Opportunistic Premise Plumbing Pathogens: Increasingly Important Pathogens in Drinking Water

Can free chlorine residuals entering building plumbing systems really be maintained to prevent microbial growth?

Secondary disinfection aims to prevent microbial regrowth during distribution by maintaining disinfectant residuals in water systems. However, multi-factorial interactions contribute to free chlorine decay in distribution systems, and even more so in building plumbing. Assembling 1737 samples from nine large institutional buildings, a meta-analysis was conducted to determine whether building managers can actively rely on incoming free chlorine residuals to prevent in-building microbial amplification. Findings showed that free chlorine concentrations in first draws met the 0.2 mg/L common guide level in respectively 26 %, 6 % and 2 % of cold, tepid and hot water samples, whereas flushing for 2-60 min only significantly increased this ratio in cold water (83 %), without reaching background levels found in service lines. Free chlorine was significantly but weakly (R≤ 0.2) correlated to adenosine triphosphate, heterotrophic plate count and total and intact cell counts, thus evidencing that residuals contributed to decreased culturable and viable biomass. Detection of culturable Legionella pneumophila spanning over a 4-log distribution solely occurred when free chlorine levels were below 0.2 mg/L, but no such trend could be distinguished clearly for culturable Pseudomonas aeruginosa. Water temperatures below 20 °C and >60 °C also completely prevented L. pneumophila detection. Overall, the majority of elevated microbial counts were measured in distal sites and in tepid and hot water, where free chlorine is less likely to be present due to stagnation and increased temperature. Therefore, building managers cannot solely rely on this chemical barrier to mitigate bacterial growth in bulk water.

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.

Linkage of in-refrigerator water dispensing systems to elevated exposure to microbial contamination at the microbiome scale

In-refrigerator water dispensing systems are ubiquitous in residential homes with tap water as the inflow. Passage through these systems resulted in significant microbial growth in the water, with the abundance of potential opportunistic pathogens Mycobacterium and Pseudomonas increasing by 8,053- and 221-fold, respectively. Elevated exposure to microbial contaminants linked to in-refrigerator water dispensing systems may represent a significant public health concern.

Increased flushing frequency of a model plumbing system initially promoted the formation of viable but non culturable cells but ultimately reduced the concentration of culturable and total Legionella DNA

Legionella is the causative agent of Legionnaires' disease, and its prevalence in potable water is a significant public health issue. Water stagnation within buildings increases the risk of Legionella. However, there are limited studies investigating how stagnation arising through intermittent usage affects Legionella proliferation and the studies that are available do not consider viable but non culturable (VBNC) Legionella. This study used a model plumbing system to examine how intermittent water stagnation affects both VBNC and culturable Legionella. The model plumbing system contained a water tank supplying two biofilm reactors. The model was initially left stagnant for ≈5 months (147 days), after which one reactor was flushed daily, and the other weekly. Biofilm coupons, and water samples were collected for analysis at days 0, 14 and 28. These samples were analysed for culturable and VBNC Legionella, free-living amoebae, and heterotrophic bacteria. After 28 days, once-a-day flushing significantly (p < 0.001) reduced the amount of biofilm-associated culturable Legionella (1.5 log10 reduction) compared with weekly flushing. However, higher counts of biofilm-associated VBNC Legionella (1 log10 higher) were recovered from the reactor with once-a-day flushing compared with weekly flushing. Likewise, once-a-day flushing increased the population of biofilm-associated Vermamoeba vermiformis (approximately 3 log10 higher) compared with weekly flushing, which indicated a positive relationship between VBNC Legionella and V. vermiformis. This is the first study to investigate the influence of stagnation on VBNC Legionella under environmental conditions. Overall, this study showed that a reduction in water stagnation decreased culturable Legionella but not VBNC Legionella.

An outbreak of Legionnaires' disease linked to a municipal and industrial wastewater treatment plant, The Netherlands, September-October 2022

Wastewater treatment plants (WWTPs) are increasingly identified as Legionnaires' disease (LD) sources. An outbreak investigation was initiated following five LD cases reported in September 2022 in Houten, the Netherlands. Case identification was based on the European LD case definition, with symptom onset from 1 September 2022, residence in or within 5 km of Houten, or visit to Houten within the incubation period, without other likely sources. We sampled potential sources and genotyped environmental and clinical isolates. We identified 15 LD cases with onset between 13 September and 23 October 2022. A spatial source identification and wind direction model suggested an industrial (iWWTP) and a municipal WWTP (mWWTP) as potential sources, with the first discharging water into the latter. Both tested positive for Legionella pneumophila serogroups 1 and 6 with multiple sequence types (ST). We detected L. pneumophila sg1 ST42 in the mWWTP, matching with one of three available clinical isolates. Following control measures at the WWTPs, no further cases were observed. This outbreak underlines that municipal and industrial WWTPs can play an important role in community LD cases and outbreaks, especially those with favourable conditions for Legionella growth and dissemination, or even non-favourable conditions for growth but with the influx of contaminated water.

Occurrences and implications of pathogenic and antibiotic-resistant bacteria in different stages of drinking water treatment plants and distribution systems

Different stages of drinking water treatment plants (DWTPs) play specific roles in diverse contaminants' removal present in natural water sources. Although the stages are recorded to promote adequate treatment of water, the occurrence of pathogenic bacteria (PB) and antibiotic-resistant bacteria (ARB) in the treated water and the changes in their diversity and abundance as it passed down to the end users through the drinking water distribution systems (DWDSs), is a great concern, especially to human health. This could imply that the different stages and the distribution system provide a good microenvironment for their growth. Hence, it becomes pertinent to constantly monitor and document the diversity of PB and ARB present at each stage of the treatment and distribution system. This review aimed at documenting the occurrence of PB and ARB at different stages of treatment and distribution systems as well as the implication of their occurrence globally. An exhaustive literature search from Web of Science, Science-Direct database, Google Scholar, Academic Research Databases like the National Center for Biotechnology Information, Scopus, and SpringerLink was done. The obtained information showed that the different treatment stages and distribution systems influence the PB and ARB that proliferate. To minimize the human health risks associated with the occurrence of these PB, the present review, suggests the development of advanced technologies that can promote quick monitoring of PB/ARB at each treatment stage and distribution system as well as reduction of the cost of environomics analysis to promote better microbial analysis.

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.

High-Throughput Short Sequence Typing Schemes for Pseudomonas aeruginosa and Stenotrophomonas maltophilia Pure Culture and Environmental DNA

Molecular typing techniques are utilized to determine genetic similarities between bacterial isolates. However, the use of environmental DNA profiling to assess epidemiologic links between patients and their environment has not been fully explored. This work reports the development and validation of two high-throughput short sequence typing (HiSST) schemes targeting the opportunistic pathogens Pseudomonas aeruginosa and Stenotrophomonas maltophilia, along with a modified SM2I selective medium for the specific isolation of S. maltophilia. These HiSST schemes are based on four discriminative loci for each species and demonstrate high discriminating power, comparable to pairwise whole-genome comparisons. Each scheme includes species-specific PCR primers for precise differentiation from closely related taxa, without the need for upstream culture-dependent methods. For example, the primers targeting the bvgS locus make it possible to distinguish P. aeruginosa from the very closely related Pseudomonas paraeruginosa sp. nov. The selected loci included in the schemes are adapted to massive parallel amplicon sequencing technology. An R-based script implemented in the DADA2 pipeline was assembled to facilitate HiSST analyses for efficient and accurate genotyping of P. aeruginosa and S. maltophilia. We demonstrate the performance of both schemes through in silico validations, assessments against reference culture collections, and a case study involving environmental samples.

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.

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.

The Role of Chlorine in the Formation and Development of Tap Water Biofilms under Different Flow Regimes

Water companies make efforts to reduce the risk of microbial contamination in drinking water. A widely used strategy is to introduce chlorine into the drinking water distribution system (DWDS). A subtle potential risk is that non-lethal chlorine residuals may select for chlorine resistant species in the biofilms that reside in DWDS. Here, we quantify the thickness, density, and coverage of naturally occurring multi-species biofilms grown on slides in tap water with and without chlorine, using fluorescence microscopy. We then place the slides in an annular rotating reactor and expose them to fluid-wall shears, which are redolent of those on pipe walls in DWDS. We found that biofilms in chlorine experiment were thicker, denser and with higher coverage than in non-chlorine conditions under all flow regimes and during incubation. This suggests that the formation and development of biofilms was promoted by chlorine. Surprisingly, for both chlorinated and non-chlorinated conditions, biofilm thickness, density and coverage were all positively correlated with shear stress. More differences were detected in biofilms under the different flow regimes in non-chlorine than in chlorine experiments. This suggests a more robust biofilm under chlorine conditions. While this might imply less mobilization of biofilms in high shear events in pipe networks, it might also provide refuge from chlorine residuals for pathogens.

Assessing residential activity in a home plumbing system simulator: monitoring the occurrence and relationship of major opportunistic pathogens and phagocytic amoebas

Opportunistic premise plumbing pathogens (OPPPs) have been detected in buildings' plumbing systems causing waterborne disease outbreaks in the United States. In this study, we monitored the occurrence of OPPPs along with free-living amoeba (FLA) and investigated the effects of residential activities in a simulated home plumbing system (HPS). Water samples were collected from various locations in the HPS and analyzed for three major OPPPs: Legionella pneumophila, nontuberculous mycobacterial species (e.g., Mycobacterium avium, M. intracellulare, and M. abscessus), and Pseudomonas aeruginosa along with two groups of amoebas (Acanthamoeba and Vermamoeba vermiformis). A metagenomic approach was also used to further characterize the microbial communities. Results show that the microbial community is highly diverse with evidence of spatial and temporal structuring influenced by environmental conditions. L. pneumophila was the most prevalent pathogen (86% of samples), followed by M. intracellulare (66%) and P. aeruginosa (21%). Interestingly, M. avium and M. abscessus were not detected in any samples. The data revealed a relatively low prevalence of Acanthamoeba spp. (4%), while V. vermiformis was widely detected (81%) across all the sampling locations within the HPS. Locations with a high concentration of L. pneumophila and M. intracellulare coincided with the highest detection of V. vermiformis, suggesting the potential growth of both populations within FLA and additional protection in drinking water. After a period of stagnation lasting at least 2-weeks, the concentrations of OPPPs and amoeba immediately increased and then decreased gradually back to the baseline. Furthermore, monitoring the microbial population after drainage of the hot water tank and partial drainage of the entire HPS demonstrated no significant mitigation of the selected OPPPs. This study demonstrates that these organisms can adjust to their environment during such events and may survive in biofilms and/or grow within FLA, protecting them from stressors in the supplied 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.

The composition of planktonic prokaryotic communities in a hospital building water system depends on both incoming water and flow dynamics

In recent years, the frequency of nosocomial infections has increased. Hospital water systems support the growth of microbes, especially opportunistic premise plumbing pathogens. In this study, planktonic prokaryotic communities present in water samples taken from hospital showers and hand basins, collected over three different sampling phases, were characterized by 16S rRNA gene amplicon sequencing. Significant differences in the abundance of various prokaryotic taxa were found through univariate and multivariate analysis. Overall, the prokaryotic communities of hospital water were taxonomically diverse and dominated by biofilm forming, corrosion causing, and potentially pathogenic bacteria. The phyla Proteobacteria, Actinobacteriota, Bacteroidota, Planctomycetota, Firmicutes, and Cyanobacteria made up 96% of the relative abundance. The α-diversity measurements of prokaryotic communities showed no difference in taxa evenness and richness based on sampling sites (shower or hand basins), sampling phases (months), and presence or absence of Vermamoeba vermiformis. However, β-diversity measurements showed significant clustering of prokaryotic communities based on sampling phases, with the greatest difference observed between the samples collected in phase 1 vs phase 2/3. Importantly, significant difference was observed in prokaryotic communities based on flow dynamics of the incoming water. The Pielou's evenness diversity index revealed a significant difference (Kruskal Wallis, p < 0.05) and showed higher species richness in low flow regime (< 13 minutes water flushing per week and ≤ 765 flushing events per six months). Similarly, Bray-Curtis dissimilarity index found significant differences (PERMANOVA, p < 0.05) in the prokaryotic communities of low vs medium/high flow regimes. Furthermore, linear discriminant analysis effect size showed that several biofilm forming (e.g., Pseudomonadales), corrosion causing (e.g., Desulfobacterales), extremely environmental stress resistant (e.g., Deinococcales), and potentially pathogenic (e.g., Pseudomonas) bacterial taxa were in higher amounts under low flow regime conditions. This study demonstrated that a hospital building water system consists of a complex microbiome that is shaped by incoming water quality and the building flow dynamics arising through usage.

The Many Hosts of Mycobacteria 9 (MHM9): A conference report

The Many Hosts of Mycobacteria (MHM) meeting series brings together basic scientists, clinicians and veterinarians to promote robust discussion and dissemination of recent advances in our knowledge of numerous mycobacterial diseases, including human and bovine tuberculosis (TB), nontuberculous mycobacteria (NTM) infection, Hansen's disease (leprosy), Buruli ulcer and Johne's disease. The 9th MHM conference (MHM9) was held in July 2022 at The Ohio State University (OSU) and centered around the theme of "Confounders of Mycobacterial Disease." Confounders can and often do drive the transmission of mycobacterial diseases, as well as impact surveillance and treatment outcomes. Various confounders were presented and discussed at MHM9 including those that originate from the host (comorbidities and coinfections) as well as those arising from the environment (e.g., zoonotic exposures), economic inequality (e.g. healthcare disparities), stigma (a confounder of leprosy and TB for millennia), and historical neglect (a confounder in Native American Nations). This conference report summarizes select talks given at MHM9 highlighting recent research advances, as well as talks regarding the historic and ongoing impact of TB and other infectious diseases on Native American Nations, including those in Southwestern Alaska where the regional TB incidence rate is among the highest in the Western hemisphere.

Legionella detection in wastewater treatment plants with increased risk for Legionella growth and emission

Legionnaires' disease (LD) is a severe pneumonia mainly caused by the bacterium Legionella pneumophila. Although many environmental sources of LD have been described, the sources of the majority of non-outbreak LD cases have not been identified. In several outbreaks in the Netherlands, wastewater treatment plants (WWTPs) were identified as the most likely source of infection. In this study, four criteria for Legionella growth and emission to air and surface waters were selected based on the literature and a risk matrix was drafted. An inventory was made of all WWTPs and their characteristics in the Netherlands. The risk matrix was applied to identify WWTPs at risk for Legionella growth and emission. Wastewater was collected at WWTPs with moderate to high risk for Legionella growth and emission. In 18% of the sampled WWTPs, Legionella spp. was detected using culture methods. The presented risk matrix can be used to assess the risks of Legionella growth and emission for WWTPs and support surveillance by prioritizing WWTPs. When Legionella is detected in the wastewater, it is recommended to take action to prevent emission to air or discharge on surface waters and, if possible, reduce the Legionella concentration.

Mycobacterial contamination in tap and shower waters in Thailand

Waterborne disease is increasingly becoming associated with opportunistic premise plumbing pathogens (OPPPs), which can resist residual chlorination, regrow throughout drinking water distribution systems, and colonize premise plumbing. Nontuberculous mycobacteria (NTM) include clinically important species and exert a high burden on healthcare systems. We briefly report a qPCR-based survey of Mycobacterium spp. numbers in tap, POU-treated, and shower waters from Bangkok, Thailand. Non-stagnant tap waters and non-stagnant shower waters had mean numbers of 1.3 × 103 and 2.4 × 103 copies/mL, respectively. Water stagnation resulted in mean numbers higher by up to 1.0 log. The lowest number, 25 copies/mL, was obtained from a POU-treated sample, while the highest number, 2.0 × 104 copies/mL, came from a stagnant tap. Comparing with international data, mean numbers in this study were greater than those in nine out of 11 (82%) comparable studies, and the maximum numbers in this study were also high. Our samples of Bangkok waters exhibited relatively high Mycobacterium spp. numbers, suggesting the need for appropriate POU treatment systems where NTM infection is a health concern. This survey data can be used to set inactivation performance targets in POU water disinfection system design and may also lead to quantitative microbial risk assessment (QMRA) studies.

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

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

Building water quality deterioration during water supply restoration after interruption: Influences of premise plumbing configuration

Premise plumbing plays an essential role in determining the final quality of drinking water consumed by customers. However, little is known about the influences of plumbing configuration on water quality changes. This study selected parallel premise plumbing in the same building with different configurations, i.e., laboratory and toilet plumbing. Water quality deteriorations induced by premise plumbing under regular and interrupted water supply were investigated. The results showed that most of the water quality parameters did not vary under regular supply, except Zn, which was significantly increased by laboratory plumbing (78.2 to 260.7 µg/l). For the bacterial community, the Chao1 index was significantly increased by both plumbing types to a similar level (52 to 104). Laboratory plumbing significantly changed the bacterial community, but toilet plumbing did not. Remarkably, water supply interruption/restoration led to serious water quality deterioration in both plumbing types but resulted in different changes. Physiochemically, discoloration was observed only in laboratory plumbing, along with sharp increases in Mn and Zn. Microbiologically, the increase in ATP was sharper in toilet plumbing than in laboratory plumbing. Some opportunistic pathogen-containing genera, e.g., Legionella spp. and Pseudomonas spp., were present in both plumbing types but only in disturbed samples. This study highlighted the esthetic, chemical, and microbiological risks associated with premise plumbing, for which system configuration plays an important role. Attention should be given to optimizing premise plumbing design for managing building water quality.

Conceptual model to inform Legionella-amoebae control, including the roles of extracellular vesicles in engineered water system infections

Extracellular vesicles (EVs or exosomes) are well described for bacterial pathogens associated with our gastrointestinal system, and more recently as a novel mechanism for environmental persistence, dissemination and infection for human enteric viruses. However, the roles played by EVs in the ancient arms race that continues between amoebae and one of their prey, Legionella pneumophila, is poorly understood. At best we know of intracellular vesicles of amoebae containing a mix of bacterial prey species, which also provides an enhanced niche for bacteriophage infection/spread. Free-living amoeba-associated pathogens have recently been recognized to have enhanced resistance to disinfection and environmental stressors, adding to previously understood (but for relatively few species of) bacteria sequestered within amoebal cysts. However, the focus of the current work is to review the likely impacts of large numbers of respiratory-sized EVs containing numerous L. pneumophila cells studied in pure and biofilm systems with mixed prey species. These encapsulated pathogens are orders of magnitude more resistant to disinfection than free cells, and our engineered systems with residual disinfectants could promote evolution of resistance (including AMR), enhanced virulence and EV release. All these are key features for evolution within a dead-end human pathogen post lung infection. Traditional single-hit pathogen infection models used to estimate the probability of infection/disease and critical environmental concentrations via quantitative microbial risk assessments may also need to change. In short, recognizing that EV-packaged cells are highly virulent units for transmission of legionellae, which may also modulate/avoid human host immune responses. Key data gaps are raised and a previous conceptual model expanded upon to clarify where biofilm EVs could play a role promoting risk as well as inform a more wholistic management program to proactively control legionellosis.

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.

Mechanisms of Antibiotic and Biocide Resistance That Contribute to Pseudomonas aeruginosa Persistence in the Hospital Environment

Pseudomonas aeruginosa is an opportunistic bacterial pathogen responsible for multiple hospital- and community-acquired infections, both in human and veterinary medicine. P. aeruginosa persistence in clinical settings is worrisome and is a result of its remarkable flexibility and adaptability. This species exhibits several characteristics that allow it to thrive under different environmental conditions, including the ability to colonize inert materials such as medical equipment and hospital surfaces. P. aeruginosa presents several intrinsic mechanisms of defense that allow it to survive external aggressions, but it is also able to develop strategies and evolve into multiple phenotypes to persevere, which include antimicrobial-tolerant strains, persister cells, and biofilms. Currently, these emergent pathogenic strains are a worldwide problem and a major concern. Biocides are frequently used as a complementary/combination strategy to control the dissemination of P. aeruginosa-resistant strains; however, tolerance to commonly used biocides has also already been reported, representing an impediment to the effective elimination of this important pathogen from clinical settings. This review focuses on the characteristics of P. aeruginosa responsible for its persistence in hospital environments, including those associated with its antibiotic and biocide resistance ability.

Aspects and problems associated with the water services to be considered in intensive care units

Background

Water is a product taken for granted and assumed to be a safe commodity in intensive care units (ICU). Biofilm readily becomes established in complex water services presenting a risk to vulnerable patients. Harboured within biofilms are opportunistic pathogens which can be transmitted via hand contact, splashing, aerosol and indirect contact through medical equipment. Evidence linking the role of water services in transmission of infection to patients in ICUs has increased in recent years.

Aims

This research based commentary set out to identify current problems with water and wastewater systems in ICU settings.

Methods

Databases and open source information was used to obtain data on current water and wastewater-related issues in ICU settings. This and the authors experiences have been used to describe current challenges.

Findings

the authors found a number of problems with water systems in ICU to which there has not been a cohesive response in terms of guidance to support users and designers. The resultant void permits new projects to proceed with suboptimal and designs which place patients and staff at risk.

Discussion

Hand hygiene stations are frequently misused or close enough to patients such that splashing poses a transmission risk. The wastewater system (drain) also presents a risk, from where Gram-negative antibiotic resistant organisms may be dispersed resulting in untreatable patient infections. The water and wastewater system provide a superhighway for the movement of pathogenic microorganisms and these risks need to be addressed if we are to safeguard vulnerable users in ICU.

Microbiological quality of roof tank water in an urban village in southeastern China

Urban villages are unique residential neighborhoods in urban areas in China. Roof tanks are their main form of water supply, and water quality deterioration might occur in this system because of poor hygienic conditions and maintenance. In this study, water samples were seasonally collected from an urban village to investigate the influence of roof tanks as an additional water storage device on the variation in the microbial community structure and pathogenic gene markers. Water stagnation in the roof tank induced significant decreases in chlorine (p < 0.05), residual chlorine was as low as 0.02 mg/L in spring. Propidium monoazide (PMA)-qPCR revealed a one-magnitude higher level of total viable bacterial concentration in roof tank water samples (2.14 ± 1.81 × 10⁵ gene copies/mL) than that in input water samples (3.57 ± 2.90 × 10⁴ gene copies/mL, p < 0.05), especially in spring and summer. In addition, pathogenic fungi, Mycobacterium spp., and Legionella spp. were frequently detected in the roof tanks. Terminal users might be exposed to higher microbial risk induced by high abundance of Legionella gene marker. Spearman's rank correlation and redundancy analysis showed that residual chlorine was the driving force that promoted bacterial colonization and shaped the microbial community. It is worth noted that the sediment in the pipe will be agitated when the water supply is restored after the water outages, which can trigger an increase in turbidity and bacterial biomass. Overall, the findings provide practical suggestions for controlling microbiological health risks in roof tanks in urban villages.

Inactivation kinetics of 280 nm UV-LEDs against Mycobacterium abscessus in water

Nontuberculous mycobacteria (NTM) are opportunistic premise plumbing pathogens (OPPPs) that cause a burdensome waterborne respiratory disease. Due to their resistance to chemical disinfectants and regrowth in biofilms in drinking water distribution systems, treatment can be better performed using small ultraviolet disinfection units at the point-of-use (POU), such as at a tap or showerhead. Ultraviolet light-emitting diodes (UV-LEDs) are well suited for such applications, but fluence-response data are not available for one of the most important NTM, Mycobacterium abscessus. In this study, a bench-scale 280 nm UV-LED apparatus was used to irradiate M. abscessus in a water matrix. The fluence-response profile was sigmoidal, exhibiting both shoulder and tailing phenomena. Simple linear regression and the Geeraerd's inactivation kinetics model yielded k values of 0.36 and 0.37 cm²/mJ, respectively, revealing that M. abscessus is more resistant to UV than Pseudomonas aeruginosa and Legionella pneumophila, which suggests that NTM are among the most UV-resistant OPPPs. Results of this study suggest that 280 nm UV-LED irradiation can be an effective and practical option to inactivate M. abscessus at the POU. Disinfection units that can deliver a fluence of 10 mJ/cm² are expected to achieve nearly 2 log (99%) inactivation of M. abscessus.

Spatiotemporal distribution of opportunistic pathogens and microbial community in centralized rural drinking water: One year survey in China

Centralized water supply in rural areas, supported by small waterworks (small-central mode) and by municipal water treatment plants (urban-extension mode), is an important guarantee to implement the Rural Revitalization Strategy Plan (2018-2022) in China. Opportunistic pathogens (OPs) could not be evaluated by the national drinking water sanitation standards in China (GB 5749-2022), posing potential microbial risks in rural drinking water. In this study, the spatiotemporal distribution of OPs, microbial community and the associated functional composition under two central water supply modes were investigated by molecular approaches. The results indicated that OPs were widely presented in the rural drinking water regardless of water supply modes, and were more abundant than those in the urban tap water. The insufficient residual chlorine and higher turbidity triggered more microbial proliferation, posing a seasonal variation of OPs gene copy numbers and bacterial community compositions. In warm seasons of summer and autumn, the gene copies of E. coli, M. avium, Pseudomonas spp. and the amoeba host Acanthamoeba spp. achieved up to 4.92, 3.94, 6.75 and 3.74 log₁₀ (gene copies/mL), respectively. Potential functional prediction indicated higher relative abundance of pathogenic genes and infectious risks associated with the rural drinking water under small-central water supply mode. This one-year survey of the spatiotemporal distribution of OPs and microbial community provided scientific insights into microbial safety of rural drinking water, prompting attention on small-central water supply mode against OPs risks.

Inaccuracies of the ISO 11731 Method for Environmental Validation of Legionella in Building Water Systems: Opportunities to Improve Sensitivity and Detect Viable but Non-Culturable Legionella

Current environmental diagnostics for the detection of Legionella fail to detect viable but non-culturable Legionella, have sensitivity limitations and are time-consuming (10-14 days to results). The objective of this study was to compare Legionella detection results between the standard ISO 11731 and an innovative Legionella detection method that utilizes a hybrid methodology of traditional microbiology and molecular detection. In this study, four hundred and seventy-six (476) potable building water samples were analyzed with ISO 11731 and the novel method in parallel. Of the 476 total samples that were tested, a discrepancy of 21% was observed when comparing the ISO 11731 method to the novel method. Separating the samples based on hazard control methods yielded a 15.4% discrepancy for chlorinated systems (n = 284) and a 29% discrepancy for monochloraminated systems (n = 192). The data presented here conclusively show inaccuracies in environmental validation for building water systems based on results returned by the standard ISO 11731 method. This is especially evident in systems primarily disinfected with monochloramines. Overall, these data highlight the need for new and innovative methods to overcome the inaccuracies of the traditional ISO 11731 spread plates to prevent disease and injury caused by Legionella.

Surveillance of Legionella spp. in Open Fountains: Does It Pose a Risk?

Clusters of outbreaks or cases of legionellosis have been linked to fountains. The function of fountains, along with their inadequate design and poor sanitation, in combination with the warm Mediterranean climate, can favor the proliferation of Legionella in water systems. Public fountains in Mediterranean cities may pose a significant risk for public health due to the aerosolization of water. Nevertheless, few studies have been conducted on Legionella and the risk of infection in humans through fountains. In our study, the presence and quantity of Legionella spp. in fifteen external public fountains were investigated. Two samplings were performed in two different periods (dry and wet). Sixty samples were collected, quantified and analyzed with a culture ISO method. The operation of all fountains was evaluated twice using a standardized checklist. In accordance with their operation, a ranking factor (R factor) was suggested. Finally, based on these results, a quantitative microbial risk assessment was performed. Thirty water samples taken from the fountains (100%) during the dry sampling period were positive for Legionella (mean log concentration: 3.64 ± 0.45 cfu/L), whereas 24 water samples taken from the fountains during the wet period were Legionella-positive (mean log concentration: 2.36 ± 1.23 cfu/L). All fountains were classified as unsatisfactory according to the checklist for the evaluation of their function. A statistically significant correlation was found between Legionella concentration and the assessment score. The risk of Legionella infection was estimated in both periods, with higher risk in the dry period. The surveillance and risk assessment of Legionella spp. in the fountains of Patras confirmed a high prevalence and a high risk to public health.

Biofilm Control in Flow-Through Systems Using Polyvalent Phages Delivered by Peptide-Modified M13 Coliphages with Enhanced Polysaccharide Affinity

Eradication of biofilms that may harbor pathogens in water distribution systems is an elusive goal due to limited penetration of residual disinfectants. Here, we explore the use of engineered filamentous coliphage M13 for enhanced biofilm affinity and precise delivery of lytic polyvalent phages (i.e., broad-host-range phages lysing multiple host strains after infection). To promote biofilm attachment, we modified the M13 major coat protein (pVIII) by inserting a peptide sequence with high affinity for Pseudomonas aeruginosa (P. aeruginosa) extracellular polysaccharides (commonly present on the surface of biofilms in natural and engineered systems). Additionally, we engineered the M13 tail fiber protein (pIII) to contain a peptide sequence capable of binding a specific polyvalent lytic phage. The modified M13 had 102- and 5-fold higher affinity for P. aeruginosa-dominated mixed-species biofilms than wildtype M13 and unconjugated polyvalent phage, respectively. When applied to a simulated water distribution system, the resulting phage conjugates achieved targeted phage delivery to the biofilm and were more effective than polyvalent phages alone in reducing live bacterial biomass (84 vs 34%) and biofilm surface coverage (81 vs 22%). Biofilm regrowth was also mitigated as high phage concentrations induced residual bacteria to downregulate genes associated with quorum sensing and extracellular polymeric substance secretion. Overall, we demonstrate that engineered M13 can enable more accurate delivery of polyvalent phages to biofilms in flow-through systems for enhanced biofilm control.

A dual-functional sulfone biscompound containing 1,2,3-triazole moiety for decolorization and disinfection of contaminated water

Water decontamination from toxic dyes and pathogenic microorganisms is critical for life on Earth. Herein, we report the synthesis of sulfone biscompound containing 1,2,3-triazole moiety and evaluation of its dye decolorization and biocidal and disinfection efficiencies. The decolorization efficiency was tested under different experimental conditions, while the biocidal action was examined against various types of waterborne pathogens, and the disinfection of some pathogenic microbes was executed in artificially contaminated water. The findindgs illustrated that the solution initial pH (pHi) affected the decolorization efficiency significantly. About complete removal of 10 mg/L malachite green (MG) dye was achieved after 10 min using 3 g/L of the sulfone biscompound at pHi 6. The pseudo-second-order equation suited the adsorption kinetics accurately, while the equilibrium data was suited by Langmuir isotherm model. Electrostatic, n-π, and π-π interactions brought about the adsorption of MG onto the sulfone biscompound. The biocidal results indicated that the sulfone biscompound had a powerful antibacterial potential against the tested bacterial species. Likewise, the distinction trail revealed that after 70-90 min of direct contact with an effective dose, the tested pathogens could be completely eliminated (6-log reduction). Overall, the newly synthesized sulfone biscompound can efficiently remove cationic dyes and disinfect contaminated water.

An Automated Toolchain for Camera-Enabled Sensing of Drinking Water Chlorine Residual

Chlorine residual concentration is an important parameter to prevent pathogen growth in drinking water. Disposable color changing test strips that measure chlorine in tap water are commercially available to the public; however, the color changes are difficult to read by eye, and the data are not captured for water service providers. Here we present an automated toolchain designed to process digital images of free chlorine residual test strips taken with mobile phone cameras. The toolchain crops the image using image processing algorithms that isolate the areas relevant for analysis and automatically white balances the image to allow for use with different phones and lighting conditions. The average red, green, and blue (RGB) color values of the image are used to predict a free chlorine concentration that is classified into three concentration tiers (<0.2 mg/L, 0.2-0.5 mg/L, or >0.5 mg/L), which can be reported to water users and recorded for utility use. The proposed approach was applied to three different phone types under three different lighting conditions using a standard background. This approach can discriminate between concentrations above and below 0.5 mg/L with an accuracy of 90% and 94% for training and testing data sets, respectively. Furthermore, it can discriminate between concentrations of <0.2 mg/L, 0.2-0.5 mg/L, or >0.5 mg/L with weighted-averaged F1 scores of 79% and 88% for training and testing data sets, respectively. This tool sets the stage for tap water consumers and water utilities to gather frequent measurements and high-resolution temporal and spatial data on drinking water quality.

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.

Succession and change of potential pathogens in the co-composting of rural sewage sludge and food waste

Composting is an effective way to prevent and control the spread of pathogenic microorganisms which could put potential risk to humans and environment, from rural solid waste, especially sewage sludge and food waste. In the study, we aim to analyze the changes of pathogenic bacteria during the co-composting of rural sewage sludge and food waste. The results showed that only 27 pathogenic bacteria were detected after composting, compared to 50 pathogenic bacteria in the raw mixed pile. About 74% of pathogen concentrations dropped below 1000 copies/g after composting. Lactobacillus, Bacillus, Paenibacillus and Comamonas were the core pathogenic bacteria in the compost, of which concentrations were all significantly lower than that in the raw mixed pile at the end of composting. The concentration of Lactobacillus decreased to 3.03 × 10³ copies/g compared to 0 d with 1.25 × 10⁹ copies/g by the end of the composting, while that of Bacillus, Paenibacillus and Comamonas decreased to 2.77 × 10⁴ copies/g, 2.13 × 10⁴ copies/g and 3.38 × 10² copies/g, respectively, with 1.26 × 10⁷ copies/g, 4.71 × 10⁶ copies/g, 1.69 × 10⁸ copies/g on 0 d. Redundancy analysis (RDA) indicated that physicochemical factors and substances could affect the changes of pathogenic bacteria during composting, while temperature was the key influencing factor. In addition, certain potential pathogenic bacteria, such as Bacteroides-Bifidobacterium, show statistically strong and significant co-occurrence during composting, which may increase the risk of multiple infections and also influence their distribution. These findings provide a theoretical reference for biosafety prevention and control in the treatment and disposal of rural solid waste.

Occurrence of opportunistic pathogens in private wells after major flooding events: A four state molecular survey

Private wells can become contaminated with waterborne pathogens during flooding events; however, testing efforts focus almost exclusively on fecal indicator bacteria. Opportunistic pathogens (OPs), which are the leading cause of identified waterborne disease in the United States, are understudied in private wells. We conducted a quantitative polymerase chain reaction survey of Legionella spp., L. pneumophila, Mycobacterium spp., M. avium, Naegleria fowleri, and shiga toxin-producing Escherichia coli gene markers and total coliform and E. coli in drinking water supplied by private wells following the Louisiana Floods (2016), Hurricane Harvey (2017), Hurricane Irma (2017), and Hurricane Florence (2018). Self-reported well characteristics and recovery status were collected via questionnaires. Of the 211 water samples collected, 40.3% and 5.2% were positive for total coliform and E. coli, which were slightly elevated positivity rates compared to prior work in coastal aquifers. DNA markers for Legionella and Mycobacterium were detected in 54.5% and 36.5% of samples, with L. pneumophila and M. avium detected in 15.6% and 17.1%, which was a similar positivity rate relative to municipal system surveys. Total bacterial 16S rRNA gene copies were positively associated with Legionella and Mycobacterium, indicating that conditions that favor occurrence of general bacteria can also favor OPs. N. fowleri DNA was detected in 6.6% of samples and was the only OP that was more prevalent in submerged wells compared to non-submerged wells. Self-reported well characteristics were not associated with OP occurrence. This study exposes the value of routine baseline monitoring and timely sampling after flooding events in order to effectively assess well water contamination risks.

Direct evidence of microbiological water quality changes on bacterial quantity and community caused by plumbing system

Drinking water quality deteriorates from treatment plant to customer taps, especially in the plumbing system. There is no direct evidence about what the differences are contributed by plumbing system. This study compared the water quality in the water main and at customer tap by preparing a sampling tap on the water main. The biomass was quantified by adenosine triphosphate (ATP) and the microbial community was profiled by 454 pyrosequencing. The results showed that in distribution pipes, biofilm contributed >94% of the total biomass, while loose deposits showed little contribution (< 2%) because of the low amount of loose deposits. The distribution of biological stable water had minor effects on the microbiocidal water quality regarding both quantity (ATP 1 ng/L vs. 1.7 ng/L) and community of the bacteria. Whereas the plumbing system has significant contribution to the increase of active biomass (1.7 ng/L vs. 2.9 ng/L) and the changes of bacterial community. The relative abundance of Sphingomonas spp. at tap (22%) was higher than that at water main (2%), while the relative abundance of Pseudomonas spp. in tap water (15%) was lower than that in the water from street water main (29%). Though only one location was prepared and studied, the present study showed that the protocol of making sampling tap on water main offered directly evidences about the impacts of plumbing system on tap water quality, which makes it possible to distinguish and study the processes in distribution system and plumbing system separately.

Does Chlorination Promote Antimicrobial Resistance in Waterborne Pathogens? Mechanistic Insight into Co-Resistance and Its Implication for Public Health

Chemical agents including chlorine and antibiotics are used extensively to control infectious microorganisms. While antibiotics are mainly used to treat bacterial infections, chlorine is widely used for microbial inactivation in the post-secondary disinfection steps of water treatment. The extensive use of these agents has been acknowledged as a driving force for the expansion of antimicrobial resistance (AMR) and has prompted discourse on their roles in the evolution and proliferation of resistant pathogens in the aquatic milieus. We live in a possible “post-antibiotic” era when resistant microbes spread at startling levels with dire predictions relating to a potential lack of effective therapeutic antibacterial drugs. There have been reports of enhancement of resistance among some waterborne pathogens due to chlorination. In this context, it is pertinent to investigate the various factors and mechanisms underlying the emergence and spread of resistance and the possible association between chlorination and AMR. We, therefore, reflect on the specifics of bacterial resistance development, the mechanisms of intrinsic and acquired resistance with emphasis on their environmental and public health implications, the co-selection for antibiotic resistance due to chlorination, biofilm microbiology, and multidrug efflux activity. In-depth knowledge of the molecular basis of resistance development in bacteria will significantly contribute to the more rational utilization of these biocidal agents and aid in filling identified knowledge gap toward curbing resistance expansion.

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.

Influence of point-of-use filters and stagnation on water quality at a preschool and under laboratory conditions

A local preschool installed NSF/ANSI 42 and 53 certified point-of-use (POU) filters in its classroom sinks and drinking fountains to protect children from the possibility of elevated lead (Pb) levels in drinking water. We examined the effects of these filters during flowing water and immediately following stagnation periods on Pb, chlorine, and bacterial concentrations in the field and the laboratory. Before and after typical school stagnation periods, we collected samples from filtered classroom sinks, a filtered drinking fountain and nearby unfiltered sinks for a year. No unfiltered samples exceeded Illinois State limits of 5 µg/L for Pb in pre-K through 5th grade schools. However, following stagnation periods as short as overnight (14.5 h), over half of post-stagnation filtered samples from classroom sinks exceeded 5 µg/L while post-stagnation unfiltered samples remained below 5 µg/L. Laboratory testing showed no significant increases in Pb with stagnation, suggesting that the preschool classrooms may have had Pb-bearing plumbing downstream of the filters which released Pb into the filtered drinking water. The filters effectively removed free chlorine (99% decrease) in both the preschool and laboratory. Installing the filters had the unintended consequence of significantly increasing the bacterial concentrations (as measured by qPCR) in the preschool's drinking water and in laboratory filter effluent. Legionella pneumophila, Pseudomonas aeruginosa, and Mycobacterium spp. were not detected in pre-stagnation unfiltered and post-stagnation filtered samples. These results suggest that the installation of POU filters be considered as one component of an overall strategy to decrease Pb concentrations in school drinking water that holistically considers the premise plumbing system. A 5-minute flush significantly decreased concentrations of Pb and bacteria in filtered sinks. Replacing Pb-bearing plumbing components downstream of a POU filter may also be needed to combat Pb levels in drinking water.

Compromised Effectiveness of Thermal Inactivation of Legionella pneumophila in Water Heater Sediments and Water, and Influence of the Presence of Vermamoeba vermiformis

Intermittent reduction of temperature set-points and periodic shutdowns of water heaters have been proposed to reduce energy consumption in buildings. However, the consequences of such measures on the occurrence and proliferation of Legionella pneumophila (Lp) in hot water systems have not been documented. The impact of single and repeated heat shocks was investigated using an environmental strain of L. pneumophila and a reference strain of V. vermiformis. Heat shocks at temperatures ranging from 50 °C to 70 °C were applied for 1 h and 4 h in water and water heaters loose deposits (sludge). The regrowth potential of heat-treated culturable L. pneumophila in presence of V. vermiformis in water heaters sludges was evaluated. A 2.5-log loss of culturability of L. pneumophila was observed in simulated drinking water at 60 °C while a 4-log reduction was reached in water heaters loose deposits. Persistence of Lp after 4 h at 55 °C was shown and the presence of V. vermiformis in water heater’s loose deposits resulted in a drastic amplification (5-log). Results show that thermal inactivation by heat shock is only efficient at elevated temperatures (50 °C) in both water and loose deposits. The few remaining organisms can rapidly proliferate during storage at lower temperature in the presence of hosts.

Quantitative Microbial Risk Assessment Applied to Legionella Contamination on Long-Distance Public Transport

The quantitative microbial risk assessment (QMRA) framework is used for assessing health risk coming from pathogens in the environment. In this paper, we used QMRA to evaluate the infection risk of L. pneumophila attributable to sink usage in a toilet cabin on Italian long-distance public transportation (LDT). LDT has water distribution systems with risk points for Legionella proliferation, as well as premise plumbing for drinking water, but they are not considered for risk assessment. Monitoring data revealed that approximately 55% of water samples (217/398) were positive for L. pneumophila, and the most frequently isolated was L. pneumophila sg1 (64%, 139/217); therefore, such data were fitted to the best probability distribution function to be used as a stochastic variable in the QMRA model. Then, a sink-specific aerosolization ratio was applied to calculate the inhaled dose, also considering inhalation rate and exposure time, which were used as stochastic parameters based on literature data. At L. pneumophila sg1 concentration ≤100 CFU/L, health risk was approximately 1 infection per 1 million exposures, with an increase of up to 5 infections per 10,000 exposures when the concentrations were ≥10,000 CFU/L. Our QMRA results showed a low Legionella infection risk from faucets on LDT; however, it deserves consideration since LDT can be used by people highly susceptible for the development of a severe form of the disease, owing to their immunological status or other predisposing factors. Further investigations could also evaluate Legionella-laden aerosols from toilet flushing.

From Copper Tolerance to Resistance in Pseudomonas aeruginosa towards Patho-Adaptation and Hospital Success

The hospital environment constitutes a reservoir of opportunistic pathogens responsible for healthcare-associated infections (HCAI) such as Pseudomonas aeruginosa (Pa). Pa persistence within technological niches, the increasing emergence of epidemic high-risk clones in HCAI, the epidemiological link between plumbing strains and clinical strains, make it a major nosocomial pathogen. Therefore, understanding the mechanisms of Pa adaptation to hospital water systems would be useful in preventing HCAI. This review deciphers how copper resistance contributes to Pa adaptation and persistence in a hospital environment, especially within copper water systems, and ultimately to its success as a causative agent of HCAI. Numerous factors are involved in copper homeostasis in Pa, among which active efflux conferring copper tolerance, and copper-binding proteins regulating the copper compartmentalization between periplasm and cytoplasm. The functional harmony of copper homeostasis is regulated by several transcriptional regulators. The genomic island GI-7 appeared as especially responsible for the copper resistance in Pa. Mechanisms of copper and antibiotic cross-resistance and co-resistance are also identified, with potential co-regulation processes between them. Finally, copper resistance of Pa confers selective advantages in colonizing and persisting in hospital environments but also appears as an asset at the host/pathogen interface that helps in HCAI occurrence.

The epidemiology, demographics, and comorbidities of pulmonary and extra-pulmonary non-tuberculous mycobacterial infections at a large central Florida Academic Hospital

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Non-tuberculous mycoabcteria (NTM) cases have been increasing in the state of Florida, especially in the central portion of the state, where the population has been steadily increasing.

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Our analysis suggests that in our Mycobacterium abscessus complex was the most prevalent NTM seen in our patients, with Mycobacterium avium Complex being a distant second.

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Our GIS mapping of these local NTM cases describes where the patients lived relative to the organism which they grew.

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Furthermore, for the NTM isolates that we obtained data, we demonstrate the actual variability of antibiotic susceptibility, and with a few isolates, this was observed over time.

Rationale

In the United States, non-tuberculous mycobacterium (NTM) infections are considered an important cause of morbidity and mortality, especially in people with progressive lung disease. The state of Florida has an extremely high incidence and prevalence of NTM disease which is likely a rapidly emerging infection in the state due to environmental and demographic factors.

Objectives

Adjemian et al. [1] To determine the burden of NTM disease of patients admitted to a large Central Florida academic center, Falkinham [2] to identify the most common risk factors associated with developing NTM disease in this area, and Sfeir et al. [4] to categorize antimicrobial susceptibilities and genetic resistance markers.

Methods

We conducted a retrospective case review from January 1, 2011 to December 31, 2017 in a large university-associated metropolitan hospital in west-central Florida. NTM infections were identified using TheraDoc® during the study period with the inclusion criteria of any inpatient admission, culture confirmed NTM at any site, and age ≥ 12 years. Demographic variables (including residential zip code) and comorbidity data (including solid organ transplant status, HIV status and subsequent testing results, intrinsic pulmonary disease, and cancer diagnosis of any site) were collected for each patient. Microbiologic data collected included NTM species/subspecies, anatomic location of specimen collection, antimicrobial susceptibility including minimum inhibitory concentration (MIC). All collected data were analyzed within Stata/IC14.2. Geospatial relationships between zip codes, diagnosis type, and co-morbidities were computed using Arc GIS Pro.

Results

Our results demonstrated that a substantial number of our inpatient cases with NTM were of the M. abscessus group, and with M. avium complex and M. fortuitum also representing the pathogen in numerous cases. Novel findings included compilation of the first hospital wide comprehensive NTM resistance plot to our knowledge. Our results did show a concordance with previous data with expected predominance of NTM inpatient cases in Caucasian males with pre-existing pulmonary disease, though additional work could be done with isolates within the transplant and immunosuppressed populations.

Conclusions

Our data set demonstrates the most common species/subspecies of NTM infections and their associated conditions seen at our central Florida hospital, and includes an antimicrobial sensitivity analysis in toto. This could be insight into the possible prevalence of NTM in the area, and provides the foundation for future studies on both the acquisition and prevention for NTM infections in central Florida.

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).

Biofilm growth under continuous UVC irradiation: Quantitative effects of growth conditions and growth time on intensity response parameters

Biofilms can harbor a wide range of microorganisms, including opportunistic respiratory pathogens, and their establishment on engineered surfaces poses a risk to public health and industry. The emergence of compact germicidal ultraviolet light-emitting diodes (UV LEDs) may enable their incorporation into confined spaces to inhibit bacterial surface colonization on inaccessible surfaces, such as those in premise plumbing. Such applications necessitate knowledge of the quantitative response of biofilm growth rates to UV exposure on continuously irradiated surfaces. Herein, we performed experiments at varying flow cell temperatures in order to control baseline biofilm growth rates in the absence of UV; then, biofilm growth was compared under the same conditions but with simultaneous UVC irradiation. The inhibiting effect of UV irradiation on biofilm growth kinetics was diminished by more favorable growth conditions (higher temperature). Increasing the temperature by 10 °C resulted in an increase in biovolume by 193% under a UVC (254 nm) intensity of ∼60 µW/cm². We further fitted an existing intensity response model to the biofilm growth data and analyzed the effects of temperature on model parameters, which were consistent with a hypothesized shielding effect arising from the deposition of extracellular colloidal materials. The shielding effect was found to result in breakthrough behavior of irradiated biofilms after 48 h, wherein accumulation of shielding substances eventually enabled biofilm establishment at even relatively high irradiation intensities (102.3 µW/cm²). With respect to applications of UVC irradiation for biofilm prevention, these results imply that surfaces more prone to bacterial colonization require disproportionately higher-intensity UVC irradiation for prevention of biofilm establishment, and continuous surface irradiation may be inadequate as a sole intervention for biofilm prevention in many scenarios.

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.

Mapping the Terrain for Pathogen Persistence and Proliferation in Non-potable Reuse Distribution Systems: Interactive Effects of Biofiltration, Disinfection, and Water Age

Diverse pathogens can potentially persist and proliferate in reclaimed water distribution systems (RWDSs). The goal of this study was to evaluate interactive effects of reclaimed water treatments and water age on persistence and proliferation of multiple fecal (e.g., Klebsiella, Enterobacter) and non-fecal (e.g., Legionella, mycobacteria) gene markers in RWDSs. Six laboratory-scale RWDSs were operated in parallel receiving the influent with or without biologically active carbon (BAC) filtration + chlorination, chloramination, or no disinfectant residual. After 3 years of operation, the RWDSs were subject to sacrificial sampling and shotgun metagenomic sequencing. We developed an in-house metagenome-derived pathogen quantification pipeline, validated by quantitative polymerase chain reaction and mock community analysis, to estimate changes in abundance of ∼30 genera containing waterborne pathogens. Microbial community composition in the RWDS bulk water, biofilm, and sediments was clearly shaped by BAC filtration, disinfectant conditions, and water age. Key commonalities were noted in the ecological niches occupied by fecal pathogen markers in the RWDSs, while non-fecal pathogen markers were more varied in their distribution. BAC-filtration + chlorine was found to most effectively control the widest range of target genera. However, filtration alone or chlorine secondary disinfection alone resulted in proliferation of some of these genera containing waterborne pathogens.

Water Safety and Health Care: Preventing Infections Caused by Opportunistic Premise Plumbing Pathogens

Health care facility water systems have been associated with the transmission of opportunistic premise plumbing pathogens such as Legionella and nontuberculous mycobacteria. These pathogens can enter a building's water system in low numbers and then proliferate when conditions are conducive to their growth. Patients and residents in health care facilities are often at heightened risk for opportunistic infections, and cases and outbreaks in the literature highlight the importance of routine water management programs and occasions for intervention to prevent additional cases. A multidisciplinary proactive approach to water safety is critical for sustained prevention of health care-associated water-related infections.

Photodynamic Inactivation of Legionella pneumophila Biofilm Formation by Cationic Tetra- and Tripyridylporphyrins in Waters of Different Hardness

The bacterium Legionella pneumophila is still one of the probable causes of waterborne diseases, causing serious respiratory illnesses. In the aquatic systems, L. pneumophila exists inside free-living amoebae or can form biofilms. Currently developed disinfection methods are not sufficient for complete eradication of L. pneumophila biofilms in water systems of interest. Photodynamic inactivation (PDI) is a method that results in an antimicrobial effect by using a combination of light and a photosensitizer (PS). In this work, the effect of PDI in waters of natural origin and of different hardness, as a treatment against L. pneumophila biofilm, was investigated. Three cationic tripyridylporphyrins, which were previously described as efficient agents against L. pneumophila alone, were used as PSs. We studied how differences in water hardness affect the PSs’ stability, the production of singlet oxygen, and the PDI activity on L. pneumophila adhesion and biofilm formation and in biofilm destruction. Amphiphilic porphyrin showed a stronger tendency for aggregation in hard and soft water, but its production of singlet oxygen was higher in comparison to tri- and tetracationic hydrophilic porphyrins that were stable in all water samples. All three studied porphyrins were shown to be effective as PDI agents against the adhesion of the L. pneumophila to polystyrene, against biofilm formation, and in the destruction of the formed biofilm, in their micromolar concentrations. However, a higher number of dissolved ions, i.e., water hardness, generally reduced somewhat the PDI activity of all the porphyrins at all tested biofilm growth stages.

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.