Pseudomonas aeruginosa Infections in the Intensive Care Unit

Facts and Control Measures

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170823.1WGL

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Pseudomonas aeruginosa

P. aeruginosa (PA) is a Gram-negative bacillus which,

is tolerant of a wide variety of physical conditions, has

minimal nutrition requirements, and is a major opportunistic

pathogen 1, 2. PA appears sporadically in drinking water

distribution systems, but seems to occur at a higher

frequency in premise plumbing systems compared to

water mains 3, 4.

PA is one of the most common and problematic bacteria

in healthcare facilities, and is responsible for approximately

10-20 % of hospital-associated infections (HAI) (pneumonia,

wound infections, blood stream infections and urinary

tract infections) in intensive care units (ICUs) 5-10. Length

of stay, severity of underlying disease and exposure to

invasive procedures, bacterial adherence, virulence factors,

and antimicrobial drug resistance are associated with PA

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PA may colonise biofilms in water systems and be released from the outlet.

infections in ICUs 11, 12. The incidence of HAI is 5 - 10 times

higher in ICU than general wards 13.

Although endogenous origin was considered as the most

relevant route of PA infections, in the last ten years a

significant proportion of PA isolates have been shown to

stem from the ICU environment and cross-transmission 14,15.

Several studies have shown that up to 50 % of hospital

acquired PA infections may be derived from the in-premise

water distribution system 8, 16, 17. Unlike patient and pathogen

characteristics, environmental factors such as nursing

workload or contamination of water outlets can be more

easiy managed and modified 6.

PA can colonise many types of fluids (even distilled water)

and rapidly forms biofilms 2, 14, 18-21. Moreover, PA can

PA may colonise flow straighteners and aerators as well as bottled water. PA living within biofilms typically exerts higher resistance towards chemical and thermal disinfection measures than planktonic PA, thus making PA contamination difficult to eradicate in a water system.

thrive in water fittings including the faucet body,

connectors and flow straighteners, sinks, drains, toilets,

shower heads and hoses 19, 22, 23. Automatic sensor

faucets have been shown to be more likely to become

contaminated than non-sensor manual outlets 19.

PA has been observed growing within drinking water

biofilms 3, 24, thus protected and more difficult to eradicate

than planktonic bacteria 2, 25. PA is resistant to chlorine

and other disinfectants used in water treatments 2, 26 and

may survive in the hospital ward environment even after

disinfection 27, increasing the risk of acquisition by

patients 28. PA living in biofilms exerts a higher resistance

towards disinfectants due to the mechanical protection

provided by the biofilm matrix 29 - 31. It has been shown

that the use of sublethal concentrations of chlorine-based

oxidising agents (sodium hypochlorite, chlorine dioxide,

electrochemically activated chlorine, continuous treatment

with 0.15 ppm chlorine or shock treatment with 10 ppm

chlorine for 6 hours (h)) can lead to a cyclical regrowth of

biofilm after treatment end and the survival of PA living

in the biofilm. Under unfavourable operating conditions in

a drinking water system, PA has been shown to survive

sequentially 24 h 50 parts per million (ppm) chlorine

dioxide (ClO2), 3 minutes (min) 70 °C and 24 h 50 ppm

ClO2 27.

In a large hospital in Taiwan, a comparative study on

infection rates with and without continuous treatment with

ClO2 has been described. Building 1 was continuously

treated (over 11 months) with ClO2, whereas building 2

was not treated. In both cases infections were monitored.

The overall rate of non-fermentative Gram-negative bacilli

nosocomial infections did not decline after ClO2 disinfection.

Furthermore, PA infection rates increased in both buildings,

showing no evidence for a relationship between ClO2

treatment and PA infection rates 32.

PA is a major pathogen in cystic fibrosis patients with

water being a source of infection 2, 33. PA is also the

organism most commonly detected in gastrointenstinal

endoscopy-related and bronchoscopy-associated

outbreaks 34.

PA may be carried by healthy individuals (2–10 % of

individuals, mainly aural) but can be recovered from

50-60 % of hospitalised patients 2,16. PA is the main

cause of otitis externa (‘swimmer’s ear’), with a

magnitude of 2.4 million cases per year and an estimated

54 www.pall .com/medical © 2016, Pall Corporation

Bacteria living in water installation biofilms communicate and may exchange resistance genes.

Multi-Drug Resistent PA (MDR PA) in the ICU

Number of annual non-hospitalised AOE visits

2.5 Mio (8.1 visits / 1000 patients)

Mean cost per non-hospitalised AOE visit

$ 200

Direct annual healthcare costs for AOE

$ 0.5 billion

Hours of clinicians’ time annually

600,000 hours

Table 1: Cost overview of Acute Otitis Externa (AOE) in the US, 2003-2007 31.

MDR Gram-negative bacteria (MDRGN) are defined as having

3 or more antimicrobial resistance mechanisms affecting

different antibiotic classes 28. The rise of antibiotic resistance in

pathogenic bacteria is considered to be an emerging threat to

human health and therefore of concern, being associated with

increased mortality and limited treatment options 10, 38-40.

The European Antimicrobial Resistance Surveillance System

(EARSS) reported that for Gram-negative bacteria the

situation is especially worrying with high, increasing resistance

percentages reported from many parts of Europe. For PA

the weighted mean percentage for carbapenem resistance

increased significantly between 2011 and 2014 36. A post-

antibiotic era – in which common infections and minor injuries

can kill – is a real possibility for the 21st century 41.

Opportunistic Gram-negative bacteria that present

increasing resistance issues include Enterobacteriaceae

(Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia

spp., Citrobacter spp.) and the non-fermenters, PA and

Acinetobacter baumannii 42. Stenotrophomonas maltophilia

is inherently MDR, but a less common reported cause of

cross-infection 28. PA strains have developed resistance

against commonly used antibiotics, rendering effective

treatment increasingly complicated and expensive 2, 42-45.

Data collected from MDR Krankenhaus-Infektionen-

Surveillance-System (MDRO-KISS) from January 2013

through February 2014 identified 5,171 cases of MDRGN

from 341 German ICUs; 848 (16 %) of which were

carbapenem-resistent organisms (CRO) 46. Infections with

CRO are of particular concern as only a few treatment

options remain for patients and outcomes are poor 47-48.

61 % of CRO were Pseudomonas spp. (n = 516), mostly

PA (n = 493, 58 %), followed by CRE (carbapenem-

resistent Enterobacteriaceae) (n=212; 25 %) and

Acinetocacter spp. (n = 120; 14 %) dominated by

Acinetobacter baumannii (n = 115, 14 %) 46.

A point prevalence study of 56 German hospitals in 2011

found prevalence of resistance was highest in ICUs and

higher on medical ICU wards compared with surgical ICU

wards 49. Similar UK results have been found 50.

A European survey of 19,888 patients, mainly in Belgium

and France, showed the highest prevalence of HAI in

ICUs (28.1 %) 51. ICUs in acute hospitals and long-term

care facilities have higher prevalence of MDR Gram-

negative bacteria than general wards, mainly due to their

extremely vulnerable population of critically ill patients,

the high use of (invasive) procedure and prolonged use

of antibiotics 10, 28, 52. Several factors may influence the

spread of multi-drug-resistant pathogens in the ICU,

e.g. new mutations, selection of resistant strains, and

suboptimal infection control 52.

MDR PA may be clinically manifested in the lung causing

pneumonia, urinary tract, surgical site, bloodstream, cystic

fibrosis lung and burns 53-55. In a neonatal ICU in Turkey a PA

outbreak which involved 12 patients has been reported, with

electronic faucet fittings being the likely source, and 8 of 12

invasive isolates being 4 Multi-Resistant Gram-Negative 56. In

2010, Inglis et al. described an increased incidence of MDR

PA in the ICU and High Dependency Unit of an Australian

hospital with contaminated aerators and the water system

being the possible source 57. MDR PA is also a rare cause of

community-acquired infections 58.

Transmission pathways of PA

Enterobacteriaceae, PA and Acinetobacter spp. may be

transferred among vulnerable patients by staff vectors

and contaminated equipment. PA and MDR PA are

commonly transmitted by contact and aspiration, with

the premise plumbing system being one infection source.

In such epidemiology, a single clone or small number

of clones cause infections in multiple patients without

obvious links and over a prolonged period, sometimes

extending several years with gaps of several months

between cases 18.

Patient exposure typically occurs while showering,

bathing, drinking and through contact with medical

equipment rinsed with contaminated water 18, 59. During

daily routines, water is used for personal hygiene. ICU

patients often have multiple access devices such as

catheters, drains and tracheal tubes. These portals

represent potential entrance sites for bacteria. Droplets

of contaminated water can inadvertently come into

contact with those entrance sites 14, 18, 60-61. Rogues

et al. reported 14 % of ICU healthcare professionals’

hands were Pseudomonas positive, when washed

with contaminated tap water and 12 % positive, when

the last contact was with a Pseudomonas positive

patient 14. Patient-to-patient transmission can occur

outpatient cost of approximately $ 500 million (table 1) 35.

Moreover, PA is a frequent cause of skin infections such

as folliculitis 36. With patients being released earlier from

hospital, PA is increasingly recognized as a problematic

water pathogen outside of hospital settings.

Due to the increasing numbers of immunocompromised

patients and inherent resistance of PA to many antibiotics,

hospitals are often facing the real problem of PA infection

management as an important public health concern 37.

clinical samples isolated from the patients affected 19.

In a review from different European ICUs a genomic

identity between tap water and colonised/infected

patients has been shown in 19.2 – 50 % of the

reported cases 80.

A prospective multicenter study performed in 10 French

ICUs evaluated the contributions of ICU environmental

risk factors for PA acquisition and revealed previously

contaminated faucet water in the room, and nursing

workload were next to individual patient risk factors 6.

In a Spanish NICU, PA outbreak was described with 9

infections and 1 colonisation. PA had been detected in

tap water, which had been used to warm up mothers’

milk. After introduction of sterile water instead of tap

water, no further infection cases appeared 81.

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There are 4 main presentations of PA infection:

a) Bacteremia in immunocompromised individuals

b) Pneumonia in cystic fibrosis patients

c) Community-acquired ear and pneumonia infections

d) Hospital-acquired outbreaks, mainly associated with

contaminated solutions or medical devices 66.

In all 4 presentations, water containing PA may be an

infection source.

Studies have shown that clinical strains of environmental

bacteria, including PA and/or their modes of resistance,

often originate from the natural environment, including

within soil and water 67, 68. Multidrug-resistant bacteria

have been detected from various water sources, including

drinking water or tap water 69. Antibiotic resistant bacteria,

at least for some classes of antibiotics, may be more

prevalent in tap water than in the water source 44, 69-71.

Vincenti et al. suggest that high bacterial resistance rates

Water-associated PA infections

could develop when the original environmental clone

already had high rates of antibiotic resistance 40.

A cross-sectional study evaluating the recovery of

Non-Fermenting Gram-Negative Bacteria (NFGNB)

in water sources from the hospital environment was

performed in different wards of a tertiary care centre

and assessed the antibiotic resistance profile 40. Of

3268 water samples collected, 4.6 % were positive

for NFGNB with PA being the most represented

strain (34.9 %) followed by P. fluorescens (17.5 %)

and Stenotrophomonas maltophilia (10.7 %) 40. More

than half (55.6 %) of isolated strains showed antibiotic

resistance with up to 56 % of PA in the bronchoscopy

unit being antibiotic resistant (48 % MDR and 8 %

extensively drug-resistant) 40, 67, 72.

Of ten patients affected in a multiresistant PA outbreak

in a UK adult ICU, typing revealed 2/3 strains of PA

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via air among patients with cystic fibrosis 62 or via patient

hand and environmental contamination 63. Contaminated

bottled water or contaminated water from drinking water

dispensers has also been described as a source of hospital-

associated Pseudomonas infections in ICUs and Bone Marrow

Transplantations (BMTs) 64, 65.

Waterborne bacteria including PA may cause infection by consumption via drinking, inhalation of aerosols and application via contact.

detected in water samples matched strains isolated

from patients 73.

Cystic fibrosis (CF) patients become colonised with PA

early in life, and the prevalence of colonisation increases

with age: 60- 80 % of CF patients are infected 74.

Although a proportion of CF patients are infected with

PA from other patients (cohabitating hospital wards), the

main recognised source of infection is water 75, 76.

Pseudomonas can persist in hospital water systems

for expanded time periods and can result in outbreak

situations 26, 39, 73, 77-79. In a PA outbreak in a neonatal unit

in Northern Ireland, where 4 neonates died, the typing

data of the strains from 2 neonatal units linked the PA

strains recovered from the biofilm on the faucet surface

and flow straightener, and/or the water samples to the

Water as an infection source may be proven by comparison of patient and environmental sample DNA.

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Wound cleansing and PA

Special Notes

Patients with chronic wounds may be frequently

colonised by multiple bacterial species including PA,

thus delaying or even preventing the wound healing

process. A longitudinal analysis of continuous ulceration

in a cohort of chronic wound patients found that

patients with ≥ 3 x confirmations of PA in their swabs

had a longer wound duration compared to all patients

analyzed 82. Biopsy from chronic venous leg ulcers

were investigated by culture and Fluorescence-In-Situ-

Hybridization using Peptide Nucleic Acid probes (PNA-

FISH). PA was found to aggregate as microcolonies

and these wounds had significantly higher numbers of

neutrophils present which may be one factor supporting

persistent inflammatory response and impaired healing 83.

Diabetic foot infections can process rapidly to irreversible

septic gangrene necessitating amputation. An analysis

of the polymicrobial nature of diabetic foot infections

from 69 swabs and 73 tissues of 42 diabetic patients

showed PA as the most frequent aerobic bacteria with

a 30.95 % distribution 84. Moreover, antibiotic resistance

is considered to be a major threat in the treatment of

diabetic foot infections 85.

Infections are a causal agent of morbidity and mortality for

burn patients 86, 87. In a study of 176 burn care centres in

North America, Pseudomonas spp. was seen as the most

life threatening infections in thermally injured patients 86.

A 6 year antibiotic susceptibility study in a US Burn Centre

to analyse MDR isolates revealed Acinetobacter baumanii

as the most prevalent organism, followed by PA 87.

Additionally, transmission of resistance genes between

Pseudomonas species and from Pseudomonas spp. to

other Gram-negative organisms has been demonstrated

and recognised in the burn population 86. Zhang & Liu

analysed 84 patients with 134 burn related sepsis and

wound infections, and found multiresistant PA and

Acinetobacter spp. the most frequent 86.

Water for wound cleansing should be free of facultative

pathogens 88-90. The European Practice Guidelines for

burn care state that removal of slough, non vital tissue and

necrosis should be by abundantly cleaning and cleansing

the wound with tap water (filtered), saline solution or sterile

water in combination with mechanical debridement in order

to reduce the bacterial load 90. For the cleansing of wounds

in immunocompromised patients, only sterile NaCl / Ringer

solution or 0.2 µm filtered water should be used in Germany 89.

By cleansing wounds with unfiltered or non-sterile water, waterborne microorganisms may colonise wounds, leading to infections.

Chronic lung infections are associated with increased

morbidity and mortality for individuals with underlying

respiratory conditions such as cystic fibrosis (CF) and

chronic obstructive pulmonary disease (COPD) 54, 55, 58, 91.

The process of chronic colonisation allows pathogens

to adapt over time to cope with changing selection

pressures, co-infecting species and antimicrobial

therapies 92. COPD is a leading cause of mortality

worldwide and is associated with morbidity related to

acute COPD exacerbations (AECOPD) 91. In an evaluation

of 401 patients with AECOPD, 54 (13 %) had a positive

PA sputum culture. Resistant PA was isolated in 35/54

(66 %) and these patients were statistically more likley

(P = 0.03) to have been exposed to cortocosteroids and

antibiotics. Sensitive PA (PA-S) was isolated in 18/54

(34 %) of patients, and the presence of PA-S was found

to be associated with higher mortality, possibly due to

increased virulence in PA-S strains causing acute infections 91. PA is often isolated in advanced stages of COPD. Of

181 COPD patients analysed, 29 (16 %) had PA in their

sputum. After 3 years, 17/29 (58.6 %) patients had died,

compared to 53/152 (34.9 %) non-PA patients (P < 0.004).

PA is a prognostic marker of 3 year mortality in COPD

patients 93.

Clinical observations link respiratory virus infection and PA

colonisation in chronic lung disease, including cystic fibrosis

and COPD. The development of PA into highly antibiotic-

resistant biofilm communities promotes airway colonisation

and accounts for disease progression in patients 94.

(34 %) of patients, and the presence of PA-S was found

increased virulence in PA-S strains causing acute infections

. PA is often isolated in advanced stages of COPD. Of

181 COPD patients analysed, 29 (16 %) had PA in their

sputum. After 3 years, 17/29 (58.6 %) patients had died,

compared to 53/152 (34.9 %) non-PA patients (P < 0.004).

Clinical observations link respiratory virus infection and PA

ibrosis

and COPD. The development of PA into highly antibiotic-

ilm communities promotes airway colonisation

Cystic fibrosis and COPD patients often carry chronic PA colonisation.

Lung disorders and PA

Cystic fibrosis and COPD patients use nebulisers as an

integral part of treatment regimens. Nebuliser hygiene

is an important, but complicated and time consuming

task for patients 95. Home nebulisers may become

colonised 96, 99 and are a potential source of infection as

bacteria may colonise both plastic surfaces and human

lungs via the formation of biofilms. Woodhouse et al.

have shown that the use of sterilising grade filtered water

for rinsing of repeatedly used nebulisers significantly

reduces bacterial contamination 100. Moreover, several

recommendations support use of sterile water for rinsing

of nebulisers, as tap water may harbour non-tuberculous

mycobacteria, fungi or PA 101, 102.

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PA infection prevention in the hospital ICU

Water has been demonstrated to be a common source of

PA colonisation and infections 8, 37, 58, 80 using genotyping

methods and comparing environmental with patients’ PA

strains 14, 80. Control of environmental PA transmission is

critical, and the rise of antibiotic resistance in pathogenic

bacteria including PA, is considered to be an emerging

threat to human health 34, 38, 42. The intensive use of

antibiotics is creating selective pressure favouring the

acquisition and spread of antibiotic resistance among

bacteria 40. High awareness for attention to hand hygiene,

especially with soap and water, is necessary 28.

Installation of Point-of-Use (POU) Water Filters has been

shown to be an effective aid in reducing waterborne PA

infection rates 18, 28, 103-107 as well as reducing critical PA

contamination events 78, 108-112 (table 2). A review, which

assessed the evidence that healthcare water systems are

associated with PA infections, was performed by Loveday

et al 18. From 196 relevant peer reviewed studies, 25 met

the criteria for data strength but only two studies provided

plausible evidence for effective control measures. Both

studies included Point-of-Use Water Filters 77, 104.

Walker et al. suggest hospitals determine which patients

are at risk in augmented units and undertake a review of

not just the water system, but also environmental cleaning

practices and related best practice to assess possible

faucet contamination with patients’ bacteria, to evaluate

patient contact with water on particular wards, and to

assess other control measures that may be required in

order to minimise risks to patients 19.

In a 10 year Swiss study, an increase of hot water

temperature to 149 °F (65 °C), eradication of

multiresistant PA strains from the environment, and use

of Point-of-Use Water Filters in burns and solid transplant

organ patient rooms, have been found to be effective

infection prevention measures in intensive care units 9.

In an Italian haemato-oncological unit a significant

increase of PA positive blood cultures was observed and

environmental tests revealed contamination of

> 50 % showerheads, faucets, basins and bidets.

Measures such as 5 minutes water flushing did not result

in a decrease in infection rate. Installation of POU water

filters led to a significant reduction in septicemia rate 103.

In a surgical ICU, endemic PA infections were observed for

a period of > 24 months, with tap water being persistently

colonised with a single PA clonotype. Different measures

to reduce the rate of new PA infections cases, including

selective digestive tract decontamination, enhanced

hygiene measures and alcohol-based hand disinfection

after handwashing, did not reduce the occurrences.

Installation of POU water filters led to a significant reduction

of colonisation and infection rates. The rate of PA positive

patients reduced from 15.5 % in the non-filtration period

to 4.3 % in the filter period (p ≤ 0.0001). Moreover, overall

infections were reduced by 22 % and PA infections by

56 % 104. It may be argued that eradication of PA is not

possible in an adult ICU, as already colonised patients

may be admitted or there may be transmission between

patients from poor hygiene practice. However, providing

hygienically controlled water in the ICU for infection

prevention purposes should be prioritised 104.

Comparison of a 5-month period with POU water filters

installed at all outlets in a subacute care unit with 29 beds

showed a significant reduction in ventilator-associated

pneumonia (VAP) cases (p = 0.0087), positive cultures

for Pseudomonas (p = 0.0004) and upper respiratory

colonisation with Pseudomonas (p = 0.0179) 110.

Barna et al. reported the reduction of PA infection rates

to 0/100 ICU patient days during the filtration period of

4 weeks versus 2.7/100 patient days over 4 weeks

without filters 105.

A reduction of nosocomial PA infections in burn patients

from 10 % to 2.5 % 106 and a 50 % reduction of Gram-

negative bacteria infections in a bone marrow transplant

unit have been reported after installation of POU water

filters 107. Furthermore, a prospective clinical study in a

liver transplant unit comparing Gram-negative infection

and colonisation rates before and after installation of

POU water filters reported a reduction of infection and

colonisation rates of 47 % per 1,000 patient days during

the filtration period 111.

Tap water was implicated as the source of a PA outbreak

in a US Neonatal ICU where 31 cases and 3 deaths were

reported 113. PA case clusters occurred before POU water

filters were installed, and after they were removed. Residing

in a room without a POU water filter was the strongest risk

factor for patients having a positive PA culture.

Country

Italy

France

Germany

France

US

US

Hungary

China

US

Patient Unit

Haematology

ICU

Surgical ICU

Burns Unit

BMT Unit

Subacute Care Unit

ICU

Liver Transplantant Unit

Neonatal ICU

Effect of POU Filtration

Reduction of PA positive blood cultures from 8 % and 18 % to 2.7 %

Reduction of PA infections from 8.7/1000 patient days to 3.9/1000 patient days

Reduction of PA colonisation by 85 % and infections by 56 %

Reduction of PA infections from 10 % to 2.5 %

50 % reduction of Gram-negative bacteria infections

90.2 % reduction in VAP cases 68.3 % and 58.6 % reduction of PA positivity in sputum and nasal samples respectively

Reduction of PA infections from 2.7/100 to 0/100 patient days

47 % reduction of Gram-negative infection and colonisation rates per 1,000 patient days

Reduction of positive PA cultures from 1-4 per week to 0 per week

Citation

Vianelli et al., 2006 103

Van der Mee-Marquet, 2005 112

Trautmann et al., 2008 104

Legrand et al., 2009 106

Cervia et al., 2010 107

Holmes et al., 2010 110

Barna et al., 2014 105

Zhou et al., 2014 111

Bicking Kinsey, 2017 113

Table 2: Reduction of patient infection /colonisation with Point-of-Use Water Filters.

12 © 2016, Pall Corporation

POU Water Filters are barriers against waterborne microorganisms and may aid in reducing PA rates in high risk patient groups.

World Health Organisation (WHO) recommendations

are recognised globally for drinking water quality

requirements, and POU water filtration is listed as one

suggested control measure for hospitals 114. In addition

POU Water Filtration recommended as a control measure against waterborne bacteria

there are national and regional drinking water guidelines,

several of which have integrated POU filtration as one

control method to prevent transmission of waterborne

pathogens to patients and users 28, 89, 115-121.

Health care-associated infections (HAIs) can be associated

with increased costs in the range of $7,453 - $15,155

per infected patient 122 (table 3). Chronic PA infections in

the cystic fibrosis population increased baseline costs by

39%. 123 PA is a major cause of pneumonia in the ICU and

following a 6 year study period, patients with PA infection

were calculated to have a higher total mean hospitalisation

cost at $213,104 vs non infected patients at $33,851

(P<0.001) 124. Additionally PA infected patients spent nearly

2 weeks longer in intensive care, and approximately 7 weeks

longer in hospital than non-infected patients. MDR-PA had

the highest mean incremental cost, which was approximately

7 x the cost of a non-infected patient 125.

The use of POU water filters was shown to prevent 7.6

infections per 100 patients staying ≥ 3 days in the ICU, and

Financial implications of PA infections and POU Water Filtration

preventing 23 infection cases per year 104. Given a moderate

estimate of the additional cost of any type of nosocomial

infection in the range of $3,000, POU water filtration resulted

in savings of $69,000 and a net saving of $64,000 when

applied in the 12 bed ICU 104.

A comparison of 5 month filtration period in a subacute

care unit with 29 rooms versus 1 month non-filtration period

found a reduction in total patient costs of $248,136 with net

cost savings of $231,036 110. After a PA outbreak affecting

17/67 patients, Bou et al. calculated €18,408 per case of

PA infection, thus being 66 % higher than non-infected

patients (p = 0.002). Based on these figures a conservative

estimate of the extra cost attributable to PA infection in

the ICU reached €312,936. The extra length of ICU stay

attributable to PA infection was 70 days (p = 0.0001) 115.

n.a.Year

2008

2009

2010

Preventable Infections by Use of POU Water Filters

23 per year

n.a.

16 in 5 months

Costs due to Infections

$3,000 per infectionper patient

Average increase of total ICU cost for € 18,408

n.d.

Water Filter Costs

$5,000 pa for a 12 bed ICU

n.a.

$17,100 for 5 months for 25 POU

Table 3: Cost of nosocomial PA infections and net cost savings with use of POU Water Filters as the control measure. n.a.= not applicable; n.d. = not defined.

www.pall .com/medical 13

Net Cost Savings

$64,000 p.a.

n.a.

$231,046 for 5 months

Citation

Trautmann et al., 2008 104

Bou et al., 2009 126

Holmes et al., 2010 110

- PA is an opportunistic bacterium developing

antimicrobial resistance and playing a major role in

hospital acquired infections

- Tap water is a common source of PA infections in

healthcare environments

Conclusion

- POU Water Filters interrupt the transmission pathway

between tap water and patients, and are

recommended as an effective control measure which

may aid in reducing PA colonisation and infection

- Prevention of PA infections leads to cost savings

Typical medical applications of sterilising grade POU Water Filters.

Food & drinkpreparation

Handwashing

Endoscopic reprocessing

Showerunit

Woundcare

14 © 2016, Pall Corporation www.pall .com/medical 15

Continued over

1. Asghari et al., “Rapid monitoring of Pseudomonas aeruginosa in hospital water systems: a key priority in prevention of nosocomial infection”, FEMS Microbiol Let, 343:77-81, 2013

2. Falkinham et al., “Epidemiology and ecology of opportunistic premise plumbing pathogens: Legionella pneumophila, Mycobacterium avium and Pseudomonas aeruginosa”, Environ Health Perspect, 123(8):749-58, 2015

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13. Cornejo-Juárez et al., “The impact of hospital-acquired infections with multidrug-resistant bacteria in an oncology intensive care unit”, Int J Infect Dis, 31:31-4, 2015

14. Rogues et al., “Contribution of tap water to patient colonisation with Pseudomonas aeruginosa in a medical intensive care unit”, J Hosp Infect, 67:72-8, 2007

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