Pseudomonas aeruginosaPseudomonas aeruginosa and hospital water and hospital water systemssystems

Dr Chinari P K SubudhiConsultant Microbiologist & Clinical LeadSalford Royal Hospital

Outbreaks of Outbreaks of P. P. aeruginosaaeruginosaIntensive care units

Neonatal intensive care units

Burns units

Haematology units

Premature babies in NICUPremature babies in NICUVery susceptible to infection with P.aeruginosa

Immature immune system

Immature and delicate skin – can be damaged and infected easily

Presence of devices i.e ventilation, catheters, etc increase the risk of colonisation and infection

Incubator – humid environment – favourable for P. aeruginosa to thrive

Water - reservoir or Water - reservoir or vehiclevehicleMoist environment and aqueous

solutions in health care settings have potential to serve as reservoirs for water borne organisms

Favourable circumstances eg., temperature, presence of source of nutrition, etc – can facilitate active growth of organisms or they remain for long periods in highly stable and resistant forms

Water – point source Water – point source outbreaksoutbreaksContaminated water baths

Humidifying equipment for ventilators

Taps and sink drains

Feeding bottles

Mineral water bottle

Water borne infections – Modes of Water borne infections – Modes of transmissiontransmissionDirect contact (eg. hydrotherapy pool)

Ingestion of water (eg. consuming contaminated ice)

Indirect contact transmission (eg. contaminated hands, devices, equipment, surfaces etc)

Inhalation of aerosols dispersed from water sources i.e. from fountains, showers, cooling towers, air-conditioning units

Aspiration of contaminated water

Water borne bacterial agents causing Water borne bacterial agents causing infections or outbreaks in health care infections or outbreaks in health care facilitiesfacilities

Legionella sp.

Pseudomonas aeruginosa

Other Gram negative bacteria – Pseudomonas sp, Burkholderia cepacia, Ralstonia picketii, Stenotrophomonas maltophila, Sphingomonas sp, Acinetobacter sp, Enterobacter sp, Serratia sp.

Nontuberculous mycobacteria

Pseudomonas aeruginosaPseudomonas aeruginosa

Commonly found in soil, water and plants

Can colonise healthy humans and animals

Tolerant to temperature as high as 45°C to 50°C

Can produce a biofilm which creates a protective layer when it grows in the water system

Opportunistic pathogen – more likely to infect those who are already very sick or vulnerable

Relatively resistant to many antibiotics

Pseudomonas aeruginosaPseudomonas aeruginosa (culture)(culture)

Habitat of Habitat of P.aeruginosaP.aeruginosa in in hospitalshospitalsCan colonise moist surfaces of patients

on axilla, ear, perineum, wounds, etc

Can be isolated from other moist, inanimate environments including water in sinks and drains, toilets and showers

Hospital equipment that comes in contact with water such as mops, respiratory ventilators, cleaning solutions and food and food processing machines, can be source

PseudomonasPseudomonas and water and water systemssystems

Water systems frequently colonised with Pseudomonas with biofilms developing in pipework, taps and U bends when there is a source of carbon for growth

Insufficient temperature favours growth – below 55°C in hot water pipes and above 20°C in cold water pipes

Stagnant water in system if taps are not used or flushed regularly

Secondary contamination of taps and sinks because of inappropriate infection control practices

Human carriage of Human carriage of P. P. aeruginosaaeruginosaUp to 7% of healthy humans carry in

throat, nasal mucosa or on the skin

Faecal carriage rates – 15% to 25% reported, higher in vegetarians

Dies rapidly on dry human skin

Survives well in moist or superhydrated skin

Examples of community Examples of community acquired infections due to acquired infections due to P. P. aeruginosaaeruginosa

Skin infections – Folliculitis - related to use of hot tubs, whirlpools, swimming pools, other baths; Toe web rot in soldiers – interdigital space between the toes

Eye infection in contact lens wearers (extended wear variety) – Ulcerative keratitis – because of contamination of the contact lens solutions

Ear infections – Otitis externa (Swimmer’s ear)

Respiratory tract infections – Cystic fibrosis, Bronchiectasis

Hot tub folliculitisHot tub folliculitis

Health care associated infections (HCAI) – Health care associated infections (HCAI) – P. aeruginosaP. aeruginosa

Ventilator associated pneumonia

Hospital acquired pneumonia

Urinary tract infections – catheter associated

Wound infections – eg. burns, ulcers, exit sites

Bacteremia

Patient on mechanical Patient on mechanical ventilationventilation

Department of Health, March Department of Health, March 20122012 Water sources and potential Pseudomonas

aeruginosa contamination of taps and water systems Advice for augmented care units

Previous guidance issued by CMO in August 2010 & February 2012 as “Dear Colleague” letters

Best practice technical guidance to reduce risk to patients and recommendations to establish systems to monitor, prevent and control infections

Intended for professionals engaged in infection prevention and control, estates and facilities and the Responsible person (Water)

Advice to health care Advice to health care providersproviders

Assessing risk to patients if water systems become contaminated with P.aeruginosa or other pathogens

What actions to take if water systems become contaminated with P.aeruginosa

Protocol for sampling, testing and monitoring water for P.aeruginosa

Developing local water safety plans

Risk assessment Risk assessment

Should be undertaken to identify actions to mitigate risks by June 2012

To ensure appropriate sampling, monitoring and clinical surveillance arrangements are being implemented and adhered to

To undertake appropriate water sampling by end of 2012 where required

Water Safety Group Water Safety Group A multi-disciplinary group to undertake risk assessment and

management of water safety issues

Identification of microbiological hazards, assessing risks, identifies and monitors control measures and develop incident protocols

Can be a sub-group of the hospital’s Infection control committee

Accountable to DIPC

Comprising:◦ Infection prevention and control team◦ Consultant Medical Microbiologist◦ Estates and Facilities◦ Senior nurses from relevant augmented care units◦ Hotel / cleaning services◦ Director of infection prevention and control (DIPC)

Risk assessment in Risk assessment in hospitalshospitalsLocal risk assessment required for

identification of vulnerable patient groups

Case mix and patient susceptibility varies between units

Risk assessment of environment and practices

For incorporating appropriate preventative measures and monitoring arrangements

Augmented care unitsAugmented care unitsCritical Care areas – Adult ICU,

Pediatric ICU, Neonatal ICUHigh Dependency unitsBurns unitsTransplant UnitsHaematology – Oncology wardsRenal units / wards

Hospital water systems and patient Hospital water systems and patient safetysafety

Correct maintenance of hot and cold water supply systems

Continuous delivery of microbiologically safe water

Effective management and operation throughout the water supply and distribution system

Role of Infection prevention and Role of Infection prevention and control teamscontrol teams

Ensure application of and compliance with appropriate guidelines to prevent HCAI

Ensure best practice advice relating to hand wash stations is followed to minimise risk of P.aeruginosa contamination

Continue to monitor clinical isolates of P.aeruginosa as an alert organism

To be aware of possible outbreaks of infection with P.aeruginosa

Hand wash stations – Best Hand wash stations – Best practicepracticeONLY FOR HANDWASHING

No disposal of body fluidsNo disposal of used environmental cleaning

fluidsNo washing of patient equipmentNo storing of used equipment awaiting

decontaminationTaps should be cleaned before the rest of

the handbasin (NHS Cleaning manual)Washing patients with water from outlets

demonstrated to be safe

Flushing tapsFlushing tapsHTM 04-01 Part B, Chapter 5

All taps that are infrequently used – to be flushed regularly manually – at least daily in the morning for 1 minute

Some taps can be programmed to flush automatically, such flushing could be recorded on the building management system

Keep a record of when the taps were flushed

Wash hand stations – problems / Wash hand stations – problems / concernsconcernsIdentify any problems or concern

relating to safety, maintenance and cleaning of wash hand stations to

◦Infection Prevention & Control Team◦Estates◦Facilities Department◦Infection control committee – if there

are unresolved issues

Risk assessment - factors to Risk assessment - factors to considerconsiderSusceptibility of patient groups

Clinical practice and ongoing care of invasive devices

Cleaning of patient equipment

Engineering assessment of water systems – installation, commissioning and maintenance

Sampling and monitoring programme

Water safety plan (WSP) – Water safety plan (WSP) – LegionellaLegionella and and P.aeruginosaP.aeruginosaTo assist with understanding and

mitigating risks associated with bacterial contamination of water distribution and supply system

To provide a risk-management approach to the microbiological safety of water

To establish good practices in local water distribution and supply

WSPsWSPsWorking documents should be kept up to date

and to be reviewed annually

Responsible person (Water) should lead the development of WSP and will be responsible for it’s implementation

Complement the existing Operational management requirements of HTM 04-0

Complement the work that has to be undertaken to fulfill the statutory requirement for a Legionella risk assessment and written scheme for the control and management of Legionella

Protecting the patients when water Protecting the patients when water contamination problem is suspected / contamination problem is suspected / confirmedconfirmedUse water of a known satisfactory quality for

direct contact with patients – sterile, filtered or a contamination free source

Review water outlets / showers where there may be patient contact (direct / indirect)

Single use wipesSupplement hand washing with use of alcohol

hand rubRigorous adherence to infection control

practicesReview cleaning, storage and usage of patient

contact equipment

Remediation of water quality Remediation of water quality deliverydelivery

Check for underused outlets Assess water distribution system for non-metallic

materials eg. Flexible hose Assess water system for blind ends and dead legs Point of use filters, where they can be fitted –

regarded as a temporary measure Consider disinfection of hot and cold water

distribution system that supply the unit to treat the contaminated outlets

Ensure TMV providing the safe hot water is located as close to the tap / shower outlet as possible

Consider replacing contaminated taps with new taps – lack of evidence

Microbiological Microbiological investigationsinvestigations

Water sampling and testing protocol for P.aeruginosa

Pre-flush and post flush water samplesSwabbing – use sterile swab to take a sample of

the tap’s aerator / flow –straightener and spout’s metal collar

Microbiological typing – environmental and water samples to be sent to HPA LHCAI for molecular analysis of P. aeruginosa – ONLY if isolates have been confirmed as P. aeruginosa and possible epidemiological link to the outbreak strain under investigation

Comparison of typing results between clinical isolates and isolates from microbiological sampling of environment / water