Emerging waterborne infections in health-care settings

A Critical Review on the Factors that Influence Opportunistic Premise Plumbing Pathogens: From Building Entry to Fixtures in Residences

Residential buildings provide unique conditions for opportunistic premise plumbing pathogen (OPPP) exposure via aerosolized water droplets produced by showerheads, faucets, and tubs. The objective of this review was to critically evaluate the existing literature that assessed the impact of potentially enhancing conditions to OPPP occurrence associated with residential plumbing and to point out knowledge gaps. Comprehensive studies on the topic were found to be lacking. Major knowledge gaps identified include the assessment of OPPP growth in the residential plumbing, from building entry to fixtures, and evaluation of the extent of the impact of typical residential plumbing design (e.g., trunk and branch and manifold), components (e.g., valves and fixtures), water heater types and temperature setting of operation, and common pipe materials (copper, PEX, and PVC/CPVC). In addition, impacts of the current plumbing code requirements on OPPP responses have not been assessed by any study and a lack of guidelines for OPPP risk management in residences was identified. Finally, the research required to expand knowledge on OPPP amplification in residences was discussed.

Persistent contamination of a hospital hot water network by Legionellapneumophila

OBJECTIVES

We assessed the contamination with Legionella pneumophila (Lp) of the hot water network (HWN) of a hospital, mapped the risk of contamination, and evaluated the relatedness of isolates. We further validated phenotypically the biological features that could account for the contamination of the network.

METHODS

We collected 360 water samples from October 2017 to September 2018 in 36 sampling points of a HWN of a building from a hospital in France. Lp were quantified and identified with culture-based methods and serotyping. Lp concentrations were correlated with water temperature, date and location of isolation. Lp isolates were genotyped by pulsed-field gel electrophoresis and compared to a collection of isolates retrieved in the same HWN two years later, or in other HWN from the same hospital.

RESULTS

207/360 (57.5%) samples were positive with Lp. In the hot water production system, Lp concentration was negatively associated with water temperature. In the distribution system, the risk of recovering Lp decreased when temperature was >55 °C (p < 10^-3), the proportion of samples with Lp increased with distance from the production network (p < 10^-3), and the risk of finding high loads of Lp increased 7.96 times in summer (p = 0.001). All Lp isolates (n = 135) were of serotype 3, and 134 (99.3%) shared the same pulsotype which is found two years later (Lp G). In vitro competition experiments showed that a 3-day culture of Lp G on agar inhibited the growth of a different pulsotype of Lp (Lp O) contaminating another HWN of the same hospital (p = 0.050). We also found that only Lp G survived to a 24h-incubation in water at 55 °C (p = 0.014).

CONCLUSION

We report here a persistent contamination with Lp of a hospital HWN. Lp concentrations were correlated with water temperature, season, and distance from the production system. Such persistent contamination could be due to biotic parameters such as intra-Legionella inhibition and tolerance to high temperature, but also to the non-optimal configuration of the HWN that prevented the maintenance of high temperature and optimal water circulation.

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.

The Impact of Storms on Legionella pneumophila in Cooling Tower Water, Implications for Human Health

At the U.S. Department of Energy’s Savannah River Site (SRS) in Aiken, SC, cooling tower water is routinely monitored for Legionella pneumophila concentrations using a direct fluorescent antibody (DFA) technique. Historically, 25–30 operating SRS cooling towers have varying concentrations of Legionella in all seasons of the year, with patterns that are unpredictable. Legionellosis, or Legionnaires’ disease (LD), is a pneumonia caused by Legionella bacteria that thrive both in man-made water distribution systems and natural surface waters including lakes, streams, and wet soil. Legionnaires’ disease is typically contracted by inhaling L. pneumophila, most often in aerosolized mists that contain the bacteria. At the SRS, L. pneumophila is typically found in cooling towers ranging from non-detectable up to 10⁸ cells/L in cooling tower water systems. Extreme weather conditions contributed to elevations in L. pneumophila to 10⁷–10⁸ cells/L in SRS cooling tower water systems in July–August 2017. L. pneumophila concentrations in Cooling Tower 785-A/2A located in SRS A-Area, stayed in the 10⁸ cells/L range despite biocide addition. During this time, other SRS cooling towers did not demonstrate this L. pneumophila increase. No significant difference was observed in the mean L. pneumophila mean concentrations for the towers (p < 0.05). There was a significant variance observed in the 285-2A/A Tower L. pneumophila results (p < 0.05). Looking to see if we could find “effects” led to model development by analyzing 13 months of water chemistry and microbial data for the main factors influencing the L. pneumophila concentrations in five cooling towers for this year. It indicated chlorine and dissolved oxygen had a significant impact (p < 0.0002) on cooling tower 785A/2A. Thus, while the variation in the log count data for the A-area tower is statistically greater than that of the other four towers, the average of the log count data for the A-Area tower was in line with that of the other towers. It was also observed that the location of 785A/2A and basin resulted in more debris entering the system during storm events. Our results suggest that future analyses should evaluate the impact of environmental conditions and cooling tower design on L. pneumophila water concentrations and human health.

Boron Doped Diamond as a Low Biofouling Material in Aquatic Environments: Assessment of Pseudomonas aeruginosa Biofilm Formation

Boron doped diamond (BDD), given the robustness of the material, is becoming an electrode of choice for applications which require long-term electrochemical monitoring of analytes in aqueous environments. However, despite the extensive work in this area, there are no studies which directly assess the biofilm formation (biofouling) capabilities of the material, which is an essential consideration because biofouling often causes deterioration in the sensor performance. Pseudomonas aeruginosa is one of the most prevalent bacterial pathogens linked to water-related diseases, with a strong capacity for forming biofilms on surfaces that are exposed to aquatic environments. In this study, we comparatively evaluate the biofouling capabilities of oxygen-terminated (O-)BDD against materials commonly employed as either the packaging or sensing element in water quality sensors, with an aim to identify factors which control biofilm formation on BDD. We assess the monospecies biofilm formation of P. aeruginosa in two different growth media, Luria-Bertani, a high nutrient source and drinking water, a low nutrient source, at two different temperatures (20 and 37 °C). Multispecies biofilm formation is also investigated. The performance of O-BDD, when tested against all other materials, promotes the lowest extent of P. aeruginosa monospecies biofilm formation, even with corrections made for total surface area (roughness). Importantly, O-BDD shows the lowest water contact angle of all materials tested, that is, greatest hydrophilicity, strongly suggesting that for these bacterial species, the factors controlling the hydrophilicity of the surface are important in reducing bacterial adhesion. This was further proven by keeping the surface topography fixed and changing surface termination to hydrogen (H-), to produce a strongly hydrophobic surface. A noticeable increase in biofilm formation was found. Doping with boron also results in changes in hydrophobicity/hydrophilicity compared to the undoped counterpart, which in turn affects the bacterial growth. For practical electrochemical sensing applications in aquatic environments, this study highlights the extremely beneficial effects of employing smooth, O-terminated (hydrophilic) BDD electrodes.

Colonization of Hospital Water Networks by Gemmata massiliana, a New Planctomycetes Bacterium

Planctomycetes have been isolated from various hydric environments. These fastidious bacteria are overlooked by routine 16S rRNA gene-based PCR detection in hospital laboratories, and their presence has not been documented in the health-care environment. Using a specific culture protocol, we recently isolated a new, non-filterable Planctomycetes species, Gemmata massiliana, from one hospital water network. The goal of the study was to monitor the presence of G. massiliana in two hospital water networks. We developed a G. massiliana-specific real-time PCR system and monitored the presence of the Planctomycetes for 12 months in two hospital water networks, in filtered water collected at the intensive care unit and in non-filtered water collected from dental chairs, tanks, and usage points. Four of 180 (2.2%) filtered water samples tested positive versus 23 of 204 (11.3%) non-filtered points (p < 0.05), including 18 of 128 (14.1%) dental chairs, 3 of 51 (5.9%) usage points, and two of 25 (8%) tank specimens. There was no significant difference in the prevalence of G. massiliana between the two hospitals (p > 0.05). However, this organism was detected significantly more frequently during April and September than the 10 other months. Because G. massiliana is deeply entrenched in the hospitalized patient's environment, evaluating this organism as a new opportunistic, health-care-associated pathogen is warranted.

The Role of Water in the Transmission of Healthcare-Associated Infections: Opportunities for Intervention through the Environment

OBJECTIVE:

To assess and synthesize available evidence in the infection control and healthcare design literature on strategies using the built environment to reduce the transmission of pathogens in water that cause healthcare-associated infections (HAIs).

BACKGROUND:

Water can serve as a reservoir or source for pathogens, which can lead to the transmission of healthcare-associated infections (HAIs). Water systems harboring pathogens, such as Legionella and Pseudomonas spp., can also foster the growth of persistent biofilms, presenting a great health risk.

TOPICAL HEADINGS:

Strategies for interrupting the chain of transmission through the built environment can be proactive or reactive, and include three primary approaches: safe plumbing practices (maintaining optimal water temperature and pressure; eliminating dead ends), decontamination of water sources (inactivating or killing pathogens to prevent contamination), and selecting appropriate design elements (fixtures and materials that minimize the potential for contamination).

CONCLUSIONS:

Current evidence clearly identifying the environment's role in the chain of infection is limited by the variance in surveillance strategies and in the methods used to assess impact of these strategies. In order to optimize the built environment to serve as a tool for mitigating infection risk from waterborne pathogens—from selecting appropriate water features to maintaining the water system—multidisciplinary collaboration and planning is essential.

Safety and underwater birth-what every risk manager should know

Underwater birthing has become a popular birth practice in some areas of the country. Although many of these deliveries occur in a home birth setting, the practice has also been implemented in hospitals and birthing centers. There is continued controversy about the risks and benefits of underwater birthing (as opposed to hydrotherapy during labor), and many risk managers are unaware of these potential risks and benefits. The purpose of this article is to review the significant risks and benefits of underwater birthing, to review relevant literature and several Professional Organizations' Position Statements regarding underwater birthing, and to provide a safety checklist for hospital risk managers who wish to consider adding underwater birthing to their current scope of perinatal care.

Biofilms on environmental surfaces: evaluation of the disinfection efficacy of a novel steam vapor system

BACKGROUND

Environmental surfaces in health care settings are often contaminated by microorganisms, and biofilms can develop on the surfaces in these settings. Steam vapor technology is of potential use for disinfection of biofilms on the environmental surfaces.

METHODS

We tested the disinfection efficacy of a thermal-accelerated nanocrystal sanitation (TANCS)-equipped steam vapor technology against biofilms through disinfecting biofilms developed by 4 bacterial strains-Escherichia coli, Acinetobacter baumannii, Pseudomonas aeruginosa, and Staphylococcus aureus-on an identical test surface (ie, polycarbonate) and biofilms developed by E coli on 4 different test surfaces: polycarbonate, rubber, stainless steel, and ceramics.

RESULTS

Our data show that a 3-second steam treatment rapidly killed each biofilm tested (>99.95 % killing efficiency). For biofilms developed on different surfaces, 3-second steam treatment achieved 99.95% killing of E coli biofilms developed on different surfaces. Compared with chemical disinfection, steam treatment for <1 second a similar level of biofilm disinfection as provided by incubation with 10-ppm sodium hypochlorite (bleach) for 10-20 minutes of contact time.

CONCLUSIONS

Our data suggest that the TANCS-equipped steam vapor disinfection is an emerging and potentially useful technology for disinfecting biofilms on environmental surfaces.

Environmental factors associated with nosocomial legionellosis after anti-tumor necrosis factor therapy: case study

In response to 2 reported cases of nosocomial legionellosis after anti-tumor necrosis factor (TNF) treatment, the environmental controls and testing facilities in a 221-bed acute care hospital were investigated. This investigation led to the implementation of a series of specific preventive measures adapted from protocols used to protect immunosuppressed patients. These 2 cases of legionellosis might be related to 2 concurrent events: treatment of hospitalized patients with anti-TNF drugs and secondary environmental changes related to major construction work. Patients undergoing anti-TNF treatment may be at increased risk for developing opportunistic infections during construction work, renovations, or water supply perturbations and require specific preventive measures.

Efficacy of copper-silver ionization in controlling biofilm- and plankton-associated waterborne pathogens

The study was to determine the efficacy of copper-silver ionization against the formation of Pseudomonas aeruginosa, Stenotrophomonas maltophilia, and Acinetobacter baumannii in biofilms and planktonic phases. At concentrations below the EPA limits, ionization has potential to control the three waterborne pathogens, in addition to Legionella, in hospital water systems for nosocomial infection control.

Patients' bath basins as potential sources of infection: a multicenter sampling study

BACKGROUND

Nosocomial infections are a marked burden on the US health care system and are linked to a high number of patient deaths.

OBJECTIVE

To identify and quantify bacteria in patients' bath basins and evaluate the basins as a possible reservoir for bacterial colonization and a risk factor for subsequent hospital-acquired infection.

METHODS

In a prospective study at 3 acute care hospitals, 92 bath basins, including basins from 3 intensive care units, were evaluated. Sterile culture sponges were used to obtain samples from the basins. The culture sponges were sent to an outside laboratory, and qualitative and quantitative microbial tests were conducted and the results reported.

RESULTS

Some form of bacteria grew in 98% of the samples (90 sponges), either by plating or on enrichment (95% confidence interval, 92%-99.7%). The organisms with the highest positive rates of growth on enrichment were enterococci (54%), gram-negative organisms (32%), Staphylococcus aureus (23%), vancomycin-resistant enterococci (13%), methicillin-resistant S aureus (8%), Pseudomonas aeruginosa (5%), Candida albicans (3%), and Escherichia coli (2%). Mean plate counts, in colony-forming units, were 10 187 for gram-negative organisms, 99 for E coli, 30 for P aeruginosa, 86 for S aureus, 207 for enterococci, and 31 for vancomycin-resistant enterococci.

CONCLUSIONS

Bath basins are a reservoir for bacteria and may be a source of transmission of hospital-acquired infections. Increased awareness of bath basins as a possible source of transmission of hospital-acquired infections is needed, particularly for high-risk patients.

Single-cell detection: test of microbial contamination using capillary electrophoresis

Single cells of bacteria and fungi were detected using a capillary electrophoresis-based test for microbial contamination in laboratory samples. This technique utilizes a dilute cationic surfactant buffer to sweep microorganisms out of the sample zone and a small plug of "blocking agent" to negate the cells' mobility and induce aggregation. Analysis times are generally under 10 min. Previously, a nutrient broth media was reported as an effective blocking agent; however, the natural background fluorescence from the nutrient broth limited the detection sensitivity to approximately 50 cells. In order to enhance the sensitivity of the technique down to a single cell, an alternative synthetic blocking agent was sought. Various potential blocking agents were screened including salts, polypeptides, small organic zwitterions, and surfactants. Zwitterionic surfactants are shown to be attractive alternatives to a nutrient broth blocker and mimic the nutrient broth's effects on cellular aggregation and mobility. Specifically, caprylyl sulfobetaine provided the sharpest cell peaks. By substituting caprylyl sulfobetaine in place of the nutrient broth, the fluorescence of the blocker plug was reduced by as much as 40 x. This reduction in background noise enables detection of a single microorganism in a sample and allows this technique to be potentially used as a rapid sterility test. All single cells analyzed using this technique displayed signal-to-noise ratios between 5 and 9.

Capillary Electrophoretic Method for the Detection of Bacterial Contamination

There has been growing interest in separations-based techniques for the identification and characterization of microorganisms because of the versatility, selectivity, sensitivity, and short analysis times of these methods. A related area of analysis that is scientifically and commercially important is the determination of the presence or complete absence of microbes (in essence, a test for sample sterility). In such a test, it is not of immediate importance to identify a particular microorganism, but rather, to know with a high degree of certainty whether any organism(s) is (are) present. Current regulations require culture-based tests that can take up to 2 weeks to complete. As a rapid alternative, capillary electrophoresis-based methods are examined. Experimental formats are developed that promote the consolidation of all cell types into a single zone (peak) which is separated from the electroosmotic flow front and any other interfering molecular constituents. This process can be accomplished using a segment of dilute cetyltrimethylammonium bromide, which serves to temporarily reverse the migration direction of the cells, and another segment of solution containing a "blocking agent", which serves to stop the cell migration and focus them into a narrow zone. Relatively wide-bore capillaries can be used to increase sample size. This approach appears to be effective for a broad spectrum of bacteria, and analyses times are less than 10 min.

Infection Control: Old Problems and New Challenges

Infection control faces radical changes at the beginning of the third millennium. The first part of this review focuses on problems not yet solved, such as 1) surveillance systems, which should be active and extremely flexible; 2) infection outbreaks in hospitals and strategies to avoid them; 3) hand washing and alternatives such as rapid hand antisepsis; 4) water and food in the hospital as potential reservoirs of nosocomial pathogens; 5) upgrading of infection control programs to turn them into systems to improve the quality of care; 6) fatal Gram-negative bacteremias in hospitals from developing countries, which can be avoided with better standards of care; 7) the elemental role of the microbiology laboratory in the prevention and control of infections; 8) the unprecedented crisis due to the emergence of specific multi-resistant pathogens; 9) the risks for healthcare workers, such as tuberculosis, hepatitis, HIV, SARS, and hemorrhagic fevers; and 10) the need for the consistent application of guidelines. The second part of this review focuses on new challenges for infection control, such as 1) the ever-growing number of immunocompromised patients and basic control measures to avoid opportunistic infections; 2) the concerns about the capacity of the public health systems to deal with terrorist acts; 3) the practice of high-risk procedures in facilities lacking trained personnel, efficient laboratories, and protective items; and 4) gene therapy and its potential infectious complications. Consideration is given to the asymmetric development of infection control globally.

Hospital water point-of-use filtration: a complementary strategy to reduce the risk of nosocomial infection

Cholera, hepatitis and typhoid are well-recognized water-borne illnesses that take the lives of many every year in areas of uncontrollable flood, but far less attention is afforded to the allegedly safe potable water in affluent nations and the presumed healthful quality of water in communities and hospitals. Recent literature, however, points to increasing awareness of serious clinical sequelae particularly experienced by immunocompromised patients at high risk for disease and death from exposure to water-borne microbes in hospitals. This review reflects the literature indicting hospital water as an important source for nosocomial infections, examines patient populations at greatest risk, uncovers examples of failures in remedial water treatment methods and the reasons for them, and introduces point-of-use water filtration as a practical alternative or complementary component of an infection control strategy that may reduce the risk of nosocomial infections.

Diversity of nontuberculoid Mycobacterium species in biofilms of urban and semiurban drinking water distribution systems

Nontuberculous mycobacteria (NTM) are ubiquitous and have been isolated from a variety of environmental sources, including water. Various NTM were isolated from biofilms in drinking water distribution systems in two urban and two semiurban areas in South Africa. Most of the isolates belonged to opportunistic pathogenic species of the NTM group, but none belonged to the Mycobacterium avium complex.

Persistent Legionella pneumophila colonization of a hospital water supply: efficacy of control methods and a molecular epidemiological analysis

After a nosocomial outbreak caused by Legionella pneumophila serogroup 5, the hospital water distribution system, which was found to be colonized by L. pneumophila serogroups 5 and 6, was decontaminated by the superheat and flush method and by installing an additional heat-shock unit in one of the hot water circuits. This unit exposed the recirculated water to a temperature of 80 degrees C. The efficacy of the decontamination measures was evaluated by monitoring the temperatures and legionella concentrations at different parts of the hot water distribution system. The genetic diversity of the colonizing legionella flora was examined using two genotyping methods: amplified fragment length polymorphism analysis (AFLP) and random amplified polymorphic DNA (RAPD) analysis. Selected serogroup 6 strains were also analyzed by sequence-based typing (SBT). The results indicated that long-term eradication of serogroup 5 strains was never achieved. Only one serogroup 6 strain was never isolated after the superheat and flush. In all, according to genetic fingerprints, the diversity of Legionella strains in a hospital water system remains stable over the years regardless of the use of recommended disinfection procedures.

Immune suppression and considerations for dental care

Immunocompromised individuals present a challenge to oral health care providers. As the spectrum of patients with dysfunctional immune responses continues to broaden, practitioners should be able to identify these patients, understand the potential for complications, and manage their dental care safely and effectively. This article reviews various immune deficiencies, addresses complications that may result from an individual's immune status, and discusses dental considerations for these patients.

Ultraviolet light disinfection of hospital water for preventing nosocomial Legionella infection: a 13-year follow-up

BACKGROUND AND OBJECTIVE

CDC has estimated that 23% of Legionella infections are nosocomial. When a new hospital was being constructed and a substantial increase in transplantation was anticipated, an ultraviolet light apparatus was installed in the water main of the new building because 27% of water samples from taps in the old hospital contained Legionella. This study reports the rate of nosocomial Legionella infection and water contamination since opening the new hospital.

METHODS

Charts of all patients with positive Legionella cultures, direct immunofluorescent antibody (DFA), or urine antigen between April 1989 and November 2001 were reviewed. Frequencies of DFAs and urine antigens were obtained from the laboratory.

RESULTS

None of the 930 cultures of hospital water have been positive since moving into the new building. Fifty-three (0.02%) of 219,521 patients had a positive Legionella test; 41 had pneumonia (40 community acquired). One definite L. pneumophila pneumonia confirmed by culture and DFA in August 1994 was nosocomial (0.0005%) by dates. This patient was transferred after prolonged hospitalization in another country, was transplanted 11 days after admission, and developed symptoms 5 days after liver transplant. However, tap water from the patient's room did not grow Legionella. Seventeen (2.5%) of 670 urine antigens were positive for Legionella (none nosocomial). Thirty-three (1.2%) of 2,671 DFAs were positive, including 7 patients (21%) without evidence of pneumonia and 6 (18%) who had an alternative diagnosis.

CONCLUSION

Ultraviolet light usage was associated with negative water cultures and lack of clearly documented nosocomial Legionella infection for 13 years at this hospital.