Common features of opportunistic premise plumbing pathogens

Residual disinfectant effectively suppresses Legionella species in drinking water distribution systems supplied by surface water in Minnesota, USA

Seven public water systems in Minnesota, USA were analyzed from one to five times over a two-year period to assess temporal changes in the concentrations of total bacteria, Legionella spp., and Legionella pneumophila from source (i.e., raw water) through the water treatment process to the end water user. Bacterial biomass was collected by filtering large volumes of raw water (12 to 425 L, median: 38 L) or finished and tap water (27 to 1205 L, median: 448 L) using ultrafiltration membrane modules. Quantitative PCR (qPCR) was then used to enumerate all bacteria (16S rRNA gene fragments), all Legionella spp. (ssrA), and Legionella pneumophila (mip). Total coliforms, Escherichia coli, and L. pneumophila also were quantified in the water samples via cultivation. Median concentrations of total bacteria and Legionella spp. (ssrA) in raw water (8.5 and 4.3 log copies/L, respectively) decreased by about 2 log units during water treatment. The concentration of Legionella spp. (ssrA) in water collected from distribution systems inversely correlated with the total chlorine concentration for chloraminated systems significantly (p = 0.03). Although only 8 samples were collected from drinking water distribution systems using free chlorine as a residual disinfectant, these samples had significantly lower concentrations of Legionella spp. (ssrA) than samples collected from the chloraminated systems (p = 5 × 10-4). There was considerable incongruity between the results obtained via cultivation-independent (qPCR) and cultivation-dependent assays. Numerous samples were positive for L. pneumophila via cultivation, none of which tested positive for L. pneumophilia (mip) via qPCR. Conversely, a single sample tested positive for L. pneumophilia (mip) via qPCR, but this sample tested negative for L. pneumophilia via cultivation. Overall, the results suggest that conventional treatment is effective at reducing, but not eliminating, Legionella spp. from surface water supplies and that residual disinfection is effective at suppressing these organisms within drinking water distribution systems.

Reconsider the burn: The transient effect of a chlorine burn on controlling opportunistic pathogens in a full-scale chloraminated engineered water system

Nitrification is a serious water-quality issue in chloraminated engineered water systems (EWSs). Nitrification is often remediated by a chlorine burn (i.e., a free‑chlorine conversion), a short-term switch from chloramination to chlorination in EWSs. Opportunistic pathogens (OPs) are the dominant infectious agents in EWSs. However, the responses of OPs to a chlorine burn are unknown. This study for the first time assessed how a chlorine burn affected OPs in a full-scale EWS. We determined the impact of a 1.5-month chlorine burn on four dominant OPs (Legionella, Mycobacterium, Pseudomonas, and Vermamoeba vermiformis) in a representative full-scale chloraminated EWS in the United States. Legionella and Mycobacterium were the most abundant OPs. In the water main, the summed concentration of the four OPs during the chlorine burn [3.27 ± 1.58 log10(GCN·L-1); GCN: genome or gene copy number] was lower (p ≤ 0.001) than before the burn [4.83 ± 0.50 log10(GCN·L-1)]. After the burn, the summed concentration increased to 4.27 ± 0.68 log10(GCN·L-1), comparable to before the burn (p > 0.05), indicating a transient effect of the chlorine burn in the water main. At the residential sites, the summed concentrations of the four OPs were comparable (p > 0.05) at 5.50 ± 0.84, 5.27 ± 1.44, and 5.08 ± 0.71 log10(GCN·L-1) before, during, and after the chlorine burn, respectively. Therefore, the chlorine burn was less effective in suppressing OP (re)growth in the premise plumbing. The low effectiveness might be due to more significant water stagnation and disinfectant residual decay in the premise plumbing. Indeed, for the entire sampling period, the total chlorine residual concentration in the premise plumbing (1.8 mg Cl2·L-1) was lower than in the water main (2.4 mg Cl2·L-1). Consequently, for the entire sampling period, the summed concentration of the four OPs in the premise plumbing [5.26 ± 1.08 log10(GCN·L-1)] was significantly higher (p < 0.001) than in the water main [4.04 ± 1.25 log10(GCN·L-1)]. In addition, the chlorine burn substantially increased the levels of disinfection by-products (DBPs) in the water main. Altogether, a chlorine burn is transient or even ineffective in suppressing OP (re)growth but raises DBP concentrations in chloraminated EWSs. Therefore, the practice of chlorine burns to control nitrification should be optimized, reconsidered, or even replaced.

Runoff microbiome quality assessment of a city center rainwater harvesting zone shows a differentiation of pathogen loads according to human mobility patterns

The hygienic quality of urban surfaces can be impaired by multiple sources of microbiological contaminants. These surfaces can trigger the development of multiple bacterial taxa and favor their spread during rain events through the circulation of runoff waters. These runoff waters are commonly directed toward sewer networks, stormwater infiltration systems or detention tanks prior a release into natural water ways. With water scarcity becoming a major worldwide issue, these runoffs are representing an alternative supply for some usage like street cleaning and plant watering. Microbiological hazards associated with these urban runoffs, and surveillance guidelines must be defined to favor these uses. Runoff microbiological quality from a recently implemented city center rainwater harvesting zone was evaluated through classical fecal indicator bacteria (FIB) assays, quantitative PCR and DNA meta-barcoding analyses. The incidence of socio-urbanistic patterns on the organization of these urban microbiomes were investigated. FIB and DNA from Human-specific Bacteroidales and pathogens such as Staphylococcus aureus were detected from most runoffs and showed broad distribution patterns. 16S rRNA DNA meta-barcoding profilings further identified core recurrent taxa of health concerns like Acinetobacter, Mycobacterium, Aeromonas and Pseudomonas, and divided these communities according to two main groups of socio-urbanistic patterns. One of these was highly impacted by heavy traffic, and showed recurrent correlation networks involving bacterial hydrocarbon degraders harboring significant virulence properties. The tpm-based meta-barcoding approach identified some of these taxa at the species level for more than 30 genera. Among these, recurrent pathogens were recorded such as P. aeruginosa, P. paraeruginosa, and Aeromonas caviae. P. aeruginosa and A. caviae tpm reads were found evenly distributed over the study site but those of P. paraeruginosa were higher among sub-catchments impacted by heavy traffic. Health risks associated with these runoff P. paraeruginosa emerging pathogens were high and associated with strong cytotoxicity on A549 lung cells. Recurrent detections of pathogens in runoff waters highlight the need of a microbiological surveillance prior allowing their use. Good microbiological quality can be obtained for certain typologies of sub-catchments with good hygienic practices but not all. A reorganization of Human mobility and behaviors would likely trigger changes in these bacterial diversity patterns and reduce the occurrences of the most hazardous groups.

Development of an analytical method to quantify N-acyl-homoserine lactones in bacterial cultures, river water, and treated wastewater

N-Acyl-homoserine lactones (AHL) play a major role in the communication of Gram-negative bacteria. They influence processes such as biofilm formation, swarming motility, and bioluminescence in the aquatic environment. A comprehensive analytical method was developed to elucidate the "chemical communication" in pure bacterial cultures as well as in the aquatic environment and engineered environments with biofilms. Due to the high diversity of AHLs and their low concentrations in water, a sensitive and selective LC-ESI-MS/MS method combined with solid-phase extraction was developed for 34 AHLs, optimized and validated to quantify AHLs in bacterial conditioned medium, river water, and treated wastewater. Furthermore, the developed method was optimized in terms of enrichment volume, internal standards, limits of detection, and limits of quantification in several matrices. An unanticipated variety of AHLs was detected in the culture media of Pseudomonas aeruginosa (in total 8 AHLs), Phaeobacter gallaeciensis (in total 6 AHLs), and Methylobacterium mesophilicum (in total 15 AHLs), which to our knowledge have not been described for these bacterial cultures so far. Furthermore, AHLs were detected in river water (in total 5 AHLs) and treated wastewater (in total 3 AHLs). Several detected AHLs were quantified (in total 24) using a standard addition method up to 7.3±1.0 µg/L 3-Oxo-C12-AHL (culture media of P. aeruginosa).

Influence of phosphate on bacterial release from activated carbon point-of-use filters and on biofilm characteristics

Point-of-use (POU) filters certified to remove lead are often composed of activated carbon and have been shown to release high concentrations of bacteria, including opportunistic pathogens. In this study, we examine the impacts of the common corrosion inhibitor phosphate on biofilm characteristics and the relationship between biofilm structure and bacterial release from POU filters. This knowledge is essential for understanding how best to use the filters and where these filters fit in a system where other lead contamination prevention measures may be in place. We measured the bacterial release from activated carbon POU filters fed with groundwater - a common source of drinking water - with and without phosphate. We used optical coherence tomography (OCT) to quantitatively characterize biofilm growing on activated carbon filter material in which the biofilms were fed groundwater with and without phosphate. Phosphate filters released significantly less (57-87 %) bacteria than groundwater filters, and phosphate biofilms (median thickness: 82-331 μm) grew to be significantly thicker than groundwater biofilms (median thickness: 122-221 μm). The phosphate biofilm roughness ranged from 97 to 142 % of the groundwater biofilm roughness and was significantly greater in most weeks. Phosphate biofilms also had fewer pores per biofilm volume and shorter channels connecting those pores.

Responses of drinking water bulk and biofilm microbiota to elevated water age in bench-scale simulated distribution systems

Reductions in nonresidential water demand during the COVID-19 pandemic highlighted the importance of understanding how water age impacts drinking water quality and microbiota in piped distribution systems. Using benchtop model distribution systems, we aimed to characterize the impacts of elevated water age on microbiota in bulk water and pipe wall biofilms. Five replicate constant-flow reactors were fed with municipal chloraminated tap water for 6 months prior to building closures and 7 months after. After building closures, chloramine levels entering the reactors dropped; in the reactor bulk water and biofilms the mean cell counts and ATP concentrations increased over an order of magnitude while the detection of opportunistic pathogens remained low. Water age, and the corresponding physicochemical changes, strongly influenced microbial abundance and community composition. Differential initial microbial colonization also had a lasting influence on microbial communities in each reactor (i.e., historical contingency).

Estimating the burden of illness caused by domestic waterborne Legionnaires' disease in Canada: 2015-2019

Legionellosis is a disease caused by the bacterium Legionella that most commonly presents as Legionnaires' disease (LD), a severe form of pneumonia. From 2015 to 2019, an average of 438 LD cases per year were reported in Canada. However, it is believed that the actual number of cases is much higher, since LD may be underdiagnosed and underreported. The purpose of this study was to develop an estimate of the true incidence of illnesses, hospitalizations, and deaths associated with LD in Canada. Values were derived using a stochastic model, based on Canadian surveillance data from 2015 to 2019, which were scaled up to account for underdiagnosis and underreporting. Overall, there were an estimated 1,113 (90% CrI: 737-1,730) illnesses, 1,008 (90% CrI: 271-2,244) hospitalizations, and 34 (90% CrI: 4-86) deaths due to domestically acquired waterborne LD annually in Canada from 2015 to 2019. It was further estimated that only 36% of illnesses and 39% of hospitalizations and deaths were captured in surveillance, and that 22% of illnesses were caused by Legionella serogroups and species other than Legionella pneumophila serogroup 1 (non-Lp1). This study highlights the true burden and areas for improvement in Canada's surveillance and detection of LD.

Validation of PVT VIABLE® for Detection of Legionella in Potable and Non-Potable Water: AOAC Performance Tested MethodSM 082303

BACKGROUND

Phigenics Validation Test (PVT) VIABLE® (Viability Identification Assay by Legionella Enrichment) is a method to detect viable Legionella bacteria in building water systems.

OBJECTIVE

To evaluate PVT VIABLE against the ISO 11731:2017 Water Quality-Enumeration of Legionella reference method for the detection of viable Legionella species in potable and non-potable water.

METHODS

PVT VIABLE was tested for inclusivity (n = 50 strains of Legionella) and exclusivity (n = 30 non-target strains), robustness, and stability. A multi-laboratory instrument variation study was performed to evaluate the PCR data. The matrix study was performed on potable and non-potable water samples inoculated with Legionella pneumophila at a low (n = 20) and high fractional level (n = 5). Samples were analyzed using the PVT VIABLE and confirmed using ISO 11731:2017.

RESULTS

Statistical analysis showed no difference between PVT VIABLE and ISO 11731:2017 for 100 mL test portions of potable and non-potable water. PVT VIABLE demonstrated high levels of specificity and sensitivity in the inclusivity and exclusivity study. Results of the robustness and stability studies demonstrated the method was sufficiently robust to handle small method changes and met the method claims of stability.

CONCLUSION

PVT VIABLE allows the end user to obtain presumptive results for viable Legionella spp. contamination of potable and non-potable water in 2-3 days.

HIGHLIGHTS

PVT VIABLE provides viable Legionella results in 2-3 days versus 10-14 days for traditional spread plating. This novel diagnostic tool also differentiates between Legionella pneumophila sg1, Legionella pneumophila sg2-15, and Legionella spp. without the need for additional confirmation steps as outlined in ISO 11731:2017.

Premise Plumbing Pipe Materials and In-Building Disinfectants Shape the Potential for Proliferation of Pathogens and Antibiotic Resistance Genes

In-building disinfectants are commonly applied to control the growth of pathogens in plumbing, particularly in facilities such as hospitals that house vulnerable populations. However, their application has not been well optimized, especially with respect to interactive effects with pipe materials and potential unintended effects, such as enrichment of antibiotic resistance genes (ARGs) across the microbial community. Here, we used triplicate convectively mixed pipe reactors consisting of three pipe materials (PVC, copper, and iron) for replicated simulation of the distal reaches of premise plumbing and evaluated the effects of incrementally increased doses of chlorine, chloramine, chlorine dioxide, and copper-silver disinfectants. We used shotgun metagenomic sequencing to characterize the resulting succession of the corresponding microbiomes over the course of 37 weeks. We found that both disinfectants and pipe material affected ARG and microbial community taxonomic composition both independently and interactively. Water quality and total bacterial numbers were not found to be predictive of pathogenic species markers. One result of particular concern was the tendency of disinfectants, especially monochloramine, to enrich ARGs. Metagenome assembly indicated that many ARGs were enriched specifically among the pathogenic species. Functional gene analysis was indicative of a response of the microbes to oxidative stress, which is known to co/cross-select for antibiotic resistance. These findings emphasize the need for a holistic evaluation of pathogen control strategies for plumbing.

Extended water stagnation in buildings during the COVID-19 pandemic increases the risks posed by opportunistic pathogens

The regrowth and subsequent exposure of opportunistic pathogens (OPs) whilst reopening buildings that have been locked down due to the stay-at-home restrictions to limit the spread of COVID-19, is a public health concern. To better understand such microbiological risks due to lowered occupancy and water demand in buildings, first and post-flush water samples (n = 48) were sampled from 24 drinking water outlets from eight university buildings in two campuses (urban and rural), with various end-user occupancies. Both campuses were served with chlorinated water originating from a single drinking water distribution system in South-East Queensland, situated 14 km apart, where the rural campus had lower chlorine residuals. Culture-dependent and culture-independent methods (such as flow cytometry, qPCR and 16S rRNA gene amplicon sequencing) were used concurrently to comprehensively characterise the OPs of interest (Legionella spp., Pseudomonas aeruginosa, and nontuberculous mycobacteria (NTM)) and the premise plumbing microbiome. Results showed that buildings with extended levels of stagnation had higher and diverse levels of microbial growth, as observed in taxonomic structure and composition of the microbial communities. NTM were ubiquitous in all the outlets sampled, regardless of campus or end-user occupancy of the buildings. qPCR and culture demonstrated prevalent and higher concentrations of NTM in buildings (averaging 3.25 log10[estimated genomic copies/mL]) with extended stagnation in the urban campus. Furthermore, flushing the outlets for 30 minutes restored residual and total chlorine, and subsequently decreased the levels of Legionella by a reduction of 1 log. However, this approach was insufficient to restore total and residual chlorine levels for the outlets in the rural campus, where both Legionella and NTM levels detected by qPCR remained unchanged, regardless of building occupancy. Our findings highlight that regular monitoring of operational parameters such as residual chlorine levels, and the implementation of water risk management plans are important for non-healthcare public buildings, as the levels of OPs in these environments are typically not assessed.

Influence of pipe materials on in-building disinfection of P. aeruginosa and A. baumannii in simulated hot water plumbing

A framework is needed to account for interactive effects of plumbing materials and disinfectants on opportunistic pathogens (OPs) in building water systems. Here we evaluated free chlorine, monochloramine, chlorine dioxide, and copper-silver ionization (CSI) for controlling Pseudomonas aeruginosa and Acinetobacter baumannii as two representative OPs that colonize hot water plumbing, in tests using polyvinylchloride (PVC), copper-PVC, and iron-PVC convectively-mixed pipe reactors (CMPRs). Pipe materials vulnerable to corrosion (i.e., iron and copper) altered the pH, dissolved oxygen, and disinfectant levels in a manner that influenced growth trends of the two OPs and total bacteria. P. aeruginosa grew well in PVC CMPRs, poorly in iron-PVC CMPRs, and was best controlled by CSI disinfection, whereas A. baumannii showed the opposite trend for pipe material and was better controlled by chlorine and chlorine dioxide. Various scenarios were identified in which pipe material and disinfectant can interact to either hinder or accelerate growth of OPs, illustrating the difficulties of controlling OPs in portions of plumbing systems experiencing warm, stagnant water.

Shotgun Metagenomics Reveals Impacts of Copper and Water Heater Anodes on Pathogens and Microbiomes in Hot Water Plumbing Systems

Hot water building plumbing systems are vulnerable to the proliferation of opportunistic pathogens (OPs), including Legionella pneumophila and Mycobacterium avium. Implementation of copper as a disinfectant could help reduce OPs, but a mechanistic understanding of the effects on the microbial community under real-world plumbing conditions is lacking. Here, we carried out a controlled pilot-scale study of hot water systems and applied shotgun metagenomic sequencing to examine the effects of copper dose (0-2 mg/L), orthophosphate corrosion control agent, and water heater anode materials (aluminum vs magnesium vs powered anode) on the bulk water and biofilm microbiome composition. Metagenomic analysis revealed that, even though a copper dose of 1.2 mg/L was required to reduce Legionella and Mycobacterium numbers, lower doses (e.g., ≤0.6 mg/L) measurably impacted the broader microbial community, indicating that the OP strains colonizing these systems were highly copper tolerant. Orthophosphate addition reduced bioavailability of copper, both to OPs and to the broader microbiome. Functional gene analysis indicated that both membrane damage and interruption of nucleic acid replication are likely at play in copper inactivation mechanisms. This study identifies key factors (e.g., orthophosphate, copper resistance, and anode materials) that can confound the efficacy of copper for controlling OPs in hot water plumbing.

Legionella spp. Monitoring in the Water Supply Systems of Accommodation Facilities in Sardinia, Italy: A Two-Year Retrospective Analysis

Travel-associated Legionnaires' disease is a significant public health concern worldwide. A high number of cases are reported every year among travellers who stay at guest houses, hotels, and spas. Indeed, hot water systems, showers, and air-conditioning systems can be contaminated by Legionella, which grows at 25-42 °C. Studies have shown that in Sardinia, especially during the summer months, the water circulation in the hotels' pipes is exposed to extremely high temperatures. As a result, this study was conducted to assess the colonization of hotel water systems by Legionella in Sardinia, concerning a recent EU directive 2020/2184 for drinking water with a limit of 1000 CFU /L. Methods. A total of 112 accommodation facilities were analyzed, of which 61.3% were found to be colonized with Legionella, and out of a total of 807 samples, 32.5% were positive for Legionella presence. The results showed a higher number of positive samples in the summer season. This was also associated with the higher concentration presence of >1000 CFU/L in the samples. Consequently, this study confirms that local hotel operators should improve their water safety and prevention plans, especially in spring and summer.

Pilot-scale assessment reveals effects of anode type and orthophosphate in governing antimicrobial capacity of copper for Legionella pneumophila control

Copper (Cu) is sometimes applied as an antimicrobial for controlling Legionella in hot water plumbing systems, but its efficacy is inconsistent. Here we examined the effects of Cu (0 - 2 mg/L), orthophosphate corrosion inhibitor (0 or 3 mg/L as phosphate), and water heater anodes (aluminum, magnesium, and powered anodes) on both bulk water and biofilm-associated L. pneumophila in pilot-scale water heater systems. Soluble, but not total, Cu was a good predictor of antimicrobial capacity of Cu. Even after months of exposure to very high Cu levels (>1.2 mg/L) and low pH (<7), which increases solubility and enhances bioavailability of Cu, culturable L. pneumophila was only reduced by ∼1-log. Cu antimicrobial capacity was shown to be limited by various factors, including binding of Cu ions by aluminum hydroxide precipitates released from corrosion of aluminum anodes, higher pH due to magnesium anode corrosion, and high Cu tolerance of the outbreak-associated L. pneumophila strain that was inoculated into the systems. L. pneumophila numbers were also higher in several instances when Cu was dosed together with orthophosphate (e.g., with an Al anode), revealing at least one scenario where high levels of total Cu appeared to stimulate Legionella. The controlled, pilot-scale nature of this study provides new understanding of the limitations of Cu as an antimicrobial in real-world plumbing systems.

Study on the distribution characteristics and metabolic mechanism of chlorine-resistant bacteria in indoor water supply networks

The presence and attachment of chlorine-resistant bacteria on the surface of water distribution network will deteriorate water quality and threaten human health. Chlorination is critical in drinking water treatment to ensure the biosafety of drinking water. However, how disinfectants affect the structures of dominant flora during biofilm development and whether the changes are consistent with the free flora remain unclear. Therefore, we investigated changes in species diversity and relative abundance of different bacterial communities in planktonic and biofilm samples at different chlorine residual concentrations (blank, 0.3 mg/L, 0.8 mg/L, 2.0 mg/L and 4.0 mg/L), and the main reasons for the development of chlorine resistance in bacteria was also discussed. The results showed that the richness of microbial species in the biofilm was higher than that in planktonic microbial samples. In the planktonic samples, Proteobacteria and Actinobacteria were the dominant groups regardless of the chlorine residual concentration. For biofilm samples, the dominant position of Proteobacteria bacteria was gradually replaced by actinobacteria bacteria with the increase of chlorine residual concentration. In addition, at higher chlorine residual concentration, Gram-positive bacteria were more concentrated to form biofilms. There are three main reasons for the generation of chlorine resistance of bacteria: enhanced function of efflux system, activated bacterial self-repair system, and enhanced nutrient uptake capacity.

Waterborne infections in haemato-oncology units - a narrative review

Bone marrow transplant and haemato-oncology patients are at risk of healthcare associated infections due to waterborne pathogens. We undertook a narrative review of waterborne outbreaks in haemato-oncology patients from 2000-2022. Databases searched included Pubmed, DARE and CDSR and were undertaken by two authors. We analysed the organisms implicated, sources identified and infection prevention and control strategies implemented. The most commonly implicated pathogens were Pseudomonas aeruginosa, non-tuberculous mycobacteria and Legionella pneumophila. Bloodstream infection was the most common clinical presentation. The majority of incidents employed multimodal strategies to achieve control, addressing both the water source and routes of transmission. This review highlights the risk to haemato-oncology patients from waterborne pathogens and discusses future preventative strategies and the requirement for new UK guidance for haemato-oncology units.

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.

Misidentification as Pseudomonas aeruginosa in hospital water supply samples

Drinking water in hospitals is often tested for Pseudomonas aeruginosa because of its virulence potential. This article describes a case where, based on EN ISO 16266, seven of 11 (64%) samples taken simultaneously from the drinking water system at a single hospital tested positive for P. aeruginosa. This resulted in extensive investigations and interventions, and a number of measures were implemented. However, supplementary analyses with more discriminatory power (matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, 16S-rRNA sequencing) ruled out P. aeruginosa completely. The authors wish to raise awareness of this problem, and suggest that diagnostic uncertainty of results obtained by EN ISO 16266 should be indicated on laboratory reports. Wrongly assuming the presence of P. aeruginosa in hospital water supply systems can lead to unnecessary control measures, as analytical uncertainty massively influences the health risk assessment and the remediation measures initiated in medical environments.

Effect of UV Light and Sodium Hypochlorite on Formation and Destruction of Pseudomonas fluorescens Biofilm In Vitro

Pseudomonas fluorescens is one of the first colonizers of bacterial biofilm in water systems and a member of opportunistic premise plumbing pathogens (OPPPs). The aim of this study was to examine the effect of UV light and sodium hypochlorite on the formation and destruction of mature P. fluorescens biofilm on ceramic tiles. Planktonic bacteria or bacteria in mature biofilm were exposed to UV light (254 nm) for 5, 20 s. and to 0.4 mg/L sodium hypochlorite for 1 min. Mature biofilm was also exposed to increased concentration of sodium hypochlorite of 2 mg/L for 0.5, 1 and 2 h and combined with UV. Prolonged action of sodium hypochlorite and an increase in its concentration in combination with UV gave the best results in the inhibition of biofilm formation after the pre-treatment and destruction of mature biofilm. The effect of hyperchlorination in combination with UV radiation shows better results after a long exposure time, although even after 120 min there was no completely destroyed biofilm. Furthermore, the mechanism of the effect of combined methods should be explored as well as the importance of mechanical cleaning that is crucial in combating bacterial biofilm in swimming pools.

Hospital water as the source of healthcare-associated infection and antimicrobial-resistant organisms

PURPOSE OF REVIEW

Drinking water is considered one of the most overlooked and underestimated sources of healthcare-associated infections (HAIs). Recently, the prevention and control of opportunistic premise plumbing pathogens (OPPPs) in healthcare water systems has been receiving increasing attention in infection control guidelines. However, these fail to address colonization of pathogens that do not originate from source water. Subsequently, this review explores the role of water and premise plumbing biofilm in HAIs. The potential mechanisms of contamination and transmission of antimicrobial-resistant (AMR) pathogens originating both from supply water and human microbiota are discussed.

RECENT FINDINGS

OPPPs, such as Legionella pneumophila, Pseudomonas aeruginosa and Mycobacterium avium have been described as native to the plumbing environment. However, other pathogens, not found in the source water, have been found to proliferate in biofilms formed on outlets devices and cause HAI outbreaks.

SUMMARY

Biofilms formed on outlet devices, such as tap faucets, showers and drains provide an ideal niche for the dissemination of antimicrobial resistance. Thus, comprehensive surveillance guidelines are required to understand the role that drinking water and water-related devices play in the transmission of AMR HAIs and to improve infection control guidelines.

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

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

The control of red water occurrence and opportunistic pathogens risks in drinking water distribution systems: A review

Many problems in drinking water distribution systems (DWDSs) are caused by microbe, such as biofilm formation, biocorrosion and opportunistic pathogens growth. More iron release from corrosion scales may induce red water. Biofilm played great roles on the corrosion. The iron-oxidizing bacteria (IOB) promoted corrosion. However, when iron-reducing bacteria (IRB) and nitrate-reducing bacteria (NRB) became the main bacteria in biofilm, they could induce iron redox cycling in corrosion process. This process enhanced the precipitation of iron oxides and formation of more Fe₃O₄ in corrosion scales, which inhibited corrosion effectively. Therefore, the IRB and NRB in the biofilm can reduce iron release and red water occurrence. Moreover, there are many opportunistic pathogens in biofilm of DWDSs. The opportunistic pathogens growth in DWDSs related to the bacterial community changes due to the effects of micropollutants. Micropollutants increased the number of bacteria with antibiotic resistance genes (ARGs). Furthermore, extracellular polymeric substances (EPS) production was increased by the antibiotic resistant bacteria, leading to greater bacterial aggregation and adsorption, increasing the chlorine-resistance capability, which was responsible for the enhancement of the particle-associated opportunistic pathogens in DWDSs. Moreover, O₃-biological activated carbon filtration-UV-Cl₂ treatment could be used to control the iron release, red water occurrence and opportunistic pathogens growth in DWDSs.

Legionella: A Promising Supplementary Indicator of Microbial Drinking Water Quality in Municipal Engineered Water Systems

Opportunistic pathogens (OPs) are natural inhabitants and the predominant disease causative biotic agents in municipal engineered water systems (EWSs). In EWSs, OPs occur at high frequencies and concentrations, cause drinking-water-related disease outbreaks, and are a major factor threatening public health. Therefore, the prevalence of OPs in EWSs represents microbial drinking water quality. Closely or routinely monitoring the dynamics of OPs in municipal EWSs is thus critical to ensuring drinking water quality and protecting public health. Monitoring the dynamics of conventional (fecal) indicators (e.g., total coliforms, fecal coliforms, and Escherichia coli) is the customary or even exclusive means of assessing microbial drinking water quality. However, those indicators infer only fecal contamination due to treatment (e.g., disinfection within water utilities) failure and EWS infrastructure issues (e.g., water main breaks and infiltration), whereas OPs are not contaminants in drinking water. In addition, those indicators appear in EWSs at low concentrations (often absent in well-maintained EWSs) and are uncorrelated with OPs. For instance, conventional indicators decay, while OPs regrow with increasing hydraulic residence time. As a result, conventional indicators are poor indicators of OPs (the major aspect of microbial drinking water quality) in EWSs. An additional or supplementary indicator that can well infer the prevalence of OPs in EWSs is highly needed. This systematic review argues that Legionella as a dominant OP-containing genus and natural inhabitant in EWSs is a promising candidate for such a supplementary indicator. Through comprehensively comparing the behavior (i.e., occurrence, growth and regrowth, spatiotemporal variations in concentrations, resistance to disinfectant residuals, and responses to physicochemical water quality parameters) of major OPs (e.g., Legionella especially L. pneumophila, Mycobacterium, and Pseudomonas especially P. aeruginosa), this review proves that Legionella is a promising supplementary indicator for the prevalence of OPs in EWSs while other OPs lack this indication feature. Legionella as a dominant natural inhabitant in EWSs occurs frequently, has a high concentration, and correlates with more microbial and physicochemical water quality parameters than other common OPs. Legionella and OPs in EWSs share multiple key features such as high disinfectant resistance, biofilm formation, proliferation within amoebae, and significant spatiotemporal variations in concentrations. Therefore, the presence and concentration of Legionella well indicate the presence and concentrations of OPs (especially L. pneumophila) and microbial drinking water quality in EWSs. In addition, Legionella concentration indicates the efficacies of disinfectant residuals in EWSs. Furthermore, with the development of modern Legionella quantification methods (especially quantitative polymerase chain reactions), monitoring Legionella in ESWs is becoming easier, more affordable, and less labor-intensive. Those features make Legionella a proper supplementary indicator for microbial drinking water quality (especially the prevalence of OPs) in EWSs. Water authorities may use Legionella and conventional indicators in combination to more comprehensively assess microbial drinking water quality in municipal EWSs. Future work should further explore the indication role of Legionella in EWSs and propose drinking water Legionella concentration limits that indicate serious public health effects and require enhanced treatment (e.g., booster disinfection).

Legionella and other opportunistic pathogens in full-scale chloraminated municipal drinking water distribution systems

Water-based opportunistic pathogens (OPs) are a leading cause of drinking-water-related disease outbreaks, especially in developed countries such as the United States (US). Physicochemical water quality parameters, especially disinfectant residuals, control the (re)growth, presence, colonization, and concentrations of OPs in drinking water distribution systems (DWDSs), while the relationship between OPs and those parameters remain unclear. This study aimed to quantify how physicochemical parameters, mainly monochloramine residual concentration, hydraulic residence time (HRT), and seasonality, affected the occurrence and concentrations of four common OPs (Legionella, Mycobacterium, Pseudomonas, and Vermamoeba vermiformis) in four full-scale DWDSs in the US. Legionella as a dominant OP occurred in 93.8% of the 64 sampling events and had a mean density of 4.27 × 105 genome copies per liter. Legionella positively correlated with Mycobacterium, Pseudomonas, and total bacteria. Multiple regression with data from the four DWDSs showed that Legionella had significant correlations with total chlorine residual level, free ammonia concentration, and trihalomethane concentration. Therefore, Legionella is a promising indicator of water-based OPs, reflecting microbial water quality in chloraminated DWDSs. The OP concentrations had strong seasonal variations and peaked in winter and/or spring possibly because of reduced water usage (i.e., increased water stagnation or HRT) during cold seasons. The OP concentrations generally increased with HRT presumably because of disinfectant residual decay, indicating the importance of well-maintaining disinfectant residuals in DWDSs for OP control. The concentrations of Mycobacterium, Pseudomonas, and V. vermiformis were significantly associated with total chlorine residual concentration, free ammonia concentration, and pH and trihalomethane concentration, respectively. Overall, this study demonstrates how the significant spatiotemporal variations of OP concentrations in chloraminated DWDSs correlated with critical physicochemical water quality parameters such as disinfectant residual levels. This work also indicates that Legionella is a promising indicator of OPs and microbial water quality in chloraminated DWDSs.

Bacteriophage treatment before chemical disinfection can enhance removal of plastic surface-associated Pseudomonas aeruginosa

Opportunistic pathogens can linger on surfaces in hospital and building plumbing environments, leading to infections in at-risk populations. Further, biofilm-associated bacteria are protected from removal and inactivation protocols, such as disinfection. Bacteriophages show promise as tools to treat antibiotic resistant infections. As such, phages may also be useful in environmental applications to prevent newly acquired infections. In the current study, the potential of synergies between bacteriophage and chemical disinfection of the opportunistic pathogen Pseudomonas aeruginosa was assessed under various conditions. Specifically, surface-associated P. aeruginosa was treated with various concentrations of phages (P1 or JG004), chemical disinfectant (sodium hypochlorite or benzalkonium chloride), or combined sequential treatments under three distinct attachment models (spot inoculations, dry biofilms, and wet biofilms). Phages were very effective at removing bacteria in spot inoculation (>3.2 log₁₀ removal) and wet biofilms (up to 2.6 log₁₀ removal), while phages prevented regrowth of dry biofilms in the application time. In addition, phage treatment followed by chemical disinfection inactivated more P. aeruginosa under wet biofilm conditions better than either treatment alone. This effect was hindered when chemical disinfection was applied first, followed by phage treatment, suggesting additive benefits of combination treatments are lost when phage is applied last. Further, we confirm prior evidence of greater phage tolerance to benzalkonium chloride relative to sodium hypochlorite, informing choices for combination phage-disinfectant approaches. Overall, this paper further supports the potential of using combination phage and chemical disinfectant treatments to improve inactivation of surface-associated P. aeruginosa. Importance Phages are already utilized in the healthcare industry to treat antibiotic resistant infections, such as on implant-associated biofilms and in compassionate care cases. Phage treatment could also be a promising new tool to control pathogens in the built environment, preventing infections from occurring. This study shows that phage can be combined effectively with chemical disinfectants to improve removal of wet biofilms and bacteria spotted onto surfaces while preventing regrowth in dry biofilms. This has the potential to improve pathogen containment within the built environment and drinking water infrastructure to prevent infections of opportunistic pathogens.

Optimizing disinfectant residual dosage in engineered water systems to minimize the overall health risks of opportunistic pathogens and disinfection by-products

This Discussion argues that municipal water utilities may need to consider the health risks of both opportunistic pathogens (OPs) and disinfection by-products (DBPs) while selecting disinfectant residual dosages or levels in engineered water systems. OPs are natural inhabitants in municipal water systems and the leading cause of drinking-water-related disease outbreaks threatening public health. DBPs in water systems are genotoxic/carcinogenic and also significantly affect public health. Disinfectant residuals (such as free chlorine and chloramine residuals) dictate OP (re)growth and DBP formation in engineered water systems. Therefore, regulating the dosages or levels of disinfectant residuals is effective in controlling OP (re)growth and DBP formation. Existing effects assessing optimal disinfectant residual dosages focus solely on minimizing OP (re)growth or solely on DBP formation. However, selecting disinfectant residual dosages aiming to solely limit the formation of DBPs might compromise OP (re)growth control, and vice versa. An optimal disinfectant residual level for DBP formation control or OP (re)growth control might not be optimal for minimizing the overall or combined health effects of OPs and DBPs in drinking water. To better protect public health, water authorities may need to update the current residual disinfection practice and maintain disinfectant residuals in engineered water systems at an optimal level to minimize the overall health risks of OPs and DBPs.

Causes, Factors, and Control Measures of Opportunistic Premise Plumbing Pathogens—A Critical Review

This review critically analyses the chemical and physical parameters that influence the occurrence of opportunistic pathogens in the drinking water distribution system, specifically in premise plumbing. A comprehensive literature review reveals significant impacts of water age, disinfectant residual (type and concentration), temperature, pH, and pipe materials. Evidence suggests that there is substantial interplay between these parameters; however, the dynamics of such relationships is yet to be elucidated. There is a correlation between premise plumbing system characteristics, including those featuring water and energy conservation measures, and increased water quality issues and public health concerns. Other interconnected issues exacerbated by high water age, such as disinfectant decay and reduced corrosion control efficiency, deserve closer attention. Some common features and trends in the occurrence of opportunistic pathogens have been identified through a thorough analysis of the available literature. It is proposed that the efforts to reduce or eliminate their incidence might best focus on these common features.

Opportunistic Premise Plumbing Pathogens. A Potential Health Risk in Water Mist Systems Used as a Cooling Intervention

Water mist systems (WMS) are used for evaporative cooling in public areas. The health risks associated with their colonization by opportunistic premise plumbing pathogens (OPPPs) is not well understood. To advance the understanding of the potential health risk of OPPPs in WMS, biofilm, water and bioaerosol samples (n = 90) from ten (10) WMS in Australia were collected and analyzed by culture and polymerase chain reaction (PCR) methods to detect the occurrence of five representative OPPPs: Legionella pneumophila, Pseudomonas aeruginosa, Mycobacterium avium, Naegleria fowleri and Acanthamoeba. P. aeruginosa (44%, n = 90) occurred more frequently in samples, followed by L. pneumophila serogroup (Sg) 2–14 (18%, n = 90) and L. pneumophila Sg 1 (6%, n = 90). A negative correlation between OPPP occurrence and residual free chlorine was observed except with Acanthamoeba, rs (30) = 0.067, p > 0.05. All detected OPPPs were positively correlated with total dissolved solids (TDS) except with Acanthamoeba. Biofilms contained higher concentrations of L. pneumophila Sg 2–14 (1000–3000 CFU/mL) than water samples (0–100 CFU/mL). This study suggests that WMS can be colonized by OPPPs and are a potential health risk if OPPP contaminated aerosols get released into ambient atmospheres.

Assessing Hotel Employee Knowledge on Risk Factors and Risk Management Procedures for Microbial Contamination of Hotel Water Distribution Systems

Water management plans (WMPs), sometimes referred to as risk management plans (RMPs) or water safety plans (WSPs), are not mandatory for hotels in many countries of the world, including the US. As such, many hotel personnel are uninformed of WMPs and the precautions to take if their hotel water system is compromised. The purpose of this study was to identify hotel personnel's knowledge and practices of WMPs through a survey incorporating the Health Belief Model (HBM). Data were collected from 59 hotels within Fulton County, Georgia, USA, through a questionnaire, and questions were developed tailored to the HBM. Significant associations were found between the perceived susceptibility of contracting a waterborne illness and WMP for hotel personnel as well as between cues to action and having a WMP in general linear models (p ≤ 0.05). The study concludes that many key personnel are not aware of WMPs. Many hotel facilities do not have a plan in place, and some facilities are unaware of a current plan is in place. The study findings provide insight into the importance of WMPs and the risk factors associated with microbial contamination in a hotel building's plumbing system. Future research and potential law change should be emphasized to increase hotel employees' and owner's WMP knowledge.

Role of Williamsia and Segniliparus in human infections with the approach taxonomy, cultivation, and identification methods

The genera Williamsia and Segniliparus are of aerobic actinomycetes and at the time of writing, they have 12 and 2 species, respectively. These genera cause various infections in humans. In this review, we surveyed their taxonomy, isolation, identification, as well as their role to cause human infections.

Identification and inactivation of Gordonia, a new chlorine-resistant bacterium isolated from a drinking water distribution system

Chlorine-resistant bacteria threaten drinking water safety in water distribution systems. In this study, a novel chlorine-resistant bacterium identified as Gordonia was isolated from the drinking water supply system of Jinan City for the first time. We examined the resistance and inactivation of the isolate by investigating cell survival, changes in cell morphology, and the permeability of cell membranes exposed to chlorine. After 240 min chlorine exposure, the chlorine residual was greater than 0.5 mg L^-1 and the final inactivation was about 3 log reduction, which showed that the Gordonia strain had high chlorine tolerance. Flow-cytometric analysis indicated that, following sodium hypochlorite treatments with increasing membrane permeability, culturable cells enter a viable but nonculturable state and then die. We also investigated the inactivation kinetics of Gordonia following chlorine dioxide and ultraviolet radiation treatment. We found that these treatments can effectively inactivate Gordonia, which suggests that they may be used for the regulation of chlorine-resistant microorganisms.

Critical Review: Propensity of Premise Plumbing Pipe Materials to Enhance or Diminish Growth of Legionella and Other Opportunistic Pathogens

Growth of Legionella pneumophila and other opportunistic pathogens (OPs) in drinking water premise plumbing poses an increasing public health concern. Premise plumbing is constructed of a variety of materials, creating complex environments that vary chemically, microbiologically, spatially, and temporally in a manner likely to influence survival and growth of OPs. Here we systematically review the literature to critically examine the varied effects of common metallic (copper, iron) and plastic (PVC, cross-linked polyethylene (PEX)) pipe materials on factors influencing OP growth in drinking water, including nutrient availability, disinfectant levels, and the composition of the broader microbiome. Plastic pipes can leach organic carbon, but demonstrate a lower disinfectant demand and fewer water chemistry interactions. Iron pipes may provide OPs with nutrients directly or indirectly, exhibiting a high disinfectant demand and potential to form scales with high surface areas suitable for biofilm colonization. While copper pipes are known for their antimicrobial properties, evidence of their efficacy for OP control is inconsistent. Under some circumstances, copper's interactions with premise plumbing water chemistry and resident microbes can encourage growth of OPs. Plumbing design, configuration, and operation can be manipulated to control such interactions and health outcomes. Influences of pipe materials on OP physiology should also be considered, including the possibility of influencing virulence and antibiotic resistance. In conclusion, all known pipe materials have a potential to either stimulate or inhibit OP growth, depending on the circumstances. This review delineates some of these circumstances and informs future research and guidance towards effective deployment of pipe materials for control of OPs.

Impacts of Municipal Water-Rainwater Source Transitions on Microbial and Chemical Water Quality Dynamics at the Tap

When rainwater harvesting is utilized as an alternative water resource in buildings, a combination of municipal water and rainwater is typically required to meet water demands. Altering source water chemistry can disrupt pipe scale and biofilm and negatively impact water quality at the distribution level. Still, it is unknown if similar reactions occur within building plumbing following a transition in source water quality. The goal of this study was to investigate changes in water chemistry and microbiology at a green building following a transition between municipal water and rainwater. We monitored water chemistry (metals, alkalinity, and disinfectant byproducts) and microbiology (total cell counts, plate counts, and opportunistic pathogen gene markers) throughout two source water transitions. Several constituents including alkalinity and disinfectant byproducts served as indicators of municipal water remaining in the system since the rainwater source does not contain these constituents. In the treated rainwater, microbial proliferation and Legionella spp. gene copy numbers were often three logs higher than those in municipal water. Because of differences in source water chemistry, rainwater and municipal water uniquely interacted with building plumbing and generated distinctively different drinking water chemical and microbial quality profiles.

Juniper and immortelle essential oils synergistically inhibit adhesion of nontuberculous mycobacteria to Acanthamoeba castellanii

Acanthamoeba is an opportunistic protozoon, widespread in the aquatic environment, where it can be in endosymbiosis with over 30 pathogenic bacteria, including nontuberculous mycobacteria (NTM). Protozoa play a crucial role in mycobacterial pathogenesis and serve as a reservoir of infection. Since the first step in bacteria making contact with amoebae is adhesion, we were interested in investigating whether essential oils (EOs) can affect it. To that end we investigated the effects of juniper (Juniperus communis) and immortelle (Helichrysum italicum) EOs against Mycobacterium avium, M. intracellulare, and M. gordonae in tap water and against their adhesion to Acanthamoeba castellanii by combining them in synergistic EO concentrations. M. avium and M. intracellulare adhered to A. castellanii to a greater extent than M. gordonae. The adhesion of all NTMs was prevented by the subinhibitory concentrations of EOs. When comparing the effect of synergistic combinations of EOs and the effect of a single concentration from a combination, a higher percentage of adhesion inhibition in all synergistic combinations observed, except against M. gordonae. Neither oil was cytotoxic to A. castellanii. Our findings suggest that the EOs or their components weaken the contact of environmental NTMs and free-living amoebae and indirectly diminish their pathogenic potential, which could be of value in developing strategies for maintenance of water supply systems.

Genetic and physiological analysis of biofilm formation on different plastic surfaces by Sphingomonas sp. strain S2M10 reveals an essential function of sphingan biosynthesis

Alphaproteobacteria belonging to the group of the sphingomonads are frequently found in biofilms colonizing pure-water systems, where they cause technical and hygienic problems. In this study, physiological properties of sphingomonads for biofilm formation on plastic surfaces were analysed. Sphingomonas sp. strain S2M10 was isolated from a used water-filtration membrane and submitted to transposon mutagenesis for isolating mutants with altered biofilm formation. Mutants showing strongly decreased biofilm formation carried transposon insertions in genes for the biosynthesis of the polysaccharide sphingan and for flagellar motility. Flagella-mediated attachment was apparently important for biofilm formation on plastic materials of intermediate hydrophobicity, while a mutant with defect in spnB, encoding the first enzyme in sphingan biosynthesis, showed no biofilm formation on all tested materials. Sphingan-dependent biofilm formation was induced in the presence of specific carbon sources while it was not induced in complex medium with yeast extract and tryptone. The regulation of sphingan-based biofilm formation was investigated by interfering with the CckA/ChpT/CtrA phosphorelay, a central signal-transduction pathway in most Alphaproteobacteria. Construction and ectopic expression of a kinase-deficient histidine kinase CckA caused cell elongation and massive sphingan-dependent cell aggregation. In addition, it caused increased activity of the promotor of spnB. In conclusion, these results indicate that sphingan-based biofilm formation by sphingomonads might be triggered by specific carbon sources under prototrophic conditions resembling a milieu that often prevails in pure-water systems.

Biofilms in premise plumbing systems as a double-edged sword: microbial community composition and functional profiling of biofilms in a tropical region

To understand distributions of opportunistic premise plumbing pathogens (OPPPs) and microbial community structures governed by sample location, pipe materials, water temperature, age of property and type of house, 29 biofilm samples obtained from faucets, pipes, and shower heads in different households in Singapore were examined using next-generation sequencing technology. Predictive functional profiling of the biofilm communities was also performed to understand the potential of uncultivated microorganisms in premise plumbing systems and their involvement in various metabolic pathways. Microbial community analysis showed Proteobacteria, Bacteroidetes, Acidobacteria, Nitrospira, and Actinobacteria to be the most abundant phyla across the samples which was found to be significantly different when grouped by age of the properties, location, and the type of house. Meanwhile, opportunistic premise plumbing pathogens such as Mycobacterium, Citrobacter, Pseudomonas, Stenotrophomonas, and Methylobacterium were observed from the samples at 0.5% of the total reads. Functional prediction using 16S gene markers revealed the involvement of the biofilm communities in different metabolic pathways like nitrogen metabolism, biodegradation of xenobiotics, and bacterial secretion implying diverse functionalities that are yet to be studied in this environment. This study serves as a preliminary survey on the microbial communities harboring premise plumbing systems in a tropical region like Singapore.

Characterisation of Microbial Community Associated with Different Disinfection Treatments in Hospital hot Water Networks

Many disinfection treatments can be adopted for controlling opportunistic pathogens in hospital water networks in order to reduce infection risk for immunocompromised patients. Each method has limits and strengths and it could determine modifications on bacterial community. The aim of our investigation was to study under real-life conditions the microbial community associated with different chemical (monochloramine, hydrogen peroxide, chlorine dioxide) and non-chemical (hyperthermia) treatments, continuously applied since many years in four hot water networks of the same hospital. Municipal cold water, untreated secondary, and treated hot water were analysed for microbiome characterization by 16S amplicon sequencing. Cold waters had a common microbial profile at genera level. The hot water bacterial profiles differed according to treatment. Our results confirm the effectiveness of disinfection strategies in our hospital for controlling potential pathogens such as Legionella, as the investigated genera containing opportunistic pathogens were absent or had relative abundances ≤1%, except for non-tuberculous mycobacteria, Sphingomonas, Ochrobactrum and Brevundimonas. Monitoring the microbial complexity of healthcare water networks through 16S amplicon sequencing is an innovative and effective approach useful for Public Health purpose in order to verify possible modifications of microbiota associated with disinfection treatments.

Estimates of healthcare utilisation and deaths from waterborne pathogen exposure in Ontario, Canada

Burden of disease analyses can quantify the relative impact of different exposures on population health outcomes. Gastroenteritis where the causative pathogen was not determined and respiratory illness resulting from exposure to opportunistic pathogens transmitted by water aerosols have not always been considered in waterborne burden of disease estimates. We estimated the disease burden attributable to nine enteric pathogens, unspecified pathogens leading to gastroenteritis, and three opportunistic pathogens leading primarily to respiratory illness, in Ontario, Canada (population ~14 million). Employing a burden of disease framework, we attributed a fraction of annual (year 2016) emergency department (ED) visits, hospitalisations and deaths to waterborne transmission. Attributable fractions were developed from the literature and clinical input, and unattributed disease counts were obtained using administrative data. Our Monte Carlo simulation reflected uncertainty in the inputs. The estimated mean annual attributable rates for waterborne diseases were (per 100 000 population): 69 ED visits, 12 hospitalisations and 0.52 deaths. The corresponding 5th–95th percentile estimates were (per 100 000 population): 13–158 ED visits, 5–22 hospitalisations and 0.29–0.83 deaths. The burden of disease due to unspecified pathogens dominated these rates: 99% for ED visits, 63% for hospitalisations and 40% for deaths. However, when a causative pathogen was specified, the majority of hospitalisations (83%) and deaths (97%) resulted from exposure to the opportunistic pathogens Legionella spp., non-tuberculous mycobacteria and Pseudomonas spp. The waterborne disease burden in Ontario indicates the importance of gastroenteritis not traced back to a particular pathogen and of opportunistic pathogens transmitted primarily through contact with water aerosols.

Methylobacterium spp. as Emerging Opportunistic Premise Plumbing Pathogens

Methylobacterium spp. are emerging opportunistic premise plumbing pathogens. Human infections linked to premise plumbing provide evidence of their routes of infection. Cells of a collection of representative strains of different Methylobacterium species were tested for hydrophobicity by contact angle, adherence and biofilm formation on different plumbing materials, and temperature tolerance (50–60 °C); characteristics shared by OPPPs. Methylobacterium spp. strains were shown to grow in drinking water, have high cell-surface hydrophobicity, adhere to pipe surface materials, form biofilms, and survive exposure to high (60° C) temperatures. It can be concluded that Methylobacterium spp. strains share traits in common with other opportunistic premise plumbing pathogens (OPPPs).

Revisiting John Snow to Meet the Challenge of Nontuberculous Mycobacterial Lung Disease

Nontuberculous mycobacteria (NTM) are ubiquitous components of the soil and surface water microbiome. Disparities by sex, age, and geography demonstrate that both host and environmental factors are key determinants of NTM disease in populations, which predominates in the form of chronic pulmonary disease. As the incidence of NTM pulmonary disease rises across the United States, it becomes increasingly evident that addressing this emerging human health issue requires a bold, multi-disciplinary research framework that incorporates host risk factors for NTM pulmonary disease alongside the determinants of NTM residence in the environment. Such a framework should include the assessment of environmental characteristics promoting NTM growth in soil and surface water, detailed evaluations of water distribution systems, direct sampling of water sources for NTM contamination and species diversity, and studies of host and bacterial factors involved in NTM pathogenesis. This comprehensive approach can identify intervention points to interrupt the transmission of pathogenic NTM species from the environment to the susceptible host and to reduce NTM pulmonary disease incidence.

Reverse QMRA as a Decision Support Tool: Setting Acceptable Concentration Limits for Pseudomonas aeruginosa and Naegleria fowleri

Opportunistic premise plumbing pathogens such as Pseudomonas aeruginosa and Naegleria fowleri are a growing concern in building water systems because of their potential risks to human health. The aim of this study was to determine the critical concentrations of P. aeruginosa and N. fowleri in water that are associated with meaningful public health risks. To determine these concentrations, a reverse quantitative microbial risk assessment (QMRA) was conducted. Environmental concentrations of P. aeruginosa and N. fowleri corresponding to the risk target of one micro-disability-adjusted life year (DALY) per person per year and 10−4 annual risks of illness were calculated for several applicable exposure scenarios. To calculate the concentration of P. aeruginosa, cleaning contact lenses with potentially contaminated tap water in the absence of an appropriate cleaning solution was considered. For N. fowleri, two exposure scenarios, recreational exposure (swimming) and nasal cleansing (via the use of a neti pot™ or similar device) were considered. The highest critical concentration for P. aeruginosa was found to be 33 CFU/L with a 95% confidence interval of (2.0, 118) for the drop exposure scenario using the 10−4 annual risk target. For N. fowleri, based on the DALY approach, critical concentrations were 0.000030 N. fowleri/L for swimming and 0.00000060 N. fowleri/L for neti pot™ use scenario. Considering heat inactivation, the critical concentration limits for P. aeruginosa using the DALY approach and the 10−4 annual risk target approach were found to be 0.55 CFU/L and 55 CFU/L, respectively. For N. fowleri, the 10−4 annual risk target approach resulted in 0.022 N. fowleri/L and the DALY approach resulted in 0.00000064 N. fowleri/L for the neti pot™ scenario. For P. aeruginosa, N50 (the median infective dose) and alpha (α) contributed the most and contact rates the least to the variability and uncertainty of the estimates for all the scenarios. For N. fowleri, N50 and contact rates contributed the most and α the least to the variability and uncertainty to calculate the concentrations for all the scenarios. The QMRA framework implemented in this research can be used to incorporate more information regarding opportunistic pathogens to inform management decisions, and to prioritize the best interventions regarding estimated reduction in infections caused by opportunistic pathogens.

Mycobacterial metabolic characteristics in a water meter biofilm revealed by metagenomics and metatranscriptomics

Mycobacteria represent one of the most persistent bacterial populations in drinking water distribution system (DWDS) biofilm communities; however, mycobacterial in situ metabolic profiles are largely unknown. In this study, the metabolic characteristics of mycobacteria in a household water meter biofilm were unveiled using a coupled metagenomic/metatranscriptomic approach. The water meter biofilm appeared to express nitrogenase genes (nifDKH) and a full complement of genes coding for several carbon-fixation pathways, especially the Calvin cycle, suggesting the CO₂ sequestration and dinitrogen fixation potential of the biofilm. These findings indicate that it may be difficult to prevent the formation of DWDS biofilms simply by controlling the availability of organic carbon or nitrogen. The composite genome of mycobacteria (CG-M) was reconstructed based on the obtained omics data. CG-M shared similar genome phylogeny and virulence-factor profiles with Mycobacterium avium complex, suggesting that population CG-M might represent a member of mycobacteria with pathogenicity. According to the gene expression patterns, population CG-M showed the metabolic potential to assimilate CO₂ via the Calvin cycle and/or anaplerotic reactions, and even to grow autotrophically with CO as the sole carbon and energy source. This suggests that organic carbon may not be a limiting factor for mycobacterial growth in DWDSs. Moreover, our results suggest that mycobacterial aromatic degradation is primarily achieved through the catechol meta-cleavage pathway, and biofilm mycobacteria could prefer phosphate as the phosphorus source.

Synergistic potential of Juniperus communis and Helichrysum italicum essential oils against nontuberculous mycobacteria

OBJECTIVE

The present study evaluated the possible synergistic antimycobacterial interactions of Juniperus communis and Helichrysum italicum essential oils (EO).

METHODS

Antimycobacterial potential was tested against Mycobacterium avium and Mycobacterium intracellulare using broth and water dilution method and checkerboard synergy method. Antiadhesion and antibiofilm effect of EOs was evaluated on biotic (HeLa cells) and abiotic surface (polystyrene). To evaluate the possible mechanisms of action, cellular leakage of proteins and DNA was tested and structural changes were visualized with a transmission electron microscope.

RESULTS

MIC, minimum bactericidal concentration (MBC) and minimal effective concentration (MEC) were 1.6 mg ml^-1 for J. communis EO and 3.2 mg ml^-1 for H. italicum EO against both mycobacteria. All combinations of EOs in checkerboard synergy method produced fractional inhibitory concentration index values ranging from 0.501 to 1.5, corresponding to synergistic, additive or indifferent effects. Mycobacterium avium showed a greater tendency to create biofilm but these EOs at subinhibitory concentrations (sMIC) effectively blocked the adhesion and the establishment of biofilm. The exposure of both mycobacteria to MICs and sMICs lead to significant morphological changes: acquired a swollen form, ghost-like cell, disorganized cytoplasm detached from the cell wall. OD value of supernatant for both mycobacteria exposed to EOs have confirmed that there is a leakage of cellular material.

CONCLUSION

The leakage of the cellular material is noticeably higher in sMIC, which is probably due to cell wall damage. sMIC of both EOs have an additive or synergistic effect, reducing MICs, limiting adhesion and preventing the formation of biofilms.

Impact of blending for direct potable reuse on premise plumbing microbial ecology and regrowth of opportunistic pathogens and antibiotic resistant bacteria

Little is known about how introducing recycled water intended for direct potable reuse (DPR) into distribution systems and premise plumbing will affect water quality at the point of use, particularly with respect to effects on microbial communities and regrowth. The examination of potential growth of opportunistic pathogens (OPs) and spread of antibiotic resistance genes (ARGs), each representing serious and growing public health concerns, by introducing DPR water has not previously been evaluated. In this study, the impact of blending purified DPR water with traditional drinking water sources was investigated with respect to treatment techniques, blending location, and blending ratio. Water from four U.S. utility partners was treated in bench- and pilot-scale treatment trains to simulate DPR with blending. Water was incubated in simulated premise plumbing rigs made of PVC pipe containing brass coupons to measure regrowth of total bacteria (16S rRNA genes, heterotrophic plate count), OPs (Legionella spp., Mycobacterium spp., Pseudomonas aeruginosa), ARGs (qnrA, vanA), and an indicator of horizontal gene transfer and multi-drug resistance (intI1). The microbial community composition was profiled and the resistome (i.e., all ARGs present) was characterized in select samples using next generation sequencing. While regrowth of total bacteria (16S rRNA genes) from the start of the incubation through week eight consistently occurred across tested scenarios (Wilcoxon, p ≤ 0.0001), total bacteria were not more abundant in the water or biofilm of any DPR scenario than in the corresponding conventional potable condition (p ≥ 0.0748). Regrowth of OP marker genes, qnrA, vanA, and intI1 were not significantly greater in water or biofilm for any DPR blends treated with advanced oxidation compared to corresponding potable water (p ≥ 0.1047). This study of initial bacteria colonizing pipes after introduction of blended DPR water revealed little evidence (i.e., one target in one water type) of exacerbated regrowth of total bacteria, OPs, or ARGs in premise plumbing.

Shotgun Metagenomics Reveals Taxonomic and Functional Shifts in Hot Water Microbiome Due to Temperature Setting and Stagnation

Hot water premise plumbing has emerged as a critical nexus of energy, water, and public health. The composition of hot water microbiomes is of special interest given daily human exposure to resident flora, especially opportunistic pathogens (OPs), which rely on complex microbial ecological interactions for their proliferation. Here, we applied shotgun metagenomic sequencing to characterize taxonomic and functional shifts in microbiomes as a function of water heater temperature setting, stagnation in distal pipes, and associated shifts in water chemistry. A cross-section of samples from controlled, replicated, pilot-scale hot water plumbing rigs representing different temperature settings (39, 42, and 51°C), stagnation periods (8 h vs. 7 days), and time-points, were analyzed. Temperature setting exhibited an overarching impact on taxonomic and functional gene composition. Further, distinct taxa were selectively enriched by specific temperature settings (e.g., Legionella at 39°C vs. Deinococcus at 51°C), while relative abundances of genes encoding corresponding cellular functions were highly consistent with expectations based on the taxa driving these shifts. Stagnation in distal taps diminished taxonomic and functional differences induced by heating the cold influent water to hot water in recirculating line. In distal taps relative to recirculating hot water, reads annotated as being involved in metabolism and growth decreased, while annotations corresponding to stress response (e.g., virulence disease and defense, and specifically antibiotic resistance) increased. Reads corresponding to OPs were readily identified by metagenomic analysis, with L. pneumophila reads in particular correlating remarkably well with gene copy numbers measured by quantitative polymerase chain reaction. Positive correlations between L. pneumophila reads and those of known protozoan hosts were also identified. Elevated proportions of genes encoding metal resistance and hydrogen metabolism were noted, which was consistent with elevated corrosion-induced metal concentrations and hydrogen generation. This study provided new insights into real-world factors influencing taxonomic and functional compositions of hot water microbiomes. Here metagenomics is demonstrated as an effective tool for screening for potential presence, and even quantities, of pathogens, while also providing diagnostic capabilities for assessing functional responses of microbiomes to various operational conditions. These findings can aid in informing future monitoring and intentional control of hot water microbiomes.

Microbial Ecology and Water Chemistry Impact Regrowth of Opportunistic Pathogens in Full-Scale Reclaimed Water Distribution Systems

Need for global water security has spurred growing interest in wastewater reuse to offset demand for municipal water. While reclaimed (i.e., nonpotable) microbial water quality regulations target fecal indicator bacteria, opportunistic pathogens (OPs), which are subject to regrowth in distribution systems and spread via aerosol inhalation and other noningestion routes, may be more relevant. This study compares the occurrences of five OP gene markers ( Acanthamoeba spp., Legionella spp., Mycobacterium spp., Naegleria fowleri, Pseudomonas aeruginosa) in reclaimed versus potable water distribution systems and characterizes factors potentially contributing to their regrowth. Samples were collected over four sampling events at the point of compliance for water exiting treatment plants and at five points of use at four U.S. utilities bearing both reclaimed and potable water distribution systems. Reclaimed water systems harbored unique water chemistry (e.g., elevated nutrients), microbial community composition, and OP occurrence patterns compared to potable systems examined here and reported in the literature. Legionella spp. genes, Mycobacterium spp. genes, and total bacteria, represented by 16S rRNA genes, were more abundant in reclaimed than potable water distribution system samples ( p ≤ 0.0001). This work suggests that further consideration should be given to managing reclaimed water distribution systems with respect to nonpotable exposures to OPs.

Effects of phosphate-enhanced ozone/biofiltration on formation of disinfection byproducts and occurrence of opportunistic pathogens in drinking water distribution systems

The effects of ozone-biologically activated carbon (O₃-BAC) treatment with various phosphate doses (0, 0.3 or 0.6 mg/L) were investigated on the formation of disinfection by-products (DBPs) and occurrence of opportunistic pathogens (OPs) in drinking water distribution systems (DWDSs) simulated by annular reactors (ARs). It was found that the lowest DBPs and the highest inactivation of OPs such as Mycobacterium spp., Mycobacterium avium, Aeromonas spp., Pseudomonas aeruginosa and Hartmanella vermiformis, occurred in the effluent of the AR with 0.6 mg/L phosphate addition. Based on the results of different characterization techniques, for the AR with 0.6 mg/L phosphate-enhanced O₃-BAC treatment, dissolved organic carbon in the influent exhibited the lowest concentration and most stable fraction due to the improved biodegradation effect. Moreover, the total amount of suspended extracellular polymeric substances (EPS) in the bulk water of the AR decreased greatly, resulting in the lowest chlorine consumption and DBPs formation in the AR. In Fourier transform infrared spectra of the suspended EPS, the amide II band (1600-1500 cm^-1) disappeared and the protein/polysaccharide ratio decreased remarkably, indicating the destruction of protein and a decrease in hydrophobicity. Moreover, β-sheets and α-helices in the protein secondary structures were degraded while the random coils increased sharply as phosphate addition increased to 0.6 mg/L, inhibiting microbial aggregation and hence weakening the chlorine-resistance capability. Thus, most of the OPs in suspended biofilms were more easily inactivated by residual chlorine, resulting in the lowest OPs occurrence in the effluent of the AR. Our findings indicated that enhancing the efficiency of the BAC filter by adding phosphate is a promising method for improving water quality in DWDSs.