, sequence type ST111), and four drain samples where VIM-positive P. aeruginosa was not present. Microbial load and composition varied between samples, yielding between 471–18,904 distinct colonies and 8–20 genera. In two VIM-positive drain samples, P. aeruginosa was the most abundantly-isolated microorganism, and found in combination with other Gram-negative bacteria, Citrobacter, Enterobacter, or Stenotrophomonas. P. aeruginosa was in low abundance in the other two VIM-positive samples, and found with Gram-positive cocci (Enterococcus and Staphylococcus) or Sphingomonas. In VIM-negative drain samples, high abundances of Gram-negative non-fermenting bacteria, including Acinetobacter, non-aeruginosa Pseudomonas spp., Acidovorax, Chryseobacterium, Flavobacterium, and Sphingobium, as well as Candida, were cultured. Although additional experiments are needed to draw more firm conclusions on which microorganisms enable or inhibit VIM-positive P. aeruginosa persistence, our data provide unique insights into the microbial compositions of sink drain inlets.

Temporal variations in bacterial community diversity and composition throughout intensive care unit renovations

BACKGROUND

Inanimate surfaces within a hospital serve as a reservoir of microbial life that may colonize patients and ultimately result in healthcare associated infections (HAIs). Critically ill patients in intensive care units (ICUs) are particularly vulnerable to HAIs. Little is known about how the microbiome of the ICU is established or what factors influence its evolution over time. A unique opportunity to bridge the knowledge gap into how the ICU microbiome evolves emerged in our health system, where we were able to characterize microbial communities in an established hospital ICU prior to closing for renovations, during renovations, and then after re-opening.

RESULTS

We collected swab specimens from ICU bedrails, computer keyboards, and sinks longitudinally at each renovation stage, and analyzed the bacterial compositions on these surfaces by 16S rRNA gene sequencing. Specimens collected before ICU closure had the greatest alpha diversity, while specimens collected after the ICU had been closed for over 300 days had the least. We sampled the ICU during the 45 days after re-opening; however, within that time frame, the alpha diversity never reached pre-closure levels. There were clear and significant differences in microbiota compositions at each renovation stage, which was driven by environmental bacteria after closure and human-associated bacteria after re-opening and before closure.

CONCLUSIONS

Overall, we identified significant differences in microbiota diversity and community composition at each renovation stage. These data help to decipher the evolution of the microbiome in the most critical part of the hospital and demonstrate the significant impacts that microbiota from patients and staff have on the evolution of ICU surfaces. Video Abstract.

Determinants of Sanitation and Hygiene Status Among Food Establishments in Addis Ababa, Ethiopia

INTRODUCTION

Despite advancements in food science and technology, foodborne disease remains one of the major public health problems. Poor sanitation and hygiene conditions of food establishments are the major causes for the occurrence of foodborne disease. Therefore, this study aimed to investigate core determinants of sanitation and hygiene status among food establishments.

METHODS

Institution-based cross-sectional study design was conducted in Addis Ababa city. A stratified random sampling technique was deployed to select 413 study participants. Data were collected through interview and using observational checklist. Sample size was determined by using a single population proportion formula. To analyze the data, binary logistic regression and multivariable logistic regression analysis was conducted. In all analysis, P-value less than .05 were considered statistically significant.

RESULTS

The study revealed that 57.4% of the food establishments were under poor sanitation status. In the multivariable analysis, presence of trained managers on hygiene and sanitation (adjusted odds ratio [AOR] = 6.10 with 95% confidence interval [CI]: 2.41-15.45), presence of renewed licenses (AOR = 3.07 with 95% CI: 1.18-7.99), absence of bureaucratic function to obtain permission to renew the food establishment buildings (AOR = 2.43 with 95% CI: 1.25-4.70), and presence of at least 10-m distance between toilet and kitchen (AOR = 9.19, at 95% CI: 5.63-15.02) were associated significantly with sanitation and hygiene status.

CONCLUSIONS

Above average of the food establishments were found to be in poor sanitation and hygiene state. Many core determinant factors that influence sanitation and hygienic status of food establishments were identified. The researchers suggest that formal training on sanitation and hygiene for managers of food establishments should be provided to reduce the occurrence of foodborne diseases. Moreover, strong food and water safety policy and strategy should be promulgated to improve sanitation and hygiene status of food establishments.

Whole-genome sequencing identifies highly related Pseudomonas aeruginosa strains in multiple washbasin U-bends at several locations in one hospital: evidence for trafficking of potential pathogens via wastewater pipes

BACKGROUND

Hand washbasin U-bends have increasingly been associated with nosocomial outbreaks by Gram-negative bacteria, including Pseudomonas aeruginosa which is virtually ubiquitous in U-bends. Wastewater networks servicing U-bends are potential highways for trafficking pathogenic bacteria.

AIM

To use P. aeruginosa to investigate trafficking of bacteria between hospital washbasin U-bends.

METHODS

Twenty-five washbasin U-bends in five locations in Dublin Dental University Hospital (DDUH) were investigated for trafficking of P. aeruginosa: 10 in Clinic 2 (C2), 10 in the Accident & Emergency Department (A&E) and five in three other locations. In addition, washbasin tap samples (N=80) and mains and tap water samples (N=72) were cultured for P. aeruginosa. Selected P. aeruginosa isolates recovered over 29 months underwent whole-genome sequencing, and relatedness was interpreted using whole-genome multi-locus sequence typing and pairwise single nucleotide polymorphism (SNP) analysis.

FINDINGS

P. aeruginosa was recovered from all U-bends but not from taps or water. Eighty-three U-bend isolates yielded 10 sequence types (STs), with ST560 and ST179 from A&E, C2 and two other locations predominating (70%). ST560 was also recovered from a common downstream pipe. Isolates within ST560 and ST179 were highly related regardless of source. ST560 was divided into Cluster I (N=25) and Cluster II (N=2) with average allelic differences and SNPs of three and zero, and two and five, respectively. The 31 ST179 isolates exhibited an average allelic difference and SNPs of three and 12, respectively.

CONCLUSION

Highly related P. aeruginosa strains were identified in multiple U-bends in several DDUH locations, indicating trafficking via the wastewater network.

A bronchoscopy-associated pseudo-outbreak of Mycobacterium mucogenicum traced to use of contaminated ice used for bronchoalveolar lavage

Clonal Mycobacterium mucogenicum isolates (determined by molecular typing) were recovered from 19 bronchoscopic specimens from 15 patients. None of these patients had evidence of mycobacterial infection. Laboratory culture materials and bronchoscopes were negative for Mycobacteria. This pseudo-outbreak was caused by contaminated ice used to provide bronchoscopic lavage. Control was achieved by transitioning to sterile ice.

Pseudo-outbreak of Mycobacterium chimaera through aerators of hand-washing machines at a hematopoietic stem cell transplantation center

We identified a waterborne pseudo-outbreak of Mycobacterium chimaera in our stem cell transplantation center, which likely resulted from biofilm on the aerators of the handwashing machines in each patient’s room. Regular replacement of faucet parts can prevent biofilm formation and pseudo-outbreaks of M. chimaera through aerators.

Strong correlation of total phenotypic resistance of samples from household environments and the prevalence of class 1 integrons suggests for the use of the relative prevalence of intI1 as a screening tool for multi-resistance

One of the biggest challenges of health care systems worldwide is the increasing number of pathogenic bacteria resistant to a growing number of antibiotics. In this respect, class 1 integrons which are part of mobile genetic elements can confer several phenotypes including resistance to a broad range of antibiotic classes, heavy metals and biocides. They are linked to common resistance genes and have penetrated pathogenic and commensal bacteria likewise. Therefore its relative prevalence can be a proxy for antimicrobial resistance and anthropogenic pollution. Household environments are areas with a high influx of bacteria from humans, animals and foods, and biocides and detergents are frequently used. In this study we aimed to investigate the relative prevalence of class 1 integrons in household environments, in relation to the number of antibiotic and benzalkonium chloride resistant phenotypes of a sample point, for the validation of the relative prevalence of class 1 integrons as a screening tool for multi-resistance. Kitchen sink and bathroom sink U-bends, dishwasher, washing machines and toothbrushes of 28 households were probed. Copies /mL of class 1 integron integrase gene and 16SrDNA gene were determined by qPCR and bacteria of the respective sample were isolated on ampicillin selective agar plates, followed by the determination of the species and phenotypic resistance profiles. The relative prevalence of class 1 integrons in relation to 16SrDNA was calculated and correlated to phenotypic resistance. Our findings show a high relative prevalence of class 1 integrons in water reticulation systems of household environments and in particular shower U-bends. Furthermore, prevalence of class 1 integrons correlates strongly (r_s = 0.95) with total phenotypic resistance at a sample point and suggest that a standardized assay determining the relative prevalence of class 1 integrons could be used as a useful screening tool in the assessment of multi-resistance in environmental samples.

Blue Light Disinfection in Hospital Infection Control: Advantages, Drawbacks, and Pitfalls

Hospital acquired infections (HAIs) are a serious problem that potentially affects millions of patients whenever in contact with hospital settings. Worsening the panorama is the emergence of antimicrobial resistance by most microorganisms implicated in HAIs. Therefore, the improvement of the actual surveillance methods and the discovery of alternative approaches with novel modes of action is vital to overcome the threats created by the emergence of such resistances. Light therapy modalities represent a viable and effective alternative to the conventional antimicrobial treatment and can be preponderant in the control of HAIs, even against multidrug resistant organisms (MDROs). This review will initially focus on the actual state of HAIs and MDROs and which methods are currently available to fight them, which is followed by the exploration of antimicrobial photodynamic therapy (aPDT) and antimicrobial blue light therapy (aBLT) as alternative approaches to control microorganisms involved in HAIs. The advantages and drawbacks of BLT relatively to aPDT and conventional antimicrobial drugs as well as its potential applications to destroy microorganisms in the healthcare setting will also be discussed.

Investigation of healthcare infection risks from water-related organisms: Summary of CDC consultations, 2014-2017

OBJECTIVE

Water exposures in healthcare settings and during healthcare delivery can place patients at risk for infection with water-related organisms and can potentially lead to outbreaks. We aimed to describe Centers for Disease Control and Prevention (CDC) consultations involving water-related organisms leading to healthcare-associated infections (HAIs).

DESIGN

Retrospective observational study.

METHODS

We reviewed internal CDC records from January 1, 2014, through December 31, 2017, using water-related terms and organisms, excluding Legionella, to identify consultations that involved potential or confirmed transmission of water-related organisms in healthcare. We determined plausible exposure pathways and routes of transmission when possible.

RESULTS

Of 620 consultations during the study period, we identified 134 consultations (21.6%), with 1,380 patients, that involved the investigation of potential water-related HAIs or infection control lapses with the potential for water-related HAIs. Nontuberculous mycobacteria were involved in the greatest number of investigations (n = 40, 29.9%). Most frequently, investigations involved medical products (n = 48, 35.8%), and most of these products were medical devices (n = 40, 83.3%). We identified a variety of plausible water-exposure pathways, including medication preparation near water splash zones and water contamination at the manufacturing sites of medications and medical devices.

CONCLUSIONS

Water-related investigations represent a substantial proportion of CDC HAI consultations and likely represent only a fraction of all water-related HAI investigations and outbreaks occurring in US healthcare facilities. Water-related HAI investigations should consider all potential pathways of water exposure. Finally, healthcare facilities should develop and implement water management programs to limit the growth and spread of water-related organisms.

Increased detection of carbapenemase-producing Enterobacteriaceae on post-clean sampling of a burns unit's wet surfaces

Wet surface biofilms are a potential reservoir for multidrug-resistant Gram-negative organisms, including carbapenemase-producing Enterobacteriaceae (CPE). Recognition of environmental sources is important in reducing secondary patient transmission. We report the increased detection of blaIMP-4⁺ CPE in environmental samples from floor drains in burns unit shower rooms, when collected following cleaning as compared to pre-cleaning. We propose that disruption of biofilms during cleaning may account for the increased detection of multi-resistant organisms. The results highlight the role of the wet environment as an under-recognized potential source of CPE transmission. Environmental screening focusing on pre-cleaning samples alone will likely underestimate environmental contamination.

Sink-Related Outbreaks and Mitigation Strategies in Healthcare Facilities

PURPOSE OF REVIEW

In this review, we summarize recent outbreaks attributed to hospital sinks and examine design features and behaviors that contributed to these outbreaks. The effectiveness of various risk mitigation strategies is presented. Finally, we examine investigational strategies targeted at reducing the risk of sink-related infections.

RECENT FINDINGS

Outbreaks of hospital sink-related infections involve a diverse spectrum of microorganisms. They can be attributed to defects in sink design and hospital wastewater systems that promote the formation and dispersion of biofilm, as well as healthcare practitioner and patient behaviors. Risk mitigation strategies are often bundled; while they may reduce clinical cases, sink colonization may persist. Novel approaches targeting biofilms show promise but require more investigation. Emphasis should be placed on optimizing best practices in sink design and placement to prevent infections. Hospitals should consider developing a rational surveillance and prevention strategy based on the current design and state of their sinks.

The Role of Environmental Contamination in the Transmission of Nosocomial Pathogens and Healthcare-Associated Infections

PURPOSE OF REVIEW

The aim of this review is to highlight the role of environmental contamination in healthcare-associated infections (HAIs) and to discuss the most commonly implicated nosocomial pathogens.

RECENT FINDINGS

Recent studies suggest that environmental contamination plays a significant role in HAIs and in the unrecognized transmission of nosocomial pathogens during outbreaks, as well as ongoing sporadic transmission. Several pathogens can persist in the environment for extended periods and serve as vehicles of transmission and dissemination in the hospital setting. Cross-transmission of these pathogens can occur via hands of healthcare workers, who become contaminated directly from patient contact or indirectly by touching contaminated environmental surfaces. Less commonly, a patient could become colonized by direct contact with a contaminated environmental surface. This review describes the role of environmental contamination in HAIs and provides context for reinforcing the importance of hand hygiene and environmental decontamination for the prevention and control of HAIs.

Hospital Water Management Programs for Legionella Prevention, Minnesota, 2017

Infection preventionists at Minnesota hospitals were surveyed to determine whether they had Legionella water management plans. Of 137 hospitals, 84 (61%) responded. Among them, 27% hospitals had a water management plan, 21% regularly sampled for Legionella, and 51% had knowledge of ASHRAE Legionella prevention standards. Significant changes are needed to protect patients from nosocomial infection.

Infect Control Hosp Epidemiol 2018;39:336–338

The Hospital Water Environment as a Reservoir for Carbapenem-Resistant Organisms Causing Hospital-Acquired Infections-A Systematic Review of the Literature

Over the last 20 years there have been 32 reports of carbapenem-resistant organisms in the hospital water environment, with half of these occurring since 2010. The majority of these reports have described associated clinical outbreaks in the intensive care setting, affecting the critically ill and the immunocompromised. Drains, sinks, and faucets were most frequently colonized, and Pseudomonas aeruginosa the predominant organism. Imipenemase (IMP), Klebsiella pneumoniae carbapenemase (KPC), and Verona integron-encoded metallo-β-lactamase (VIM) were the most common carbapenemases found. Molecular typing was performed in almost all studies, with pulse field gel electrophoresis being most commonly used. Seventy-two percent of studies reported controlling outbreaks, of which just more than one-third eliminated the organism from the water environment. A combination of interventions seems to be most successful, including reinforcement of general infection control measures, alongside chemical disinfection. The most appropriate disinfection method remains unclear, however, and it is likely that replacement of colonized water reservoirs may be required for long-term clearance.

Recovery of Surgical Equipment Sterile Processing During a Floodwater Boil Advisory

Excessive rainfall and dam failures resulted in floodwater contaminating our public water supply. The endotoxin risk in the contaminated water created challenges in recovery of sterile processing for our surgical equipment. Recovery plans should include a potable water source and a method to connect it to the required location. We share our solution of plumbing our sterile processing equipment to tanker-transported potable water sources. (Disaster Med Public Health Preparedness. 2018; 12: 415-418).

Whole-genome sequencing for identification of the source in hospital-acquired Legionnaires' disease

Acquisition of Legionnaires' disease is a serious complication of hospitalization. Rapid determination of whether or not the infection is caused by strains of Legionella pneumophila in the hospital environment is crucial to avoid further cases. This study investigated the use of whole-genome sequencing to identify the source of infection in hospital-acquired Legionnaires' disease. Phylogenetic analyses showed close relatedness between one patient isolate and a strain found in hospital water, confirming suspicion of nosocomial infection. It was found that whole-genome sequencing can be a useful tool in the investigation of hospital-acquired Legionnaires' disease.

Spread from the Sink to the Patient: In Situ Study Using Green Fluorescent Protein (GFP)-Expressing Escherichia coli To Model Bacterial Dispersion from Hand-Washing Sink-Trap Reservoirs

There have been an increasing number of reports implicating Gammaproteobacteria as often carrying genes of drug resistance from colonized sink traps to vulnerable hospitalized patients. However, the mechanism of transmission from the wastewater of the sink P-trap to patients remains poorly understood. Herein we report the use of a designated hand-washing sink lab gallery to model dispersion of green fluorescent protein (GFP)-expressing Escherichia coli from sink wastewater to the surrounding environment. We found no dispersion of GFP-expressing E. coli directly from the P-trap to the sink basin or surrounding countertop with coincident water flow from a faucet. However, when the GFP-expressing E. coli cells were allowed to mature in the P-trap under conditions similar to those in a hospital environment, a GFP-expressing E. coli-containing putative biofilm extended upward over 7 days to reach the strainer. This subsequently resulted in droplet dispersion to the surrounding areas (<30 in.) during faucet operation. We also demonstrated that P-trap colonization could occur by retrograde transmission along a common pipe. We postulate that the organisms mobilize up to the strainer from the P-trap, resulting in droplet dispersion rather than dispersion directly from the P-trap. This work helps to further define the mode of transmission of bacteria from a P-trap reservoir to a vulnerable hospitalized patient.

IMPORTANCE Many recent reports demonstrate that sink drain pipes become colonized with highly consequential multidrug-resistant bacteria, which then results in hospital-acquired infections. However, the mechanism of dispersal of bacteria from the sink to patients has not been fully elucidated. Through establishment of a unique sink gallery, this work found that a staged mode of transmission involving biofilm growth from the lower pipe to the sink strainer and subsequent splatter to the bowl and surrounding area occurs rather than splatter directly from the water in the lower pipe. We have also demonstrated that bacterial transmission can occur via connections in wastewater plumbing to neighboring sinks. This work helps to more clearly define the mechanism and risk of transmission from a wastewater source to hospitalized patients in a world with increasingly antibiotic-resistant bacteria that can thrive in wastewater environments and cause infections in vulnerable patients.